- Email: [email protected]
Primary ovarian pregnancy: A report of twenty-five cases
Primary ovarian pregnancy: A report of twenty-five cases JACK
G.
Los Angeles,
HALLATT,
M.D.
Calfomzia
Ovarian pregnancy occurs within the ovary and on the corpus luteum, usually with rupture of the ovary and a massive hemoperitoneum. It presents as a hemorrhagic ovary and is frequently misdiagnosed as a ruptured corpus luteum. It occurs in the highly fertile patient and is often assodated with the use of the intrauterine contraceptive device, which does not prevent the chance occurrence of ovarian pregnancy. (AM. J. OBSTET. GYNECOL. 143:55, 1982.)
is a unique form of ectopic pregnancy that must be documented by the four postulates of Spiegelberg,’ which establish that the pregnancy is in the ovary and does not involve the tube. Ovarian pregnancy is the most common form of abdominal pregnancy, but it must be distinguished from primary peritoneal implantation, which can involve any intraperitoneal site with different problems of diagnosis and management related to the organs involved. The ovary has no peritoneal covering, and the implantation within the ovary results in a predictable sequence of events because of the consistent vascular anatomy of the ovary. This vascularity results in maternal hemorrhage early in the first trimester, which disrupts the pregnancy and usually ruptures the ovary with sufficient hemoperitoneum to require emergency operation. This inherent self-destruction occurs so early that ovarian pregnancy presents surgically as a hemorrhagic ovary and is usually not correctly diagnosed. This study of 25 consecutive cases of documented ovarian pregnancy reveals a consistent pattern of events which makes this rare anomaly of human reproduction more understandable and, therefore, more amenable to diagnosis. The etiology, pathology, incidence, and relation to the use of the intrauterine contraceptive device (IUCD) are discussed. OVARIAN
PREGNANCY
From the Department Southern California
of Obstetrics Pennanente
and Gynecology,
Medical Center.
Presented at the Forty-eighth Annual Meeting of the Pacijic Coast Obstetrical and Gynecological Society, Kauai, Hawaii, September 27-October 3, 1981. Reprint requests: Jack G. Halkztt, M.D., Department of Gynecology, Southern California Permanente Medical Center, 4900 Sunset Boulevard, Los Angeles, California 90027. 0002-9378/821090055+06$00.60/0
0
1982 The C. V. Mosby Co.
Material and analysis Table I summarizes the relevant significant findings of 25 cases of ovarian pregnancy which fulfill Spiegelberg’s postulates. These cases have occurred in patients of the Southern California Permanente Medical Group from 1953 to 1981. The obstetric setting for these cases is seen in Table II, which reveals that there was one ectopic pregnancy for every 113 deliveries overall. Almost 1% of all ectopic pregnancies were documented ovarian pregnancies. There were many cases involving both the tube and ovary, which does not qualify as primary ovarian pregnancy. Several of the abdominal pregnancies involved the ovary. Twenty percent of the ovarian pregnancies were associated with the IUCD, and all occurred in the last 5 years. Table III compares the clinical features of ovarian pregnancy with those of the more common tubal pregnancy. The principal distinguishing features are related to the excellent fertility of the ovarian pregnancy patient and the impaired fertility of the tubal pregnancy patient. This explains the younger age, higher parity, and fewer fertility problems in the ovarian pregnancy patients. The one patient with infertility of 5 years prior to the ovarian pregnancy subsequently had two term intrauterine pregnancies. Vaginal bleeding was common and irregular and followed the same pattern in both groups. Amenorrhea was present in only 17% of tubal pregnancy patients and 16% of ovarian pregnancy patients. Most patients did not suspect that they were pregnant. The IUCD-associated pregnancies did not differ significantly from the other ovarian pregnancies clinically or surgically. The severe pain of hemoperitoneum was identical in both groups and resulted in operation at an earlier gestational age in the ovarian pregnancy than in the 55
56
May 1. 1982 Am. J. Obstet. Gynecol.
Hallatt
Table
I.
Primary
ovarian
pregnancy:
Summary
of significant
findings-25
Daysfrom &Se No.
(Yd
Parity
1953 1954 1956 1957 1961 1962 1962 1963 1966 1966 1967 1968 1968 1969 1970 1973 1974
28 35 26 33 24 24 34 35 28 21 36 27 25 37 25 21 27
2
20 21
1976 1977 1978 1979
33 27 23 35
22 23 24 25
1979 1980 1980 1980
22 27 23 26
1 2
3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18
19
Average
Year
Age
28
1 I 2 0
Contraception
Infertility, 5 yr
3 1 10
2 2 3 5 2 5
1 0 0 0 1 1 2
IUCD, 10 yr IUCD, 7 mo IUCD, 18 mo Tubal ligation, 1973
1 2
1 2
IUCD, 6 mo ILJCD, 3 yr
LNMP to bleeding
cases
pain
Days from LNMP to operation
45
45
Days from LNMP to
30 32 36 37 30 42 28 28 30 28 30 0 30 30 30
51
51
54 44 60 55 45 57 60 51 42 38,49 62 63 63
61 0
61 0
54 44 60 59 45 57 60 51 42 50 62 63 63 68 60
28 32 31 0
31 60
60 61 28 0
74
46 39
61
34 0
2t
LNMP = Last normal menstrual period. TAB = Therapeutic tubal pregnancy. The four cases without hemoperitoneum were not associated with pain. Two were diagnosed by an attempted elective therapeutic abortion, which revealed no villi, but an adnexal mass was present. One case was an incidental finding of a hemorrhagic ovary at a staging operation for Hodgkin’s disease. The fourth case was diagnosed by ultrasound as an ectopic pregnancy in a patient who was treated for a threatened abortion and who had an adnexal mass. Five of the eight ovarian pregnancies occurring in the last 5 years were associated with the IUCD. In the last five years 14% of all tubal pregnancies at the Kaiser Foundation Hospital in Los Angeles were associated with the IUCD. Table IV shows the surgical features of ovarian pregnancy. Operation is performed with the first episode of pain in 68% of ovarian pregnancies but only 34% of tubal pregnancies. This is due to the vascularity of the ovary resulting in a more massive hemoperitoneum at an earlier stage. The hemoperitoneum was over 500 ml in 81% of the ovarian pregnancy patients as contrasted to 51% of the tubal pregnancy patients. The most significant finding in this study was the inability to distinguish the ovarian pregnancy from a bleeding hemorrhagic ovary or ruptured corpus lu-
Hemopen’taeum (4 500+ 500+ 500+ 500+
1,000 1,000 800 800 500 50 2,000 800 2,000 400 600 0 0
60 48 40
300 500+ 500+ 500+
74 87 36 55
300 0 1,500 0
51
740
abortion. POC = Polycystic ovary. teum cyst. A correct surgical diagnosis was made in only 28% of the cases. An embryo was identified in only three of the 25 cases to establish the diagnosis. The entire ovary was removed in nine cases and enucleation or wedge excision was accomplished in 16 cases. The hemorrhagic mass was adjacent to the corpus luteum in all cases. In no case was a so-called intrafollicular ovarian pregnancy within a corpus luteum documented. The only associated pathologic condition was gross pelvic inflammatory disease in two patients, and one patient had had a bilateral tubal ligation six years before. The records of the Los Angeles County/University of Southern California Women’s Hospital were reviewed by the author for ovarian pregnancy and only four cases were identified, during which time interval there were almost 1,200 ectopic pregnancies. If 1% of all ectopic pregnancies are ovarian, there should have been twelve ovarian pregnancies instead of only four.” Because ovarian pregnancy surgically resembles a hemorrhagic corpus luteum, the records of all cases of ruptured corpus luteum with hemoperitoneum at the Women’s Hospital in 1973 were then reviewed by the author. Thirty-four of the 60 patients admitted to the hospital were observed and discharged. Fifteen pa-
Volume Number
143 1
Primary
ovarian
pregnancy
57
Table II. Primary ovarian pregnancy: Obstetric experience,* 1953 to 1981 Surgical
Total deliveries Ectopic pregnancies: With IUCD Ovarian pregnancy With IUCD Tuboovarian pregnancy Abdominal pregnancy
diagnosis
Bleeding corpus luteum Ovarian pregnancy; 7 mm embryo Bleeding corpus luteum Bleeding corpus luteum Bleeding corpus luteum Bleeding corpus luteum Ovarian pregnancy Bleeding corpus luteum Bleeding corpus luteum Ruptured ovarian cyst Bleeding corpus luteum Bleeding corpus luteum Bleeding corpus luteum Ruptured ovarian cyst Ovarian pregnancy; 10 mm embryo TAB; no POC; adnexal mass Hemorrhagic ovary or staging laparotomy for Hodgkin’s disease Bleeding corpus luteum Bleeding corpus luteum Ovarian pregnancy Bleeding corpus luteum
*Southern
California
279,925 2,478 178 25 5 12 13
Permanente
Medical
Group.
Table III. Primary ovarian pregnancy: Clinical features-Tubal and ovarian pregnancy
Average age (yr) Multiparous (%) Infertility (%) Amenorrhea (%) IUCD (%) Average days from
LNMP
1 Tubal
1 Ovarian
30 68 28 17 14 58
28 a4 4 16 20 55
to operation
1 1
Table IV. Primary Surgical features
Bleeding corpus luteum Ectopic pregnancy by ultrasound Bleeding corpus luteum TAB; no POC; adnexal mass
ovarian
pregnancy:
Operation on first day of pain (%) Hemoperitoneum (No. = 21) (%) >500 ml (No. = 17)
68 84 81
Surgical diagnosis (No.): Ovarian pregnancy Hemorrhagic ovary Surgical procedure (%): Oophorectomy Wedge excision or enucleation Location adjacent to corpus luteum
tients had laparoscopy only and no active bleeding was noted from the hemorrhagic ovary. Eleven patients underwent operation which consisted of ,oversewing the bleeding ovary without a tissue diagnosis. None of these
procedures
could
have
diagnosed
an
7 18 36 64 100
(%)
ovarian
pregnancy. This management is consistent with the analysis of 200 cases of operation for ruptured corpus luteum by Hibbard3 from the same institution in 1979.
corpus luteum, which is in the vascular stage of its development. On about the fortieth day of gestation, trophoblastic invasion of maternal ovarian arteries occurs with
Comment In the rabbit the ovulated ovum is always adherent to the ovarian stigma or operculum until mechanically removed by the tubal fimbria. This is presumed to be the physiologic etiology of ovarian pregnancy in the human where ovum migration usually facilitates tubal pickup. The abundant granulosa cells which form the sticky cumulus of the corona radiata of the ovum adhere to the operculum of the ruptured follicle. If there are enough sperm with enough hyaluronidase to lyse the radiata and expose the zona pellucida to sperm penetration, fertilization occurs and the resulting zygote develops. On the sixth day implantation will occur wherever the blastocyst happens to be, as seen in all cases of ectopic pregnancy. If the blastocyst is still adherent to the ovary, implantation is within the ovary and on the
a resulting
hemorrhage
into
the
ovary
and
gesta-
tional sac which disrupts the pregnancy and usually ruptures the capsule of the ovary which has covered the implantation site. Figs. 1 and 2 show the typical appearance of ovarian pregnancy. It is probably not possible for a pregnancy to develop within a corpus luteum which is well developed before implantation can occur. If there is no hemoperitoneum, there may be a transient localized pain which is not severe enough to warrant
operation
and
be resorbed. It has been established pregnancy
patients
do not
the
disrupted
pregnancy
that one third require
operation
will
of ectopic and
there
is complete resorption of the pregnancy.4 How often this occurs in ovarian pregnancy is unknown, but it was documented by the case diagnosed incidental to the Hodgkin’s staging operation as the products of con-
58
Hallatt
May
Am. J. Obstet.
Fig. 1. The appearance pregnancy.
The
capsule
of the hemorrhagic was bursting and
ovary
in ovarian
bleeding.
ception were necrotic and the patient was asymptomatic. For this reason and the fact that ovarian pregnancy is so frequently misdiagnosed at operation, the true
incidence
of this
rare
anomaly
of
human
repro-
duction is unknown. The reported incidence in the literature is 1% of all ectopic pregnancies.’ Every patient with irregular bleeding and ovarian pain or the pain of hemoperitoneum should have a pregnancy test for the beta subunit of human chorionic gonadotropin to diagnose ectopic pregnancy. When a hemorrhagic ovary is found at operation, it should be wedge resectioned or enucleated for a tissue diagnosis. This is a simple procedure which does not impair ovarian function. It is common practice for the gynecologist to enucleate dermoids, endometriomas, and benign ovarian
Fig. 2. The cut section of Fig. 1 shows the hemorrhagic on the periphery of the corpus luteum.
1. 1982
Gpecol.
mass
cysts of any nature, with a normally functioning ovary subsequently. There has been an apparent increase in ovarian pregnancy because of the widespread use of the IUCD, which does not prevent ectopic pregnancy. There have been 28 articles in the last 10 years reporting 44 cases of ovarian pregnancy associated with the IUCD.” The high incidence of tubal and ovarian pregnancy associated with the IUCD is probably a reflection of the true incidence of tubal pregnancy in the unprotected, predisposed patient and of the chance occurrence of the ovarian pregnancy in the unprotected very fertile patient. This chance occurrence is not likely to recur as there were no repeat ovarian pregnancies in this study and none was noted in a review of the world’s literature.
REFERENCES 1. Spiegelberg, 0.: Zur Casuistik der Ovarialschwangerschaft, Arch. Gynaekol. l&73, 1878. 2. Gerin-Lajoie, L.: Ovarian pregnancy, AM. J. OBSTET. GYNECOL. 62:920, 1951. 3. Hibbard, L. T.: Corpus luteum surgery, AM. J. OBSTET. GYNECOL. 135:666, 1979.
Discussion DR. JOHN E. MAYO, Los Angeles, California. Dr. Hallatt has compiled this report based on a large number of patients with ovarian pregnancy. This volume represents an experience with which very few practitioners will become personally acquainted. He has very rightly pointed out to us the necessity of a tissue diagnosis when hemorrhagic corpus luteum or hemorrhagic ovary is the operative diagnosis. Likewise, his advocacy of the more liberal use of the beta subunit serum pregnancy test is certainly appropriate. In his series, the finding of 1% of ectopic pregnancies presenting as
4. Lund, J. J.: Ectopic pregnancy, J. Obstet. Gynaecol. Br. Emp. 62:1, 1955. 5. McMorries, K., Lofton, R. H., Stinson, J. C., and Cummings, R. V.: Is the IUD increasing the number of ovarian pregnancies? Contemp. Ob/GYN 13:165, 1979.
ovarian pregnancy is within the range found in the literature.‘, 2 The findings that 26% of the patients with ovarian pregnancy are primigravid and that the average age was 28 are also consistent with those of other reports.* His finding of 2.8% (51178) ovarian pregnancies compared to all other ectopic pregnancies in women using the IUD is low compared to that in other reports. 3-5 Perhaps this reflects a greater incidence of infertility in his population. This may also account for the slightly increased incidence of ectopic gestation in his series (0.91%) as compared to about 0.5% found in other large, racially mixed studies from the United
Volume Number
143 1
However, in recent years the occurrence of ectopic pregnancy is increasing, and this makes the time frame of data collection important when series are compared. There are several comments I would like to make in reference to Dr. Hallatt’s remarks that IUCDs do not prevent ectopic pregnancy; that ovarian pregnancy occurs in the fertile patient in contrast to tubal ectopic pregnancy, which is associated with impaired fertility; and that the high incidence of tubal and ovarian pregnancy associated with the IUD is probably a reflection of the true incidence of tubal pregnancy in the unprotected, predisposed patient and the chance ovarian pregnancy in the unprotected, highly fertile patient. The finding of only two patients in the ovarian pregnancy group with evidence of tubal inflammatory disease at operation certainly supports the conclusion that this type of ectopic gestation occurs in the fertile patient. However, it is difficult to make firm comparisons because the statistical significance of the figures is not presented, and the criteria upon which the decision was made to classify a patient as fertile or infertile are not given. This is especially true in the tubal pregnancy group. Other fertility factors including the use of all forms of contraceptives are very important. All of these factors and others, which are obviously operative, make conclusions about the incidence of tubal or ovarian pregnancy associated with various fertility states and IUD usage very difficult. In order to draw these conclusions, a well-controlled, statistical study is necessary. In this regard, I would like to present what seems to me to be some salient points made in the literature. Lehfeldt and associates4 studied the data from the cooperative statistical program. Based on 45,000 woman years of experience with the IUD and a projected 180,000 fertilized ova, they expected to find 900 ectopic pregnancies, five of which would be ovarian. In reality, they found 42 tubal pregnancies and five ovarian pregnancies. They concluded that the IUD is 99.5% effective in preventing intrauterine pregnancies and 95% effective in preventing tubal ectopic gestation but has no protective influence against ovarian implantation. Ory,6 in a collaborative, multicenter, case-controlled study designed to examine the occurrence of ectopic pregnancy related to the use of the IUD, concluded: (1) Current use of any form of contraceptive, including IUD, decreases one’s risk of ectopic pregnancy. (2) Among current users of contraceptives, IUD users have three times the risk of ectopic pregnancy as users of oral contraceptives and about the same risk as users of traditional contraceptives. If a woman changes from oral contraceptives to an IUD, her increased risk of having an ectopic pregnancy is not due to the presence of an IUD; rather, it is due to the absence of oral contraceptives. (3) Women who use the IUD for 25 or more months have about three times the risk of ectopic pregnancy as women who use it for a lesser period of time. After 24 months of IUD use, the risk remains States.’
Primary
ovarian
pregnancy
59
constant and is still only as high as it is in women who have never used the IUD. (4) This study strongly suggests that the IUD is not responsible for any part of the recent tripling of ectopic pregnancies in the United States. A more likely explanation of the tripling is a marked increase in pelvic inflammatory disease that has occurred in recent years in the United States. This epidemic created a large number of women who had as much as six times the risk of ectopic pregnancy compared to women who have never had pelvic inflammatory disease. REFERENCES 1.
Pivers, M. S., Baer, K. A., and Zachery, pregnancy and intrauterine device, JAMA
T. V.: Ovarian 201:107, 1967. H. K.: Ovarian pregnancy: Report Loop in situ, Acta Obstet. Gynecol.
2. Bjorn, G., and Jensen, of a case with Lippes’ Sand. 49:297, 1970. 3. Vessey, M. P., Johnson, B., et al.: Outcome of pregnancy in women using an intrauterine device, Lancet 1:495, 1974. 4. Lehfeldt, H., Tietze, C., and Gorstein, F.: Ovarian pregnancy and the intrauterine device, AM. J. OBSTET. GYNECOL. 108:1005, 1970. G., Lancet, M., and Czernobilsky, B.: Ovarian preg5. Graff, nancy with intrauterine device in situ, Obstet. Gynecol. 40:535, 1972. 6. Ory, H.: Ectopic pregnancy and intrauterine contraceptive device: New perspective, Obstet. Gynecol. 57:173, 1981.
DR. S. GAINER PILLSBURY, Long Beach, California. Dr. Hallatt has again demonstrated his interest in ectopic gestation by collecting the largest series of ovarian pregnancy to be found in the literature. This condition is a rare one, however, and his data suggest that one ovarian pregnancy will occur for every 100 ectopic pregnancies, with an incidence of 1 in every 11,300 deliveries. To my knowledge, I have never seen a case, and a physician might not encounter one during a lifetime of a relatively busy practice. It is an extremely interesting entity, however, and should be kept in mind when one is considering the differential diagnosis in a patient suspected of having a tubal pregnancy or a bleeding corpus luteum. Speigelberg’s criteria for diagnosing an ovarian pregnancy should be strictly adhered to. Some investigators have recently suggested that many cases of tubal pregnancy are associated with microscopic foci of endometriosis. I would like to ask Dr. Hallatt if any of his cases showed evidence of ectopic endometrial tissue in the ovary. Although none occurred in this series, there are several authentic cases reported in the literature where ovarian pregnancies have gone to the stage of fetal viability. As with other cases of abdominal pregnancy, most are not diagnosed prior to operative delivery, but apparently the ovary can accommodate a developing pregnancy better than a tube can. The availability of a test for the beta subunit of human chorionic gonadotropin and ultrasound have
60
Hallatl
enabled the earlier diagnosis of ectopic gestation. Since there is a high incidence of spontaneous resolution of early ovarian pregnancy and since the gross appearance of this condition closely resembles a corpus luteum cyst, I wonder whether Dr. Hallatt would insist on a tissue diagnosis if at the time of laparoscopy an ovarian “cyst” were found which was not bleeding or which had minimal bleeding that could be controlled by coagulation. Dr. Hallatt’s report will be a valuable addition to the literature on ectopic gestation. DR. RODNEY WEST, Honolulu, Hawaii. Two things in the paper come to my attention. First, in the first 23 years there were no cases of ovarian pregnancy in a patient using an IUCD. Second, in the last five years, 62% of the cases occurred in patients using IUCDs. Also, the total incidence of numbers of abdominal pregnancy has doubled in the last five years, as compared with the first 23 years. My question is: Is the incidence of ovarian pregnancy, in relation to the number of deliveries, the same during the last five years as it was during the first 23 years? IUCDs were used before the last five years, so I am wondering if the type of IUCD used has made a difference. I know some of these figures are not statistically significant, but I think they do leave a trail which should be followed. DR. ROBERT ISRAEL, Los Angeles, California. I wouid like to mention the results obtained in the Collaborative Study Project of 30,000 women and 45,000 woman years in which the actual number of pregnancies that occurred as an IUD failure is compared to the expected number of pregnancies if no contraception had been utilized. The data show that the IUD reduces intrauterine pregnancies very well, tubal pregnancies less well, and ovarian pregnancies not at all. The theory behind all this, of course, is that the IUD acts locally in the uterus, has a minimal effect on the fallopian tube, and has no effect whatsoever on a distant structure, the ovary. To back up the previous speaker’s comments, I have a question for Dr. Hallatt. I respect his surgical ability, but I still wonder if it is necessary and/or safe to resect every corpus luteum. I congratulate him that he has had no complications in the resections he has performed. However, others have reported complications following conservative ovarian surgery. Both Kistner and the Baylor group have reported the development of periovarian adhesions following conservative ovarian surgery in young women wishing future fertility. In addition, what happens to an unsuspected intrauterine pregnancy with the elimination of its supportive corpus luteum? DR. DAVID C. FIGCE, Seattle, Washington. I would simply like to remind our group that none of the subdisciplines of our specialty is immune to an encounter with the ovarian pregnancy. Our most recent case, occurring within the past 12 months, was diagnosed without the presence of hemoperitoneum but with the
May 1, 1982 Am. J. Obstet. Gynecol.
finding of a persistent adnexal mass, observed over a period of 5 weeks. At the time of celiotomy, the gross appearance was quite suggestive of a malignant ovarian tumor and only upon cut section was the diagnosis established. DR. HALLA-IT (Closing). Dr. Pillsbury mentioned the possibility of endometriosis as an etiologic factor. This, of course, is very tempting because the fertilized ovum or zygote cannot distinguish whether endometrium is in the uterus or in the tube or in an aberrant location. The first time this idea was introduced, it was felt to be very valid. However, it was found, on closer survey, that the endometriosis was nothing but decidual reaction, and of course there is florid decidual reaction in very early pregnancy, involving practically every abdominal organ. I do not think endometriosis is a factor and there was no evidence of any endometriosis in any of my cases. It is a fascinating fact that in the tubal pregnancies there is a lower incidence of endometriosis then we find in the normal population. Dr. Pillsbury suggests the possibility that a tissue diagnosis may not be necessary and this is indeed true. If you read between the lines, it is obvious that oversewing will probably cure ovarian pregnancy. I hesitate to mention this, because I do not think we should do it, because I feel that a hemorrhagic ovary requires a diagnosis. It may look like a corpus luteum, which we know to be innocent, benign, and physiologic, but, on the other hand, with the high malignant potential of the ovary, I think it is mandatory that we obtain a tissue diagnosis for any pathologic presentation. Dr. West implies that the IUCD is a very conspicuous factor in ovarian pregnancy. I must admit that he is right. However, I certainly do not believe that it is an etiologic factor. We have never had an opportunity to observe unprotected aberrant fertility in any of our patients until the introduction of the IUCD. All other methods of contraception have been used over the years and will definitely influence our statistics. With the IUCD, the patient feels that she is protected, but she is not at all protected either from tubal pregnancy or from ovarian pregnancy. Tietze’s statistics showing that the IUCD protects somewhat against tubal pregnancy are not proved. I do not believe they are valid. I do not think that IUCD prevents tubal pregnancies in the slightest degree. Dr. Israel also asks if it is necessary to resect the ovary. In most cases, it certainly is not necessary, but, in the interest of good diagnosis, I think that it is necessary. I have not seen the high incidence of adhesions of the ovary following ovarian surgery that are reported, especially by the Baylor group. If their statistics are true, we should never operate on an ovary unless it is absolutely necessary. I have not seen this to be the case and, as a matter of fact, the ovary ruptures every month with occasional slight bleeding and there are never adhesions at the site of ovulation.
G.
Los Angeles,
HALLATT,
M.D.
Calfomzia
Ovarian pregnancy occurs within the ovary and on the corpus luteum, usually with rupture of the ovary and a massive hemoperitoneum. It presents as a hemorrhagic ovary and is frequently misdiagnosed as a ruptured corpus luteum. It occurs in the highly fertile patient and is often assodated with the use of the intrauterine contraceptive device, which does not prevent the chance occurrence of ovarian pregnancy. (AM. J. OBSTET. GYNECOL. 143:55, 1982.)
is a unique form of ectopic pregnancy that must be documented by the four postulates of Spiegelberg,’ which establish that the pregnancy is in the ovary and does not involve the tube. Ovarian pregnancy is the most common form of abdominal pregnancy, but it must be distinguished from primary peritoneal implantation, which can involve any intraperitoneal site with different problems of diagnosis and management related to the organs involved. The ovary has no peritoneal covering, and the implantation within the ovary results in a predictable sequence of events because of the consistent vascular anatomy of the ovary. This vascularity results in maternal hemorrhage early in the first trimester, which disrupts the pregnancy and usually ruptures the ovary with sufficient hemoperitoneum to require emergency operation. This inherent self-destruction occurs so early that ovarian pregnancy presents surgically as a hemorrhagic ovary and is usually not correctly diagnosed. This study of 25 consecutive cases of documented ovarian pregnancy reveals a consistent pattern of events which makes this rare anomaly of human reproduction more understandable and, therefore, more amenable to diagnosis. The etiology, pathology, incidence, and relation to the use of the intrauterine contraceptive device (IUCD) are discussed. OVARIAN
PREGNANCY
From the Department Southern California
of Obstetrics Pennanente
and Gynecology,
Medical Center.
Presented at the Forty-eighth Annual Meeting of the Pacijic Coast Obstetrical and Gynecological Society, Kauai, Hawaii, September 27-October 3, 1981. Reprint requests: Jack G. Halkztt, M.D., Department of Gynecology, Southern California Permanente Medical Center, 4900 Sunset Boulevard, Los Angeles, California 90027. 0002-9378/821090055+06$00.60/0
0
1982 The C. V. Mosby Co.
Material and analysis Table I summarizes the relevant significant findings of 25 cases of ovarian pregnancy which fulfill Spiegelberg’s postulates. These cases have occurred in patients of the Southern California Permanente Medical Group from 1953 to 1981. The obstetric setting for these cases is seen in Table II, which reveals that there was one ectopic pregnancy for every 113 deliveries overall. Almost 1% of all ectopic pregnancies were documented ovarian pregnancies. There were many cases involving both the tube and ovary, which does not qualify as primary ovarian pregnancy. Several of the abdominal pregnancies involved the ovary. Twenty percent of the ovarian pregnancies were associated with the IUCD, and all occurred in the last 5 years. Table III compares the clinical features of ovarian pregnancy with those of the more common tubal pregnancy. The principal distinguishing features are related to the excellent fertility of the ovarian pregnancy patient and the impaired fertility of the tubal pregnancy patient. This explains the younger age, higher parity, and fewer fertility problems in the ovarian pregnancy patients. The one patient with infertility of 5 years prior to the ovarian pregnancy subsequently had two term intrauterine pregnancies. Vaginal bleeding was common and irregular and followed the same pattern in both groups. Amenorrhea was present in only 17% of tubal pregnancy patients and 16% of ovarian pregnancy patients. Most patients did not suspect that they were pregnant. The IUCD-associated pregnancies did not differ significantly from the other ovarian pregnancies clinically or surgically. The severe pain of hemoperitoneum was identical in both groups and resulted in operation at an earlier gestational age in the ovarian pregnancy than in the 55
56
May 1. 1982 Am. J. Obstet. Gynecol.
Hallatt
Table
I.
Primary
ovarian
pregnancy:
Summary
of significant
findings-25
Daysfrom &Se No.
(Yd
Parity
1953 1954 1956 1957 1961 1962 1962 1963 1966 1966 1967 1968 1968 1969 1970 1973 1974
28 35 26 33 24 24 34 35 28 21 36 27 25 37 25 21 27
2
20 21
1976 1977 1978 1979
33 27 23 35
22 23 24 25
1979 1980 1980 1980
22 27 23 26
1 2
3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18
19
Average
Year
Age
28
1 I 2 0
Contraception
Infertility, 5 yr
3 1 10
2 2 3 5 2 5
1 0 0 0 1 1 2
IUCD, 10 yr IUCD, 7 mo IUCD, 18 mo Tubal ligation, 1973
1 2
1 2
IUCD, 6 mo ILJCD, 3 yr
LNMP to bleeding
cases
pain
Days from LNMP to operation
45
45
Days from LNMP to
30 32 36 37 30 42 28 28 30 28 30 0 30 30 30
51
51
54 44 60 55 45 57 60 51 42 38,49 62 63 63
61 0
61 0
54 44 60 59 45 57 60 51 42 50 62 63 63 68 60
28 32 31 0
31 60
60 61 28 0
74
46 39
61
34 0
2t
LNMP = Last normal menstrual period. TAB = Therapeutic tubal pregnancy. The four cases without hemoperitoneum were not associated with pain. Two were diagnosed by an attempted elective therapeutic abortion, which revealed no villi, but an adnexal mass was present. One case was an incidental finding of a hemorrhagic ovary at a staging operation for Hodgkin’s disease. The fourth case was diagnosed by ultrasound as an ectopic pregnancy in a patient who was treated for a threatened abortion and who had an adnexal mass. Five of the eight ovarian pregnancies occurring in the last 5 years were associated with the IUCD. In the last five years 14% of all tubal pregnancies at the Kaiser Foundation Hospital in Los Angeles were associated with the IUCD. Table IV shows the surgical features of ovarian pregnancy. Operation is performed with the first episode of pain in 68% of ovarian pregnancies but only 34% of tubal pregnancies. This is due to the vascularity of the ovary resulting in a more massive hemoperitoneum at an earlier stage. The hemoperitoneum was over 500 ml in 81% of the ovarian pregnancy patients as contrasted to 51% of the tubal pregnancy patients. The most significant finding in this study was the inability to distinguish the ovarian pregnancy from a bleeding hemorrhagic ovary or ruptured corpus lu-
Hemopen’taeum (4 500+ 500+ 500+ 500+
1,000 1,000 800 800 500 50 2,000 800 2,000 400 600 0 0
60 48 40
300 500+ 500+ 500+
74 87 36 55
300 0 1,500 0
51
740
abortion. POC = Polycystic ovary. teum cyst. A correct surgical diagnosis was made in only 28% of the cases. An embryo was identified in only three of the 25 cases to establish the diagnosis. The entire ovary was removed in nine cases and enucleation or wedge excision was accomplished in 16 cases. The hemorrhagic mass was adjacent to the corpus luteum in all cases. In no case was a so-called intrafollicular ovarian pregnancy within a corpus luteum documented. The only associated pathologic condition was gross pelvic inflammatory disease in two patients, and one patient had had a bilateral tubal ligation six years before. The records of the Los Angeles County/University of Southern California Women’s Hospital were reviewed by the author for ovarian pregnancy and only four cases were identified, during which time interval there were almost 1,200 ectopic pregnancies. If 1% of all ectopic pregnancies are ovarian, there should have been twelve ovarian pregnancies instead of only four.” Because ovarian pregnancy surgically resembles a hemorrhagic corpus luteum, the records of all cases of ruptured corpus luteum with hemoperitoneum at the Women’s Hospital in 1973 were then reviewed by the author. Thirty-four of the 60 patients admitted to the hospital were observed and discharged. Fifteen pa-
Volume Number
143 1
Primary
ovarian
pregnancy
57
Table II. Primary ovarian pregnancy: Obstetric experience,* 1953 to 1981 Surgical
Total deliveries Ectopic pregnancies: With IUCD Ovarian pregnancy With IUCD Tuboovarian pregnancy Abdominal pregnancy
diagnosis
Bleeding corpus luteum Ovarian pregnancy; 7 mm embryo Bleeding corpus luteum Bleeding corpus luteum Bleeding corpus luteum Bleeding corpus luteum Ovarian pregnancy Bleeding corpus luteum Bleeding corpus luteum Ruptured ovarian cyst Bleeding corpus luteum Bleeding corpus luteum Bleeding corpus luteum Ruptured ovarian cyst Ovarian pregnancy; 10 mm embryo TAB; no POC; adnexal mass Hemorrhagic ovary or staging laparotomy for Hodgkin’s disease Bleeding corpus luteum Bleeding corpus luteum Ovarian pregnancy Bleeding corpus luteum
*Southern
California
279,925 2,478 178 25 5 12 13
Permanente
Medical
Group.
Table III. Primary ovarian pregnancy: Clinical features-Tubal and ovarian pregnancy
Average age (yr) Multiparous (%) Infertility (%) Amenorrhea (%) IUCD (%) Average days from
LNMP
1 Tubal
1 Ovarian
30 68 28 17 14 58
28 a4 4 16 20 55
to operation
1 1
Table IV. Primary Surgical features
Bleeding corpus luteum Ectopic pregnancy by ultrasound Bleeding corpus luteum TAB; no POC; adnexal mass
ovarian
pregnancy:
Operation on first day of pain (%) Hemoperitoneum (No. = 21) (%) >500 ml (No. = 17)
68 84 81
Surgical diagnosis (No.): Ovarian pregnancy Hemorrhagic ovary Surgical procedure (%): Oophorectomy Wedge excision or enucleation Location adjacent to corpus luteum
tients had laparoscopy only and no active bleeding was noted from the hemorrhagic ovary. Eleven patients underwent operation which consisted of ,oversewing the bleeding ovary without a tissue diagnosis. None of these
procedures
could
have
diagnosed
an
7 18 36 64 100
(%)
ovarian
pregnancy. This management is consistent with the analysis of 200 cases of operation for ruptured corpus luteum by Hibbard3 from the same institution in 1979.
corpus luteum, which is in the vascular stage of its development. On about the fortieth day of gestation, trophoblastic invasion of maternal ovarian arteries occurs with
Comment In the rabbit the ovulated ovum is always adherent to the ovarian stigma or operculum until mechanically removed by the tubal fimbria. This is presumed to be the physiologic etiology of ovarian pregnancy in the human where ovum migration usually facilitates tubal pickup. The abundant granulosa cells which form the sticky cumulus of the corona radiata of the ovum adhere to the operculum of the ruptured follicle. If there are enough sperm with enough hyaluronidase to lyse the radiata and expose the zona pellucida to sperm penetration, fertilization occurs and the resulting zygote develops. On the sixth day implantation will occur wherever the blastocyst happens to be, as seen in all cases of ectopic pregnancy. If the blastocyst is still adherent to the ovary, implantation is within the ovary and on the
a resulting
hemorrhage
into
the
ovary
and
gesta-
tional sac which disrupts the pregnancy and usually ruptures the capsule of the ovary which has covered the implantation site. Figs. 1 and 2 show the typical appearance of ovarian pregnancy. It is probably not possible for a pregnancy to develop within a corpus luteum which is well developed before implantation can occur. If there is no hemoperitoneum, there may be a transient localized pain which is not severe enough to warrant
operation
and
be resorbed. It has been established pregnancy
patients
do not
the
disrupted
pregnancy
that one third require
operation
will
of ectopic and
there
is complete resorption of the pregnancy.4 How often this occurs in ovarian pregnancy is unknown, but it was documented by the case diagnosed incidental to the Hodgkin’s staging operation as the products of con-
58
Hallatt
May
Am. J. Obstet.
Fig. 1. The appearance pregnancy.
The
capsule
of the hemorrhagic was bursting and
ovary
in ovarian
bleeding.
ception were necrotic and the patient was asymptomatic. For this reason and the fact that ovarian pregnancy is so frequently misdiagnosed at operation, the true
incidence
of this
rare
anomaly
of
human
repro-
duction is unknown. The reported incidence in the literature is 1% of all ectopic pregnancies.’ Every patient with irregular bleeding and ovarian pain or the pain of hemoperitoneum should have a pregnancy test for the beta subunit of human chorionic gonadotropin to diagnose ectopic pregnancy. When a hemorrhagic ovary is found at operation, it should be wedge resectioned or enucleated for a tissue diagnosis. This is a simple procedure which does not impair ovarian function. It is common practice for the gynecologist to enucleate dermoids, endometriomas, and benign ovarian
Fig. 2. The cut section of Fig. 1 shows the hemorrhagic on the periphery of the corpus luteum.
1. 1982
Gpecol.
mass
cysts of any nature, with a normally functioning ovary subsequently. There has been an apparent increase in ovarian pregnancy because of the widespread use of the IUCD, which does not prevent ectopic pregnancy. There have been 28 articles in the last 10 years reporting 44 cases of ovarian pregnancy associated with the IUCD.” The high incidence of tubal and ovarian pregnancy associated with the IUCD is probably a reflection of the true incidence of tubal pregnancy in the unprotected, predisposed patient and of the chance occurrence of the ovarian pregnancy in the unprotected very fertile patient. This chance occurrence is not likely to recur as there were no repeat ovarian pregnancies in this study and none was noted in a review of the world’s literature.
REFERENCES 1. Spiegelberg, 0.: Zur Casuistik der Ovarialschwangerschaft, Arch. Gynaekol. l&73, 1878. 2. Gerin-Lajoie, L.: Ovarian pregnancy, AM. J. OBSTET. GYNECOL. 62:920, 1951. 3. Hibbard, L. T.: Corpus luteum surgery, AM. J. OBSTET. GYNECOL. 135:666, 1979.
Discussion DR. JOHN E. MAYO, Los Angeles, California. Dr. Hallatt has compiled this report based on a large number of patients with ovarian pregnancy. This volume represents an experience with which very few practitioners will become personally acquainted. He has very rightly pointed out to us the necessity of a tissue diagnosis when hemorrhagic corpus luteum or hemorrhagic ovary is the operative diagnosis. Likewise, his advocacy of the more liberal use of the beta subunit serum pregnancy test is certainly appropriate. In his series, the finding of 1% of ectopic pregnancies presenting as
4. Lund, J. J.: Ectopic pregnancy, J. Obstet. Gynaecol. Br. Emp. 62:1, 1955. 5. McMorries, K., Lofton, R. H., Stinson, J. C., and Cummings, R. V.: Is the IUD increasing the number of ovarian pregnancies? Contemp. Ob/GYN 13:165, 1979.
ovarian pregnancy is within the range found in the literature.‘, 2 The findings that 26% of the patients with ovarian pregnancy are primigravid and that the average age was 28 are also consistent with those of other reports.* His finding of 2.8% (51178) ovarian pregnancies compared to all other ectopic pregnancies in women using the IUD is low compared to that in other reports. 3-5 Perhaps this reflects a greater incidence of infertility in his population. This may also account for the slightly increased incidence of ectopic gestation in his series (0.91%) as compared to about 0.5% found in other large, racially mixed studies from the United
Volume Number
143 1
However, in recent years the occurrence of ectopic pregnancy is increasing, and this makes the time frame of data collection important when series are compared. There are several comments I would like to make in reference to Dr. Hallatt’s remarks that IUCDs do not prevent ectopic pregnancy; that ovarian pregnancy occurs in the fertile patient in contrast to tubal ectopic pregnancy, which is associated with impaired fertility; and that the high incidence of tubal and ovarian pregnancy associated with the IUD is probably a reflection of the true incidence of tubal pregnancy in the unprotected, predisposed patient and the chance ovarian pregnancy in the unprotected, highly fertile patient. The finding of only two patients in the ovarian pregnancy group with evidence of tubal inflammatory disease at operation certainly supports the conclusion that this type of ectopic gestation occurs in the fertile patient. However, it is difficult to make firm comparisons because the statistical significance of the figures is not presented, and the criteria upon which the decision was made to classify a patient as fertile or infertile are not given. This is especially true in the tubal pregnancy group. Other fertility factors including the use of all forms of contraceptives are very important. All of these factors and others, which are obviously operative, make conclusions about the incidence of tubal or ovarian pregnancy associated with various fertility states and IUD usage very difficult. In order to draw these conclusions, a well-controlled, statistical study is necessary. In this regard, I would like to present what seems to me to be some salient points made in the literature. Lehfeldt and associates4 studied the data from the cooperative statistical program. Based on 45,000 woman years of experience with the IUD and a projected 180,000 fertilized ova, they expected to find 900 ectopic pregnancies, five of which would be ovarian. In reality, they found 42 tubal pregnancies and five ovarian pregnancies. They concluded that the IUD is 99.5% effective in preventing intrauterine pregnancies and 95% effective in preventing tubal ectopic gestation but has no protective influence against ovarian implantation. Ory,6 in a collaborative, multicenter, case-controlled study designed to examine the occurrence of ectopic pregnancy related to the use of the IUD, concluded: (1) Current use of any form of contraceptive, including IUD, decreases one’s risk of ectopic pregnancy. (2) Among current users of contraceptives, IUD users have three times the risk of ectopic pregnancy as users of oral contraceptives and about the same risk as users of traditional contraceptives. If a woman changes from oral contraceptives to an IUD, her increased risk of having an ectopic pregnancy is not due to the presence of an IUD; rather, it is due to the absence of oral contraceptives. (3) Women who use the IUD for 25 or more months have about three times the risk of ectopic pregnancy as women who use it for a lesser period of time. After 24 months of IUD use, the risk remains States.’
Primary
ovarian
pregnancy
59
constant and is still only as high as it is in women who have never used the IUD. (4) This study strongly suggests that the IUD is not responsible for any part of the recent tripling of ectopic pregnancies in the United States. A more likely explanation of the tripling is a marked increase in pelvic inflammatory disease that has occurred in recent years in the United States. This epidemic created a large number of women who had as much as six times the risk of ectopic pregnancy compared to women who have never had pelvic inflammatory disease. REFERENCES 1.
Pivers, M. S., Baer, K. A., and Zachery, pregnancy and intrauterine device, JAMA
T. V.: Ovarian 201:107, 1967. H. K.: Ovarian pregnancy: Report Loop in situ, Acta Obstet. Gynecol.
2. Bjorn, G., and Jensen, of a case with Lippes’ Sand. 49:297, 1970. 3. Vessey, M. P., Johnson, B., et al.: Outcome of pregnancy in women using an intrauterine device, Lancet 1:495, 1974. 4. Lehfeldt, H., Tietze, C., and Gorstein, F.: Ovarian pregnancy and the intrauterine device, AM. J. OBSTET. GYNECOL. 108:1005, 1970. G., Lancet, M., and Czernobilsky, B.: Ovarian preg5. Graff, nancy with intrauterine device in situ, Obstet. Gynecol. 40:535, 1972. 6. Ory, H.: Ectopic pregnancy and intrauterine contraceptive device: New perspective, Obstet. Gynecol. 57:173, 1981.
DR. S. GAINER PILLSBURY, Long Beach, California. Dr. Hallatt has again demonstrated his interest in ectopic gestation by collecting the largest series of ovarian pregnancy to be found in the literature. This condition is a rare one, however, and his data suggest that one ovarian pregnancy will occur for every 100 ectopic pregnancies, with an incidence of 1 in every 11,300 deliveries. To my knowledge, I have never seen a case, and a physician might not encounter one during a lifetime of a relatively busy practice. It is an extremely interesting entity, however, and should be kept in mind when one is considering the differential diagnosis in a patient suspected of having a tubal pregnancy or a bleeding corpus luteum. Speigelberg’s criteria for diagnosing an ovarian pregnancy should be strictly adhered to. Some investigators have recently suggested that many cases of tubal pregnancy are associated with microscopic foci of endometriosis. I would like to ask Dr. Hallatt if any of his cases showed evidence of ectopic endometrial tissue in the ovary. Although none occurred in this series, there are several authentic cases reported in the literature where ovarian pregnancies have gone to the stage of fetal viability. As with other cases of abdominal pregnancy, most are not diagnosed prior to operative delivery, but apparently the ovary can accommodate a developing pregnancy better than a tube can. The availability of a test for the beta subunit of human chorionic gonadotropin and ultrasound have
60
Hallatl
enabled the earlier diagnosis of ectopic gestation. Since there is a high incidence of spontaneous resolution of early ovarian pregnancy and since the gross appearance of this condition closely resembles a corpus luteum cyst, I wonder whether Dr. Hallatt would insist on a tissue diagnosis if at the time of laparoscopy an ovarian “cyst” were found which was not bleeding or which had minimal bleeding that could be controlled by coagulation. Dr. Hallatt’s report will be a valuable addition to the literature on ectopic gestation. DR. RODNEY WEST, Honolulu, Hawaii. Two things in the paper come to my attention. First, in the first 23 years there were no cases of ovarian pregnancy in a patient using an IUCD. Second, in the last five years, 62% of the cases occurred in patients using IUCDs. Also, the total incidence of numbers of abdominal pregnancy has doubled in the last five years, as compared with the first 23 years. My question is: Is the incidence of ovarian pregnancy, in relation to the number of deliveries, the same during the last five years as it was during the first 23 years? IUCDs were used before the last five years, so I am wondering if the type of IUCD used has made a difference. I know some of these figures are not statistically significant, but I think they do leave a trail which should be followed. DR. ROBERT ISRAEL, Los Angeles, California. I wouid like to mention the results obtained in the Collaborative Study Project of 30,000 women and 45,000 woman years in which the actual number of pregnancies that occurred as an IUD failure is compared to the expected number of pregnancies if no contraception had been utilized. The data show that the IUD reduces intrauterine pregnancies very well, tubal pregnancies less well, and ovarian pregnancies not at all. The theory behind all this, of course, is that the IUD acts locally in the uterus, has a minimal effect on the fallopian tube, and has no effect whatsoever on a distant structure, the ovary. To back up the previous speaker’s comments, I have a question for Dr. Hallatt. I respect his surgical ability, but I still wonder if it is necessary and/or safe to resect every corpus luteum. I congratulate him that he has had no complications in the resections he has performed. However, others have reported complications following conservative ovarian surgery. Both Kistner and the Baylor group have reported the development of periovarian adhesions following conservative ovarian surgery in young women wishing future fertility. In addition, what happens to an unsuspected intrauterine pregnancy with the elimination of its supportive corpus luteum? DR. DAVID C. FIGCE, Seattle, Washington. I would simply like to remind our group that none of the subdisciplines of our specialty is immune to an encounter with the ovarian pregnancy. Our most recent case, occurring within the past 12 months, was diagnosed without the presence of hemoperitoneum but with the
May 1, 1982 Am. J. Obstet. Gynecol.
finding of a persistent adnexal mass, observed over a period of 5 weeks. At the time of celiotomy, the gross appearance was quite suggestive of a malignant ovarian tumor and only upon cut section was the diagnosis established. DR. HALLA-IT (Closing). Dr. Pillsbury mentioned the possibility of endometriosis as an etiologic factor. This, of course, is very tempting because the fertilized ovum or zygote cannot distinguish whether endometrium is in the uterus or in the tube or in an aberrant location. The first time this idea was introduced, it was felt to be very valid. However, it was found, on closer survey, that the endometriosis was nothing but decidual reaction, and of course there is florid decidual reaction in very early pregnancy, involving practically every abdominal organ. I do not think endometriosis is a factor and there was no evidence of any endometriosis in any of my cases. It is a fascinating fact that in the tubal pregnancies there is a lower incidence of endometriosis then we find in the normal population. Dr. Pillsbury suggests the possibility that a tissue diagnosis may not be necessary and this is indeed true. If you read between the lines, it is obvious that oversewing will probably cure ovarian pregnancy. I hesitate to mention this, because I do not think we should do it, because I feel that a hemorrhagic ovary requires a diagnosis. It may look like a corpus luteum, which we know to be innocent, benign, and physiologic, but, on the other hand, with the high malignant potential of the ovary, I think it is mandatory that we obtain a tissue diagnosis for any pathologic presentation. Dr. West implies that the IUCD is a very conspicuous factor in ovarian pregnancy. I must admit that he is right. However, I certainly do not believe that it is an etiologic factor. We have never had an opportunity to observe unprotected aberrant fertility in any of our patients until the introduction of the IUCD. All other methods of contraception have been used over the years and will definitely influence our statistics. With the IUCD, the patient feels that she is protected, but she is not at all protected either from tubal pregnancy or from ovarian pregnancy. Tietze’s statistics showing that the IUCD protects somewhat against tubal pregnancy are not proved. I do not believe they are valid. I do not think that IUCD prevents tubal pregnancies in the slightest degree. Dr. Israel also asks if it is necessary to resect the ovary. In most cases, it certainly is not necessary, but, in the interest of good diagnosis, I think that it is necessary. I have not seen the high incidence of adhesions of the ovary following ovarian surgery that are reported, especially by the Baylor group. If their statistics are true, we should never operate on an ovary unless it is absolutely necessary. I have not seen this to be the case and, as a matter of fact, the ovary ruptures every month with occasional slight bleeding and there are never adhesions at the site of ovulation.