Pelvic infections following ultrasound-guided transvaginal
oocyte retrieval (TVOR) are rare complications
with an incidence of 0.6% (
A 26-year-old, nulliparous woman underwent in
vitro fertilization (IVF) for male factor subfertility in
an assisted reproduction unit, Ankara, Turkey. Her
medical history was unremarkable and physical examination
was normal. Basal ultrasound examination
on the 3rd day of menstrual cycle revealed a normal
pelvic anatomy without appearance of an ovarian cyst
including endometrioma. Following a standard ovarian
stimulation with gonadotropins, TVOR was performed
at the 36th hour of ovulation trigger using 250
µg of recombinant human chorionic gonadotropin
(rhCG, ovitrelle, Merck Serono, Turkey). Retrieval
process was uneventful without any complications.
The patient was prescribed a 5-day course of oral doxycycline
(Monodoks, Deva, Turkey) (100 mg, twice
daily) as a part of routine medication after retrieval
process and vaginal micronized progesterone (Progestan,
Kocak, Turkey) (200 mg, three times a day)
for luteal phase support. On the 14th day of transfer,
pregnancy was confirmed with a quantitative betahCG
(ß-hCG) value of 240 mIU/ml. A subsequent
doubling in serum hCG levels was also observed suggestive
of an early ongoing intrauterine pregnancy.
Three weeks after the retrieval procedure, the patient
was admitted to the emergency unit with mild abdominal
pain and elevated body temperature (38.3℃). Her
physical examination revealed rebound tenderness in
the lower abdomen and tenderness during bimanual
pelvic examination. Pelvic sonography revealed a
4.5×4 cm echogenic cystic mass on the left adnexa
with mild fluid in the Douglas pouch. Laboratory tests
were within the normal range except for leukocytosis (12.500/mm3) and elevated C-reactive protein (8 mg/L) (CRP). An ultrasound-guided drainage of the mass was considered, but due to the anatomic position of the mass and poor cooperation from the patient, the procedure was not successful. Thus an initial empirical antibiotic therapy was started within travenous (IV) ceftriaxone sodium (Iesef, Ulagay, Turkey) 1gr twice a day and metronidazole 500 mg (Flagyl, Sanofi Aventis, Turkey) three times a day, as we were also unable to obtain satisfactory amount of culture sample from Douglas pouch. Despite full course of antibiotics for 48 hours, mild fever (38℃) and abdominal tenderness persisted and a laparoscopic drainage was decided. On initial evaluation, formations of left ovarian abscess and diffuse pus were confirmed (Figes
The initial view of the pelvis, depicting a left ovarian mass consistent with abscess, disseminated purulent fluid.
Drainage of purulent fluid from the left ovarian mass.
Appearance after excision of the mass and irrigation of the pelvis.
Oocyte retrieval process is an invasive procedure with the potential risk of inoculation of the vaginal microorganisms into abdomen. The risk of pelvic infection after TVOR is estimated as 0.6% (
Topical antiseptic usage for vaginal preparation before TVOR is another controversial issue in the presence of risk factors. However, there has been no such accepted universal approach. Povidone-iodine or chlorhexidine are commonly used to sterilize the vagina, whereas other options include saline irrigation, careful removal with dry swabs, or avoiding them completely by cleansing the vagina with only saline solutions. Tsai et al. (
Review of cases with Pelvic abscess formation following oocyte retrieval in the literature
|Reference||Age (Y)||Opu procedure||Time of symptoms||Possible risk factor(s)||Treatment||Maternal / fetal outcome|
|32||NA||16th week of gestation||Unilateral salpingectomy for ectopic pregnancy||Antibiotherapy, delivery of a first fetus at 16th week and laparotomic drainage||Delivery of second fetus without complications at 30th week|
|36||NA||25 week 4 days of gestation||Surgery for endometriosis and presence of endometrioma during OPU||Laparotomic bilateral multiple ovarian abscess drainage and antibiotherapy.||Delivery at 26 weeks, hypoalbuminemia , pulmonary edema, re-laparotomy for peritonitis and ileus 1. Baby: After treatment for prematurity related complications, he is well and 8 months old; 2. Baby: died at 9th week with severe brain damage|
|35||Vagina cleansed with saline||13th week of gestation||Endometriosis and aspiration of an endometrioma during OPU||Antibiotherapy and observation||Delivery at 31st week by C-section. Drain left to pelvis and abscess resolved completelyThere were no neonatal complications|
|35||NA||16th week of gestation||Presence of endometriosis and endometrioma||Antibiotherapy at 16th and 20th week. Delivery of unviable fetus at 22nd week and laparotomic left salpingoophorectomy for large abscess||Unevet Full postoperative course|
|29||NA||22 days after oocyte pick up||Bilaterally endometriomas||Antibiotherapy without surgical intervention||Delivery at term without neonatal or maternal complications|
|34||Vaginal iodinization followed by saline irrigation||21 days after oocyte pick up||Aspiration of endometrioma during OPU||Antibiotherapy and L/S drainage of abscess||7 weeks of ongoing pregnancy|
|27||NA||23rd day of IVF cycle||Presence of endometrioma||Antibiotherapy and L/S drainage (interval of 5 days between 2 L/S)||Delivery at 37th week of gestation without any maternal complications. Newborn was operated for cardiac anomaly and well after the operation|
|34||NA||36th week of gestation||Surgery for tubal pregnancy||NA||Delivery at 38th week of gestation without any maternal complications|
|26||Vaginal iodinization followed by saline irrigation||21 days after OPU||No||Antibiotherapy and L/S drainage of abscess||Missed abortus at 8th week of gestation|
NA; Not available, OPU; Oocyte pick up, L/S;Laparoscopy and IVF; In vitro fertilization.
Life threatening complications as a result of assisted reproductive techniques obviously require close surveillance and active management. Ideally, less invasive and conservative approaches should be the first option; nevertheless, severe complications such as pelvic abscess sometimes require more aggressive treatment. Trans-vaginal ultrasound-guided drainage of pelvic abscess is a relatively easy, safe and effective procedure. It has also been proven to be significantly more effective than medical therapy and has been associated with a low surgical morbidity (
Management of tubal-ovarian abscess is quite complicated in women of reproductive age, and especially in pregnant patients. Today, in the light of growing evidence, majority of clinicians choose to perform fertility-sparing procedures in management of pelvic abscess. Laparoscopy provides direct visualization of pelvis and allows clinicians to perform additional procedures such as adhesiolysis, salpingotomy, and excision of necrotic tissues, simultaneously.
Even though the exact cause of fetal loss is unclear in this case report, pelvic infection can be assumed to be the plausible cause as there was evidence of inflammation reported in the pathological examination of the fetal material. As the duration between surgery and fetal loss was relatively long, it is really hard to say that fetal loss may be linked with the surgical procedure.Long duration of parenteral antibiotic usage is another questionable issue in this case for its toxic consequences on the fetus. However, beyond the etiology of the loss, this report was aimed at raising the issue of alternative management of an abscess when the case is not suitable for ultrasound-guided drainage. In seeking for a more accurate and safe method, especially applicable in early pregnancy, further studies are definitely required.
In sum, formation of pelvic abscess following TVOR is a rare, but a serious complication and laparoscopy may be a feasible option when less invasive approaches are unsuccessful during early pregnancy.