Endometriosis-related pneumothorax after in vitro fertilization embryo transfer procedure : a case report

In October 2006, a 32-year-old woman presented with dyspnea and acute right-sided chest pain. Her clinical history was negative except for a mild pain located on the right side of the back close to the scapula, associated with a cough recurring every menses for 5 years. She underwent an unsuccessful IVF-ET cycle 2 weeks before. In August 2006, she started the hormone therapy and was initially placed on a gonadotropin-releasing hormone agonist to suppress the pituitary activity. Then she received follitropin alpha starting from a fixed daily dose of 150 IU to obtain controlled ovarian hyperstimulation. Finally, chorionic gonadotropin at a dose of 10,000 IU was administered to induce the ovulation. Thirteen oocytes were obtained and 2 fertilized, and 2 were implanted according to Joint Society of Obstetricians and Gynecologists of Canada–Canadian Society of Fertility and Andrology Guidelines. 4 When she presented to the Thoracic Surgery Unit, Ospedale San Paolo, a chest radiograph revealed a complete right pneumothorax. A chest tube was inserted, and the lung was fully reexpanded. However, air leaks persisted for 7 days, and she underwent surgery. During the operation, a 3-port thoracoscopy was performed. There were no pleural adhesions. On the dorsal parietal pleura ( Figure 1) at the level of the scapula and on the tendinous center of the diaphragm ( Figure 2), some tiny blue brown nodules were detected. They were suspected to be endometriosis, as confirmed by frozen biopsy sections. The diaphragm was accurately inspected, and no holes were found to be present ( Figure 2). Moreover, when pulling the diaphragm by forceps, no air was found to be passing through it and the intra-abdominal vacuum persisted. At the apex of the inferior lobe, some blebs were found that appeared to have ruptured. They were removed by stapler. No endometriosis was identified on the parenchyma specimen during histologic study. Pleural and diaphragmatic endometrial foci were coagulated by argon plasma and removed. Pleural abrasion was performed in association with partial pleurectomy corresponding with the internal surface from the first to sixth rib. The clinical course was uneventful, and the patient was discharged on the sixth postoperative day.