Human Reproduction, Vol. 18, No. 8, 1641-1642,
August 2003
© 2003 European Society of Human Reproduction and Embryology
Exercise-induced ovarian torsion in the cycle following gonadotrophin therapy: Case report
Stanford University Medical Center, Department of Obstetrics and Gynecology, 300 Pasteur Drive, HH333, Stanford CA 94305, USA
1 To whom correspondence should be addressed: e-mail: milki4{at}aol.com
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Abstract |
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The incidence of ovarian torsion has been reported to be increased during controlled ovarian hyperstimulation. In this report we describe exercise-induced ovarian torsion in an ovary with a persistent cyst, following a failed gonadotrophin-stimulated intra-uterine insemination cycle. This report suggests that the risk of ovarian torsion persists beyond the treatment cycle and that patients should be instructed to refrain from exercise or strenuous activity if regression to normal ovarian size has not been documented. Ovarian torsion should be high in the differential diagnosis in patients experiencing abdominal pain with a history of recent gonadotrophin stimulation.
Key words: exercise/gonadotrophin stimulation/laparoscopy/ovarian torsion
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Introduction |
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Ovarian torsion is a potential complication of gonadotrophin stimulation, which prompts practitioners to caution patients against strenuous activity during the stimulation cycle. Patients who do not conceive are typically not monitored in the subsequent cycle unless they plan back-to-back gonadotrophin stimulation. In this case report, we describe a patient who developed ovarian torsion while exercising during the natural cycle following a failed gonadotrophin cycle.
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Case report |
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The patient is a 38-year-old, gravida 1, para 1 female, with a history of unexplained infertility, who previously was able to conceive and successfully deliver, after her first cycle of gonadotrophin stimulation and intra-uterine insemination (IUI). Approximately 1 year after delivery of her first child, the patient returned to her primary gynaecologist for further therapy to achieve a second pregnancy. She underwent a gonadotrophin/IUI cycle, which resulted in two follicles on the right ovary (20 mm, 16 mm) and two follicles on the left ovary (18 mm, 13 mm). She received an injection of hCG, and underwent IUI
38 h later. The cycle was unsuccessful and the patient was found to have persistent cysts on the left ovary measuring 25 mm and 11 mm, on a baseline ultrasound performed on day 3 of her menstrual cycle. This led to the cancellation of a repeat gonadotrophin cycle. Two weeks later, while the patient was participating in a kick-boxing class, in which no abdominal trauma was sustained, she began experiencing severe pelvic and abdominal pain. She was seen by an Urgent Care physician who attributed the pain to abdominal wall sprain. Over the next 2 weeks she had intermittent abdominal pain of a colicky nature which radiated to the left groin area. She reported to her gynaecologist for another baseline ultrasound after her subsequent menstrual period, in order to begin a new gonadotrophin cycle. Transvaginal ultrasound revealed an enlarged left ovary measuring 7 x 8 x 10 cm. She was diagnosed with chronic left ovarian torsion and was taken to the operating room for further therapy. A laparoscopy was performed and showed an enlarged, mostly necrotic, left ovary. The necrotic portion, which was thought to represent 80% of the ovary, was removed. The patient recovered well from her laparoscopic surgery and since then has undergone two gonadotrophin-injection cycles and one IVF cycle without success. During the IVF cycle one oocyte was retrieved from the left ovary. |
Discussion |
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Adnexal torsion has been reported to account for 2.7% of major gynaecologic surgical emergencies based on a 10-year survey at the University of Southern California Women’s Hospital (Hibbard et al., 1985
). It ranked fifth after ectopic pregnancy, corpus luteum accident, pelvic infection, and appendicitis. The incidence of adnexal torsion is likely to increase in gonadotrophin-stimulated cycles especially those resulting in a pregnancy (Kemmann et al., 1990). The frequency increases dramatically in the setting of a pregnancy complicated by ovarian hyperstimulation syndrome (Mashiach et al., 1990).
Sudden body movements have been reported as risk factors for adnexal torsion (Provost 1972; Hibbard, 1985; Droegemuller et al., 1997). While it is not uncommon for infertility patients to use exercise as a way to relax and reduce stress, patients undergoing gonadotrophin stimulation are often instructed to forego exercise or strenuous activity during the cycle, as enlarged ovaries are more prone to torsion. A significant proportion of patients who fail gonadotrophin stimulation take a break before undergoing a repeat cycle, either by choice or due to persistent cysts. These women typically resume normal activities, which often include exercise during this drug-free cycle. Patients who plan an immediate repeat cycle typically undergo a baseline ultrasound which may reveal one or more persistent cysts and potentially lead to deferring their subsequent cycle, similar to the present case. Based on our report, it is important to warn patients against exercise if a persistent cyst is found. It also may be necessary to caution patients who are not planning back-to-back cycles against exercise in the month following gonadotrophin therapy, or at least to confirm ovarian regression to normal by performing a baseline ultrasound prior to allowing them to resume normal activities.
The diagnosis of ovarian torsion in this patient was not made until 2 weeks after her initial presentation to a healthcare provider. By the time of surgery, >80% of her left ovary was considered to be necrotic and therefore was removed. Conservative management of ovarian torsion by untwisting the apparently ischaemic ovary can lead to return of viability and function if performed promptly (Descargues et al., 2001). Laparoscopic unwinding of the adnexum with returned viability has been described by several authors as early as the 1980’s (Manhes et al., 1984; Vancaille and Schmidt, 1987; Ben-Rafael et al., 1990). They also showed that there is a return of normal appearance and function by performing long-term follow-up of patients who have undergone laparoscopic detorsion of what appeared to be a non-viable ovary. Therefore, it is possible that earlier diagnosis of our patient’s condition would have allowed for more conservative management.
In conclusion, this report suggests that the risk of ovarian torsion persists beyond the treatment cycle and that patients should be instructed to limit strenuous activity if regression to normal ovarian size has not been documented. Furthermore, healthcare providers should have a low threshold for including ovarian torsion in the differential diagnosis of abdominal pain following a gonadotrophin cycle.
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References |
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Ben-Rafael, Z., Bider, D. and Mashiach, S. (1990) Laparoscopic unwinding of twisted ischemic hemorrhagic adnexa after in vitro fertilization. Fertil. Steril., 53, 569–571.[Medline]
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Submitted on February 17, 2003; accepted on May 7, 2003.
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