Key words:

acute renal failure/IVF/OHSS/ultrasound

Introduction

 During the last 35 years, IVF has become an important treatment option in patients with infertility. Following hormone stimulation, the oocytes are collected from the ovaries transvaginally using ultrasound guidance. The procedure is regarded as safe. . The most common complications are hemorrhages, pelvic abscesses and pain. There are also some reports of ureteric damage after puncture by the collecting needle.  ^(1,4) We report a case where a woman with pre existing endometriosis developed acute renal failure due to compression of both ureters from enlarged stimulated ovaries.

Case report: 

A 28 year old woman married for eight years, with two previous first trimester miscarriages presented to us for treatment of secondary subfertility. She had history of 2 laparoscopies elsewhere suggestive of bilateral tubal block and extensive adhesions between tubes, ovaries and uterus suggestive of stage IV endometriosis. She had regular cycles with a BMI of 20. She had a past history of surgically corrected atrial septal defect at 5years of age, asymptomatic since then with good left ventricular ejection fraction .She  had  ureteric  calculi  diagnosed on both sides  on  ultrasound done outside  with no renal changes  3 years back ,for which she underwent conservative management  .

Her FSH was 12.3 MIU/L, and LH was 14.2 MIU/L, AMH-1.2 with reduced antral follicle count with  2 cm endometriotic cyst on both ovaries .Kidneys were normal. Husband’s semen analysis was normal. Hysteroscopy and trial transfer was done as pre-IVF evaluation. She was counseled for therapeutic trial and a flexible antagonist protocol was followed. Recombinant FSH was used for stimulation. Five oocytes were retrieved under ultrasound guidance 35 hours of HCG trigger. Three embryos fertilized and three 8 cell grade A embryos transferred without any difficulty.

Six days following embryo transfer, she reported with loin pain and high grade fever and reduced urinary output. There was no tenderness on abdominal examination. Investigations revealed normal leucocyte count with more than hundred pus cells on routine urine analysis. Renal function test revealed a picture of pre-renal failure with a serum urea of 100 mg/dl and creatinine of 7.9 mg/dl. Serum electrolytes showed hyperkalemia. Investigations to rule out other causes of pyrexia were normal. Ultrasound showed bilateral enlarged ovaries measuring Rt. 5 cm x 6 cm and Lt. 6 cm x7 cm and bilateral hydronephrosis. MRI scan showed bilateral hydronephrosis and enlarged ovaries which led to compression of ureters. She was catheterized and her urine output was only 300 ml/24 hrs. Nephrologist’s  & Urologist’s  opinion taken. Injection carbepenem following sensitivity to Klebsiella and ESBL growth on culture was started. Patient was transferred to nephrology department and dialysis was done as her creatinine showed increasing trend & persistent oliguria.Serum creatinine started to decline following dialysis.Double DJ stent was inserted. The post-operative course was uneventful and her creatinine level showed declining trends. Oral progesterone was continued as luteal support and on day sixteen of embryo transfer, β-hcg was positive .Her β-hcg showed an increasing trend .  Renal sonogram was repeated and it was normal. The patient was asymptomatic and urine culture was negative. 

At six weeks from LMP, ultrasound showed evidence of echogenic ring and presence of yolk sac with no cardiac activity and fluid collection seen in the right adenexa suggestive of right ectopic pregnancy. She was posted for an emergency laparoscopy as she was hemodynamically stable which needed conversion to laparotomy in view of frozen pelvis.

Approximately,one litre of blood  and  clots were removed along with necrotic and hemorrhagic  tissue scattered in the abdominal cavity. Right tube was the seat of rupture and salphingectomy done. Right ovary was stuck to the back of uterus, and left ovary stuck to lateral pelvic wall. Abdomen washed with saline and a drain was placed. Two units of packed cells were transfused, postoperatively. Histopathology confirmed ruptured ectopic gestation in the right tube. She was discharged in a stable condition . Double-J-stent was removed 6 weeks later.

MRI showing bilateral stimulated enlarged ovaries compressing both ureters showing the stimulated ovaries compressing both ureters resulting in bilateral hydronephrosis

Discussion:

Trans vaginally, ultrasound-guided oocyte retrieval has become the gold standard for IVF therapy. It is considered as a well tolerated, cost effective and safe procedure.^(3,5) A few cases of ureteral damage due to puncture of the ureter by the collecting needle have been described. In one case, the ureter was compressed by a stimulated ovary in a patient with a transplanted pelvic kidney.⁽²⁾ The diagnosis of ureteral compression was confirmed by MRI scan, a procedure without ionizing radiation and which should not cause any harm to fertilized embryos. ⁽⁶⁾  Severe pelvic adhesions may have worsened the situation by limiting the normal movement of the ovaries. Ovarian hyperstimulation syndrome (OHSS) is a common complication in assisted reproductive technologies. In spite of frequent occurrence of Abdominal Compartment Syndrome and oliguria in OHSS, acute renal failure secondary to obstructive uropathy is uncommon in OHSS.⁽⁸⁾Acute renal failure due to a hypovolumic state following production of protein-rich ascites in patients with OHSS has been reported ⁽⁷⁾ , but in this case no ascites and only slight haemoconcentration  was noted . The most pronounced finding was the huge enlargement of the ovaries and bilateral hydronephrosis . To date there have been just two case reports of obstructive uropathy associated with OHSS. ⁽⁹⁾The patient was diagnosed earlier as having stage 4 endometriosis and frozen pelvis. Even though the complication risk related to IVF is low, one should be aware of a possible compression or damage to the ureters with subsequent development of acute renal failure. Injury, either by direct puncture or extrinsic compression, compromised ureteral function, but did not completely halt urination—a testimony to the resilient nature of this structure and an intimation of more frequent, unrecognized injury.

 We,therefore,suggest that obstructive uropathy should also be considered as a possible etiology in patients with enlarged ovaries  who develop oliguria or acute renal failure.

References:

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