I presented this presentation in 22nd all india conference of Assisted Reproduction-ISAR 2017,Gurgaon,Hariyana on 22nd April,2017

1. • The young, enthusiastic and energetic chief
consultant at Rupal Hospital For Women,
Surat, India for last 18 years
• Medical director and IVF consultant at
Blossom IVF Centre,Surat,India
• Diploma in Reproductive Medicine from Kiel,
Germany
• Intense training in Advanced infertility
treatment at numerous workshops and
conferences in USA and Europe.
• Specialized in all kind of gynec endoscopic
surgeries.
• Invited as a faculty in various state,national and
international conferences.
• Promotes health awareness by conducting
Seminars and writing articles and specialty
related books
• In addition of being techno-savvy person, she
loves making friends, and keenly interested in
music and Guajarati literature. She is actively
associated with the leading cultural club of
Surat-Tarbatar.
Dr Rupal N Shah
M.D.(OBGYN)
Diploma in Reproductive Medicine
(Germany)
04/30/17 Dr Rupal Shah-ISAR 2017 1

2. Managing cysts other than
endometriomas
Dr Rupal N Shah
M.D;D.G.O
Diploma in Reproductive Medicine,Germany
Rupal Hospital For Women &
Blossom Fertility and IVF Centre
Surat, Gujarat

3. The relationship
between ovarian
cysts and infertility is
a subject of debate,
mainly because it is
difficult to
determine the real
impact of the cyst
and its treatment on
later fertility.04/30/17 Dr Rupal Shah-ISAR 2017 3

4. The management of ovarian cysts in an
infertile woman raises two questions:
1. Do these cysts impair
the prognosis of
assisted reproductive
technologies (ART)?
2. How does treatment
of a cyst affect these
results?
These two questions
obviously depend on
various factors,
including the size,
number, and
histologic type of
cysts.
04/30/17 Dr Rupal Shah-ISAR 2017 4

5. Ovarian Cysts in Reproductive Age
● Functional cysts
○ follicular cysts
○ cysts following GnRH agonist treatment 24%
○ corpus luteum cysts
○ theca lutein cysts
•Hemorrhagic cysts
● Benign cystic teratoma (Dermoid)
● Endometrioma 70%
•Cystadenomas-Serous /mucinous
● Malignant cyst 6%
04/30/17 Dr Rupal Shah-ISAR 2017 5

6. Diagnosis
04/30/17 Dr Rupal Shah-ISAR 2017 6

7. Ultrasonography
Transvaginal US, with
transabdominal US as
needed, remains the
primary, and in most cases
the preferred, imaging
modality to evaluate ovarian
cysts.
Society of Radiologists in
Ultrasound Consensus
Conference Statement1,201004/30/17 Dr Rupal Shah-ISAR 2017 7

8. Doppler Ultrasound
Doppler ultrasound assessment of cyst wall
blood flow does not always appear to
differentiate between benign and malignant
ovarian cysts. This is probably because of the
presence of neo-angiogenesis in both malignant
and functional tumors.
04/30/17
Malignant Benign
Dr Rupal Shah-ISAR 2017 8

9. Other Imaging Modalities
Computed tomography (CT) scan and magnetic
resonance imaging (MRI) is reserved for cases with
suspicion for malignancy.
Routine use of computed tomography and MRI for
assessment of ovarian masses does not improve the
sensitivity or specificity obtained by transvaginal
ultrasonography in the detection of ovarian
malignancy.
RCOG Green-top Guideline No. 62,2011
04/30/17 Dr Rupal Shah-ISAR 2017 9

10. Evaluation of ovarian reserve
When evaluating a patient with an ovarian cyst
undergoing ART treatment, we should assess
her ovarian reserve.
It helps us to tailor the best treatment option
for the specific patient.
04/30/17 Dr Rupal Shah-ISAR 2017 10

11. AMH
• Reduced ovarian reserve as measured by
serum levels of AMH may contraindicate
surgical management in the specific patient.
• Pre-operative and post-operative AMH levels
may be used as a tool for evaluating ovarian
damage after surgery.
Gnoth, C., et al. (2008)
04/30/17 Dr Rupal Shah-ISAR 2017 11

12. Tumour Markers
• Serum CA-125 does not need to be undertaken
in all infertile women with USG diagnosis of a
simple ovarian cyst of < 5 cms.
• CA-125 in the reproductive age rises in
fibroids, endometriosis, adenomyosis and
pelvic infections.
So, it is an unreliable marker for differentiating
benign from malignant masses and not
helpful at all in D/D of benign cysts
04/30/17 Dr Rupal Shah-ISAR 2017 12

13. Tumour Markers
Lactate dehydrogenase
(LDH), α-FP and hCG
should be measured in all
women under age 40 with a
complex ovarian mass
because of the possibility of
germ cell tumours.
RCOG Green-top Guideline
No. 62,2011
04/30/17 Dr Rupal Shah-ISAR 2017 13

14. Management and follow up of cysts
other than endometrioma
04/30/17 Dr Rupal Shah-ISAR 2017 14

15. Functional Cysts
Round or oval anechoic space with smooth thin
walls, posterior acoustic enhancement, no solid
component or septation, and no internal flow at
color Doppler US.
04/30/17 Post acoustic enhancementDr Rupal Shah-ISAR 2017 15

16. Functional cysts
• Benign and usually asymptomatic
• Do not require any treatment.
• Follow-up and repeated scans will usually
confirm spontaneous resolution of the cysts.
• This is not the case when the cyst is large and
may interfere with fertility treatments and in
vitro fertilization (IVF).
• Simple cysts up to 10 cm are highly likely to be
benign, with malignancy rates of less than 1%
04/30/17 Dr Rupal Shah-ISAR 2017 16

17. Functinal Cysts-Follow Up
• Cysts 􏰁</= 5 cms: Do not need follow-up.
• Cysts >5 and </=􏰁7 cms: Yearly follow-up
with US recommended.
• Cysts >7 cms: Further imaging with magnetic
resonance (MR) or surgical evaluation
Levine, D., et al. (2010) Society of Radiologists in Ultrasound
Consensus Conference Statement1
04/30/17 Dr Rupal Shah-ISAR 2017 17

18. Cysts following GnRH agonist treatment
• may be of no clinical significance or may
negatively influence its outcome
Qublan, H.S., et al. (2006)
Mechanism
• primary flare-up caused by the GnRHa
affecting gonadotropins;
• the persistence of a follicular or corpus
luteum cyst formed in the preceding cycle
(Rizk 2009)
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19. Management in relation to ART
Transvaginal cyst aspiration
safe and straightforward approach
04/30/17 Dr Rupal Shah-ISAR 2017 19

20. Insufficient evidence to determine whether
drainage of functional ovarian cysts prior to COH
influences live birth rate, clinical pregnancy rate,
number of follicles recruited, or oocytes
collected.
04/30/17 Dr Rupal Shah-ISAR 2017 20

21. 04/30/17 Dr Rupal Shah-ISAR 2017 21
Despite of this proven insufficient advantages
,trans-vaginal Ultrasonography guided cyst
aspiration is often performed in cysts more
than 2 cms ,before starting ovarian
stimulation.
Cycle cancellation rate of 2.2% in the cyst
aspiration group and 14.9% in the
conservatively managed group
Firouzabadi et al,2010

22. Medical Management
• The use of the combined oral
contraceptive pill does not promote the
resolution of functional ovarian cysts.
• Combined oral contraceptives may be
used to prevent the reccurrence of these
cysts.
RCOG Green-top Guideline No. 62,2011
04/30/17 Dr Rupal Shah-ISAR 2017 22

23. • Ovarian surgery for benign cysts significantly
reduces folliculogenesis.
• Adverse effect on ovarian response to
stimulation with gonadotrophins and on the
results of fertility therapy
04/30/17 Dr Rupal Shah-ISAR 2017 23

24. Hemorrhagic ovarian cyst.
• Complex cystic mass with a
reticular pattern of internal
echoes (also known as fishnet,
cobweb, spiderweb, or lacy
appearance) and/or a solid-
appearing area with concave
margins.
• No internal flow at color
Doppler US, and usually
circumferential flow in the
wall of the cyst
04/30/17 Dr Rupal Shah-ISAR 2017 24

25. Hemorrhagic ovarian cyst
Follow up
Formed because of occurrence of bleeding into
a follicular or corpus luteum cyst.
•Cysts 􏰁</=5 cms: Do not need follow-up.
•Cysts >5 cms: Short-interval follow-up (6–12
weeks) with US recommended to ensure
resolution.
Typically resolve within 8 weeks
•.04/30/17 Dr Rupal Shah-ISAR 2017 25

26. Hemorrhagic Ovarian cyst
Surgical Intervention
• Large persistant cysts greater than 5
cm
• Severe persistent abdominal pain
• Occurrence of complications such as
rupture and ovarian torsion
• High WBC count and low
hemoglobin level.04/30/17 Dr Rupal Shah-ISAR 2017 26

27. Benign cystic teratoma (Dermoid)
• fat-fluid level
• intra-cystic floating balls
• focal or diffuse hyperechoic
components
• hyperechoic lines and dots,
• area of acoustic shadowing,
• tip of the iceberg sign ,with no
internal flow at color Doppler
US04/30/17 Dr Rupal Shah-ISAR 2017 27

28. Benign cystic teratoma (dermoid cyst)
Management
• Dermoid cyst, especially smaller than 6 cm,
can be followed conservatively.
O’Neill, K.E. and Cooper, A.R. (2011)
• Followed with US at an initial interval of
between 6 months and 1 year, regardless of
age, if they are not removed.
• No medical treatment
04/30/17 Dr Rupal Shah-ISAR 2017 28

29. 04/30/17
Ovarian dermoid cyst excision could significantly reduce ovarian
reserve to a similar extent as the cyst itself. The presence or
resection of dermoid cysts will not affect the main IVF outcomes.
Dr Rupal Shah-ISAR 2017 29

30. Benign epithelial cysts
• Cystadenomas may not always lead to
infertility. However, they do present the risk
of turning cancerous and hence, treating them
is a wise approach.
• A growing cystadenoma can lead to adhesions
or septations in the ovarian tissues that can
impair the ovulation cycle and disrupt the
secretion of ovarian hormones.
04/30/17 Dr Rupal Shah-ISAR 2017 30

31. Serous cystadenoma
Ultrasound
•Usually seen as a unilocular
cystic lesion,ocassionally with
septations
•Papillary projections are absent
MRI
•Unilocular thin walled adnexal
cyst. MRI may show a beak sign
which may suggest an ovarian
origin
•
04/30/17 Dr Rupal Shah-ISAR 2017 31

32. Mucinous cystadenoma
Ultrasound
• Large cystic adnexal
mass,multilocular with numerous thin
septations
•loculations may contain low-level
internal echogenicity due to increased
mucin content
MRI
• large multilocular cysts containing
fluid of various viscosity- “stained
glass” appearance.
04/30/17 Dr Rupal Shah-ISAR 2017 32

33. Benign Cystadenoma-Management
• Conservative approach of ovarian cystectomy
to retain functioning ovarian tissue ,for future
conception.
• Complete excision is must to minimize
recurrence
• Laparoscopic fertility sparing ovarian
cystectomy is safe and effective.
04/30/17 Dr Rupal Shah-ISAR 2017 33

34. Malignant ovarian cysts
• Incidence:
0.4–8.9/100 000(reproductive age group)
Germ cell tumours most common,followed by
epithelial cells and metastatic
• Symptoms:
abdominal bloating, abdominal and pelvic
pain, and early satiety and appetite changes
• Physical examination
an irregular, solid, fixed and nodular mass or a
bilateral finding. The presence of ascites04/30/17 Dr Rupal Shah-ISAR 2017 34

35. Malignant ovarian cyst
• Thick septations (􏰂3 mm) & solid elements
• flow at Doppler US, and focal areas of wall
thickening (􏰂3 mm)
• Omental or peritoneal masses,
• ascitic fluid in the pelvis
• A cyst with a nodule that has internal
blood flow
No follow-up imaging but , should be
considered for surgical evaluation.
Society of Radiologists in Ultrasound Consensus
Conference Statement1,201104/30/17 Dr Rupal Shah-ISAR 2017 35

36. • Usually, in reproductive age group ovarian tumors
are low-stage and low-grade.
• Borderline tumours can be operated conservatively
at all stages.
• Conservative surgical approaches for ovarian
tumours after surgical staging includes,
cystectomy, unilateral salpingo-oophorectomy and
unilateral salpingo-oophorectomy plus contralateral
cystectomy.
04/30/17 Dr Rupal Shah-ISAR 2017 36

37. • fertility saving surgery can be performed
safely in germ cell, borderline and early stage
epithelial ovarian tumours in selected cases.
• Spontaneous pregnancy rates following
fertility saving surgery has been reported as
60-88%. Because of this ,over-treatment of
these patients for fertility should be
avoided.
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38. Surgical Management of ovarian cysts
04/30/17 Dr Rupal Shah-ISAR 2017 38

39. Surgical Management
Only when tissue diagnosis is necessary
or when the ovarian cyst interferes with
oocyte retrieval or ovarian stimulation.
04/30/17 Dr Rupal Shah-ISAR 2017 39

40. Which surgical method?
• When surgical management is indicated, the
laparoscopic approach should be
undertaken.
• Laparotomy occasionally be necessary in
women with a large cyst, if there is suspicion
of malignancy or if the patient is unfit for
laparoscopy because of obesity or extensive
abdominal scarring following previous
surgery.
04/30/17 Dr Rupal Shah-ISAR 2017 40

41. SURGICAL TECHNIQUES OF
CYSTECTOMY (EXCISION)
• Laparoscopy Gold standard .
• Bipolar energy should be
preferred to monopolar.
• coagulation of the cyst walls
should be avoided.
• No differences in benefits for
fertility between bipolar
coagulation and hemostatic
suture of the ovary.(Ferrero S,
Venturini PL,J. Minim Invasive
Gynecol 2012;19:722–30.)
04/30/17 Dr Rupal Shah-ISAR 2017 41

42. single-center retrospective study of 17 excisions of non-
endometriotic cysts that averaged 37 mm (one serous and
seven dermoid cysts) found that after excision, compared
with a healthy ovary, ovarian reserve decreased in volume by
40%; the number of dominant follicles also decreased
The ovarian reserve should be assessed prior to
the procedure and if severely reduced,
surgery may be deferred in order to decide for
further treatment options.
04/30/17 Dr Rupal Shah-ISAR 2017 42

43. Significantly greater decrease in the AMH rate
after cystectomy for the seven
nonendometriotic cysts (one mucinous and six
dermoid)
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44. •A recent randomized trial compared two
different techniques (mesial incision vs.
antimesial incision) for the risk of a dermoid cyst
rupture.
•The authors sought as a secondary objective to
analyze the impact on fertility of these two
techniques and reported that ,
FSH levels decreased less at 3 months and 12
months when the incision was mesial.04/30/17 Dr Rupal Shah-ISAR 2017 45

45. • After the surgical removal of an ovarian cyst,
the resulting defect in the ovarian surface
may either be closed with sutures, treated
with bipolar cautery or left open to heal.
• No method has been clearly shown to be
superior in terms of healing and postoperative
adhesion formation.
04/30/17 Dr Rupal Shah-ISAR 2017 46

46. Straightforward messages…
● Conservative management ,where possible.
● Use of laparoscopic techniques where
appropriate, thus avoiding laparotomy where
possible
● Referral to a gynaecological oncologist where
appropriate.
RCOG Green-top Guideline No. 62
04/30/17 Dr Rupal Shah-ISAR 2017 47

47. www.www. blossomivfblossomivfindia.comindia.com04/30/17 Dr Rupal Shah-ISAR 2017
THANK
YOU
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