Does performing an egg retrieval for In Vitro Fertilization (IVF) increase the risk of developing a tubo-ovarian abscess?

Risk of Tubo-Ovarian Abscess After IVF Egg Retrieval

Tubo-ovarian abscess (TOA) is a rare but potentially serious complication of transvaginal oocyte retrieval for IVF, occurring in approximately 0.5% of procedures.

Incidence and Risk Factors

The risk of developing a tubo-ovarian abscess following egg retrieval appears to be low but significant. Several factors may increase this risk:

• History of pelvic inflammatory disease (PID) 1
• Presence of hydrosalpinges 1
• Endometriosis 2
• Possible reactivation of latent pelvic infections during the procedure 1

Pathophysiology

Tubo-ovarian abscesses after egg retrieval may develop through several mechanisms:

• Direct inoculation of vaginal bacteria during transvaginal needle puncture
• Reactivation of previous pelvic infections 1
• Contamination from puncture of endometriotic cysts 3
• Potential spread from aspirated hydrosalpinges during the procedure 1

Clinical Presentation

TOA following egg retrieval may present with:

• Abdominal/pelvic pain
• Fever
• Leukocytosis
• Constitutional symptoms
• Vaginal discharge in some cases 4

Importantly, symptoms may develop at various timepoints:

• Most commonly within days of the procedure
• In rare cases, delayed presentation weeks or even months after retrieval 4

Diagnosis

When TOA is suspected following egg retrieval:

• Transvaginal ultrasound is the first-line imaging modality 5
• CT with contrast may be helpful when ultrasound is equivocal, showing complex cystic masses with thick enhancing walls 5
• MRI can provide additional soft-tissue detail in complex cases 5

Management

According to guidelines for intra-abdominal infections:

• Patients with tubo-ovarian abscess that does not respond to antibiotics should undergo surgical drainage 5
• Options for drainage include:
  • Transvaginal ultrasound-guided drainage 6, 3
  • Posterior colpotomy with drain placement 6
  • Laparoscopic or open surgical drainage in severe cases 3

Prevention Strategies

While specific guidelines for prevention of TOA after egg retrieval are limited, several approaches may be considered:

• Antibiotic prophylaxis in high-risk patients (though consensus on optimal regimen is lacking) 2
• Vaginal preparation with povidone-iodine solution prior to oocyte retrieval, which appears to decrease infection rates 2
• Careful aspiration technique to avoid contamination

Pregnancy Outcomes

With prompt diagnosis and appropriate management, successful pregnancy outcomes are possible even after TOA complicating IVF:

• Case reports document successful term deliveries following appropriate drainage and antibiotic therapy 6
• Preservation of the uterus and unaffected adnexa should be attempted when possible if future fertility is desired 1

Clinical Pearls and Pitfalls

• TOA should be considered in the differential diagnosis of any patient with fever, abdominal pain, or leukocytosis following egg retrieval 1
• The presentation may be delayed by weeks or months after the procedure 4
• Drainage (either percutaneous or surgical) is typically necessary for definitive resolution 4
• Antibiotic coverage should be broad-spectrum to cover polymicrobial pelvic infections

While rare, clinicians should maintain awareness of this potential complication to ensure prompt diagnosis and treatment, which can preserve fertility and optimize outcomes.