Pelvic Pain and In Vitro Fertilization

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1 September 2006 Pelvic Pain and In Vitro Fertilization Celeste Lopez, Harvard Medical School Year III September 18, 2006

2 Mrs. G 37yo with IVF oocyte retrieval the day before presentation to the ED Complains of lower abdominal pain and distention Normal vitals Tenderness at RLQ and McBurney s Point Negative HCG 2

3 In Vitro Fertilization Ovaries are stimulated with exogenous gonadotropins Serum estradiol is measured and transvaginal US is performed, until dominant follicle is >17mm, hcg is then administered 3

4 Anatomy of Hysterosalpingogram Uterine ostium Right adnexa Isthmus of uterine tube Ampulla of uterine tube 4

5 Anatomy of the female pelvis 5

6 Differential Diagnosis: Ovarian Hyper stimulation syndrome (OHSS) Ovarian Torsion Appendicitis Ectopic Pregnancy Ruptured or Hemorrhagic cysts Pelvic inflammatory disease Tubo ovarian Abscess (TOA) Degenerating leiomyoma (fibroids) Endometriosis 6

7 Menu of Radiographic Tests Ultrasonography Transvaginal- visualize ovaries for size and follicles, r/o OHSS, ruptured cysts, PID, TOA Transabdominal-visualize uterus to r/o fibroids and endometriosis Doppler- visualize arterial and venous flow to r/o ovarian torsion CT- visualize ovaries and appendix Sagittal Axial Coronal MRI for pregnant patients or other contraindications to CT 7

8 Mrs. G s Normal Uterus mass * uterus bladder Source: PACS BIDMC This is a sagittal transabdominal ultrasound that shows a normal appearing uterus. Above the uterus the bladder is visualized. There is a mass that is better visualized in a later view. 8

9 Mrs. G s Enlarged Right Ovary Source: PACS BIDMC ovary follicle * * * * * * * * * * * The mass in the previous images is now more clearly seen on this sagittal transvaginal US and represents a massively enlarged right ovary. This view is also used to rule out hemorrhagic cysts, which were not seen in this patient. The patient was mildly tender over this ovary during US. 9

10 Companion patient 1 Normal ovary follicle * ovary Source: PACS BIDMC The increased size and quantity of follicles in Mrs. G s ovary can be appreciated with evaluation of companion patient 1 s ovary, which also has fewer follicles. Companion patient 1 is a healthy female of similar age to Mrs. G. 10

11 Mrs. G s Enlarged Left Ovary follicle ovary * * * * * * * * * * * * Source: PACS BIDMC This is a sagittal transvaginal US of the enlarged left ovary. The outlines of the enlarged, individual cyst shaped follicles have a crisp, distinct interface. There are no masses. 11

12 Companion patient 2 Ovarian torsion ovary If Mrs. G had ovarian torsion the outline would be boggier, as is seen in companion patient 2 who did have a diagnosis of ovarian torsion. As the surrounding fluid merged with that of the torsed ovary, the interface between the two densities would become so similar that the outline would be blurry and no line would be visualized. 12

13 Mrs. G s Enlarged Left Ovary ovary Source: PACS BIDMC This is a coronal abdominal/pelvic CT, done at a later time, and will be discussed further later. It demonstrates well the enlarged left ovary, seen to the left of the uterus. 13

14 Companion patient 3 Normal ovary ovary Source: PACS BIDMC The enlargement becomes more apparent when compared to companion patient 3, a normal healthy female of similar age. 14

15 Free fluid from follicle rupture Free fluid * Bowel loops Source: PACS BIDMC This is an axial transvaginal view of the right ovary. Visualized here is a moderate amount of free fluid in the pelvis, with low-level internal echoes. It is located to the right of the bowel in this image. A pristine, simple fluid would be black, and a hemoperitoneum would appear denser. This free fluid is probably secondary to rupture of the follicles during the oocyte retrieval process she underwent the day prior, in which a needle was inserted into the ovary to retrieve the oocyte nucleus. 15

16 Free fluid from follicle rupture * * * * Free fluid spleen Source: PACS BIDMC This is an axial abdominal CT at the level of the abdomen, the free peritoneal fluid can be seen on the left surrounding the spleen with a density less than that of the surrounding muscle and soft tissue. It is of an intermediate attenuation value, measured at 33 Hounsfield units. Simple fluid would be 0-20 and hemo-peritoneum would be 60 units. 16

17 Ovarian Hyper Stimulation Syndrome Ovarian enlargement involves an acute fluid shift out of intravascular space, often creating free peritoneal fluid. It is due to increased capillary permeability during maturation and luteinization of multiple follicles. COMPLICATIONS: Ovarian torsion (8%), renal failure, hypovolemic shock, thromboembolic episodes, ARDS, death 17

18 Ovarian Hyper Stimulation Syndrome Classification Grade I (mild)- ovaries measuring up to 5 by 5 cm, w/multiple follicles Grade II (moderate)- up to 12 by 12 cm, abdominal discomfort and GI symptoms Grade III (severe)- >12 by 12 cm, ascites, pleural/pericardial effusion, hypovolemic shock. 18

19 Torsion of vascular pedicles impedes lymphatic and venous outflow and arterial inflow Ovarian Torsion Continuous arterial perfusion with blocked outflow leads to ovarian enlargement 19

20 Ovarian Torsion Occurs as a result of increased weight of the ovary from stromal edema, hyperstimulation or a mass (40-60%) 3% of surgical gynecological emergencies 20

21 Menu of Radiographic Tests for Ovarian Torsion Ultrasound can image the enlarged ovary Color Doppler Ultrasound (100% sensitivity and 98% specificity) Determines flow impairment Gray scale and spectral findings are correlated with the age of the torsion and degree of twist Twisted vascular pedicle occasionally seen MRI and CT can image ovarian edema which is suggestive but not indicative 21

22 Foshager M, Walsh J. CT Anatomy of the Female Pelvis: A second look. Radiographics 1994; 14(1): Pelvic Vasculature Although a lack of intraovarian arterial and venous flow enables confident diagnosis, torsion may be incomplete when only one or part of one of the pedicles is twisted This condition may be associated with adnexal flow, as depicted with color Doppler sonography. There is still risk of hemorrhagic rupture and gangrenous infection even in incomplete torsion A Doppler that reveals flow does not completely rule out the diagnosis of ovarian torsion. 22

23 Companion Patient 4 Ovarian Torsion Gray scale and color doppler images reveal a large predominantly hyperechoic midline pelvic mass Multiple peripherally located follicles. Color Doppler, arterial and venous waveforms absent. 23

24 Companion Patient 5 Ovarian Torsion Urinary bladder Twister Vascular pedicle Whirlpool sign Ovarian cyst Boopathy Viajayaraghavan S. Sonographic Whirlpool Sign in Ovarian n Torsion. J Ultrasound Med 2004; 23:

25 Mrs. G s US Doppler study of Right Ovary Source: PACS BIDMC This color Doppler shows normal color blood flow. Red is away from the transducer and blue is towards it. 25

26 Mrs. G s Left Ovary Arterial Waveforms Source: PACS BIDMC The patient s left ovary demonstrates arterial waveforms with an amplitude of about 10cm/s consistently. This modality measures the activity of the small branches of the ovarian artery, the arterioles, not the main ovarian vessel. 26

27 Mrs. G s Left Ovary Venous Waveforms Source: PACS BIDMC The left ovary demonstrates venous waveforms consistent with normal ovarian blood flow. 27

28 Appendix Visualized ovary appendix Source: PACS BIDMC The referring physician was still sufficiently concerned enough to exclude the possibility of appendicitis by ordering a CT of the abdomen and pelvis. The appendix can be visualized to the left of the superior portion of the ovary, as a tubule cut at an angle. It is of normal size and orientation. The close spatial relationship to the enlarged right ovary could explain tenderness at McBurney s point. 28

29 Tuboovarian Abscess Involves ovary and fallopian tube mostly due to pelvic inflammatory disease (PID) TOA can also develop following pelvic surgery.04% of women undergoing IVF develop TOA due to pelvic infection 29

30 Companion patient 1 Tuboovarian Abscess ovary abscess Source: PACS BIDMC Axial transabdominal US of the right ovary shows a hyper echoic, well circumscribed sphere, that appears to be an abscess, and the normal size ovary. 30

31 Companion patient 1 Tuboovarian Abscess abscess Source: PACS BIDMC A closer look at the hyperechoic structure reveals a thick walled cystic structure, who in a patient with fever and tenderness, likely represents an tubo-ovarian abscess (TOA), the diagnosis of companion patient 1. An air fluid level or septations are present in multiloculated TOAs, however this was not the case for companion patient 1. 31

32 Mrs. G s Diagnosis Findings consistent with Ovarian Hyper stimulation Syndrome, the favored diagnosis for Mrs. G s symptoms Moderate amount of fluid in pelvis extending around liver and spleen, given density is possible mixture of blood or fluid (likely secondary to egg retrieval). No torsion No appendicitis 32

33 Conclusion OHSS is self-limiting limiting and laparotomy is reserved only for those with ovarian torsion, rupture or hemorrhage Grade II OHSS Recommendations Daily weights Abdominal measurements Visit ED for increased pain or SOB sonographically monitor follicle size 33

34 References Ben-Ami M, Perlitz Y, Haddad S. The effectiveness of spectral and color c Doppler in predicting ovarian torsion. A prospective study. Eur J Obstet Gynecol Reprod d Biol 2002; 104:64. Boopathy Viajayaraghavan S. Sonographic Whirlpool Sign in Ovarian n Torsion. J Ultrasound Med 2004; 23: Fleischer A. Ovarian Torsion emedicine.com Foshager M, Walsh J. CT Anatomy of the Female Pelvis: A second look. l Radiographics 1994; 14(1): Gorkemli H, Camus M, Clasen K. Adnexal torsion after gonadotropin n ovulation for IVF or ICSI and its conservative treatment. Arch Gynecol Obstet 2002; 267(1): Pena JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography ography in the diagnosis of ovarian torsion. Fertil Steril 2000;73(5): Growden W, Laufer M. UpToDate: : Ovarian Torsion 2006 Insler V, Lunenfeld B. UpToDate: : Pathogenesis of ovarian hyperstimulation syndrome and Classification and treatment of ovarian hyperstimulation syndrome and Prevention of ovarian hyperstimulation syndrome 2006 Macklon N, Fauser B. UpToDate: : Overview of ovulation induction ariantorsion p.html 34

35 Acknowledgements Andrew Hines-Peralta, MD Eric Zeikus, MD Pamela Lepkowski Larry Barbaras 35

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