Clinical case of ovarian cancer after in-vitro fertilization: Forensic medical malpractice – clinical case and data review

Background. Ovarian cancer is a leading cause of death amongst women. The extreme hormonal stimulation plays an important role for the cancerous development if there is an existing predisposition. Introduction. In-vitro fertilization procedures (IVF) are a part of the assisted reproductive technologies (ART). Factors that may increase the risk of development of ovarian cancer are, but are not limited to, genetic mutations, lack of pregnancy, hormone replacement therapy in menopause, oral contraceptives and inherited mutations in the BRCA-1 and BRCA-2 genes. Case report. A 45-year-old woman with no family history of cancer, with almost diminished ovarian reserve started IVF procedures. The doses of the hormone medications that were used – Merional and Cetrotide, do not exceed the recommended values. The subsequent IVF attempt was successful and the patient had a normal pregnancy and delivery. Three months later, during a gynecological ultrasound examination, formations were found as follows: 30.5 mm in the right ovary and 20 mm in the left ovary - unilocular cysts. Tumor markers indicated slightly higher level of ROMA - 12.36%, Ca-125 - 37.34, HE4 - 61.8. Therapy with Dufaston was prescribed with the assumption that the ovarian cysts indicate Luteinized unruptured follicle (LUF) syndrome. After another 3 months, during a gynecological ultrasound examination it was established that the formations persisted: in the right ovary - 49 mm, in the left ovary - 15 mm. Half a year later, ultrasound diagnostics revealed a formation measuring 25 cm/15 cm. The tumor markers indicated as follows: Ca-125 - 38.54, HE4 - 106.3. A total hysterectomy with bilateral tumor adnexectomy was performed. During the surgery two formations were found - one originating from the right ovary with dimensions 25 cm/25 cm, and a solid formation 5 cm/5 cm from the left ovary. Histological examination confirmed the diagnosis: malignant mixed Müllerian tumor. Discussion. There are known cases of cystic and malignant formations in the ovaries, as well as ovarian hyper stimulation syndrome, after IVF procedures due to the usage of ovulation stimulating drugs. There is a theory that hyper stimulation with the purpose of provoking repeated ovulations lead to malignant transformation of the ovarian parenchyma. Conclusion. Each IVF procedure needs to be tailored to the individual patient with regards to the specific health conditions. It is a necessity for a detailed medical history of inherited oncological diseases to be established, as well as for genetic testing of BRCA-1 and BRCA-2 mutations to be performed. The strict and regular disease control is important if pathological changes are confirmed. It is a mandatory condition for implementing a good clinical practice. (author)