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With the increasing popularity of assisted reproductive technology ARTradiologists are more likely to encounter associated complications, especially in an emergency setting. These complications include ovarian hyperstimulation syndrome OHSSovarian torsion, and ectopic and heterotopic pregnancy. OHSS occurs following ovulation induction or ovarian stimulation and manifests with bilateral ovarian enlargement by multiple cysts, third-spacing of fluids, and clinical findings ranging from gastrointestinal discomfort to life-threatening renal failure and coagulopathy.

Enlarged hyperstimulated ovaries are at risk for torsion. Clinical symptoms are often nonspecific, and ovarian torsion should be suspected and excluded in any female patient undergoing infertility treatment who presents with severe abdominal pain. The most consistent imaging finding is asymmetric enlargement of the twisted ovary. There is also an increased risk for ectopic pregnancy following ART, with a relative increased risk for rarer and more lethal forms, including interstitial and cervical ectopic pregnancies. Careful evaluation of the adnexa is critical in this patient population, even when an intrauterine pregnancy has been confirmed.

Ultrasonography is the first-line imaging modality for the evaluation of complications of ART, although nonspecific symptoms may sometimes lead to cross-sectional imaging being performed. Familiarity with the multimodality imaging appearance of these entities will allow accurate and timely Looking for girlfriends in Engelberg ct and help avert potentially fatal consequences. The incidence of assisted conception has increased dramatically, doubling over the past decade 1. Numerous complications of assisted reproduction have characteristic imaging findings with which the radiologist should be familiar.

In this article, we review the multimodality imaging findings of maternal complications of assisted reproduction that are most likely to be seen in the emergency department: ovarian hyperstimulation syndrome OHSSovarian torsion, and ectopic and heterotopic pregnancy. Awareness of these entities and their imaging features will facilitate accurate and timely diagnosis and help avoid potentially fatal consequences.

Although ultrasonography US should be the first-line imaging modality in the assessment of such complications, given the increasing use of cross-sectional imaging 3computed tomographic CT and magnetic resonance MR imaging findings are also discussed. The Centers for Disease Control and Prevention defines ART as fertility treatment in which both eggs and sperm are handled outside the body 1. This strict definition of ART excludes treatments involving only ovulation induction, with or without intrauterine insemination. Ovulation induction is often the first-line therapy for infertility related to ovulatory disorders, as well as for unexplained infertility.

Oral medication commonly clomiphene citrate is used to stimulate ovarian follicular development and may sometimes be combined with intrauterine insemination to achieve pregnancy. In contrast, in vitro fertilization IVF generally involves more potent ovarian stimulation by means of gonadotropin injection, followed by oocyte retrieval, laboratory ie, in vitro fertilization, and transfer into the uterine cavity Fig 1. In IVF and sometimes in ovulation inductionthe administration of exogenous human chorionic gonadotropin hCG is used to trigger ovulation when Looking for girlfriends in Engelberg ct are deemed mature.

IVF is used to treat infertility related to many causes, including tubal obstruction, ovulatory dysfunction, diminished ovarian reserve or ovarian failure, endometriosis, severe male factor infertility, and unexplained infertility.

Risks of assisted conception are largely related to ovarian stimulation and include OHSS and its associated risk for ovarian torsion, as well as ectopic and heterotopic pregnancy 4. Figure 1 Drawings illustrate the IVF procedure, which consists of four steps: ovarian stimulation by a combination of fertility medications step 1oocyte retrieval by means of transvaginal US—guided follicle aspiration step 2laboratory ie, in vitro fertilization of the oocyte and sperm step 3and transcervical transfer of the embryo into the uterine cavity step 4.

OHSS is a potentially life-threatening iatrogenic complication of ovulation induction or ovarian stimulation. It occurs during the luteal phase of the menstrual cycle or in early pregnancy, almost always following the administration of endogenous or exogenous luteinizing hormone or its surrogate, hCG 5. OHSS manifests with a combination of ovarian enlargement by multiple follicular cysts and acute fluid shift out of the intravascular space, resulting in ascites and hemoconcentration 6.

Its pathogenesis involves secretion of ovarian vasoactive angiogenic substances, which cause increased capillary permeability and accumulation of fluid in the extravascular space Fig 2 7. Following the administration of fertility medications, a large cohort of ovarian follicles is developed and sustained. The granulosa-lutein cells, under the influence of hCG, produce vascular endothelial growth factor VEGFwhich in turn acts on endothelial cells to produce vascular permeability and accumulation of fluid in the extravascular space.

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Adapted, with permission, from reference 7. Numerous classification schemes have been developed to characterize OHSS. The modified Golan classification scheme categorizes OHSS as mild, moderate, or severe on the basis of symptom severity, s, and US findings, including ovarian size and evidence of ascites Table 8.

Development of pleural effusions can compromise lung function and result in adult respiratory distress syndrome 5. The incidence of OHSS varies by stimulation regimen, classification scheme, and study. Clomiphene induction is associated with rates of mild and moderate OHSS of approximately The hallmark imaging findings of OHSS are similar at US, CT 9and MR imaging 10 : bilateral symmetrically enlarged ovaries containing multiple variable-sized cystic lesions representing enlarged follicles or corpus luteum cysts, in the presence of ascites Fig 3.

The cysts are generally anechoic but may be complicated by hemorrhage Fig 5. At CT, the central ovarian stroma is relatively higher in attenuation than the surrounding water-attenuation cysts Fig 6 12although higher cyst attenuation may be seen in the setting of hemorrhage.

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At MR imaging, the cysts are predominantly T1 hypointense and T2 hyperintense Fig 7although again, high T1 al intensity may be seen with internal hemorrhage The enlarged cystic ovaries seen in OHSS should not be mistaken for cystic ovarian neoplasm; at CT or MR imaging, there should be no enhancing abnormal soft tissue in or around the cystic ovarian mass, and the normal central ovarian stroma should be recognizable In addition, follow-up imaging should demonstrate resolution 10 Additional imaging features of OHSS are related to its complications, such as pleural effusion and thromboembolism Fig 8 The free fluid seen in OHSS is generally simple ascites, although it may be slightly higher in attenuation due to ruptured hemorrhagic cysts.

OHSS in a year-old woman who had undergone gonadotropin injection and intrauterine insemination. The patient presented with lower abdominal pain, bloating, and decreased urine output. Transvaginal US images of the pelvis demonstrate marked enlargement of the right a and left b ovaries, both of which contain numerous large follicles.

Wheel spoke appearance of a hyperstimulated ovary in OHSS. Longitudinal transvaginal US image of an enlarged, hyperstimulated right ovary calipers shows a dominant cyst with echogenic material adhering to the cyst wall, a finding that is consistent with a retracting blood clot a normal finding. A small amount of free fluid is seen surrounding the ovary. Figure 6 OHSS. Coronal CT scan obtained following the intravenous and oral administration of contrast material shows bilateral ovarian enlargement by multiple cysts arrowsas well as limited perihepatic ascites arrowhead.

MR imaging was performed for clinical suspicion of appendicitis.

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Coronal fat-saturated T2-weighted MR image shows bilateral ovarian enlargement arrows and limited ascites arrowhead. Head CT scan shows acute infarction of the right middle cerebral artery. Thromboembolic events are the most feared complication of OHSS. Reprinted, with permission, from reference Enlarged hyperstimulated ovaries are at risk for torsion, which is reported to occur 11 times more frequently in ART pregnancies than in non-ART pregnancies 4. The risk for torsion increases in the presence of OHSS, in which the large cysts serve as a lead point for twisting on the vascular pedicle, possibility facilitated by pelvic ascites The absolute incidence of ovarian torsion ranges from 0.

Prompt diagnosis of ovarian torsion is essential to prevent irreversible ischemia and infarction. Ovarian salvage is particularly important in patients who are already pregnant and in those desiring future conception. Symptoms are often nonspecific, and maintaining a high degree of suspicion is important, especially in infertility patients. Ovarian torsion should be considered and excluded in any female patient undergoing ovulation induction or IVF who presents with severe abdominal pain.

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Additional clinical findings may include anorexia, nausea, vomiting, low-grade fever, leukocytosis, and a palpable mass The pathogenesis of ovarian torsion involves twisting of the ovarian vascular pedicle on its suspensory ligament, initially compromising venous and lymphatic outflow and ultimately compromising arterial supply. Resultant gangrene and hemorrhagic necrosis predispose to infection, which, if left untreated, may lead to peritonitis and even death US Findings.

The most consistent finding is unilateral asymmetric enlargement of the affected ovary Fig 9 Additional imaging findings include ovarian stromal heterogeneity due to hemorrhage and edema 21 and peripheral displacement of follicles Fig 10 The variability of color Doppler imaging limits its diagnostic value Absence or abnormality of color Doppler flow is a specific, but not sensitive, of torsion Patients with ovarian torsion and apparently normal ovarian flow may experience a delay in diagnosis 24 ; therefore, it is crucial to understand that the presence of color Doppler flow does not exclude torsion In two studies, the absence of demonstrable vascular pedicle flow correlated with necrosis or infarction at surgery 2526and this imaging finding may be useful for assessing preoperative viability.

However, management decisions in cases of suspected ovarian torsion should still be based on clinical grounds. Right ovarian torsion in OHSS. The right ovary is asymmetrically enlarged arrowthe only clue to ovarian torsion in this case.

Torsion of a hyperstimulated ovary.

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Figure 11 Whirlpool in ovarian torsion. Distinguishing ovarian torsion from mild hyperstimulation can be challenging, both clinically and radiologically. Both entities may manifest with abdominal pain, nausea, and vomiting. There is overlap in the gray-scale US appearance of these conditions, since both may demonstrate ovarian enlargement, heterogeneous stroma, and multiple follicles Although the follicles tend to be larger in OHSS, the increase in the of follicles may preclude their migrating peripherally, a finding classically seen in ovarian torsion Free pelvic fluid is seen in the majority of cases of ovarian torsion 21 but is also by definition present in OHSS without torsion.

Graif et al 20 described four cases of ovarian torsion in the setting of OHSS. In their series, the unaffected side demonstrated hyperstimulated ovarian follicles separated by thin walls, whereas the twisted ovary was asymmetrically enlarged by stromal edema, with cortical cysts separated by thickened parenchyma It is this asymmetric enlargement in the appropriate clinical context that is the key to suggesting the diagnosis of torsion. US is the preferred first-line imaging modality in the evaluation of female patients with pelvic pain, especially in the setting of ART and suspected OHSS, torsion, or ectopic pregnancy.

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