OOCYTE RETRIEVAL Prof. Aboubakr Elnashar

Benha university, Egypt

Aboubakr Elnashar

Contents

1. APPROACH

2. EQUIPMENTS

3. TECHNIQUE

4. PRECAUTIONS

5. COMPLICATIONS

6. PROFICIENCY

Aboubakr Elnashar

1. APPROACH laparoscopy

Technique of choice in first 10 ys of IVF era.

Ultrasound

1. TVOR Wikland et al. in 1985.

Simple, rare complications: gold standard

2. TA OR

ovaries are not accessible transvaginally

safe and effective

comparable with results of TV (Borton et al, 2011)

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2. EQUIPMENTS 1. Ultrasound machine:

Frequency: 5–7MHz: sufficient penetration depth and enough resolution

Transducer:

long (total length 40cm): easy to handle during the

scanning and puncture procedure.

Shape: easy to put into a slim sterile cover or a

finger of a sterile surgical glove.

Needle guide

easy to attach to the transducer when it has been

placed in a sterile cover.

Aboubakr Elnashar

Aboubakr Elnashar

2. Aspiration needles:

Types:.

1-Single lumen

•Most, IVF centers

•Smaller diameter: less

discomfort.

•Flushing technique

Aspirate follicle

Refill with media

Reaspirate

Single Lumen Ovum Aspiration

Needle

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Gynetics:

Aspiration needles:

different sizes and flexibility,

Laser etched markings on tip: stable and excellent vision

during ultrasound.

translucent tubing

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2. Double lumen

Technique:

constant infusion of

oocyte collection media

into the follicle at the

same time as the follicular

fluid is being removed:

increase the turbulence

within the follicle: assist in

dislodging the oocyte–

cumulus complex from

the follicle wall: increase

the chances of oocyte

collection.

Cook® EchoTip® Double

Lumen Aspiration Needle

Used for aspiration and

flushing of oocytes from

ovarian follicles. Aboubakr Elnashar

looks like a needle within a needle: the inner (bigger) hole is used

to aspirate up the egg (like with a single lumen needle), but the

double lumen needle has the added functionality of being able to

squirt water from the outer hole into the follicle and ‘rinse’ it out.

The rinse can be aspirated out again to catch the egg if it wasn’t

sucked up the first time.

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Characters: 1. Sharpness

most important factor.

: less pain if the puncture is performed in analgesia.

2. Near the tip

Small band of highly reflective surface

: visualization as the needle enters the ovary and

once it is in the follicles.

3. Tip

some kind of preparation that will increase the

ultrasound echo: easier to identify the position of the

needle tip.

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4. The diameter

Ideal:

18–20 gage: less pain when the analgesia only is

used.

An 18 gage needle (outer diameter) thin walled with an

inner diameter of 20 gage is ideal.

{20 G/ 35 mm (thin) or 17 G/ 35 mm (standard)}

does not affect oocyte yield

As long as the inner diameter of the needle is 0.8–1

mm: oocyte cumulus complex is unaffected, provided

that the aspiration pressure is <120 mmHg.

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Too small inner diameter:

1. ±harmful to the oocyte cumulus complex.

2. deviating away from the puncturing line,

particularly if the ovary is situated high up in the

pelvis.

3. significantly prolong operating time.

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5. ±Fingertip handle

on the distal end of the needle: puncture with good

clinical touch. To increase the recovery, it was shown earlier that Teflon tubing between the needle and the sampling

tube was important. Commercially available follicle aspiration needles do have such tubing as well as a

sampling tube.

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Follicle aspiration set

1. Needle

2. Tubing

3. Sampling tubes.

Ready to use and only

needs to be connected to

the suction pump.

Sterile and mouse

embryo tested

Single use

Vitrolife:

Needle with tubing for aspiration,

silicone rubber cork and a blunt

cannula for flushing. The needle

consists of a reduced part (tip) and

an unreduced part (body). Aboubakr Elnashar

3. Suction pump:

Negative pressure

Aspirating mature follicles.

90–120mmHg:

good recovery

no harm on the oocyte cumulus complex

Aspirating immature oocytes

from follicles of 5mm diameter with very small volume needs

much less pressure

40–60mmHg.

Pressure can be controlled in a standardized

manner: safest and the best way. Aboubakr Elnashar

Cook Aspiration Unit ™

Used to provide a low flow,

regulated vacuum up mm Hg for

general suction .

Vacuum Line and Filter

Hydrophobic filter lines

used to connect ovum

aspiration needles to Cook

Aspiration Unit™ to

prevent contamination of

the unit.

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In the early days

aspiration of follicular fluid was performed by syringe

connected to the puncturing needle.

Risky {difficult to control the negative pressure: high

negative pressure: damage to the oocyte cumulus

complex}.

In conclusion, one should use:

Ready-to-use follicle aspiration set and connect it to

a calibrated suction pump using a negative pressure

of 100mmHg for retrieval of mature oocytes and 50

mmHg for immature oocytes.

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Video 7

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3. TECHNIQUE

1. Anesthesia or Analgesia

A good analgesic method:

• satisfactory pain relief

• rapid onset, rapid recovery

• ease of administration and monitoring.

• safe and has no toxic effect on the oocytes.

a. General anesthesia.

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b. Conscious sedation.

The most commonly used method of pain relief for

oocyte retrieval in UK and USA.

Pain relief is superior when a paracervical block

(PCB) is used combined with sedation as

compared to sedation alone.

Patients who received only a PCB during egg

collection experienced 2.5 times higher levels of

vaginal and abdominal pain as compared to those

who received both PCB and conscious sedation.

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PCB:

local anesthetic is usually deposited in four

locations around the cervix in the vaginal mucosa.

In total 100 mg lidocaine (10 ml of 1% lidocaine,

XylocaineTM 10 mg/ml) injected at four points

around the cervix and alfentanil 0.5 mg IV. If

needed, a supplementary 0.25 mg alfentanil

(Rapifen 0.5 mg/ml) is given once or twice during

the procedure. With this combination, 99.5% of

oocyte aspirations are performed.

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c. Electro-acupuncture.

Comparing electro-acupuncture and conventional

medical analgesia during oocyte aspiration showed

that no method seems to be superior to another.

Electro-acupuncture can in many patients be a good

alternative for pain relief during oocyte aspiration

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2. Aspiration

1. An aspirating needle is introduced through a guide

attached to a transvaginal probe

•Avoid contaminating the needle tip

2. The ovary should lined up to the most accessible

position on the screen

•Line the most accessible follicle up against the biopsy

lines.

3. Push the probe against the ovary and carefully insert

the needle inside the follicle

•The path of the needle as it is guided into each ovarian

follicle is accurately defined by a biopsy guideline

imposed on the ultrasound screen

•The highly reflective walls of the needle identify its

path quite easy in most cases. Aboubakr Elnashar

•The needle tip can be observed as it is maneuvered

within the ovaries and into each follicle.

4. The follicular fluid containing the oocyte/cumulus

complex is then aspirated by application of suction.

•The walls of the follicle collapse as the fluid is

aspirated, the needle moved within the follicle

{ensure that all the follicular fluid is withdrawn}.

5. Advance the needle into an adjacent follicle or

withdraw to the edge of the ovary, realign and

advance into an adjacent follicle

•The probe should not be moved with the needle in

the advanced position

•The tip of the needle should be seen on the screen

at all times, it should never be advanced if the tip is

not visible.

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•All follicles should be aspirated-follicles should only be

left if they are difficult to reach

•Safe, competent practice should ensure that the large

pelvic blood vessels and the bowel are not perforated

6. The needle should be flushed between the 2

ovaries of any potential blockage caused by blood

clots

7. If there has been a significant blood loss during the

procedure, or there is any a steady loss vaginally ,

•speculum is inserted and the bleeding points

identified:

•Apply pressure to the bleeding point with a gauze

swab held in the end of sponge holding forceps.

Vaginal pack may be inserted

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Aboubakr Elnashar

Flushing Follicles

The rationale:

Larger number of oocytes being collected

No significant differences in number of oocytes

retrieved, fertilization rate, or PR between those

where flushing had been used as compared to no

flushing.

operating time was significantly shortened in the

non-flushing group. (MA: Rouke et al, 2012).

Many IVF centers do not flush follicles and have

had a recovery rate of 70% per punctured follicle.

Routine flushing: unnecessary

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Aspiration of hydrosalpingeal fluid at the time of

oocyte retrieval

Simple

Safe and

Effective aspiration or uterine fluid collection

during the IVF-ET cycles.

(Fouda and sayed2011)

Video 1

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4. PRECAUTIONS 1. CBC

anaemia and thrombocytopenia increase the risk

of bleeding.

2. Prophylactic antibiotic:

1 g ceftazidime IV immediately after sedation. (Aragona et al, 2011)

3. TVS:

before being discharged from the unit,

∼4 h after the procedure.

4. Not to perform endometrial injury

on the day of OR {reduce PR} (Nastri et al, 2012)

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5. COMPLICATIONS

I. Bleeding

II. Infection

III. Pain

IV. Rare

V. EFS

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I. Bleeding

Uncomplicated OR

Blood loss:

Median: 72 ml.

Maximum: ≤ 200 ml

Hgb reduction ≤2 g/day

Pelvic free fluid ≤ 200 ml

(Dessole et al. ,2001; Ragni et al. 2009)

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1. Vaginal bleeding: 2.8%

Requiring compression >1 min 2.7%

Tamponade >2 h 0.1%

vaginal ≥100 mL: 0.8%

Risk factors: factor IX deficiency

ovarian necrotizing vasculitis

anticoagulant tt

Rarely a major problem

TT: 1. local pressure

2. oversewing.

3. laparoscopy or laparotomy: in the case of heavy bleeding. Aboubakr Elnashar

2. Intra-abdominal hge: From: ovarian vessels

capsule puncture sites

other pelvic vessels

High risk 1. lean patients with PCOS: 4.5%. (Liberty et al, 2010)

2. lower BMI

3. history of surgery

S and S •weakness, dizziness

•dyspnea, abdominal pain,

•tachycardia, low blood pressure

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Management

1. Early hemodynamic monitoring: serial measurement

of hgb: drop indicates: intraabdominal bleeding until

proved otherwise

2. Transfusion

3. Laparoscopy: blood is aspirated from the peritoneal cavity

bleeding site is identified on the ovary

follicle is aspirated

bleeding is coagulated with bipolar coagulation forceps.

4. Laparotomy

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3. Retroperitoneal bleeding: •{sacral vein injury}

•±difficult to diagnose

{absence of free fluid in the pouch of Douglas}

•±present several hrs after OR. •Periumbilical hematoma (Cullen's sign) following US-guided TV oocyte retrieval

reflects a retroperitoneal hematoma of a benign course.

•Emergency laparotomy.

Intraperitoneal: 0.07%

Punctured iliac vessels: 0.04%

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Prevention of bleeding: 1. Visualizing a peripheral follicle in cross-section {dd it from a

blood vessel}

2. Aspirating all follicles without withdrawing the needle

tip from the ovary {avoid vaginal multiple punctures}

3. Gentle manipulation of the needle

4. Proper visualization of tip of the needle

5. If color Doppler is available, puncture of blood vessels can be

avoided

6. Avoidance of overdistension of follicles during flushing

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Routine coagulation screening

To prevent bleeding before OR.

534 coagulation tests were needed to prevent one

case of bleeding associated with an abnormal

coagulation test result.

(Revel et al,2011)

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Routine Clour Doppler US

Did not predict (45%) of the patients with

moderate peritoneal bleeding.

15%:

vaginal bleeding was detected and correctly

predicted during oocyte aspiration

Colour Doppler US guidance

easily accessible technology

(Rísquez , Confino; 2010)

. Aboubakr Elnashar

II. Infection

Types:

Pelvic abscess

ovarian abscess, or

infected endometriotic cyst.

Incidence:

0.1-3%

0.6%

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Depend upon

1. Technique of vaginal puncture

2. Presence or absence of pelvic infection or pelvic

endometriosis

3. Puncture of hydrosalpinx or bowel during the procedure

4. Preoperative vaginal preparation by 10%

povidone iodine or normal saline

5. Prophylactic antibiotics are used or not.

6. The presence of pelvic adhesions may be

associated with pelvic infections after TVOR

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Routes for pelvic infection: 1. Reactivation of latent infection

2. Contamination after trauma to the bowel

3. Direct inoculation of vaginal organisms

4. Puncture of a hydrosalpinx.

Symptoms: 1. Lower abdominal pain more than a week after OR

2. Dysuria

3. Fever

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Prevention:

1. History of pelvic infection: antibiotic prophylaxis

2. Antibiotics for all OR: data do not support

3. Signs of clinical infection before ET:

cryopreservation& ET in a future cycle

4. Before starting stimulation: culture for vaginal

infections: if negative to proceed.

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III. Pain

Incidence:

Severe to very severe: 3%

Severe pain 2 d after OR: 2%

Hospitalization for pain treatment:

0.7%

The pain level increased with the

number of oocytes retrieved.

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IV. Rare

1. Ruptured endometriotic or dermoid cysts:

acute abdominal symptoms: laparotomy

2. Acute appendicitis with puncture holes in the

appendix

3. Injury to the ureter:

ureterovaginal fistula

4. Injury to the ureter:

acute ureteral obstruction.

5. Rectus sheath hematoma: TAOR

6. Vaginal perforation in older patients with a history

of repeated OR, particularly when the ovaries are

difficult to visualize,

7. Vertebral osteomyelitis: severe low back pain:

antibiotics.

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V. Unsuccessful oocyte retrieval

Empty follicle syndrome

Incidence

1–7% of cycles

Define:

No oocytes are retrieved from apparently normally

ovarian follicles with normal steroidogenesis after

ovarian stimulation and

meticulous follicular aspiration.

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Types:

1. Genuine: 33%

Failure to retrieve oocytes despite optimal hCG

levels on the day of oocyte retrieval.

2. False: 67%

Failure to retrieve oocytes in the presence of low

hCG (<40 IU/L) due to an error in the

administration or the bioavailability of hCG

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Causes

I. False

1. hCG-related faults: main cause.

•hCG injection later than scheduled (11 h before

retrieval)

•failure of the hCG injection, confirmed by the

undetectable hCG serum concentrations.

2. Rapid metabolic clearance

3. Manufacturer defects in hCG production:

4. Low bioavailability of hCG

after bariatric surgery may induce EFS.

II. Genuine

Early oocyte atresia

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Risk factors

1) advanced age (37.7±6.0 years vs. 34.2±6.0

years, p< 0.001),

2) longer infertility duration (8.8±10.6 years vs.

6.3±8.4 years, p<0.05),

3) higher baseline FSH levels (8.7±4.7 IU/L vs.

6.7±2.9 IU/L, p<0.001),

4) lower E2 levels before the hCG injection (499.9±

480.9 pg/mL vs. 1,516.3±887.5 pg/mL, p<0.001)

The risk factors of EFS are similar to those of low

ovarian reserve, and this suggests that ovarian

ageing may be involved in the etiology of EFS.

EFS may be a gradual biological occurrence

related to ovarian ageing. Aboubakr Elnashar

Therapeutic approach

Prevention

1. Assessment of serum hCG the day after the

trigger

2. Second bolus of hCG administration.

{rarity of this occurrence in our practice}

some clinicians may hesitate to adopt such a

policy as a uniform practice.

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1. Readministering hCG and reaspiration. 36 hs

after this 2nd hCG shot.

2. use recombinant hCG (Ovitrelle) to trigger

ovulation

3. increase the dose of hCG to 20000 IU (instead

of the standard 10000 IU we use routinely)

4. Prolonging the interval between ovulation

triggering and OPU.

5. Prolonging the interval between ovulation

triggering and OPU and inducing ovulation

using GnRHa

ovulation was triggered using GnRHa 40 hs prior

to OPU and hCG was added 6 hs after 1st trigger.

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6. PROFICIENCY in oocyte retrieval: how many procedures are

necessary for training? (Goldman et al, 2011)

Define: practicing without supervision

Practice standards require that physicians perform

20 follicular aspirations under direct supervision

prior to independent practice (ASRM, 2008)

Proficiency scores (PS)

dividing the number of oocytes retrieved by the

number of oocytes predicted based on the total

number of follicles ≥12mm measured by ultrasound

on the day of hCG trigger.

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SUMMARY

1. Prophylactic use of antibiotics and antimycotics

2. Proper vaginal sterilization

3. Minimal number of vaginal punctures

4. Ultrasound visualization of peripheral follicles in a

cross-section before puncture

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5. Use of color Doppler if available

6. Gentle manipulation of the needle all through the

procedure

7. Proper visualization of tip of the needle all through the

procedure

8. Postoperative sedation if necessary

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Thank you

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