Advanced high-grade serous carcinoma of the ovary after IVF treatment in a 38-year-old nulligravida: A case report of diagnostic challenges in the presence of OHSS

Abstract

Objective

When there is massive ascites in a patient who has recently undergone IVF treatment, differentiating OHSS from ovarian cancer can be challenging. A detailed evaluation combining clinical history, ultrasound characteristics, and laboratory findings is essential. In cases where these initial evaluations are inconclusive, advanced imaging and histopathological examination may be necessary to achieve an accurate diagnosis.

Case report

We report the case of a 38-year-old nulligravida woman with no family history of breast or ovarian cancer who presented with progressive exertional dyspnea and massive ascites six weeks after completing two cycles of in vitro fertilization (IVF) at a private fertility clinic. She was initially diagnosed and treated for ovarian hyperstimulation syndrome (OHSS)at the clinic, a known complication of controlled ovarian stimulation at the clinic. However, her symptoms persisted and progressed beyond the typical 10–14-day resolution period for mild-to-moderate OHSS.

Upon presentation to our internal thoracic outpatient department, physical examination and imaging revealed right-sided pleural effusion and estimated ascites more than 2000 mL. Abdominal computed tomography demonstrated a large, multilocular, hypodense cystic mass measuring 12 × 12 cm originating from the right adnexa, accompanied by bilateral pleural effusions and diffuse ascites, raising suspicion for an underlying ovarian malignancy. The patient underwent thoracentesis and paracentesis twice within a seven-day interval, each time draining over 200 mL of pleural fluid and 2500 mL of ascitic fluid. Despite repeatedly negative cytological findings, the clinical course and radiologic features warranted surgical exploration.

Laparotomy confirmed the diagnosis of high-grade serous carcinoma of the ovary with extensive peritoneal and pleural metastases. Given the patient's strong desire for fertility preservation, a suboptimal debulking procedure was performed, including right salpingo-oophorectomy, left salpingectomy, left ovarian cystectomy, tumor debulking, omentectomy, and enterolysis. Postoperatively, she commenced chemotherapy with carboplatin and paclitaxel. Although BRCA1/2 testing was negative, she was found to carry a homologous recombination repair (HRR) mutation, and maintenance therapy with a PARP inhibitor is being considered. Additionally, adoptive immunotherapy with cytokine-induced killer (CIK) cells is under evaluation as part of a multimodal treatment approach.

Conclusions

This case highlights the diagnostic challenges in differentiating OHSS from malignancy in IVF patients with persistent and atypical symptoms. Comprehensive diagnostic approaches, including imaging and surgical exploration, are crucial for accurate diagnosis and appropriate management.