Adnexal torsion comprises 2.7% of all gynecological emergencies1 presenting with acute abdominal pain in patients of reproductive age. Ultrasonography with Doppler imaging may prove useful in the diagnosis2,4.
We report a case of adnexal torsion two hours after embryo transfer in a 28 years old female with primary infertility who conceived even after extensive laparoscopic surgery.
28-year-old female, with primary infertility was taken for IVF on antagonist protocol with 150 IU Gonal 'F'. 16 eggs were retrieved on 17th June 2012.
She underwent day 3 Embryo transfer on 20th June 2012. Two grade A embryos of 8 cells were transferred.
Patient had severe abdominal pain 1 hour after embryo transfer. She also had vomiting, syncope and giddiness.
Pain was not relieved with analgesics. Emergency Color Doppler-USG was done which revealed haemoperitoneum with enlarged hemorrhagic right adnexa with torsion.
Patient was taken for emergency operative laparoscopy.
Anesthesia time to be kept to minimum.
No intrauterine manipulation done.
Avoiding Trendelenburg position.
Minimal handling of uterus.
Intra-operative findings :
On laparoscopy, there was gross haemoperitoneum. Left ovary was enlarged due to stimulation but normal. Right ovary was enlarged about 12-15 cm, fragile, hemorrhagic and had undergone torsion (Fig 1) and was bleeding from multiple sites.
Untwisting of torsion was attempted, but ovary was very fragile and also hemostasis could not be achieved with techniques like cautery or local coagulants hence decision for right oophorectomy was taken. The mass was retrieved out by morcellation in endobag. (Fig. 2)
Throughout the procedure, the uterine handling was avoided even while cleaning the pouch of Douglas. Careful and thorough irrigation and lavage of the entire pelvic and abdominal cavity was done. Hemostasis confirmed (Fig 3).
Postoperatively, patient was put on antibiotics, analgesics and luteal phase support with estrogen and progesterones.
She was stable on discharge.
On 16th postoperative day the Beta-HCG values were 832. She continued to take luteal phase supports.
On 30th post-operative day Ultrasonography was done which revealed fetal pole with cardiac activity.
Adnexal torsion can occur after ovarian stimulation for IVF 5,6.
Ultrasonography remains an important primary modality in evaluation apart from clinical picture.
If diagnosed early, before necrosis sets in, detorsion and conservation of adnexa is possible. In this case, though diagnosed immediately, could not save adnexa, as was enlarged due to stimulation, fragile and was bleeding from multiple sites due to rupture of multiple follicles.
Dialogue of good embryo and healthy endometrium: This case clearly shows that if the embryo is good quality and the endometrium well prepared in spite of an intervention immediately post transfer implantation can be achieved.
Laparoscopy gives upper hand in reducing uterine handling and reducing the operative time: This case exemplifies how endoscopy goes hand in hand with infertility as without laparoscopic surgery neither the operative time could have been reduced nor could we have managed to avoid uterine handling which was so important in the end to get the desired implantation.