Outside operating room procedure

1. ANAESTHESIA FOR IVF

2. • In Vitro fertilization is a well established speciality.
• It involves the following steps
1.Ovarian stimulation
2.Oocyte retrieval
3.Sperm processing &
4.Fertilization & embryo transfer
• This technique of using Vaginal ultra-sound probe is less invasive and
associated with higher pregnancy rates, it forms one of the most stressful and
painful components of the entire assisted reproductive treatment.

3. Role of Anesthesiologist
• Anesthesia may be required in various aspects of the patient's treatment,
which demands judicious perioperative management.
• Aproper medical , surgical , drug history must be elicited along-with a proper
pre op counselling to allay the patients anxiety which can be detrimental for
the procedure and hence the outcome.
• General Considerations: Such patients are either suffering from some
illnesses or are on some kind of medication.
1. Co existing illnesses:
-Tuberculosis
-Thyroid medications
-Anticoagulation therapy
-Antidepressant medications.
2.Medications : For the above illnesses and their interactions with
anesthtetic medications.

4. Special Considerations
• In morbidly obese patients,patients with severe
renal/cardiac/pulmonary disease
• In cancer patients on chemo/radiotherapy.
Anesthesia considerations
• Pain -to provide adequate pain relief to immobilise the patient , to be
short acting and readily reversible with a few side effects.
• Anxiety-Another major challenge for the anaesthetistis to allay the
anxiety

5. Types of Anesthesia Techniques
1. Monitored anesthesia care with conscious sedation
2. GeneralAnesthesia
3. Regional
• SpinalAnesthesia
• EpiduralAnesthesia
• Paracervical and preovarian block
4. Total IntravenousAnesthesia
5. Patient controlled analgesia

6. Monitored Anesthesia Care
• Monitored anesthesia care is relatively easy to deliver, drugs are well tolerated
and best suited in day care setting.
• Monitored anesthesia technique with remifentanil resulted in a higher
pregnancy rate than GAwith alfentanil+ propofol or isoflurane + propofol for
maintenance.

7. GENERAL ANESTHESIA
• Almost all anesthetic drugs that are used are found in follicular fluid.
• With a relaxed uterus, it becomes easier for the gynecologist to aspirate even
the small ovarian follicles, unlike sedation where a contracted myometrium
fibrils pose a hinderance for oocyte retrieval
• Aim is to reduce the pharmacological exposure to the shortest duration.
Drugs commonly used
• Propofol – widely used in assisted reproduction and its role is established , also
has an antiemetic property to its advantage.
• Benzodiazepine - Midazolam is the most commonly used benzodiazepine.A
combination of midazolam and fentanyl was found to be safe for oocyte
retrieval.

8. • Opioids-Fentanyl or alfentanil were found to be favourable agents when
used in combination with Propofol. Fentanyl has minimal penetration into
follicular fluid
• Ketamine-Arandomized prospective study, found the combination of
midazolam and ketamine a good alternative to general anaesthesia.
• Etomidate
• A prospective comparative study in 18 patients found that etomidate
could also interfere with the endocrine function of the ovary by observing
a sharp decrease in the plasma concentration of 17 beta- oestradiol,
progesterone, 17-hydroxyprogesterone -progesterone, and testosterone
within 10 min after induction of anesthesia with etomidate (0.25 mg/kg)
followed by a gradual return to the baseline levels thereafter.

9. Nitrous oxide
General. in their retrospective analysis of three groups sedation
combined with local anesthesia, epidural block, and GA with N 2 O
found that N 2 O had a deleterious effect on IVF outcome.
• N 2 O deactivates methionine synthetase thereby reducing the amount
of thymidine available for DNAsynthesis in dividing cells
Volatile halogenated agents
Most of the studies have demonstrated the deleterious effect of
halogenated fluorocarbons on IVF outcomes

10. • Postoperative nausea and vomiting and antiemetic agents
PONV is a common problem after IVF procedures under anesthesia
• Its frequency is related to peak plasma level of estradiol and previous history
of PONV
• Higher incidence of PONV was found following inhalational anesthesia for
IVF procedures as compared to TIVA
• Bromocriptine
Sopelak et al, in their study on 32 patients observed that bromocriptine, a
potent dopamine agonist, given before anesthesia can suppress transient,
anesthesia-induced hyperprolactinemia, and had have a positive influence on
embryonic development.

11. RegionalAnesthesia
• Epidural anesthesia also forms a viable option but does not demonstrate any
advantage over intravenous sedation.
• Spinal anesthesia is also an efficient method for oocyte retrieval.
-Low dose hyperbaric 1.5% lidocaine (45mg) spinal with low dose fentanyl
10mcg for egg retrieval(Martin et al).
-Bupivacaine compared favorably to lidocaine in all aspect except taking
approximately 30 min longer to micturition and to discharge.
• Paracervical block with different doses of lidocaine/bupivacaine with
sedation has been used for egg retrieval.
-Various conscious sedation regimens using midazolam, diazepam,
alfentanyl have been used along with paracervical block to enhance the
analgesia.
• Hormonal response to follicular puncture is fully attenuated by regional
anesthesia and partially by technique requiring sedation.

12. • Total IntravenousAnalgesia
TIV
Awith propofol and alfentanil is superior to inhalational anesthesia with
N 2 O and enflurane in view of less nausea and vomiting.
• Patient ControlledAnalgesia (PCA)
- It is an alternative technique of analgesia with higher levels of patient
satisfaction by allowing women to control over their drug administration.
- It was concluded that intraoperative PCA with fentanyl is an effective
alternative to physician-administered techniques in terms of patient comfort
and satisfaction.
• Acupunture
It is a conventional therapy which activates the endogenous opioid system
by increasing beta-endorphin levels. It has the additional benefit of
providing antidepressant, anxiolytic, and sympathoinhibitory actions.

13. Conclusion:
1. Role of anesthetist is to provide pain relief and comfort.
2. Modality of anesthesia used should be decided in consultation with
patient.
3. Each patient can be provided with a different mode of anesthesia
4. To keep patient comorbidities while deciding a specific modality.
5. Anesthesia must be provided for the shortest duration.
References
1. Jain D, KohliA, Gupta L, Bhadoria P,Anand R.Anaesthesia for In Vitro
Fertilisation. Indian Journal of Anaesthesia. 2009;53(4):408-413.
2. SharmaA, BorleA, TrikhaA.Anesthesia for in vitro fertilization. J Obstet
Anaesth Crit Care 2015;5:62-72

14. THANK YOU