What is the Risk of Ovarian Torsion During Egg Freezing?

Egg freezing (oocyte cryopreservation) has become an increasingly common option for those looking for more control over family planning. While the procedure is considered safe, like any medical procedure from getting Botox to an appendectomy, it's important to understand all potential risks, including rare complications like ovarian torsion. At Cofertility, we believe in providing complete transparency about the egg freezing process, including both the benefits and potential risks, so you can make informed decisions about your reproductive health.

Ovarian torsion occurs when an ovary twists around its supporting ligaments, potentially cutting off its blood supply. This is considered a gynecological emergency requiring immediate medical attention. In the context of egg freezing, the risk of torsion is linked to the temporary enlargement of the ovaries that happens during the stimulation phase of the process.

This article explores what ovarian torsion is, why egg freezing may increase the risk, how common it actually is, and most importantly, what you and your medical team can do to minimize this risk. We'll also look at symptoms to watch for and what happens if torsion does occur.

What is ovarian torsion?

Ovarian torsion happens when an ovary rotates around the ligaments that support it, twisting off the blood vessels in its stalk. This can rapidly decrease or block blood flow to the ovary (and often the fallopian tube), causing ischemia (loss of oxygen) in the ovarian tissue.

If not promptly treated, the lack of circulation can lead to necrosis (death) of the ovary, which necessitates medical attention. (This used to require surgical removal, but more recent data support that even a necrotic ovary can be untwisted and left alone and will often re-perfuse.) Ovarian torsion is therefore considered a medical emergency requiring urgent surgical intervention to untwist (detorse) the ovary and restore blood flow. When treated in time, the ovary can often be saved, and future fertility is usually not compromised.

Symptoms of ovarian torsion

The hallmark symptom of ovarian torsion is sudden, severe abdominal or pelvic pain, typically on one side (the side of the affected ovary). The pain often has an acute onset and can be intense and sharp; some patients also report crampy or intermittent pain if the ovary twists and untwists intermittently.

Additional symptoms may include:

• Nausea and vomiting 
• Fever 
• Abnormal bleeding

These symptoms can mimic other conditions like appendicitis or kidney stones, so prompt evaluation (often with transvaginal ultrasound Doppler imaging) is critical to diagnose torsion.

Common causes and risk factors

Ovarian torsion is typically triggered by an imbalance in the ovary's weight or support that makes it prone to flipping over. The most common precipitating factor is the presence of an ovarian mass or cyst, especially one larger than ~5 cm in diameter. A heavy cyst or benign tumor on the ovary can make the ovary top-heavy and more likely to twist on its ligament. In fact, studies indicate that in up to 85% of torsion cases, an ovarian cyst or other mass is present.

General risk factors for ovarian torsion include:

• Reproductive age: About 70–75% of cases occur in females of reproductive age (often in their 20s-30s)
• Ovarian cysts or tumors: Especially those larger than 5 cm
• Fertility treatments: Including egg freezing and IVF
• Polycystic Ovary Syndrome (PCOS): Due to multiple ovarian follicles and enlarged ovaries
• Pregnancy: Approximately 20–25% of ovarian torsion cases occur in pregnancy
• Long ovarian ligaments: Some individuals are born with longer-than-normal utero-ovarian ligaments
• Prior tubal ligation: A history of tubal ligation has been noted as a risk factor
• Previous ovarian torsion: Having had an ovarian torsion in the past increases the risk of recurrence

Overall, ovarian torsion is uncommon in the general population, but it is one of the more frequent gynecologic emergencies. Estimates suggest it accounts for roughly 3% of gynecologic emergency surgeries, making it the fifth most common gynecological surgical emergency.

Why does egg freezing increase torsion risk?

In egg freezing (as in IVF), patients undergo controlled ovarian hyperstimulation – a process of using hormonal medications to make the ovaries produce multiple mature eggs in one cycle. Normally, a woman releases one egg per month and the ovary remains small (about the size of a walnut). In an egg freezing cycle, however, many follicles (egg sacs) develop simultaneously, each filling with fluid as the eggs mature.

By the time of the egg retrieval, the ovaries can become significantly enlarged due to numerous enlarged follicles. This temporary ovarian enlargement and increased weight makes the ovary more mobile and prone to twisting. In short, ovarian stimulation causes the ovaries to be heavier and less stable, which increases the risk of ovarian torsion.

During stimulation, the ovarian ligaments also may loosen slightly under hormonal influence, and the abdomen has more space as the ovaries move away from their normal position. Fertility doctors note that twisting or vigorous movement of the body can precipitate torsion when the ovaries are enlarged. For example, sudden motions, exercise, or intercourse can cause an already heavy ovary to swing and rotate around its tether.

Ovarian torsion can happen at different points in the egg freezing process:

• Most commonly, torsion occurs shortly after the egg retrieval procedure, when the ovaries are at their largest and beginning to shift back in position
• It can also occur during the stimulation phase or around the time of the trigger injection, though this is less common
• There have even been a few reported cases of torsion before the egg retrieval (after the trigger shot but prior to retrieval)

In any case, the risk period for torsion spans from the start of the cycle through the couple of weeks following the egg retrieval, until the ovaries shrink back to normal size.

To summarize, egg freezing increases torsion risk because it creates the perfect storm of risk factors for torsion: multiple ovarian cysts (follicles), significantly enlarged ovaries, and often a high estrogen environment that can loosen ligaments. While this risk is low, both patients and providers remain vigilant for torsion during egg freezing cycles due to the ovaries' temporarily vulnerable state.

How common is ovarian torsion during egg freezing?

Thankfully, ovarian torsion is rare during egg freezing or IVF cycles, but it does occur infrequently. 

Studies of IVF (which is analogous to egg freezing in terms of stimulation) have reported ovarian torsion rates ranging from about 0.02% to 0.2% of cycles. This is roughly between 1 in 4,000 and 1 in 500 cycles.

Overall, acute complications like ovarian torsion, bleeding, or infection occur in under 0.5% of egg freezing cycles. 

So to put it in perspective, ovarian torsion is far less common than other egg freezing side effects like bloating or mild ovarian hyperstimulation. It is a rare event – on the order of a fraction of a percent of cycles – but one that fertility clinics watch out for closely. 

What you can do to reduce torsion risk during egg freezing

While your medical team plays an important role in minimizing torsion risk through careful protocol (medication and dosing) selection and monitoring, there are several steps you can take to protect yourself during the egg freezing process:

Modify your activity level appropriately

During the stimulation phase and especially around and after the egg retrieval, avoid strenuous exercise and heavy lifting. This isn't the time for activities that involve:

• Bouncing movements
• Twisting your midsection
• Rapid changes in direction
• High-impact aerobics or running
• Heavy weightlifting

Instead, stick to gentle activities like walking or light stretching. Many fertility doctors recommend avoiding exercise entirely during the week of egg retrieval and a few days after, when your ovaries are at their largest size and torsion risk peaks. Remember that this limitation is temporary—your normal fitness routine can resume once your ovaries return to their usual size.

Take recovery seriously

After your egg retrieval procedure:

• Rest for at least the remainder of that day
• Have someone drive you home and stay with you for the first 24 hours if possible
• Stay hydrated 
• Avoid strenuous activity for several days following the procedure
• Ease back into your routine gradually, avoiding intense workouts or heavy household chores for about a week
• Listen to your body and don't push yourself if you're experiencing discomfort

Abstain from sexual intercourse

Your doctor will likely advise you to avoid sexual intercourse during the stimulation cycle and for a short period after retrieval. This recommendation serves two purposes:

1. Prevents jostling of the enlarged ovaries that could trigger torsion
2. Avoids unintended pregnancy during a time when you're extremely fertile

Know the warning signs

Familiarize yourself with symptoms that require immediate medical attention:

• Sudden, severe abdominal or pelvic pain (especially on one side)
• Pain that doesn't improve or worsens
• Nausea and vomiting
• Fever
• Significant bloating or abdominal swelling
• Dizziness or feeling faint
• Heavy bleeding

If you experience any of these symptoms, contact your clinic immediately or go to the emergency room. Don't hesitate or downplay severe pain—prompt intervention can save your ovary if torsion has occurred.

Summing it up

The risk of ovarian torsion during egg freezing is very low but not zero. A combination of precautions (limiting physical strain, watching symptoms) and medical management (careful stimulation and monitoring) helps keep this complication rare.

For the vast majority of individuals undergoing egg freezing, torsion never occurs. For those unlucky few who do experience it, prompt surgical care usually results in a good outcome with preservation of the ovary.

By understanding the causes, risk factors, and preventive measures, patients can feel confident that everything possible is being done to make egg freezing both a successful and safe process. We wish you all the best on your journey!