Haemoperitoneum due to ovarian rupture after oocyte retrieval procedure

Abstract

Transvaginal ultrasound-guided oocyte retrieval is the gold-standard technique for oocyte retrieval that has few associated procedural and post-procedural complications. Rarely, severe complications can occur including haemoperitoneum, for which the incidence reported in the literature is approximately 0.08–0.22%. In this report, we present the case of a nulliparous woman in her late 30s who presented to the hospital with severe abdominal pain following transvaginal ultrasound-guided oocyte retrieval and was found to have extensive haemoperitoneum attributed to ovarian rupture.

Background

Transvaginal ultrasound-guided oocyte retrieval (TVOR) under intravenous sedation is currently the gold-standard technique for oocyte retrieval in patients using assisted reproductive technology. This procedure involves transvaginal aspiration of oocytes from ovarian follicles by use of a needle attachment adapted for transvaginal ultrasound probes. This method has fewer associated procedural risks compared with those associated with operative laparoscopic oocyte retrieval and transabdominal oocyte retrieval techniques. With this minimally invasive method, surgical risks and complications, risks associated with general anaesthesia, costs of procedure, post-procedural pain and recovery time are all decreased.^{1 2}

While the transvaginal approach for oocyte retrieval has substantially reduced risks to patients compared with transabdominal or laparoscopic approaches, there are a few procedural complications that may arise. Possible complications include bleeding, post-procedural pain, injury to pelvic organs and blood vessels, infection with possible abscess formation, and complications from procedural and local anaesthesia.³ Vaginal bleeding is the most common post-procedural complication which typically arises from the needle entry site at the lateral fornix which can be stopped with compression during the procedure.

In the literature, there are very rare cases that describe severe complications from the procedure including onset of acute haemorrhage from the ovary or haematoma formation resulting from damage to vasculature supplying pelvic organs, ultimately requiring surgical intervention.^3–5 The incidence of severe complications including haemoperitoneum following TVOR ranges from 0.08% to 0.22%.⁴ In this report, we present the case of a nulliparous woman in her late 30s who presented to the hospital with severe abdominal pain following TVOR and was found to have extensive acute haemoperitoneum attributed to ovarian rupture. This report adds to the literature regarding complications resulting from oocyte retrieval procedures.

Case presentation

A nulliparous woman in her late 30s presented to the emergency department after experiencing abdominal pain and bloating that started earlier in the early afternoon and persisted throughout the day. She had undergone oocyte retrieval earlier in the morning that same day. She did not disclose the reason for egg retrieval or cause of infertility and preferred to keep that information private. She presented to the hospital after the pain worsened in the evening, and reported the pain score being 10 out of 10 with 10 being the worst pain. She started feeling increased discomfort, difficulty breathing, lightheadedness, dizziness, and nausea and vomiting. Upon presentation, she had intermittent periods of hypotension, with blood pressure measuring 96/65, and was in significant pain. She reported difficulty breathing but did have a normal respiratory rate. Her gynaecological, medical, surgical, familial and social histories were otherwise unremarkable. She had regular menstrual cycles, approximately every 28 days. On abdominal examination, she was distended and exhibited active guarding and diffuse tenderness to palpation.

Investigations

Bedside ultrasound was immediately performed and the FAST examination was positive with free fluids noted in the perisplenic area, the subxiphoid area, Morison pouch and Douglas pouch. The patient was immediately boarded for a diagnostic laparoscopy, haemoperitoneum evacuation and all other indicated procedures. In the interim, an abdominal and pelvic CT was performed, and it showed large-volume haemorrhage in the pelvis with complex free fluid extending into the paracolic gutters. The haemorrhage obscured the ovaries which were not definitely visualised; however, there were cystic structures in the bilateral adnexa which were likely of ovarian origin. A few of these structures had contents that measured above simple fluid and were possibly haemorrhagic. In addition, baseline laboratory results were obtained and her starting haemoglobin on presentation was 109 g/L and decreased to 99 g/L before the start of the procedure.

Differential diagnosis

Following the completion of these diagnostic studies, the differential diagnosis included haemoperitoneum secondary to a ruptured ovarian cyst, ruptured ovary or arterial perforation. Ovarian hyperstimulation syndrome was also on our differential diagnosis; however, based on the acute presentation and imaging findings, haemoperitoneum was our primary diagnosis and intraoperative findings confirmed haemoperitoneum due to bleeding from the lacerated portion of the ovary likely from haemorrhagic cyst formation from oocyte retrieval.

Treatment

Subsequently, the patient underwent laparoscopic right oophorectomy and evacuation of haemoperitoneum. Intraoperative findings were remarkable for 1700 mL of haemoperitoneum that filled the lower abdominal region, upper abdominal region and pelvic region (figure 1). The right ovary was noted to be fragmented and dissected spontaneously into two parts and active bleeding was appreciated from the lacerated regions (figure 2). A 3 cm simple cyst was appreciated on the left ovary. Otherwise, the uterus and bilateral fallopian tubes appeared normal. Evacuation of the haemoperitoneum was first performed. Due to inability to retrieve any healthy ovarian tissue, and the inability to surgically repair any remaining ovarian capsule, a decision was then made to proceed with a right oophorectomy (figure 3). The procedure was uncomplicated. Final pathology was consistent with haemorrhagic ovarian tissue and blood clots.

Figure 1.

Haemoperitoneum filling the lower abdominal region (A), upper abdominal region (B) and pelvic region (C).

Figure 2.

Right ovary is noted to be dissected spontaneously into two parts. Active bleeding appreciated from the lacerated region.

Figure 3.

Uterus status after right oophorectomy.

Outcome and follow-up

The patient was admitted overnight for extended recovery. On postoperative day 1, she was meeting postoperative milestones, and she no longer was experiencing pain or shortness of breath. She had a haemoglobin drop from 9.9 g/dL (preoperatively) to 7.1 g/dL. She received an intravenous iron infusion. She remained haemodynamically stable and asymptomatic and was discharged later that same day.

Discussion

Oocyte retrieval is an essential procedure used in in vitro fertilisation. Eggs are removed from the ovaries and fertilised in a laboratory setting for manual implantation into the uterus. Techniques to perform this procedure have evolved overtime, and the gold standard today is TVOR.⁵ The technique consists of a transvaginal ultrasound probe accompanied by a needle guide for precise extraction of eggs within the ovaries via needle aspiration.⁶

TVOR has evolved to be the gold standard due to its proven efficacy and safety. In a study of 23 827 oocyte retrievals, only 96 patients (0.76%) experienced complications.⁷ Two other independent studies reported a 0.4% and 1.6% complication risk, respectively, of a combined 6722 patients studied.^{8 9} Even though complications are very uncommon, those that do occur are most frequently due to haemorrhage from vaginal puncture site, pelvic infection or pelvic injury due to trauma of pelvic content.¹⁰

Regarding our case of haemoperitoneum caused by ovarian haemorrhage post-TVOR, only a very small sample of cases has been recorded. When looking for specific cases of haemoperitoneum and intra-abdominal bleeding in the retrospective studies listed above, only 68 cases reported ovarian haemorrhage and/or haemoperitoneum (0.2%). Out of those 68 cases, only 26 (0.08% of total cases) resulted in surgical intervention to regain homeostasis (3 laparotomy, 23 laparoscopy).^7–9 Direct causes of haemoperitoneum were not recorded for all cases and there were no exact numbers provided to determine how many were caused by ovarian haemorrhage. In a more detailed literature search for cases of haemoperitoneum caused by ovarian haemorrhage post-TVOR, a retrospective study reported only 3 cases of haemoperitoneum due to ovarian haemorrhage post-TVOR out of 3656 cases recorded (0.08%).¹¹ A comprehensive literature review had similar findings, stating that the incidence of haemoperitoneum due to ovarian bleeding was 0.09% of patients in the pooled analysis of 31 555 patients who received TVOR.⁴

Haemoperitoneum due to ovarian haemorrhage post-TVOR is a very rare presentation but must be discussed to better understand complications and treatment options for future occurrences. The infertility provider explained that the procedure was straightforward and uncomplicated. The patient was subsequently monitored for 30 min after the procedure and a follow-up ultrasound prior to discharge revealed little to no free fluid. Nonetheless, she presented with abdominal pain and bloating that significantly worsened over time, and was associated with difficulty breathing, lightheadedness, and nausea and vomiting. She was ultimately noted to have large-volume haemoperitoneum on imaging and underwent a diagnostic laparoscopy with oophorectomy given evidence of ovarian rupture. It is worth noting that bedside ultrasound remains the best screening modality for haemoperitoneum in such cases. If no imaging modalities are available otherwise, one would rely on the vitals, physical examination and the clinical setting. If acute abdomen is suspected, then laparoscopy is indicated. In a comprehensive literature review, 43 cases of haemoperitoneum caused by ovarian haemorrhage due to TVOR were recorded out of 18 studies reviewed. Out of these 43 cases, only 1 case was treated with unilateral ovariectomy with suturing and electrocoagulation being the most common treatment options.⁴ In the case of ovarian haemorrhage and acute life-threatening bleeding, and when the contralateral ovary appears normal, oophorectomy can be justified given the greater risk and little benefit to leaving the ovary in place. Our case adds to the literature on complications following oocyte retrieval and respective management. Recognition of haemoperitoneum from ovarian source as a possible cause of pain and distension following oocyte retrieval may allow for timely diagnosis and intervention.

Learning points.

• Complications following oocyte retrieval are very rare but can have life-threatening consequences if not promptly addressed.

• Same-day follow-up is recommended, and clear precautions and warning signs that would warrant presentation to the emergency department should be reviewed with the patient after oocyte retrieval.

• When haemoperitoneum is suspected, immediate surgical intervention is necessary to address the source of bleeding.

• Ovarian rupture is a very rare complication and may necessitate oophorectomy if retrieval of healthy ovarian tissue is not possible.

Ethics statements

Patient consent for publication

Obtained.