Tubercular Ascites Simulating Ovarian Hyperstimulation Syndrome following In Vitro Fertilization and Embryo Transfer Pregnancy

Ovarian hyperstimulation syndrome (OHSS) is a known complication of using ovulation induction drugs in assisted reproductive techniques. Its incidence and severity vary. Tuberculosis is a very common disease in the developing world, and ascites is one of its sequelae. The newer aids in diagnosing tuberculosis include measuring levels of Adenosine DeAminase (ADA) in the third-space fluids or serum. This case report is from a tertiary care center, reflecting how tubercular ascites simulated OHSS, and the right diagnosis was made and managed. This is being presented due to its rarity. 1. Introduction Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of assisted reproductive techniques (ARTs) and is characterized by enlargement of the ovaries and fluid shift from the intravascular compartment to the third space [1]. Tuberculosis is common in developing countries, and peritoneal tuberculosis (TB) which is the 6th most frequent extrapulmonary TB usually presents with ascites. We report a case of a 31-year-old lady who presented with tubercular ascites that simulated ovarian hyperstimulation (OHSS). The patient had no evidence of tuberculosis as proven by a negative Mantoux, chest X-ray, acid fast staining of ascitic fluid, and a negative PCR. The final diagnosis and management were based on a rising Adenosine DeAminase (ADA) level and a low haematocrit of 19.8%. The uniqueness lies in the yet unreported simulation leading to a suspicion of an unknown pathological mechanism in stimulating the ovaries, which might have caused a flare-up of tuberculosis. 2. Case Report A 31-year-old lady came to us with evidence of spontaneous abortion at 14 weeks of her pregnancy, which was conceived following in vitro fertilization. An ultrasound scan done showed an empty uterine cavity, indicating a complete abortion. She had fever at the time, and hence a course of antibiotics was given. Her hemoglobin levels were low, for which she was given a unit of packed red blood cells. She was a booked case with us and had a past history of two episodes of ascites (OHSS) following the embryo transfer. The first episode was within 12 days of embryo transfer, and the second episode was at 9-10 weeks of gestation. Both episodes were diagnosed as OHSS and treated symptomatically with albumin infusion. At 14 weeks of gestation, she had fever and recurrence of ascites. Ascites did not subside even with albumin and Cabergoline; hence other causes of ascites were evaluated by Mantoux test and chest X-ray, which were negative for tuberculosis. Her bleeding per vaginum