OOCYTE RETRIEVAL Prof. Aboubakr Elnashar

1. OOCYTE RETRIEVAL
Prof. Aboubakr Elnashar
Benha university, Egypt
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2. Contents
1. APPROACH
2. EQUIPMENTS
3. TECHNIQUE
4. PRECAUTIONS
5. COMPLICATIONS
6. PROFICIENCY
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3. 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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4. 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.
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5. AboubakrElnashar

6. 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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7. Gynetics:
Aspiration needles:
different sizes and flexibility,
Laser etched markings on tip: stable and excellent vision
during ultrasound.
translucent tubing
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8. 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.
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9. 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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10. 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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11. 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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12. 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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13. 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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14. 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).AboubakrElnashar

15. 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.
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16. 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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17. 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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18. Video 7
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19. 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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20. 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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21. 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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22. 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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23. 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.
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24. •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. AboubakrElnashar

25. •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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26. AboubakrElnashar

27. 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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28. 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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29. 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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30. 5. COMPLICATIONS
I. Bleeding
II. Infection
III. Pain
IV. Rare
V. EFS
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31. 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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32. 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.
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33. 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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34. 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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35. 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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36. 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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37. 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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38. 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)
.
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39. II. Infection
Types:
Pelvic abscess
ovarian abscess, or
infected endometriotic cyst.
Incidence:
0.1-3%
0.6%
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40. 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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41. 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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42. 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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43. 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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44. 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. AboubakrElnashar

45. 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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46. 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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47. 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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48. 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.
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49. 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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50. 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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51. 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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52. 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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53. 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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54. Thank you
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