Spontaneous ovarian hyperstimulation syndrome and hyperreactio luteinalis are entities in continuum

O-RADS Ultrasound Version 1: A Scenario-Based Review of Implementation Challenges

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk stratification and management system was first published by the American College of Radiology in 2020. It provides standardized terminology for evaluation of ovarian and adnexal masses, aids risk stratification, and provides management guidelines for different categories of lesions. This system has been validated by subsequent research and found to be a useful diagnostic and management tool. However, as noted in the system's governing concepts, in some clinical scenarios, such as patients with acute symptoms or with a history of ovarian malignancy, O-RADS US does not apply, or the system's standard management may be adjusted. Additional scenarios, such as an adnexal mass in pregnancy, present challenges in the application of O-RADS US to assist diagnosis and management. The purpose of this article is to highlight 10 clinical scenarios in which O-RADS US version 1 may not apply, may be difficult to apply, or may require modified management. Additional scenarios in which O-RADS US can be appropriately applied are also described.

Maternal complications of fetal triploidy: a case report

A 32-year-old woman underwent a medical termination in the second trimester of a spontaneously conceived triploid pregnancy after developing early-onset preeclampsia with subsequent haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Placental histology was normal (non-molar) and unusually, she developed ovarian hyperstimulation syndrome (OHSS) 4 weeks later. She was managed conservatively following multidisciplinary team input to exclude malignant pathology. The rarity of late-onset spontaneous OHSS could have resulted in inappropriate surgical management. In the absence of supportive treatment there is also a risk of the condition progressing to a critical stage. Follow-up ultrasonography after termination of pregnancy should be considered for women with evidence of ovarian hyperstimulation, particularly if other risk factors for OHSS are present. Delayed-onset OHSS should be considered in women presenting with bilateral cystic ovarian enlargement after triploid pregnancy.

Testosterone serum levels are not predictive of maternal virilization in hyperreactio luteinalis

Background

Elevated concentrations of circulating testosterone are present in hyperreactio luteinalis (HL), a pregnancy-specific, self-limited condition. HL is associated with maternal virilization in about 30% of cases. The correlation between testosterone levels and maternal virilization has not yet been quantified. Our aim was to identify a testosterone cut-off level which may allow to predict maternal virilization.

Methods

A literature research was performed. Publications were chosen if serum testosterone concentrations and presence or absence of maternal virilization was mentioned. Additionally, we report serial levels of steroids analyzed by Liquid chromatography–tandem mass spectrometry (LC–MS/MS) in one case of HL managed at our institution.

Results

In all, 31 cases fulfilled the search criteria. We found significant overlap between testosterone levels in asymptomatic women and women with signs of virilization (range 6.2–37.3 nmol/l and 13.7–197.5 nmol/l, respectively). The method applied for testosterone analysis was mentioned in three reports only. Peak serum testosterone concentration in our case was 120.3 nmol/l.

Conclusion

From the available data, maternal virilization in HL cannot be predicted by the level of circulating testosterone. However, comparability of results is hampered by the analytical methods applied. LC–MS/MS should preferably be used for reporting concentrations of circulating testosterone.

Hyperreactio luteinalis mimicking malignancy during pregnancy with elevated CA-125

OBJECTIVE

To report a case with benign bilateral ovarian tumor during pregnancy mimicking malignancy.

CASE REPORT

A 32-year-old women at 20 weeks gestation with large bilateral adnexal masses found on prenatal ultrasound. The cysts had been growing gradually over the course of the pregnancy. MRI show huge multiple cysts in both ovaries. CA-125 was elevated at 260 U/mL. Due to initial impression was malignancy, an excisional surgery was done. Pathology revealed multiple luteinized granulosa cells with benign nature.

CONCLUSION

Hyperreactio luteinalis (HL) is often asymptomatic and discovered incidentally on ultrasound or at the time of cesarean section. As the lesions are self-resolving, management is conservative and surgical intervention is required only in cases with severe complications. HL can be mistaken for malignancy, especially in cases in which the tumor marker CA-125 is elevated, leading to inadvertent surgery.

Persistent megalocystic ovaries after ovarian hyperstimulation syndrome in a postpartum patient with polycystic ovarian syndrome: a case report

Background

Ovary enlargement is common in controlled ovarian stimulation, which could continue several months during a successful pregnancy. However, persistent megalocystic ovaries 3 years after ovarian hyperstimulation syndrome (OHSS) were rare. Here we will present you the case and treatment as well as discuss the probable etiology.

Case presentation

A 34-year-old woman with polycystic ovarian syndrome (PCOS) and a history of infertility presented to the Department of Obstetrics and Gynecology at Peking Union Medical College Hospital with abdominal pain and persistently enlarged ovaries 36 months after OHSS. Enlarged ovaries were evaluated with ultrasonography and serum tests. Diagnostic laparoscopic surgery with detorsion and drainage followed by GnRHa treatment was performed. Symptoms and ovarian size evaluated by vaginal ultrasound were the main outcome measures. The patient was discharged from the hospital 5 days after surgery without any remarkable complications. Both ovaries recovered to almost normal after a monthly injection of GnRHa for 3 months.

Conclusions

Ovarian enlargement may persist for a long time in patients with severe OHSS even after sex hormone levels and ovarian functions return to normal. Long term follow-up is necessary and ovarian torsion should be suspected when accompanied by abdominal pain. Acupuncture plus GnRHa treatment may be an effective way for these cases.

Ovarian hyperstimulation syndrome in a spontaneous singleton pregnancy

The ovarian hyperstimulation syndrome is the combination of increased ovarian volume, due to the presence of multiple cysts and vascular hyperpermeability, with subsequent hypovolemia and hemoconcentration. We report a case of spontaneous syndrome in a singleton pregnancy. This was a spontaneous pregnancy with 12 weeks of gestational age. The pregnancy was uneventful until 11 weeks of gestational age. After that, the pregnant woman complained of progressive abdominal distention associated with abdominal discomfort. She did not report other symptoms. In the first trimester, a routine ultrasonography showed enlarged ovaries, multiples cysts and ascites. Upon admission, the patient was hemodynamically stable, her serum β-hCG was 24,487mIU/mL, thyroid-stimulating hormone was 2.2µUI/mL and free T4 was 1.8ng/dL. All results were within normal parameters. However, levels of estradiol were high (10,562pg/mL). During hospitalization, she received albumin, furosemide and prophylactic dose of enoxaparin. The patient was discharged on the sixth hospital day.

Hyperreactio luteinalis encountered during caesarean delivery of an uncomplicated spontaneous singleton pregnancy

We report a rare case of hyperreactio luteinalis presenting as an incidental finding during caesarean section in an uncomplicated spontaneous singleton pregnancy. Caesarean section was performed due to failure to progress in labour, and delivered a healthy male neonate. The mother's analytical tests revealed a hyperandrogenic state without any other relevant alterations. Ovarian volume and testosterone serum concentration normalised in 2 months. The expectant management of this case permitted conservation of both ovaries in a young woman without adding morbidity.

Androgens in pregnancy: roles in parturition

BACKGROUND

Understanding the physiology of pregnancy enables effective management of pregnancy complications that could otherwise be life threatening for both mother and fetus. A functional uterus (i) retains the fetus in utero during pregnancy without initiating stretch-induced contractions and (ii) is able to dilate the cervix and contract the myometrium at term to deliver the fetus. The onset of labour is associated with successful cervical remodelling and contraction of myometrium, arising from concomitant activation of uterine immune and endocrine systems. A large body of evidence suggests that actions of local steroid hormones may drive changes occurring in the uterine microenvironment at term. Although there have been a number of studies considering the potential role(s) played by progesterone and estrogen at the time of parturition, the bio-availability and effects of androgens during pregnancy have received less scrutiny. The aim of this review is to highlight potential roles of androgens in the biology of pregnancy and parturition.

METHODS

A review of published literature was performed to address (i) androgen concentrations, including biosynthesis and clearance, in maternal and fetal compartments throughout gestation, (ii) associations of androgen concentrations with adverse pregnancy outcomes, (iii) the role of androgens in the physiology of cervical remodelling and finally (iv) the role of androgens in the physiology of myometrial function including any impact on contractility.

RESULTS

Some, but not all, androgens increase throughout gestation in maternal circulation. The effects of this increase are not fully understood; however, evidence suggests that increased androgens might regulate key processes during pregnancy and parturition. For example, androgens are believed to be critical for cervical remodelling at term, in particular cervical ripening, via regulation of cervical collagen fibril organization. Additionally, a number of studies highlight potential roles for androgens in myometrial relaxation via non-genomic, AR-independent pathways critical for the pregnancy reaching term. Understanding of the molecular events leading to myometrial relaxation is an important step towards development of novel targeted tocolytic drugs.

CONCLUSIONS

The increase in androgen levels throughout gestation is likely to be important for establishment and maintenance of pregnancy and initiation of parturition. Further investigation of the underlying mechanisms of androgen action on cervical remodelling and myometrial contractility is needed. The insights gained may facilitate the development of new therapeutic approaches to manage pregnancy complications such as preterm birth.

Late presentation of hyperandrogenism in pregnancy: clinical features and differential diagnosis

Background

Hyperandrogenic states in pregnancy are rare but arise most commonly due to new-onset ovarian pathology in pregnancy. We describe the case of a young woman who presented in the latter half of her pregnancy with features of hyperandrogenism. We review the biochemical and imaging findings and discuss the differential diagnosis.

Case presentation

A 26-year-old woman presented in the later part of her pregnancy with widespread hirsutism. Biochemical testing confirmed hyperandrogenism (testosterone, 13.7 nmol/l and second-trimester pregnancy range, 0.9–4.9 nmol/l), although she had no history of menstrual disturbance, hirsutism or acne prior to conception. Radiological evaluation (ultrasound and magnetic resonance imaging) revealed multiple cystic lesions in both ovaries, leading to a presumptive diagnosis of hyperreactio luteinalis (HL). The implications of maternal hyperandrogenism on foetal virilisation were considered and the patient was counselled appropriately. She delivered a healthy baby boy uneventfully. Androgen levels, hirsutism and acne normalised within a few weeks of delivery.

Conclusion

HL can occur at any stage of pregnancy and is an important differential diagnosis in pregnant patients with features of androgen excess. Most cases regress spontaneously after delivery and major interventions are usually not needed.

Learning points

Hyperandrogenism in pregnancy is rare.

Clinical features are similar to the non-pregnant state in the mother but virilisation in the foetus can have profound consequences.

HL and pregnancy luteoma are the most common ovarian pathologies leading to hyperandrogenism in pregnancy.

Spontaneous regression occurs in the post-partum period in the vast majority of cases and surgery is only required for local complications.

Successful pregnancy complicated by spontaneous, familial, recurrent ovarian hyperstimulation syndrome: report of two cases

We here report two cases of spontaneous, familial, recurrent ovarian hyperstimulation syndrome ended in a successful pregnancy. First case was a 26-year-old woman, gravida 3 para 0 and two previous terminations of pregnancy due to spontaneous ovarian hyperstimulation syndrome (OHSS). During her pregnancy, patient was treated with IV fluid therapy, albumin and thromboembolic prophylaxis and required pleural and peritoneal drainage. She was referred to the hospital twice, at 8 and 28 weeks'. At 32 weeks due to worsening of clinical condition, decision was made for a caesarean section. A live, healthy preterm baby of 1950 g was delivered. Second case was a 27-year-old woman, gravida 2 para 0 with one previous termination of pregnancy due to spontaneous OHSS. During her pregnancy patient was treated with IV fluid therapy, albumin, and thromboembolic prophylaxis. She did not require any pleural or peritoneal drainage. She was referred to the hospital twice, at 8 and 30 weeks. At 37 weeks of gestation, due to worsening of clinical condition decision for a caesarean section was made. A live, healthy term baby of 2700 g was delivered. Our experience seems to confirm that management of spontaneous OHSS during pregnancy should be conservative and treatment tailored to severity of symptoms.

Hyperreactio luteinalis (enlarged ovaries) during the second and third trimesters of pregnancy: common clinical associations

The objective of this series was to assess sonographic and clinical findings in patients with hyperreactio luteinalis (HL; enlarged ovaries). We retrospectively identified 31 patients with HL and collected data including gestational age, maximum ovarian size, and pregnancy outcomes. Hyperreactio luteinalis was detected at a mean gestational age of 21.6 weeks, reaching average maximum ovarian volumes of 417 and 359 mL on the right and left, respectively. After the first trimester, HL appears to be associated with multiple gestations, twin-twin transfusion syndrome, gestational trophoblastic disease, and Beckwith-Wiedemann syndrome. When HL is present, maternal complications such as preeclampsia are common, and preterm delivery often results.

Ovarian cyst regression with levothyroxine in ovarian hyperstimulation syndrome associated with hypothyroidism

BACKGROUND

Spontaneous ovarian hyperstimulation syndrome (sOHSS) can occur following hypothyroidism. Ultrasonography facilitates diagnosis and monitoring of this syndrome. We describe ovarian sonographic changes in a hypothyroid patient with sOHSS after treatment with levothyroxine (l-T4).

CASE PRESENTATION

A 15-year-old girl presented with abdominal pain and distension for a few months. On examination, she had classical features of hypothyroidism. Abdominal and pelvic ultrasound revealed enlarged ovaries with multiple thin-walled cysts and mild ascitic fluid. On follow-up, abdominal ultrasound showed significant reduction of ovary size after 6 weeks of initiation of l-T4. Normal ovary size with complete regression of ovarian cysts was seen after 4 months.

CONCLUSION

Serial ultrasound in sOHSS associated with hypothyroidism showed regression of ovarian cysts and ovarian volume after 4 months whereas in other studies, it is reported to happen in various durations, presumably according to its etiology.

LEARNING POINTS

OHSS can rarely occur due to hypothyroidism.This type of OHSS can be simply treated by l-T4 replacement, rather than conservative management or surgery in severe cases.Ultrasound follow-up shows significant regression of ovarian size and cysts within 6 weeks of initiation of l-T4.Ultrasound follow-up shows normal ovarian size with complete resolution of ovarian cysts 4 months after treatment.

Spontaneous ovarian hyperstimulation syndrome: case report, pathophysiological classification and diagnostic algorithm

Spontaneous ovarian hyperstimulation syndrome is an extremely rare condition that occurs in the absence of ovarian hyperstimulation treatment. It can lead to significant morbidity and mortality, and therefore early diagnosis and supportive treatment are essential. We report an affected mother and her daughter with a previously reported heterozygous activating mutation in the FSHR gene. We performed a literature review with particular regard to pathogenesis, with a view to suggesting a pathophysiological classification system and a diagnostic algorithm to assist in the management of this rare condition.

Hyperreactio luteinalis in a spontaneously conceived pregnancy associated with polycystic ovarian syndrome and high levels of human chorionic gonadotropin

Aim: To report a case of hyperreactio luteinalis in a spontaneously conceived pregnancy.

Patient: A 29-year-old primigravida presenting with painful multicystic ovarian lesions.

Methods: Laparotomy and reconstruction of the ovaries.

Main outcome measures: Successful pregnancy and delivery of a 3650 g female infant at 39 weeks, without any abnormalities.

Results: Highly elevated human chorionic gonadotropin, estradiol, progesterone, testosterone, and free testosterone levels were observed. Ultrasound revealed bilaterally enlarged multicystic ovaries with several cysts of up to 9 cm in diameter.

Conclusions: In this case, laparotomy appeared to be an appropriate therapy to prevent further suffering in the mother without doing harm to the fetus.

Case report: a most peculiar family with spontaneous, recurrent ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) mostly occurs as a complication of induction of ovulation. However, rarely, it may occur spontaneously at the beginning of a natural pregnancy and in the absence of any assisted reproductive treatment. Spontaneous OHSS has been reported in pregnant women affected by hypothyroidism, polycystic ovary syndrome, gonadotropin-producing pituitary adenoma, but also in normal pregnancies. The aetiology of this condition is still unclear. We hereby report on a case of spontaneous, familial, recurrent OHSS in a 26-year-old primipara whose first-degree cousin, paternal grandmother and a number of other members of her father's family had suffered from a similar condition. This case seems to support the concept of a genetic predisposition for spontaneous OHSS thereby suggesting the need for preventive and therapeutic strategies.

Bilateral megalocystic ovaries following in vitro fertilization detected during cesarean section: a case presentation

We present a patient with persistent bilateral megalocystic ovaries following in vitro fertilization which was detected during cesarean section. A 24 year-old primigravida presented to our clinic at the 36(th) week of a twin pregnancy with labour pain and cervical dilatation. On ultrasound examination, 2 masses of 90×60 and 60×70 mm were seen in the right and left adnexal regions respectively. Her history showed that she had unexplained infertility for 4 years and had undergone IVF with gonadotropin releasing hormone (GnRH)-agonist stimulation. Two embryos were transferred. Twin pregnancy was detected on ultrasound examination. The patient was delivered by emergency caesarean section due to transverse presentations at 36(th) weeks of gestation. During the operation, both adnexae were markedly enlarged, the right ovary measuring about 15×18 cm and the left about 16×18 cm. There was minimal ascites in the abdominal cavity. Ovarian biopsy was performed and the final pathology report showed bilateral follicle cysts. The patient was discharged on the postoperative 4(th) day. The patient was seen 4 weeks later. She had no complaints and ultrasound follow-up revealed a normal size uterus and ovaries. We should keep in mind that hyperstimulated, enlarged ovaries and its complication may be seen in the late weeks of pregnancy, even at term, in cases of in vitro fertilization cases. Therefore, close follow-up of pregnant IVF patints is recommended whether they had OHSS or not, because ovarian torsion caused by hyperstimulated ovaries may be difficult to diagnose during pregnancy.

Conservative management of hyperreactio luteinalis: a case report

Hyperreactio luteinalis (HL) is characterized by bilaterally enlarged ovaries containing multiple self-limited theca lutein cysts and is usually associated with increased production of human chorionic gonadotropin in the presence of trophoblastic disease or multiple pregnancies. About 30 cases of HL have been reported in patients with normal singleton pregnancies, and most of these patients required surgical intervention during their first pregnancy because of ovarian torsion or to rule out of ovarian malignancy. However, the accurate diagnosis of HL by means of laboratory tests and magnetic resonance imaging and the exclusion of ovarian malignancy in asymptomatic pregnant woman may avoid unnecessary surgical intervention or termination of pregnancy. The present report describes case of HL in a woman with a normal singleton pregnancy in whom conservative management allowed the preservation of both ovaries.

Management of ovarian disease in pregnancy

The ovary is a complex structure that is responsible for maintaining the endocrine support for a pregnancy during the first trimester until the placenta is sufficiently developed to assume this role. Most ovarian disorders of pregnancy actually relate to pre-existing ovarian conditions such as polycystic ovary syndrome and premature ovarian insufficiency. Both of these are associated with increased complications in pregnancy and require careful monitoring. Ovarian disorders that are a particular consequence of the hormonal milieu of pregnancy such as pregnancy luteoma (PL) and hyperreactio luteinalis (HL) are rare. However, they have important implications for both the mother and the foetus since they can be confused with ovarian malignancy leading to unnecessary surgery. This review focuses on the salient aspects of management of these ovarian conditions during pregnancy.

Hyperreactio luteinalis in pregnancy

OBJECTIVE

To report a case of hyperreactio luteinalis diagnosed in pregnancy.

DESIGN

Case report.

SETTING

Teaching hospital.

PATIENT(S)

A 30-year-old primigravida presenting with painful multicystic ovarian enlargement and subsequent virilizing features.

INTERVENTION(S)

Conservative management.

MAIN OUTCOME MEASURE(S)

Successful pregnancy resulting in the live birth of a female infant with no gross abnormalities.

RESULT(S)

On investigation, she developed elevated serum androgen levels and had sonographically the characteristic "spoke wheel" appearance of hyperreactio luteinalis. The patient was managed symptomatically with normal outcomes and a return postnatally to before pregnancy features.

CONCLUSION(S)

An uncommon clinical presentation in obstetrics in which conservative management can result in good outcomes.

Two different entities of spontaneous ovarian hyperstimulation in a woman with FSH receptor mutation

Spontaneous ovarian hyperstimulation syndrome (OHSS) is an extremely rare event. Normally OHSS is seen in the context of IVF. In 2003 a mutation of the FSH receptor (FSHR D567N) was identified for the first time as a cause of spontaneous OHSS. In most FSHR mutations, a hypersensitivity to human chorionic gonadotrophin (HCG) or thyroid-stimulating hormone (TSH) is described. This clinical case presents for the first time two occurrences of spontaneous OHSS in a single woman with a FSHR mutation and two different entities. Pathophysiology of both pregnancies was completely different. During the first pregnancy, elevated HCG and androgen concentrations led to spontaneous OHSS and finally to miscarriage. The second pregnancy with spontaneous OHSS was dominated by a latent hypothyroidism and normal HCG concentrations and ended in a delivery of a healthy female newborn. Due to the unusual courses of the pregnancies, the study looked for a mutation in the FSHR and surprisingly identified the same mutation previously described. This report confirms for the first time the in-vitro findings in a single clinical case that TSH as well as HCG leads to spontaneous OHSS in patients with FSHR D567N mutation. Hypothyroidism has to be treated or ruled out.

Sonographic Detection of the Ovarian Hyperreactio Luteinalis in Pregnancy

Hyperreactio luteinalis is a rare, benign ovarian finding during pregnancy, but its sonographic appearance can imitate a malignant process, and the ovarian enlargement predisposes a woman carrying this anomaly to other complications. The management of hyperreactio luteinalis during pregnancy is preferably conservative, and surgical treatment is reserved for the cases with associated complications. This article reviews maternal ovarian hyperreactio luteinalis in pregnancy and demonstrates an example. Proper assessment of the maternal hyperreactio luteinalis helps to prevent its unnecessary surgical treatment.

Hyperreactio luteinalis could be a risk factor for development of HELLP syndrome: case report

OBJECTIVE

To report a unique case of hyperreactio luteinalis in pregnancy associated with ovarian torsion and subsequent development of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

A 34-year-old primigravida woman with ovarian torsion in 13 weeks of pregnancy and subsequent intrauterine growth restriction (IUGR) and HELLP syndrome.

INTERVENTION(S)

Laparoscopic salpingo-oophorectomy due to the ovarian torsion and cesarean section (CS) due to the development of HELLP syndrome.

MAIN OUTCOME MEASURE(S)

HELLP syndrome.

RESULT(S)

In the first trimester the patient had symptoms of acute abdomen due to the ovarian torsion. Both ovaries were enlarged and multicystic. Hormonal studies confirmed an abnormally elevated level of hCG (192.000 IU/L), mild hyperthireosis, and hyperandrogenemia. Laparoscopic salpingo-oophorectomy was performed. At 30 weeks of pregnancy, IUGR was confirmed sonographically and clinically, and at 33 weeks severe preeclampsia developed. One week later, HELLP syndrome occurred. Emergency CS was preformed, and she delivered a female newborn weighing 1,640 g. Seven days after delivery, blood pressure and hormonal status returned to normal.

CONCLUSION(S)

Hyperreactio luteinalis due to the abnormally high level of hCG in the first trimester could be a consequence of inappropriate trophoblast invasion and an early sign of subsequently developing preeclampsia, eclampsia, and HELLP syndrome.

Does elevated human chorionic gonadotropin alone trigger spontaneous ovarian hyperstimulation syndrome?

OBJECTIVE

To test whether elevated hCG alone triggers spontaneous ovarian hyperstimulation syndrome (sOHSS).

DESIGN

Retrospective analysis.

SETTING

Departments of obstetrics and gynecology and of medical genetics in an academic medical center.

PATIENT(S)

A patient with sOHSS and 109 patients with elevated hCG.

INTERVENTION(S)

Collecting blood samples.

MAIN OUTCOME MEASURE(S)

Follicle-stimulating hormone receptor gene sequence, levels of TSH and hCG.

RESULT(S)

We described a case of sporadic, nonfamilial sOHSS. Sequencing of the entire coding region the FSH gene revealed wild-type alleles for all the known mutations, and the A919G and A2039G polymorphisms, previously associated with good response to FSH stimulation and severe iatrogenic OHSS. We ruled out hypothyroidism. The level of hCG reached a peak of 344,350 IU/L (95th percentile). One hundred nine pregnancies with hCG of >150,000 IU/L were identified from 2001-2006. After patients with gestational trophoblastic diseases, multiple pregnancies, and iatrogenic OHSS were excluded, 27 patients remained. None of those patients experienced OHSS.

CONCLUSION(S)

Elevated hCG cannot be responsible for sOHSS as a single factor. Factors other than the hCG-FSH-receptor interaction additionally are involved in the pathogenesis of this syndrome. A combination of mechanisms may allow understanding of this enigmatic disorder. The pathophysiology of sOHSS, a rare phenomenon, has not yet been elucidated.

Persistent megalocystic ovary following in vitro fertilization in a postpartum patient with polycystic ovarian syndrome

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) is more severe when pregnancy occurs, as the developing pregnancy produces human chorionic gonadotropin, which stimulates the ovary's persistent growth. If no pregnancy occurs, the syndrome will typically resolve within 1 week. In a maintained pregnancy, slow resolution of symptoms usually occurs over 1-2 months.

CASE REPORT

A 31-year-old woman, gravida 2, para 1, aborta 1, with polycystic ovary syndrome underwent in vitro fertilization (IVF) with clomiphene citrate and follicle-stimulating hormone/gonadotropin releasing hormone-antagonist stimulation. During transvaginal oocyte retrieval, enlarged bilateral ovaries were noted. She had an episode of OHSS after IVF/embryo transfer, for which paracentesis was performed three times. Pregnancy was achieved. Throughout antenatal examinations, bilateral ovaries were enlarged. She delivered a healthy baby by cesarean section at term. However, 1 month after delivery, the bilateral ovary had not shrunk, and levels of tumor markers CA125 and CA199 were 50.84 and 41.34 U/mL, respectively. At laparotomy for suspected malignancy, both adnexae formed "kissing ovaries", which were multinodulated with yellow serous fluid. Specimens from wedge resection submitted for frozen section showed a benign ovarian cyst. The final pathology report showed bilateral follicle cysts.

CONCLUSION

With the increasing use of gonadotropins in the management of infertility, ovarian enlargement secondary to hyperstimulation is common. Generally, symptoms appear between the 6th and 13th weeks of pregnancy and disappear thereafter. The hyperstimulated ovary often subsides after the first trimester. This case is unusual as the megalocystic ovary persisted after delivery. To the best of our knowledge, we report the first case of enlarged bilateral ovaries persisting 2 months after delivery.

Spontaneous Ovarian Hyperstimulation Syndrome in a Normal Singleton Pregnancy

OBJECTIVE

It is known that most cases of ovarian hyperstimulation syndrome (OHSS) are associated with the therapies for ovulation induction. However, OHSS may rarely be associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism or polycystic ovary syndrome.

CASE REPORT

A case of OHSS in a woman who became pregnant naturally and who had no underlying disease is presented here. The patient was managed expectantly with no complications.

CONCLUSION

Although spontaneous ovarian hyperstimulation is a rare entity, it is important to differentiate it from other causes of ovarian enlargement. Occasionally, life-threatening situations may occur, but it is usually a self-limiting process.