Pelvic Pain and In Vitro Fertilization

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					                                 September 2006




Pelvic Pain and In Vitro Fertilization


Celeste Lopez, Harvard Medical School Year III
            Gillian Lieberman, MD
             September 18, 2006
 Celeste Lopez, HMS III
 Gillian Lieberman, MD




                          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
    Celeste Lopez, HMS III
    Gillian Lieberman, MD




            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
                             http://www.ivf-midland.co.uk/images/serv_invitro1_lrg.gif


                                                                                         3
             Celeste Lopez, HMS III
             Gillian Lieberman, MD




       Anatomy of Hysterosalpingogram
                                                                                                               Uterine ostium



                                                                                                                Isthmus of
Right adnexa
                                                                                                                uterine tube




Ampulla
of uterine
tube




                                                                                                                        4
                    http://classes.kumc.edu/som/radanatomy/image.asp?Image=5001-002.jpg&Film=5001&Features=0
Celeste Lopez, HMS III
Gillian Lieberman, MD




Anatomy of the female pelvis




                               5
 Celeste Lopez, HMS III
 Gillian Lieberman, MD




                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
    Celeste Lopez, HMS III
    Gillian Lieberman, MD




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

                                                     7
          Celeste Lopez, HMS III
          Gillian Lieberman, MD


                  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
      Celeste Lopez, HMS III
      Gillian Lieberman, MD




        Mrs. G’s Enlarged Right Ovary
                                                          Source: PACS BIDMC




                                       *     * *
                       follicle   *                  *
                                      * **       *
                                                      *
                                             *
        ovary




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
           Celeste Lopez, HMS III
           Gillian Lieberman, MD




                        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
        Celeste Lopez, HMS III
        Gillian Lieberman, MD




      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
      Celeste Lopez, HMS III
      Gillian Lieberman, MD




                      Companion patient 2
                        Ovarian torsion

                                                                 ovary



                               www.uhrad.com/mamarc/mam011.htm



 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
      Celeste Lopez, HMS III
      Gillian Lieberman, MD



         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
      Celeste Lopez, HMS III
      Gillian Lieberman, MD



                       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
          Celeste Lopez, HMS III
          Gillian Lieberman, MD



             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
       Celeste Lopez, HMS III
       Gillian Lieberman, MD


         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
   Celeste Lopez, HMS III
   Gillian Lieberman, MD



     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
   Celeste Lopez, HMS III
   Gillian Lieberman, MD



          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
    Celeste Lopez, HMS III
    Gillian Lieberman, MD




                             Ovarian Torsion
Torsion of vascular
pedicles impedes
lymphatic and venous
outflow and arterial
inflow

Continuous arterial
perfusion with blocked
outflow leads to
ovarian enlargement
                                   http://bms.brown.edu/pedisurg/Brown/IBImages/Ovary/SpontaneousOvarianTorsion



                                                                                                       19
    Celeste Lopez, HMS III
    Gillian Lieberman, MD




                             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
                                    http://www.womenshealthlondon.org.uk/leaflets/ovarian/ovacystsymp.html
                                                                                                      20
    Celeste Lopez, HMS III
    Gillian Lieberman, MD




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



                                   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.
Foshager M, Walsh J. CT Anatomy of the Female Pelvis: A
                                        51-
second look. Radiographics 1994; 14(1): 51-64.
                                                                                        22
               Celeste Lopez, HMS III
               Gillian Lieberman, MD




                                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
http://rad.usuhs.mil/medpix/medpix_image.html?imageid=21710   waveforms absent.
                                                                                23
  Celeste Lopez, HMS III
  Gillian Lieberman, MD




                      Companion Patient 5
                        Ovarian Torsion
                                                                                                          Urinary bladder




                                                                                                        Twister
                                                                                                        Vascular pedicle
                                                                                                        “Whirlpool sign”




                                                                                                           Ovarian cyst


                                                                                                                    24
                                                          Ovarian                                 23:1643-
Boopathy Viajayaraghavan S. Sonographic Whirlpool Sign in Ovarian Torsion. J Ultrasound Med 2004; 23:1643-1649.
      Celeste Lopez, HMS III
      Gillian Lieberman, MD



        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
      Celeste Lopez, HMS III
      Gillian Lieberman, MD


              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
      Celeste Lopez, HMS III
      Gillian Lieberman, MD



            Mrs. G’s Left Ovary Venous
                    Waveforms




                                   Source: PACS BIDMC


The left ovary demonstrates venous waveforms consistent
with normal ovarian blood flow.
                                                          27
        Celeste Lopez, HMS III
        Gillian Lieberman, MD


                                 Appendix Visualized
                                          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
    appendix                              orientation.
                                           The close spatial
                                          relationship to the enlarged
ovary
                                          right ovary could explain
                                          tenderness at McBurney’s
                     Source: PACS BIDMC   point.
                                                                    28
   Celeste Lopez, HMS III
   Gillian Lieberman, MD




                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
                            http://www.macmed.ttuhsc.edu/Graham/gyn2/pages/newpage47.htm




                                                                             29
      Celeste Lopez, HMS III
      Gillian Lieberman, MD



              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
         Celeste Lopez, HMS III
         Gillian Lieberman, MD



                 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
 Celeste Lopez, HMS III
 Gillian Lieberman, MD




                    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
 Celeste Lopez, HMS III
 Gillian Lieberman, MD




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


                                                           33
  Celeste Lopez, HMS III
  Gillian Lieberman, MD




                           References
Ben-Ami M, Perlitz Y, Haddad S. The effectiveness of spectral and color Doppler in predicting
ovarian torsion. A prospective study. Eur J Obstet Gynecol Reprod Biol 2002; 104:64.
Boopathy Viajayaraghavan S. Sonographic Whirlpool Sign in Ovarian Torsion. J Ultrasound Med
2004; 23:1643-1649.
Fleischer A. Ovarian Torsion 2006. emedicine.com
Foshager M, Walsh J. CT Anatomy of the Female Pelvis: A second look. Radiographics 1994;
14(1): 51-64.
Gorkemli H, Camus M, Clasen K. Adnexal torsion after gonadotropin ovulation for IVF or ICSI
and its conservative treatment. Arch Gynecol Obstet 2002; 267(1):4-6.
Pena JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of
ovarian torsion. Fertil Steril 2000;73(5):1047-50.
www.uptodate.com
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 2006
http://www.ivf-midland.co.uk/images/serv_invitro1_lrg.gif
http://classes.kumc.edu/som/radanatomy/image.asp?Image=5001-
002.jpg&Film=5001&Features=0
http://bms.brown.edu/pedisurg/Brown/IBImages/Ovary/SpontaneousOvarianTorsion
http://www.womenshealthlondon.org.uk/leaflets/ovarian/ovacystsymp.html
http://rad.usuhs.mil/medpix/medpix_image.html?imageid=21710
http://www.macmed.ttuhsc.edu/Graham/gyn2/pages/newpage47.htm
                                                                                            34
 Celeste Lopez, HMS III
 Gillian Lieberman, MD




                  Acknowledgements

Andrew Hines-Peralta, MD
Eric Zeikus, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras



                                     35

				
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