Stanford University Medical Center, Department of Obstetrics and Gynecology, 300 Pasteur Drive, HH333, Stanford CA 94305, USA
1 To whom correspondence should be addressed: e-mail: milki4{at}aol.com
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Abstract |
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Key words: exercise/gonadotrophin stimulation/laparoscopy/ovarian torsion
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Introduction |
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Case report |
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Discussion |
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Sudden body movements have been reported as risk factors for adnexal torsion (Provost 1972; Hibbard, 1985
; Droegemuller et al., 1997
). While it is not uncommon for infertility patients to use exercise as a way to relax and reduce stress, patients undergoing gonadotrophin stimulation are often instructed to forego exercise or strenuous activity during the cycle, as enlarged ovaries are more prone to torsion. A significant proportion of patients who fail gonadotrophin stimulation take a break before undergoing a repeat cycle, either by choice or due to persistent cysts. These women typically resume normal activities, which often include exercise during this drug-free cycle. Patients who plan an immediate repeat cycle typically undergo a baseline ultrasound which may reveal one or more persistent cysts and potentially lead to deferring their subsequent cycle, similar to the present case. Based on our report, it is important to warn patients against exercise if a persistent cyst is found. It also may be necessary to caution patients who are not planning back-to-back cycles against exercise in the month following gonadotrophin therapy, or at least to confirm ovarian regression to normal by performing a baseline ultrasound prior to allowing them to resume normal activities.
The diagnosis of ovarian torsion in this patient was not made until 2 weeks after her initial presentation to a healthcare provider. By the time of surgery, >80% of her left ovary was considered to be necrotic and therefore was removed. Conservative management of ovarian torsion by untwisting the apparently ischaemic ovary can lead to return of viability and function if performed promptly (Descargues et al., 2001). Laparoscopic unwinding of the adnexum with returned viability has been described by several authors as early as the 1980s (Manhes et al., 1984
; Vancaille and Schmidt, 1987
; Ben-Rafael et al., 1990
). They also showed that there is a return of normal appearance and function by performing long-term follow-up of patients who have undergone laparoscopic detorsion of what appeared to be a non-viable ovary. Therefore, it is possible that earlier diagnosis of our patients condition would have allowed for more conservative management.
In conclusion, this report suggests that the risk of ovarian torsion persists beyond the treatment cycle and that patients should be instructed to limit strenuous activity if regression to normal ovarian size has not been documented. Furthermore, healthcare providers should have a low threshold for including ovarian torsion in the differential diagnosis of abdominal pain following a gonadotrophin cycle.
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References |
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Droegemueller, W., Herbst, A.L., Stenchever, M.A. and Mishell, D.R. (1997) Comprehensive Gynecology. 3rd edn, Mosby Publishing Co. p. 507.
Hibbard, L.T. (1985) Adnexal Torsion. Am. J. Obstet. Gynecol., 152, 456462.[ISI][Medline]
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Manhes, H., Canis, M., Mage, G., Pouly, J.L. and Bruhat, M.A. (1984) Laparoscopy in the diagnosis and treatment of adnexal torsion. J. Gynecol. Obstet. Biol. Reprod., 13, 825829.[Medline]
Mashiach, S., Goldenberg, M., Bider, D., Ben-Rafael, Z. and Moran, O. (1990) Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil. Steril., 53, 7680.[ISI][Medline]
Pinto, A.B., Ratts, V.S., Williams, D.B., Keller, S.L. and Odem, R.R. (2001) Reduction of ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries. Fertil. Steril., 76, 403406.[CrossRef][ISI][Medline]
Provost, R.W. (1972) Torsion of the normal fallopian tube. Obstet. Gynecol., 53, 8082.
Vancaille, T. and Schmidt, E. (1987) Recovery of ovarian function after laparoscopic treatment of acute adnexal torsion; a case report. J. Reprod. Med., 32, 561562.[ISI][Medline]
Submitted on February 17, 2003; accepted on May 7, 2003.