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Assisted reproductive technology (ART) procedures such as in vitro fertilization (IVF) can be complicated by both arterial and venous thromboembolic events. Acute portal vein thrombosis complicating IVF is particularly rare, with only one previously reported case in the literature. This thrombotic event is typically associated with various abdominal pathologies or observed in patients with thrombophilic conditions. However, IVF increases the global risk of a venous thromboembolic event by 10-fold. In this case report, we describe a 40-year-old woman who underwent IVF treatment and subsequently developed acute portal vein thrombosis with superimposed septicaemia. Despite her severe illness, the patient was found to have a viable early pregnancy during her hospital admission. She was treated with intravenous antibiotics and therapeutic anticoagulation and discharged 18 days after initial presentation. Anticoagulation was continued throughout her pregnancy without complication and the patient went on to deliver a healthy term female. Successful pregnancy distinguishes this unique case from the other reported case of acute portal vein thrombosis secondary to IVF in the literature. introduction Thromboembolic events are rare but serious complications in patients undergoing in vitro fertilization (IVF). Increased risk of venous or arterial thrombosis is secondary to the supra-physiological hormone levels resulting from controlled ovarian hyperstimulation (COH).1 Thrombosis secondary to IVF occurs in the veins of the neck and upper extremities in 80% of cases.2 Risk factors for the development of thrombosis secondary to IVF treatment include age over 39 years, being pregnant, ovarian hyperstimulation syndrome (OHSS), and inherited thrombophilias.1-3 OHSS is a serious and potentially life-threatening clinical syndrome that results from excess stimulation of the ovaries by exogenous gonadotropins, which allows growth and retrieval of oocytes during assisted reproductive technology (ART) procedures.3 Symptoms of OHSS arise from ovarian enlargement and capillary leakage resulting in fluid accumulation in third spaces, such as abdominal, pleural, and pericardial cavities.2 Acute portal vein thrombosis (PVT) is a particularly rare thromboembolic event complicating IVF, with only 1 previous case reported in the literature.4 PVT is usually associated with cirrhosis or inflammatory processes of the abdomen such as appendicitis, cholecystitis, or various abdominal cancers.5 In patients with non-cirrhotic PVT, more than half are found to have one or more thrombophilic conditions.6 case report A 37-year-old female with no previous pregnancies presented in 2012 with a 3 year history of primary infertility. Her history was unremarkable other than mild asthma. She had no history of venous thromboembolism or abnormal bleeding. General physical examination was normal, though her BMI was elevated at 31 kg/m2. She had regular menstrual cycles with 5 days of bleeding every 28-30 days. Her husband was a healthy 40-year-old with a normal semen analysis. All fertility investigations were normal, including diagnostic laparoscopy. On that basis, they had three cycles of ovarian stimulation using clomiphene citrate with intra-uterine insemination (IUI) without success. Subsequent IUI with FSH for ovarian stimulation (COH-IUI) resulted in pregnancy but early spontaneous abortion on two occasions. Routine testing for recurrent miscarriage, including a thrombophilia screen and karyotyping of both partners, was normal. The third COH-IUI cycle resulted in an uncomplicated pregnancy leading to spontaneous vaginal delivery of a healthy term female. She had no complications during or after treatment or delivery. In March of 2015 the couple returned to attempt another pregnancy. COH-IUI was repeated and she had another early pregnancy loss. They then elected to proceed with IVF treatment in October of 2016. Routine stimulation yielded 8 mature oocytes. Four embryos developed to blastocyst stage, and 1 was transferred. At the time of embryo transfer she was asymptomatic. Four days following embryo transfer, the patient presented with epigastric and right upper quadrant pain, nausea, vomiting, anorexia, and malaise. She was admitted to hospital with a presumptive diagnosis of OHSS, although she did not present with symptoms of volume overload such as ascites or dyspnea. Following her admission, she was found to have significantly elevated liver enzymes (AST 3.79, ALT 4.85, ALP 2.98, GGT 4.70 μkat/L), hyperbilirubinemia (total bilirubin 110, conjugated bilirubin 82 μmol/L), and a white cell count of 17.5x109/L. Hemoglobin was normal, and she was not hemoconcentrated. Amylase and lipase were normal. The patient denied a past history of abdominal pathology, including gallstones, jaundice, hepatitis, pancreatitis, or ulcers. Abdominal ultrasound revealed only a moderately distended gallbladder, and obscuring of the common bile duct. There was minimal dilatation of the intrahepatic biliary ducts. The patient then had a blood culture drawn which grew E. coli. She developed symptoms of jaundice, leading to concern of possible abscess or infectious process. Antibiotic therapy was switched from cephazolin to piperacillin/tazobactam (Tazocin), though her white cell count and fever had resolved. Her transaminitis did begin to trend downward, but computerized tomography (CT) of the ab-

Successful term pregnancy in a patient with acute portal vein thrombosis following in vitro fertilization