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      • Ovarian Cysts and IVF

      Dr. Geoffrey Sher Recommends

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      “Functional ovarian cysts” are literally nothing more than ovarian follicles that become enlarged, dilated and distended with fluid. They acquire special relevance when detected in women about to undergo controlled ovarian hyperstimulation (COH) with gonadotropins where they can literally, “throw a wrench in the works,” causing a slight delay, postponement or even a cancellation of the cycle of treatment.

      Ovarian cysts may be either “functional cysts” or “cystic tumors”. Functional cysts grow in response to a sustained elevation in blood levels of luteinizing hormone (LH) and/or follicle stimulating hormone (FSH), whether produced by their own pituitary glands or administered to them. By definition, tumors (in contrast with “functional” ovarian cysts) are capable of independent growth, thus cystic ovarian tumors do not respond to gonadotropin stimulation. It is this that distinguishes them from “functional” ovarian cysts. It follows that “functional” ovarian cysts may develop as a result of non-physiological, sustained pituitary gonadotropin stimulation or as a result of prolonged administration of gonadotropins (e.g. Folistim, Gonal F, Puregon, Bravelle, Menopur or Repronex).

      Aside from causing menstrual dysfunction such as a delay in the onset of bleeding, irregular cycles, and mild lower abdominal discomfort, unruptured “functional” cysts are usually relatively non-problematic. In some cases, such functional cysts undergo rapid distention (often as a result of a minor degree of bleeding inside the cyst itself) and the woman will experience a sharp or aching pain on one side of her lower abdomen and/or deep seated pain during intercourse. They may even rupture, causing the sudden onset of severe lower abdominal pain, which may simulate an attack of acute appendicitis or even a ruptured ectopic (tubal) pregnancy. While very unpleasant, a ruptured “functional” cyst hardly ever produces a degree of internal bleeding that warrants surgical intervention. The pain, which is made worse on movement, almost always subsides progressively over a period of four to five days.

      Whenever an ovarian cyst is detected (usually by ultrasound examination), the first consideration should be to determine whether it is a “functional” cyst or a cystic ovarian tumor. The reason is that tumors are subject to a variety of complications such as twisting (torsion), hemorrhage, infection and even malignant change, all of which will require surgical intervention.

      Gonadotropin releasing hormone agonists (GnRHa) such as Lupron, Buserelin, Nafarelin and Synarel, administered daily, starting a few days prior to menstruation, all elicit an initial and rapid, out-pouring (“surge”) of pituitary LH and FSH release. This “surge” lasts for a day or two. Then, as the pituitary reservoir of FSH and LH becomes depleted, the blood FSH and LH levels fall rapidly, reaching near undetectable concentrations within a day or two. At the same time, the declining FSH results in a drop in blood estradiol (E2) concentration, leading to a withdrawal bleed (menstruation).

      The progressive exhaustion of pituitary FSH/LH along with the decline in blood E2 is referred to as “down-regulation.” The continued daily administration of GnRHa or its replacement with a GnRH antagonist (e.g. Ganirelix, Cetrotide or Orgalutron) results in blood LH concentrations being sustained at a very low level throughout the ensuing cycle of controlled ovarian hyperstimulation (COH) with gonadotropins, thereby optimizing follicular maturation and promoting E2 induced endometrial proliferation.

      Regardless of whether down-regulation with GnRHa is initiated while the woman is taking birth control pills (BCPs) or by starting treatment on day 20-23 (the mid luteal phase) of a natural cycle, the initial FSH/LH “surge” sometimes so accelerates follicular growth that it leads to the development of one or more “functional” ovarian cysts. These cysts release E2 and cause the blood E2 often to remain elevated (>70pg/ml). Depending on the extent of this effect, it sometimes leads to a delay in the onset of menstruation and thus also in the initiation of ovarian stimulation with gonadotropins. While in most cases, further continuation of GnRHa therapy (with sustained suppression of FSH/LH) would ultimately (within a week or two) lead to absorption and disappearance of functional cysts followed by menstruation, delaying COH can have drawbacks. This is because prolonged uninterrupted GnRHa therapy can blunt subsequent ovarian follicular response to gonadotropins. Thus, it is not good policy to continue GnRHa administration for much longer than 14 days prior to initiating COH.

      Failure of menstruation to commence within 4-7 days of initiating treatment with GnRHa suggests a potential underlying “functional”ovarian cyst and calls for an ultrasound examination to make the diagnosis. Once diagnosed, there are two therapeutic options, depending upon the number and size of cysts detected.: 1) wait to see whether the cyst will absorb spontaneously within a few days or, 2) immediately resort to needle aspiration of the cyst(s) under local anesthesia. My preference is to perform needle aspiration, sooner rather than later in such cases. Menstruation will usually follow a successful aspiration within 2-4 days. Upon menstruation, a blood E2 level is measured. Provided it is less than 70pg/ml, COH can be initiated.

      “Functional” ovarian cysts do not present a serious health hazard. Almost without exception, they will spontaneously resolve within 4 to 6 weeks, while “cystic tumors” will not. Accordingly, the persistence of any ovarian cyst for longer than 6 weeks should raise suspicion that you are dealing with a tumor rather than with a “functional” cyst. Since ovarian tumors can be malignant (or might later undergo malignant change), all ovarian cysts that persist for longer than 6 weeks (whether in non-pregnant or pregnant women), should be treated by surgical removal, followed by pathological analysis.

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      21 Responses to “Ovarian Cysts and IVF”

      1. melissa says:
        October 22, 2009 at 11:20 am

        I have recently posted regarding OHSS and a failed IVF.

        I underwent ER 24 days ago and ET 22 days ago. I had a negative Beta 9 days ago and have had a very heavy menstrual cycle since that same day that lasted for 7 days.

        The reason for my question is the following: since last night (day 9 of my cycle) I have been experiencing a strong pain on my right side (ovary and Fallopian tube). I have also started will dark-brown spotting today.

        The pain is getting worse and I fear that I may have a cyst.I have had a functional cyst in the past on my right ovary, though I never felt any pain; it was detected via ultrasound and disappeared after a few months.

        I have endometriosis and usually experience painful periods, yet ironically, this last cycle after IVF had little to no pain. This pain is distinct and I don't know if I should go to see my specialist or see if the pain dissipates. Any ideas on what this could be?

        Thanks as always!

        Reply
      2. Geoffrey Sher, MD says:
        October 22, 2009 at 11:50 am

        Indeed. It sounds like you have another cyst or an endometrioma is developing on that ovary. Have it see to ASAP.

        Good luck!

        Geoff Sher

        Reply
      3. melissa says:
        October 27, 2009 at 3:04 pm

        Update and help:

        I went in and it they repeated my BCHG and checked my hemoglobins and did a vaginal ultrasound. The Beta turned out positive-over 700! You can imagine my surprise and concern. I had had a negative Beta and a 7 day heavy period.

        I ended up having laparascopy and they found the pregnancy (is it called fetus in this case?) in the tube, close to my ovary.

        My doctor cannot be sure if the ectopic pregnancy was a result of the IVF or if it occurred naturally due to the location. It is very rare, according to your ART book, to even have IVF result in an ectopic, especially in that portion of the tube.

        I need an answer, but fear that I will never get it. My RE is highly skilled, but error is possible.

        How can my long and heavy period be explained prior to the pain that I had.

        Sorry, so many questions, but this was shocking to say the least!

        Reply
      4. Geoffrey Sher, MD says:
        October 27, 2009 at 3:49 pm

        This is most likely ther consequence of IVF. However, it happens 1: 30 IVFF pregnancies and is not due to a "mistake" or "an error". It is unavoidable. In fact the chance of this happening again remains 1:30, following IVF.

        The prolonged period of bleeding before onset of pain is also quite expected and has no special significance.

        Good luck!

        Geoff Sher

        Reply
      5. melissa says:
        October 27, 2009 at 3:57 pm

        Thank you, Dr. Sher.

        I do have endometriosis which I know causes a higher chance of ectopic in natural cycles.

        I suppose it was my doctor's questioning because of the location, though he said it could be possible.

        Many people say that I should be positive as this indicates that I can get pregnant, well I can assure you that is the last thing I am feeling.

        Time to take a break. My RE also concurs that I need to take some time to heal,etc and then take the next step.

        How soon after ectopic pregnancies do you recommend your patients wait to TTC (either naturally or with IVF).

        Thank you again, you are so gracious to answer all of our questions and to give us a little piece of mind!

        Reply
      6. Geoffrey Sher, MD says:
        October 27, 2009 at 4:16 pm

        Its of course your call but all you need is 1 month regular cycle between.

        Good luck!

        Geoff Sher

        Reply
      7. ImaMommy says:
        November 17, 2009 at 7:06 pm

        I presented with an ovarian cyst on Day 2 of what was suppossed to be the 3rd month of meds for an IVF. The previous month I aimed for IVF and was shocked to get the call 2 days before retrieval that I was being converted to IUI, due to "only 4-5 mature follicles b/t 16-20" and considered not ideal for a 40 yo, secondary infertility patient. I am now at 33 days with no period (I am religiously a 28 day cycle) and half hoping I am pregnant and now wondering if the cyst has grown after reading your article. The only time I have been late is when I am pregnant… but is it possible this cyst kept growing and is delaying menstration even though the pain subsided weeks ago?

        Reply
      8. Geoffrey Sher, MD says:
        December 2, 2009 at 8:25 am

        Thank you kindly,

        There is an article on this blog on "Tubal Reversal"

        Geoff Sher

        Reply
      9. joanne says:
        March 18, 2010 at 5:53 pm

        Dear Doctor Sher
        I am on my third cycle of clomid with HCG trigger shot and IUI. My baseline ultrasound showed 3 cm ovarian cyst and my estradiol level was slighlty elevated (109). I was told that everything looked ok for me to start clomid. Is it safe to start clomid with a 3cm ovarian cyst? I'm afraid that it may cause it to grow and I do not want any complications.

        I would greatly appreciate any insight.

        Joanne

        Reply
      10. Radhika says:
        October 17, 2011 at 10:20 am

        Hi..
        I also have been detected Ovarian Cyst after 2regular cycle post my failed IVF..I history is have been treated for Plural effusion in 2006 then I have taken 6mth AKT, then in 2007 had my first ectopic treated medically.. then again had another ectopic in 2008 this time by laproscopy my doctors removed one of my tube.. then again I had another ectopic in 2010 this ti me my right tube was removed and doc did IVF after 2mths and it was failed next time my TB PCR was found positive again I took six months medicines then i n july she planned IVF again which was failed again.. and its Ovarian cyst which is ruptured.. last week.. can u pls suggest what is the reason for this cyst.. is it the side effect of IVF.. should I go for IVF again please help because am very disappointed with all this and my Doc wants to do IVF with IVIG drip and one doc told me to continue Rcinex during IVF this may increase your chance.. Looking forward your response asap.

        Reply
      11. Geoffrey Sher, MD says:
        October 17, 2011 at 11:26 am

        It is hard to say, but this could be a residual effect from the IVF. It sounds as if something else could be going on, however.

        Consider calling 800-780-7437 and setting up a telephone consultation with me to discuss.

        Geoff Sher

        Reply
      12. Lara says:
        May 29, 2012 at 2:34 am

        Dear Dr Shea,

        i spent a great deal of time and money today holding on at the 1-800 number trying to schedule a telephone consultation from Africa with you. As you can see, i am quite far away and i am impressed with the set up and clarity of your web site. I believe i have found my clinic and doctor in you. I will like a phone consultation and would appreciate your contacting me at your earliest convenience.

        Lara

        Reply
        • admin says:
          May 30, 2012 at 3:34 am

          Unfortunately the 800 # will not work from Africa. You need to call 702-699-7437.

          I too am fro Africa originally…South Africa!

          I look forward to talking to you.

          Geoff Sher

          Reply
      13. Kym says:
        August 17, 2012 at 5:45 am

        I’m currently down regulating and went in for my baseline scan to be told I have two cysts on m right ovary – one at just over 1cm and one at over 4cm. When I went in for the ovarian reserve test a couple of months ago they mentioned there was a cyst then but I don’t recall which ovary it was on. I have to go back in for another scan on Monday before they decide whether to continue to stimulation. My question is do you think the larger cyst is likely to be a cystic tumour? What is the likelihood of both cysts going by Monday (its Friday today), how long is treatment likely to be delayed for?
        With thanks
        Kym

        Reply
        • Geoffrey Sher says:
          August 20, 2012 at 12:20 pm

          Hard to say whether it is a cystic tumor. However, if they are still there on Monday, they need (in my opinion) to be aspirated less they interfere with egg/follicle development on the affected side(s) during ovarian stimulation.

          Good luck!

          Geoff Sher

          Reply
      14. Kelly says:
        January 20, 2013 at 4:59 pm

        Dear Dr. Shea,

        Your website is very informative. However I still have a question for you. I underwent egg retrieval early last month and 12 days afterwards afterwards had lots of cysts (I cannot remember how many. The nurse said to me “I have seen better but I have seen worse, just take it easy and they will be gone by your next period.”) I got my period 12 days later, it was nothing special except that I came down with a horrible case of the flu at the same time. This months have had dull pains in my pelvic region, shooting pains in my thighs and some back pain. And I just lifted my suitcase and got some pains on my right ovary.I addition my period is days overdue and I’m not pregnant. Are these still functional cysts causing a missed period? I don’t know and the nurse I spoke to just brushed me off saying to just “take it easy”. I’ve never missed a period before and I’ve never had any cysts or any medical issues with anything before ivf. Should I find a new clinic? Thank you for your time.

        Reply
        • Geoffrey Sher says:
          January 20, 2013 at 7:36 pm

          Your nurse was correct these innocuous theca lutein cysts occur routinely following IVF and disappear within about 4 weeks with the next period. Sometimes they leak a little or cause some capsular stretching of the ovarian capsule, This is uncomfortable but harmless. Apply some heat, lay low for a few hours and use paracetamol or ibuprophen tablets judiciously. it will pass.

          Geoff Sher

          Reply
      15. Fiona says:
        February 11, 2013 at 12:46 pm

        Dear Dr Sher,

        Thank you for a very comprehensive article on Ovarian Cysts, it helps to know there are solutions to these when they do occur.

        I have been diagnosed with a cysts. I have been on BCP for about 2 weeks prior to starting and overlapping with Lupron for a few days, my period started about 4 days after stopping BCP. I was scanned (Down regulate scan) about 12 days after starting lupron, about 3 days after a light period, my E2 was over 400 and linning about 4mm, over 10 folicles on each side. I was told to keep taking lupron and scanned again after 2 days, they found that one of the folicles was about 13mm and E2 has gone up by 100, linning around 8mm. It was decided that my cycle would be abandoned and continue on Lupron for a further 2 weeks until my next period to check again if we can do COH.

        I have been told to also use one of my Trigger shots to make sure the folicle is released. Is this a usual course of action, is is a good advice or should i be doing something else? I am not very happy about this because i have never had this situation in my past 5 cycles, could they have done something earlier to make sure i did not have such a high E2 and that many folicles? Do i need to continue with lupron or stop it?

        Thanks for your helpful insights.

        Reply
        • Geoffrey Sher says:
          February 11, 2013 at 7:52 pm

          I really do not know what to say because this is not what I do or have done. If you would like to discuss your case with me, please call 800-780-7437. In the meanwhile please read the article in my blog on “A Stepwise approach to IVF”

          Geoff Sher

          Reply
      16. meher says:
        May 7, 2013 at 10:08 pm

        Sir,
        i am currently on day 6 of my first ivf cycle.i had 2 endometriomas on each ovary .i was on bcp for a month and lupron for 10 days before starting cycle to now.
        on day 4 scan they found a 24mm follicle and many small ones…on day 6 they told that it was a simple cyst and am continuing with the cycle.Does it harm my cycle. Should they have cancelled the cycle?Please respond!

        Reply
        • Geoffrey Sher says:
          May 8, 2013 at 5:37 am

          Not necessarily cancelled but you should know that the presence of endometrioma’s in an ovary decreases egg quality in that ovary.

          Geoff sher

          Reply

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      My IVF Cycle Failed – What Went Wrong? Question #19: Why Do I Keep Having Chemical Pregnancies and Miscarrying?
      This is the 19th in a series of answers to common questions about failed IVF. Early pregnancy loss – whether due to miscarriage or chemical pregnancy – is due to two major factors. In more than 70-80% of cases the cause is attributable to... more
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      My IVF Cycle Failed – What Went Wrong? Question #18: My Fertility Clinic Reports a High Success Rate – How Could I Have 2 Failed Cycles In A Row?
      This is no. 18 in a series of answers to common questions about failed IVF. While it is true that IVF failure can be due to preventable factors, it is as important to understand that optimal medical care does not always equate with an optimal outcome... more
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      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
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      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
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      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
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      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
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      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
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      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
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