|Year : 2016 | Volume
| Issue : 1 | Page : 33-35
Three ovaries: Implications of an uncommon entity
Gaurav Shyam Desai, Shyam V Desai
Department of Obstetrics and Gynecology, Mother Care Nursing Home, Mumbai, Maharashtra, India
|Date of Web Publication||2-Jun-2016|
Gaurav Shyam Desai
Department of Obstetrics and Gynecology, Mother Care Nursing Home, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Ovaries are said to be supernumerary when an additional ovary is situated separate from the two other ovaries. Objective: To discuss a case of a supernumerary ovary found incidentally at laparotomy in a young girl with unilateral ovarian torsion and its implications in clinical practice. Background: A supernumerary ovary consists of ovarian tissue completely separated from the eutopic ovary with its own pedicle and blood supply. Differential diagnosis includes accessory ovaries which are located nearby and are connected to the eutopic ovary and its associated blood supply. Design: Case study. Case: A 14-year-old student was referred to our clinic with ruptured ovarian torsion and underwent unilateral oophorectomy for the same. An incidental additional ovary was found on the contralateral side. She was discharged on day 5 of stay and is doing well on follow-up. Conclusion: Supernumerary ovary although rare has significant implications for surgeons and gynecologists alike. Clinical Relevance: Situations in which a supernumerary functional ovary becomes relevant include ovarian torsion or malignancy in adolescents or women with reproductive potential wherein an ovary needs to be sacrificed, as in our case. The additional ovary if located in the pelvis may provide the necessary follicles for future fertility. Care should also be taken in case of ovum acquisition for artificial reproductive techniques.
Keywords: Ovarian torsion, supernumerary ovary, unilateral oophorectomy
|How to cite this article:|
Desai GS, Desai SV. Three ovaries: Implications of an uncommon entity. IVF Lite 2016;3:33-5
| Introduction|| |
Supernumerary ovaries are a unique entity. Ovaries are said to be supernumerary when an additional ovary is situated separate from the two other ovaries. This additional ovary structurally has follicles and develops from a different primordium. Locations of additional ovaries include the pouch of douglas, sigmoid colon, and even such remote anatomical locations as the kidney and omentum. , Additional ovaries are frequently overlooked on imaging probably due to their uncommon occurrence. Detection of this developmental aberration is likely to increase with the advent of laparoscopy and high-resolution imaging. The implications of such a finding do need mention. The authors describe a case of a supernumerary ovary found at laparotomy in a young girl with ovarian torsion.
| Materials and methods|| |
A 14-year-old student was referred to our clinic with abdominal pain. The pain was severe in intensity and located in the right iliac fossa. Medical and surgical histories were not significant. Per abdominal examination revealed guarding and tenderness in the right iliac fossa. She had tachycardia with a blood pressure of 100/60 mm of Hg. An ultrasonography revealed a torsion of the right ovary with free fluid within the pelvic cavity suggestive of ruptured ovarian torsion.
A written informed consent was taken from the patient and parents, and preparation for an emergency exploratory laparotomy was made.
The exploratory laparotomy was performed by the senior author (S.V.D) and assisted by the resident (G.S.D). All pertinent medical records were reviewed meticulously to provide data for this report. Premedication with analgesic and antibiotics was done. She was positioned supine on the table and urinary bladder catheterized. The surgical field was cleansed with povidone-iodine solution and draped with sterile towels. A 5 cm transverse suprapubic incision was made and the abdomen opened in layers. The peritoneum was opened with an artery forceps and 150 ml of collected blood drained via suction cannula. Intraoperative findings included a normal uterus and ruptured gangrenous right ovary which had undergone torsion along its pedicle. Although the pedicle was untwisted and left in situ for over 30 min, its blood supply did not revert to its original status and as no viable ovarian tissue was discernible, a decision to undertake an oophorectomy was made.
Inspection of the contralateral adnexal structures revealed an additional ovary with a pedicle attached to the ovarian ligament [Figure 1]. Hemostasis was achieved and organs repositioned into the pelvis. The abdomen was closed, and the patient shifted to the recovery. Postoperative management included analgesics and antibiotics. The patient was discharged on day 5 of her stay and is doing well on follow-up. Anti-Müllerian hormone (AMH) level 1 month after surgery was 2.98 and an ultrasound suggested the presence of an additional ovary with functional follicles [Figure 2].
|Figure 1: The presence of two distinct ovaries with different pedicles on the left side of a 14-year-old girl with right ovarian torsion at laparotomy|
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|Figure 2: Postoperative ultrasonography demonstrates two ovaries on the left side with follicles|
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| Discussion|| |
The occurrence of an additional ovary is very rare. Estimated incidence is approximately 1 in over 93,000 girls and about 29,000 autopsies. It is first reported in the late 19 th century, and supernumerary ovaries may be associated with anomalies of the genitourinary tract. ,, Often, associated anomalies are an absent or unicornuate uterus. Pathologies that usually involve the ovaries can occur in a supernumerary ovary. These include corpus luteal cysts, endometriomas, as well as dermoid cysts, and malignancies such as papillary serous carcinoma. ,, Others such as mucinous cystadenomas, Brenner tumor, and fibromas have also been described. Proposed theories resulting in a supernumerary ovary include arrested gonadal migration and transplantation of the gonadal ridge after gonocyte incorporation. ,
Differential diagnosis of a supernumerary ovary includes an accessory ovary. Accessory ovaries are located nearby and are connected to the eutopic ovary and its associated blood supply. A supernumerary ovary on the other hand consists of ovarian tissue completely separated from the eutopic ovary and has its own pedicle and blood supply. They may be found anywhere along the embryological migratory path of the ovarian primordium, including the mesentery, retroperitoneal space, and omentum.  Lachman and Berman have proposed an alternative nomenclature to the one put forward by Wharton et al. They classified additional ectopic ovaries as either postsurgical, postinflammatory, or truly embryological variants. This was because most additional ovarian tissue can be found postinfection or surgery.  Preoperative diagnosis is difficult, and these two variants are usually found on laparotomy. However, although ultrasound and hormonal tests can detect supernumerary ovaries, final diagnosis is made by histology.
Sharatz et al. have put forward the association between supernumerary ovaries and obesity. Our patient had a body mass index of 21 mg/kg 2 . Additional ovarian tissue theoretically will result in raised estrogen levels and markedly decreased levels of follicular stimulating hormone. Further, the antral follicular count and AMH would be elevated. Clinical situations in which a supernumerary functional ovary becomes relevant include ovarian torsion or malignancy in adolescents or women in their reproductive years wherein an ovary is required to be sacrificed as in our case. The additional ovary if located in the pelvis may provide the necessary follicles for future fertility. Care should also be taken by accurate sonographic localization of this aberration in case of ovum acquisition for artificial reproductive techniques. Further, the extra ovary could have the potential in secreting surplus estrogen resulting in a hyperestrogenic state and its consequences including malignancy. The additional ovary must be located preoperatively and screened for pathology while conducting an oophorectomy for ovarian pathology or as a prophylactic method in postmenopausal women.
| Conclusion|| |
The authors present a case of supernumerary ovary in a young girl who underwent unilateral oophorectomy for ovarian torsion. This clinical entity, although rare, has significant implications for surgeons and gynecologists alike.
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Conflicts of interest
There are no conflicts of interest.
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| Authors|| |
Gaurav Shyam Desai is a Resident Physician and Registrar in Obstetrics and Gynecology at Dr. DY Patil Hospital in Navi Mumbai, India. He has over 25 peer reviewed publications in National and International Journals, more than 55 scientific presentations at various conferences in India and abroad. His interests include endoscopic techniques and imaging methods in gynecology.
[Figure 1], [Figure 2]