Frequent ovarian monitoring by transvaginal ultrasound is central to IVF patient evaluation, and this surveillance can occasionally result in the discovery of occult, subclinical cysts that would otherwise go undetected . Even when complex ovarian cysts are incidentally noted at baseline ultrasound, the necessity of aspirating such lesions before IVF has been questioned. Indeed, an analysis of over 200 IVF patient cycles concluded that baseline cysts do not negatively affect reproductive outcome . Endometriotic cysts and dermoids account for many of these cysts, and only two prior cases of ovarian cancer related to IVF – both from USA – appear in the literature [1, 3].
Data on aspiration cytology of ovarian cysts developing in patients undergoing IVF treatment was considered rare a decade ago , and there has been little published on the topic since. The high false negative rate for nonfollicular lesions has limited the diagnostic value of aspiration cytology for many ovarian cysts  and information provided by ovarian cyst aspiration has been shown to correlate poorly with histology from tissue obtained at surgery . Indeed, a four-year series comparing ovarian cyst cytology with histologic findings based on cases collected at a single centre reported 20% of cytology specimens as non-diagnostic . Interestingly, aspiration cytology failed to determine the exact underlying nature of ovarian cysts in >50% of lesions when applied specifically to IVF patients, and an ovarian serous cystadenocarcinoma was the only malignancy identified . Others have found aspiration cytology to be an accurate predictor of malignancy in cystic ovarian lesions, but have discouraged reliance on aspiration cytology results alone .
This case is only the third published report of ovarian cancer identified during IVF, and is the first to offer long-term follow up. However, several aspects of clinical management could have been different and warrant comment. First, cytologic examination of the initial ovarian cyst fluid would have suggested malignancy about a month earlier and would have justified abandonment of the planned IVF cycle. We subsequently modified institutional policy to mandate external cytology review for any ovarian cyst aspirates obtained here. Second, bilateral oophorectomy could have been performed during formal staging. This would have obviated the need for a second surgery for removal of the contralateral ovary, and arguably could have hastened the patients' enlistment into a donor oocyte programme for definitive fertility treatment. The possibility of bilateral oophorectomy was presented before the first laparotomy, and the patient was thoroughly counselled about potential malignant spread if this was not done. We also discussed the potential for malignant spread secondary to intraperitoneal spillage during cyst puncture. Even though a frozen embryo transfer remained a possibility, the patient did not wish to have both ovaries immediately removed. The tailored, multi-stage surgical approach described here was only possible with co-management by gynaecologic oncology and should not be undertaken without such support.
In summary, although aspiration cytology of ovarian cysts sometimes presents an unclear picture  it can help identify patients for whom oncology consultation is immediately indicated. We therefore support formal cytologic assessment of any suspicious complex ovarian lesion despite the recognised limitations of this approach.