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Gynecology & Obstetrics The International Open Access Gynecology & Obstetrics
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Edris et al., Gynecol Obstet (Sunnyvale) 2014, 4:3 http://dx.doi.org/10.4172/2161-0932.1000214
Gynecology & Obstetrics Research Article
Open Access
Single Operator Ultrasound Guided Transabdominal Oocyte Retrieval in Patients with Ovaries Inaccessible Transvaginally: A Modified Technique Fawaz Edris1,2*, Nelson Holiva2, Salma Baghdadi2, Mamdoh Eskandar3, Angelos A Vilos4, Wardah Alasmari1 and George A Vilos4 Department of Obstetrics and Gynecology, Umm Al-Qura University, Makkah, Saudi Arabia Department of Obstetrics and Gynecology, International Medical Center, Jeddah, Saudi Arabia Department of Obstetrics and Gynecology, King Khalid University, Abha, Saudi Arabia 4 Department of Obstetrics and Gynecology, The Fertility Clinic, Western University, London, Canada 1 2 3
Abstract Objectives: To described the feasibility, relative safety and efficacy of a modified transabdominal ultrasoundguided follicular-aspiration technique. Methods: Retrospective cohort study in a private In-Vitro Fertilization (IVF) center. Amongst 816 IVF cycles over 3 years, 13 women (13 cycles) with inaccessible ovaries through the vagina required transabdominal retrieval. In 3 cases, both ovaries were aspirated transabdominally. Under conscious sedation and local analgesia, the same operator scanned the abdomen with one hand and retrieved the oocytes with the other; using a standard 17-gauge aspiration needle and without the use of a needle-guide. All but one ovary required one puncture. Research board of ethics approval was obtained. Results: The mean and standard deviation (± SD) number of oocytes retrieved transabdominally and transvaginally were 8.4 (± 4.8) and 10.5 (± 6.8), respectively (P=0.93). The mean (± SD) fertilization rate and “good quality” embryos was 78.1% (± 16.2) and 51.9% (± 19.8), respectively. Of the 13 patients, 12 had Embryo Transfer (ET). One patient developed ovarian hyperstimulation syndrome and her embryos were cryopreserved. Of the 12 patients, one had an ectopic pregnancy and 6 (50%) had at least one intrauterine gestational sac. Two patients conceived with a twin and four with a singleton. One of the twin cases aborted at 19 weeks due to an incompetent cervix, and one singleton pregnancy had a miscarriage at 8 weeks of gestation. The other four patients (33.3%) delivered at term, and all babies are alive and well. Of the remaining 5 patients, one conceived from a frozen ET, and delivered a healthy baby at term. Conclusion: This modified technique, performed by a single operator under conscious sedation and local analgesia, allowed maximal retrieval of oocytes through a single ovarian puncture in women undergoing IVF-ET with inaccessible ovaries transvaginally. It is safe and feasible.
Keywords: Transabdominal oocyte retrieval; Follicular aspiration; Transvaginal oocyte retrieval; Inaccessible ovaries; IVF-ET
Introduction In the 1980s, studies reported on the relative safety and ease of ultrasound-guided (US-guided) oocyte retrieval as compared with the classical laparoscopic approach for in-vitro fertilization (IVF) [1,2]. Furthermore, ultrasound-guided retrieval was shown to have higher numbers of mature oocytes and oocyte fertilization rates when compared with the laparoscopic approach [2]. This could be related to the fact that US-guided follicular aspiration allowed better assessment of the complete emptying of the follicles as one study indicated that the cumulus-oocyte complex often is likely to be aspirated when the follicle is nearly completely collapsed [3]. Additional disadvantages to laparoscopic approach include the need for general anesthesia and all potential complications associated with laparoscopic surgery. As a result, also in the 1980s, US-guided oocyte retrieval was modified and was conducted via combination of transabdominaltransvesical [4,5] or transurethral-transvesical approach [6]. These techniques however, were associated with frequent complications, mostly involving the urinary tract, including infection, urinary retention, and hematuria [7]. Because of such complications, subsequent studies reported that physicians and patients preferred a transvaginal US-guided over abdominal US for both follicular monitoring and aspiration [8,9]. With accumulation of further evidence on the feasibility, safety and efficacy of the transvaginal US-guided oocyte retrieval, today this approach has been universally adopted and it has become the standard of care worldwide. The transvaginal approach however, poses a bothersome problem when the ovaries are not accessible transvaginally due to variations in pelvic organ anatomy Gynecol Obstet (Sunnyvale) ISSN: 2161-0932 Gynecology, an open access journal
from biological variability or pelvis/abdominal disease. Historically, in such cases, clinicians had to revert back to laparoscopic follicular aspiration, or these women were denied IVF. An alternative method developed for these cases is a transabdominal US-guided retrieval, which avoids the increased time, cost, and potential complications of laparoscopy. One retrospective series and 5 case reports have been published using this latter approach [10-15]. In most, if not all, of these cases however, a needle-guide was used to facilitate oocyte retrieval and, invariably, more than one operator was required to complete the process; one to use the ultrasound and another to aspirate the follicles. Furthermore, the majority of these cases required a general or regional anesthesia. In the present study, we describe our experience using a modified transabdominal US-guided follicular aspiration technique, which does not require a needle guide and both scanning and aspiration
*Corresponding author: Dr. Fawaz Edris, Department of Obstetrics and Gynecology and Infertility, Umm Al-Qura University, P.O Box 2172, Jeddah 21451, Saudi Arabia, Tel: +966-12-650-9000; Fax: +966-12-650-9001; E-mail:
[email protected] Received February 21, 2014; Accepted March 30, 2014; Published March 31, 2014 Citation: Edris F, Holiva N, Baghdadi S, Eskandar M, Vilos AA (2014) Single Operator Ultrasound Guided Transabdominal Oocyte Retrieval in Patients with Ovaries Inaccessible Transvaginally: A Modified Technique. Gynecol Obstet (Sunnyvale) 4: 214. doi:10.4172/2161-0932.1000214 Copyright: © 2014 Edris F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Volume 4 • Issue 3 • 1000214
Citation: Edris F, Holiva N, Baghdadi S, Eskandar M, Vilos AA (2014) Single Operator Ultrasound Guided Transabdominal Oocyte Retrieval in Patients with Ovaries Inaccessible Transvaginally: A Modified Technique. Gynecol Obstet (Sunnyvale) 4: 214. doi:10.4172/2161-0932.1000214 Page 2 of 5
are performed by a single operator, when one or both ovaries are inaccessible transvaginally. All cases were done under conscious sedation.
A
Material and Methods Institutional review board approval was obtained. We retrospectively reviewed 816 IVF cycles with or without Intra Cytoplasmic Sperm Injection (ICSI) over 3 years done in our relatively new IVF center, and we identified 13 cycles (1.6%) in 13 patients involving transabdominal US-guided follicular aspiration. In three cases, both ovaries were aspirated transabdominally. In the remaining nine cases, follicles were aspirated transabdominally from one and transvaginally from the contralateral ovary. The indication for IVF/ ICSI was a male factor (decreased sperm count, motility, normal morphology, or a combination of them) in 6 of those cases, and a female factor in the remaining 7 patients (5 with polycystic ovarian syndrome, and 2 with decreased ovarian reserve).
B
Patients were prepared for oocyte retrieval using a standard ovarian long-stimulation protocol. Down regulation was achieved using Gonadotropin Releasing Hormone (GnRH) agonist (Decapeptyl, Ferring, Germany), then ovarian stimulation was initiated using an exogenous recombinant gonadotropin (Puregon, MSD, Netherlands), with a starting dose of 150 to 225 International Unit (IU). The dose was then adjusted in tandem with ovarian follicular development as monitored by serial serum estradiol and transvaginal ultrasound. Oocyte retrieval was performed 36 hours after the administration of 10,000 iu of human Chorionic Gonadotropin (hCG-Choriomon, IBSA, Switzerland), which was administrated when at least three follicles reached 17 millimetre (mm) in diameter. The need for transabdominal aspiration was recognized during follicular monitoring when one or both ovaries were not clearly visualized transvaginally and were much more apparent transabdominally. At the time of follicular aspiration, we attempted in all cases to access the ovaries transvaginally using the usual technique of applying abdominal pressure to push the ovaries into the pelvis. If transvaginal aspiration was not possible, we converted to transabdominal retrieval. Under the same conscious sedation (Fentanyl and Midazolam) used for transvaginal aspiration, the patient was repositioned from dorsal lithotomy to supine. The urinary bladder was emptied by patient voiding or in-and-out catheterization just prior to attempted transvaginal approach. When the transvaginal approach failed to access one or both ovaries, the same operator reverted to scanning the patient’s abdomen using regular ultrasound gel and an abdominal probe (3.5 MHz Probe; Philips iU22, Philips Medical Systems, Bothell, WA, USA) to identify an area in the abdominal wall for the most feasible and safest access to the ovary(s). The gel was wiped off and, using sterile techniques, the predetermined abdominal wall area, including skin and subcutaneous tissues, was injected with local anesthetic (1% Lidocaine Hydrochloride). Under ultrasound guidance, a standard 17-gauge retrieval needle (Cook Medical, Brisbane, Australia) was inserted through the abdominal wall by the same operator without the use of a needle guide (Figure 1A and 1B). All but one ovary required a single ovarian puncture to retrieve all oocytes. Only one ovary required two punctures, as some of the follicles could not be aspirated with the first attempt, however both ovarian punctures were done through the same transabdominal needle insertion. There were no failed attempts. Age, Body Mass Index (BMI), peak estradiol level reached, and the total number of follicles, number of “good size” follicles (>17 mm), Gynecol Obstet (Sunnyvale) ISSN: 2161-0932 Gynecology, an open access journal
Figure 1: (A) The single operator is holding the US probe with one hand and inserting the oocyte-retrieval needle with his other hand-No sterile cover is used for the US cord as it never touches the needle or abdominal wall puncture site. (B) Transabdominal ultrasound image showing the retrieval needle tip within one follicle-No “biopsy line or path” is seen, as there was no needle guide used-Arrows are delineating the needle path.
as well as the total number of oocytes retrieved transabdominally and transvaginally were recorded (Table 1). Additionally, number of total, damaged, and mature oocytes retrieved, as well as the number of normally fertilized oocytes, fertilization rates, number of “good quality” embryos (8-cell embryo with
