## 4 Discussion
### Treatment Strategies  
In the case of struma ovarii, surgical treatment is the first option. Because the tumor is usually unilateral and benign, unilateral salpingo-oophorectomy is adequate. Alternatively,if modifications on the contralateral ovary exist and the patient is in pre-or postmenopausal, we can perform a total hysterectomy with bilateral salpingo-oophorectomy, as was done in our study.  
Thyroid function changes may arise as a complication after struma ovarii ablation in the early post-operative period. Surgical excision is the only treatment for struma ovarii that causes thyrotoxicosis. Antithyroid medicines can be used to remove thyrotoxic symptoms and signs before surgery, and surgery should be scheduled as soon as possible to avoid malignant change. In addition to thionamides, adrenergic blocking medications coupled with iodine, ipodate, or iopanoic acid prevent the T4-to-T3 conversion, may be utilized to allow early surgery [31].  
Due to the rarity of malignant struma ovarii, there is a paucity of data regarding the optimal treatment for such patients. Standardized treatment of malignant struma ovarii remains undefined. Total abdominal hysterectomy with bilateral salpingo-oophorectomy andometectomy is one surgical option, whereas conservative surgery is another. Currently, the laparoscopic removal of the tumor may be an appropriate treatment option [32; 33]. Adjuvant therapy includes external radiotherapy, chemotherapy, thyroidectomy, and radioactive iodine ablation [34].  
Fertility-sparing surgery with unilateral salpingo-oophorectomy and preservation of the contralateral ovary and uterus is recognized to be an adequate surgical treatment for germinal cell tumors. If followed by adjuvant chemotherapy, this method may potentially be feasible in premenopausal patients with bilateral illness [35]. The histology result in our case with malignant struma ovarii was unexpected, and we observed no extension beyond the capsule. The treatment was conservative because the woman was 32 years old. Monitoring blood thyroglobulin can be done with better sensitivity in patients with or without thyroidectomy, similar to how it is done in patients with thyroid cancer [36]. Observing successive thyroglobulin levels is the key to early detection of possible recurrence of malignancy.  
Early or late pregnancy is a rare clinical setting during struma ovarii evolution [37].  
Torsion is the most common and dangerous complication of an ovarian tumor, especially during the 8-16 gestational weeks of pregnancy, and it has been reported to be 10-15%. Tumor rupture is a rather uncommon occurrence. In small tumors with no suspicion of advanced-stage ovarian cancer and total intact removal of the mass is possible, laparoscopic surgery should be used. Because it reduces manipulation of the pregnant uterus during surgery, laparoscopic excision of ovarian tumors in early pregnancy is considered as safe as laparotomy [38]. Our study group included three pregnancy-associated cases with struma ovarii. Even though the tumor was not related to a worse evolution of pregnancy, early detection is mandatory in such situations due to the increased risk of torsion, as mentioned before. We had a case with ovarian torsion at eight weeks of gestation, but the woman delivered at term.  
When it comes to struma ovarii and pregnancy, it is important to determine which ovary is the gestational body that supports pregnancy in the first semester. As a result, if the gestational body is on the removed ovary, there is a chance of miscarriage [36].