A 41-year old nulligravida presented to the University of Michigan
(UM) Reproductive Endocrinology and Infertility clinic for an
evaluation of a six year history of primary infertility. Her prior
fertility evaluation and treatment history was significant for
four previous cycles of ovulation augmentation with clomiphene
citrate in conjunction with timed intercourse and a normal
hysterosalpingogram several years earlier. Her initial workup at
UM revealed normal ovarian reserve testing, normal values for TSH
and prolactin, and her husband's semen analysis was normal.
Transvaginal ultrasonography showed persistent bilateral
3.5 cm ovarian cysts that had a ground-glass appearance
consistent with endometriomas [4
]. The patient underwent
laparoscopic evaluation due to the large endometriomas at which
time she was diagnosed with stage IV endometriosis. Due to dense
adhesive disease, the procedure was converted to an
exploratory laparotomy. Three right
ovarian endometriomas were removed, and the cyst wall of each was
excised with subsequent cauterization of the bases for hemostasis.
The left ovarian endometrioma was approached; however, it was not
removed due to severe adhesions and the patient's desire for
fertility. The patient's postoperative course was unremarkable.
Five weeks after surgery, the patient underwent a
hysterosalpingogram which showed a normal uterine cavity, right
tubal patency, and left hydrosalpinx without spillage of dye. She
subsequently underwent two cycles of gonadotropins in conjunction
with intrauterine inseminations, but had suboptimal responses.
Nine months after surgery, the patient presented to
the emergency room with fever and abdominal pain. Her temperature
was 38.7°C. Her abdominal and pelvic exams showed
moderate tenderness, small amount of vaginal discharge and
bacterial vaginosis as evidenced by clue cells on a normal saline
wet prep. Gonorrhoeae and chlamydia cultures were obtained.
Transvaginal ultrasound showed a 7 cm left adnexal mass with
uniform echogenicity (). Her WBC was
16.7 K. She was admitted to the hospital for intravenous
antibiotic administration but despite broad-spectrum coverage,
high-grade fevers continued. On hospital day 3, after discussion
of risks, benefits, and alternatives that included conservative
management, she was consented for definitive surgical management
and underwent a modified radical hysterectomy with bilateral
salpingo-oophorectomy and lysis of adhesions.
Figure 1 (a) Transvaginal ultrasound image, shortly
after initial evaluation, of persistent bilateral ovarian masses
adjacent to uterus (Ut). (b) Ultrasound image of left
ovarian cystic structure after patient presented with symptoms of
acute pelvic inflammatory (more ...)
Although all cervical, blood, and urine cultures were negative
on hospital admission, the left ovary contained an ovarian abscess
with gram negative rods within the left-sided endometrioma.
Gonorrhoeae and chlamydia cultures were negative. There was an
evidence of BV on normal saline wet prep and culture. Histology of
the left fallopian tube and ovary revealed an endometriotic cyst
with massive edema, hemorrhage, acute inflammation, and marked
eosinophilia () with an associated pyosalpinx
consistent with a TOA.
Endometrioma with associated edema, hemorrhage,
acute inflammation, and marked eosinophilia (H & E, ×40).