A rare case report of persistent megalocystic ovaries with
adenomyosis years after ovarian stimulation

V S Thrupthi¹, Indira H^2*, Girish B L³

¹ Post Graduate, ² Professor and Head, ³ Professor, Department of Obstetrics & Gynaecology
Sri Siddhartha Medical College, SSAHE Tumkur
Karnataka India

* Corresponding author

Abstract
Background: Ovarian hyperstimulation syndrome (OHSS) is an excessive response to controlled ovarian hyperstimulation during treatment cycles(ovulation induction)which is used for assisted reproduction technology (ART). Ovarian torsion, 5thcommon emergency in gynaecology, is described as the partial or complete rotation of the ovarian vascular pedicle. Ovarian enlargement followed by IVF is generally bilateral, but torsion need not occur on both sides. Case presentation: A 37 year-old nulliparous presented to our hospital with pain abdomen. She had a history of laparoscopic myomectomy and puncture of para ovarian cysts 4 years back . She had 2 failed IVF cycles 6 years back. On Bimanual examination uterus corresponds to 24 weeks size. On ultrasound examination, uterus measuring 138x109x122mm with multiple intramural fibroids largest measuring 82x67mm in posterior wall with left complex cyst of size 82x64mm with right simple cyst of size 30x28mm. MRI showed adenomyosis with fibroids with enlarged bilateral ovaries with large well defined cysts and mild free fluid in Pouch of douglas. Her CA 125 is 146.7 U/ml. She has been counselled for surgery and intraoperative findings are uterus size of 24 weeks with bilateral pyosalpinx with megalocystic ovaries of size 7x6 cms (right ovary) and 8x6cms(left ovary).Specimen sent for HPE ,report showed adenomyosis with multiple leiomyomas ,chronic cervicitis, Luteoma with chronic oophoritis and torsion of right ovary, Theca lutein cyst with chronic oopharitis and torsion of left ovary, chronic salpingitis with areas of hemorrhage and congested blood vessels.
Keywords: OHSS, Luteoma, megalocystic ovaries, HCG, Thecalutein cyst.
Introduction
Ovarian enlargement after hyperstimulation is common,particularly for PCOS with enlarged ovaries at baseline. As per Rotterdam criteria, PCOS is defined as enlarged ovary with a follicle number of ≥12 per ovary and/or an ovarian stromal volume of > 10 mL in at least one ovary.[1] During ovulation Induction,multiple small follicles grow under hormone stimulation and hCG continuously stimulate the ovaries to grow. Many cases of ovarian enlargement with multiple follicular and lutein cysts perseveres for a longer period. There are so many other benign or malignant tumors that need to be taken into account, such as hyperreactio luteinalis, teratoma, theca lutein cysts, mucinous cystadenoma, endometriosis cyst and others.[2] However, these cases of persistent megalocystic ovaries existing for a long time after IVF are reported rarely, and the possible mechanism is not known. Ovarian torsion, 5th common emergency in gynecology, is defined as the partial or complete rotation of the ovarian vascular pedicle. It is not so common for an ovary of normal size to become twisted, but the ovaries that are enlarged are prone to torsion. The incidence of ovarian torsion following IVF treatment is rare, ranging from 0.08 to 0.13%.[3] Ovarian enlargement followed by IVF is usually bilateral, but torsion need not occur on both sides.Suffering the loss of ovary due to a late diagnosis in an infertile woman is the worst consequence.[4]
Case report
We present a 37 year patient with persistent bilateral megalocystic ovaries with adenomyosis with multiple intramural fibroids with bilateral pyosalpinx following 2 failed cycles of in vitro fertilization which was detected during surgery. A 37 year-old nulliparous presented to our hospital with pain abdomen. She had a history of laparoscopic myomectomy and puncture of para ovarian cysts 4 years back . Her history showed that she had infertility for 6 years and had 2 failed cycles of IVF. On Bimanual examination uterus corresponds to 24 weeks size. On ultrasound examination, uterus measuring 138x109x122mm with multiple intramural fibroids largest measuring 82x67mm in posterior wall with left complex cyst of size 82x64mm with right simple cyst of size 30x28mm. MRI showed adenomyosis with fibroids with enlarged bilateral ovaries with large well defined cysts and mild free fluid in Pouch of douglas. Her CA 125 is 146.7 U/ml. She has been counselled for surgery and the intraoperative findings are uterus size of 24 weeks (Figure 1) with bilateral pyosalpinx with megalocystic ovaries (Figure 2) of size 7x6 cms (right ovary) and 8x6 cms (left ovary) (Figure 3). Specimen sent for histopathological examination and the report showed adenomyosis with multiple leiomyomas, chronic cervicitis, luteoma with chronic oophoritis and torsion of right ovary, theca lutein cyst with chronic oopharitis and torsion of left ovary, chronic salpingitis with areas of hemorrhage and congested blood vessels.
  
Figure 1: Bulky uterus with megalocystic ovaries            Figure 2: Cut-section of uterus showing
                                                                                                            adenomyosis

Figure 3: Megalocystic ovary
Discussion
OHSS continues to be a serious complication of assisted reproductive therapy (ART). There are well-known risk factors that must be considered during the administration of medications to treat infertility. Ovarian enlargement secondary to hyperstimulation is common. Human chorionic gonadotropin (hCG) stimulates the ovaries to continue to grow. If no pregnancy occurs, the syndrome will typically resolve within 1 week. This is a rare case of megalocystic ovaries persisting even after 6 years of IVF cycles.
Conclusion
With the increasing use of gonadotropins in the management of infertility, ovarian enlargement secondary to hyperstimulation which persists for years causing significant gynaecological morbidity.
Acknowledgement: NIL
Financial support and sponsorship: NIL
Conflict of interest: NIL
References
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Address for correspondence:
Dr. H. Indira, Professor & HOD, Department of Obstetrics & Gynaecology, Sri Siddhartha Medical College, SSAHE Tumkur Karnataka India. Email: drindirah@gmail.com