Oocyte retrieval at 140 mm Hg negative aspiration pressure – a promising alternative to flushing and aspiration in Assisted Reproduction Dr.Aswathy Kumaran** Dr.Amar Ramachandran*** Dr.Praveena Pai** Dr Satish Adiga**** Dr.Pratap Kumar**** ****Professor ***Assoc.Professor **Senior Resident

Background Standard oocyte aspiration pressure – Negative pressure of 120 mm of Hg (90 - 120 mmHg) When oocyte retrieval difficult  when antral follicle count < 5 in each ovary flushing and oocyte retrieval loss of granulosa cells corpus luteal defects Higher aspiration pressures mechanical trauma to oocyte poor oocyte quality

Aim To compare oocyte retrieval using negative aspiration pressure of 140mm Hg with retrieval by flushing and aspiration at 120mm Hg in women with poor antral follicle counts.

Materials and methods Type of study- retrospective analytic study Study group –all women undergoing IVF/ICSI following oocyte retrieval at Manipal Assisted Reproduction Centre, Dept.Of OBG, Kasturba Medical College, Manipal University, Manipal Study period - 3years (May 2010-April 2013))

women whose total antral follicle counts were less than 10 Inclusion criteria Exclusion Criteria women whose total antral follicle counts were less than 10 Women who had oocyte retrieval with Antral follicular count > 10 120 mm of Hg A combination of two methods

Methods Data collection from IVF records In each patient Oocyte pick up pressure Women with antral follicle counts less than 10 n=76 Group A 140 mm Hg n=41(54%) Group B Flushing n=35(46%) Number of Follicles tapped Number of Oocytes retrieved Number of Oocytes fertilized Number and quality of Embryos obtained In each patient Bhcg 2 weeks after embryo transfer

Flushing and aspiration Analysis Parameter Group A 140 mm of Hg n=41 Group B Flushing and aspiration n=35 p-value Mean Follicles tapped 7 6.8 >0.05 Eggs retrieved 4 3.94 Fertilized eggs 2.73 2.00 Embryos obtained 2.25 2.10 Chi-square test The means of each parameter comparable in both groups

Comparison of number of oocytes retrieved Parameter Group A 140 mm of Hg n=41 Group B Flushing and aspiration n=35 p-value Mean Eggs Retrieved/ follicles tapped 0.52 0.60 0.404 Independent sample test Rate of oocyte retrieval in both groups comparable

Flushing and aspiration Oocyte quality Parameter Group A 140 mm of Hg n=41 Group B Flushing and aspiration n=35 p-value Mean Eggs fertilised/ eggs retrieved 0.74 0.29 0.016 Embryos developed/ 0.66 0.32 0.004 Independent sample test Functional oocyte quality significantly more in Group A Loss of granulosa cells in aspirating fluid was 80% in group B versus 10 % group A

Comparison of Embryo Quality Parameter Group A 140 mm of Hg n=41 Group B Flushing and aspiration n=35 p-value Mean Gr1 embryos/eggs retrieved 0.68 0.54 0.089 Gr2 embryos/eggs retrieved 0.09 0.14 0.125 Gr3 embryos/eggs retrieved 0.04 0.165 Independent sample test SD-standard deviation Independent sample test The number of high grade embryos per oocytes retrieved more in Group A Basak Balaban et al, The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting ;Alpha Scientists in Reproductive Medicine and ESHRE SpecialInterest Group of Embryology Human Reproduction, Vol.26, No.6 pp. 1270–1283, 2011 Advanced Access publication on April 18, 2011 doi:10.1093/humrep/der037

βHCG positive Biochemical pregnancy rates significantly more in group A

Pregnancy outcomes Favourable pregnancy outcomes more in group A

Merit Limitation Study model may used to conduct large multi-centric prospective trials to arrive at a definitive recommendation Small study Confounding factors Retrospective study

Conclusion The oocyte retrieval outcomes with aspiration pressure of 140 mm of Hg is better than that after flushing and aspiration Oocyte retrieval at 140 mm of Hg in women is a promising alternative to flushing and aspiration in women with poor antral follicle count Message

Reference Hans Peter Steiner,Follicular aspiration and flushing,Milder,mildest or back to nature-Textbook of minimal stimulation IVF,JP medical Ltd,Newdelhi,2011;Pages 98-102 Hashimoto S, Aisaku Fukudaet al,Effect of aspiration vacuum on the developmental competence of immature human oocytes retrieved using a 20-gauge needle,Reproductive BioMedicine Online ,2007;Vol14, Issue 4 , Pages 444-449 Antosik et al,Vaccum Pressure on quality and number of recovered oocytes aspirated from ovarian follicles of swine and cow,Arch.Tierz,Dummerstorf,Poland,2007;Vol.3,Pages 200-204260-266

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