Infertility and chylous ascites? A case report

Abstract

Introduction

Chylous ascites is defined by an accumulation of chylous fluid in the peritoneal cavity and it clinically appears as a milky fluid in which laboratory examination reveals triglycerides, cholesterol, and sometimes chylomicrons and lymphocytes.

Presentation of case

We report the first case of primary chylous ascites observed during laparoscopy for unexplained secondary infertility.

Discussion

Chylous ascites has never been linked to fertility but bathes all internal reproductive organs surfaces and is considered a communication mean between ovaries.

Conclusion

Despite a lack of evidence, the question of peritoneal fluid role remains in infertility.

1. Introduction

Chylous ascites is defined by an accumulation of chylous fluid in the peritoneal cavity. It clinically appears as a milky fluid in which laboratory examination reveals triglycerides (above 200 mg/dL), cholesterol, and sometimes chylomicrons and lymphocytes.¹ Clinical features are unspecific. Primary chylous ascites are a quite rare event. However, secondary chylous ascites are usually caused by different pathologies such as: neoplasia with lymphatic system obstruction (lymphoma, pancreatic, ovarian or stomach cancer, carcinoid tumor, …), lymphatic fistula (after trauma or surgery), inflammatory and infectious diseases, including tuberculosis. It can also be congenital in case of lymphangiomatosis, primary lymphatic hypoplasia or intestinal lymphangiectasy.²

Systematic laparoscopic assessment of infertility is still debated.^3,4 Concerning its practice in the assessment of secondary infertility, some authors have found an interest. Thus Hovav et al., in a retrospective study, including secondary infertile patients without previous risk factors, such as abdomino-pelvic surgery or pelvic infectious disease, reported 40% of abnormal laparoscopic findings.⁵ The observations of Kahyaoglu et al. are in line with the latter.⁶ We report the first case of unexplained secondary infertility related to primary chylous ascites.

2. Presentation of case

A 35-year-old woman was referred to our institution for secondary infertility for seven years. This patient had no particular surgical or medical history excepted an anal fissure repair. Her obstetrical history with a previous partner was marked by a surgical abortion and a cesarean section with a healthy offspring. Hormonal assessment and ultrasound ovarian antral follicle count were considered normal. Spontaneous ovulation occurred and her Chlamydia Trachomatis serology was negative. Pelvic ultrasound examination showed a fibromatous uterus (with 3 subserosal leiomyoma less than 40 mm in size without endometrial distortion) and no adnexal mass. Hysterosalpingography showed two patent Fallopian tubes. Diagnostic hysteroscopy did not reveal any intrauterine pathology, and endometrium was in line with menstrual cycle. Partner's semen parameters were normal, according to the WHO classification.

After multidisciplinary discussion, diagnostic laparoscopy was carried out. It revealed a slightly profuse presence of milky fluid in the peritoneal cavity referring to chylous or infectious aetiology (Fig. 1). There were no abdominal mass nor false membranes. An interstitial and subserosal posterior myoma (40 mm) was observed on a hyperaemic uterus (Fig. 2). Appendix was normal (Fig. 3). Fallopian tubes were inflammatory and ovaries seemed normal (Fig. 2). Uterine horns were not nodular. Utero-vesical and Douglas pouches were free of adhesions.

Fig. 1.

Milky peritoneal fluid.

Fig. 2.

Hyperhaemia of the posterior uterine wall and the right Fallopian tube.

Fig. 3.

Normal appendix.

Firstly, peritoneal fluid samplings were made for cytologic, bacteriological (with mycobacteria research) and biochemical analysis. Laparoscopic dye test showed a patent right Fallopian tube and proximal obstruction of the left fallopian tube. Peritoneal washing was done, and an endometrial biopsy was sent to histopoathologic and bacteriological examination. Post-operative antibiotherapy (ofloxacin and amoxicillin-clavulanic acid association) was started.

The results of the various samplings were as follow:

• -bacteriological tests remained negative, including mycobacteria research;
• -histopathological analysis did not show any endometrial infection and peritoneal fluid contained lymphocytes, without any malignant cells;
• -Triglyceride and cholesterol levels are 5 mmol/L (320 mg/dL) and 36 mmol/L, respectively.

There was no systemic inflammatory syndrome with haemoglobin blood level 12.1 g/dL, leucocytes 6500/mm³ and platelets 270,000/mm³. C Reactive Protein was not increased.

Postoperative recovery was uneventful and the patient was discharged two days after surgery. One month later, clinical examination was normal without symptoms. Due to unexpected discovery of this chylous ascites and the absence of symptomatology, no complementary exams were proposed to the patient and she is now planned for In Vitro Fertilization.

3. Discussion

We report the first case of primary chylous ascites discovered fortunately during laparoscopy performed as part of secondary infertility investigation. Various hypotheses exist concerning the role of peritoneal fluid in fertility. Peritoneal fluid bathes all internal reproductive organs surfaces and is considered a communication mean between ovaries.⁷

Hunter et al. including female mammals noted the relatively high concentrations of diverse hormones in peritoneal fluid. Therefore, the spectrum of sex steroids could influence uterine tissues in a local manner.⁷ Reactive oxygen species may also have a role in fertility, especially in patients with endometriosis. Indeed, chronic inflammation has been associated with increased oxidative stress, especially in infertile patients with endometriosis.⁸ In mice, Ngô et al., showed that antioxidant molecules reduced endometriotic cells proliferation.⁹

4. Conclusion

However, the role of chylous ascites compounds remains unexplained in our case. We observed hyperaemia and inflammation of the uterus and Fallopian tubes during laparoscopy that could explain unilateral tubal patency without any infectious or inflammatory disease.

Unexpected discovery of primary chylous ascites during diagnostic laparoscopy for secondary infertility reinforce the suspected role of peritoneal fluid in fertility. Chylous ascites compounds could explain reactive oxygen species production leading to tubal motility alterations, spermatozoa transport, oocyte fecundation and/or embryo implantation.

Conflict of interest statement

This work did not benefit from external funding and there's no conflict of interests.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Contributors

This case report was prepared jointly and agreed by the authors. Contributions to the report and related work by the authors are equivalent.