1. Dr zhila Abedi asl Fellowship of infertility Bahman hospital IVF center Tehran Iran

2. Content 1. APPROACH 2. EQUIPMENTS 3. TECHNIQUE 4. PRECAUTIONS 5. COMPLICATIONS 6. PROFICIENCY

3. 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)

4. Anesthesia /Analgesia : Propofol, fentanyl, midazolam used frequently With low incidence of adverse effects on oocyte and embryo quality. Cleansings /Sterilizing vagina: use of normal saline

5. EQUIPMENT 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.

6. 2- Aspiration needles: single & double lumen 3-Follicle aspiration set 4-Suction pump

7. Precuations CBC: anaemia and thrombocytopenia increase the risk of bleeding. Prophylactic antibiotic: 1 g ceftazidime IV immediately after sedation. (Aragona et al, 2011) TVS: before being discharged from the unit, ∼ 4 h after the procedure. Not to perform endometrial injury on the day of OR {reduce PR} (Nastri et al, 2012)

8. 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

9. Complication The Commonest operative: -Hemorrhage -Trauma to pelvic structures -Pelvic infection, tubo-ovarian, or pelvic abscess Rarely reported : -ovarian torsion -Rapture of endometrioma -Appendicitis -Ureteral obstraction -Uretero vaginal fistula -Vertebral osteomyelitis -Anesthetic complications

10. Hemorrhage 1. Vaginal bleeding: 2.8% Requiring compression >1 min 2.7% Tamponade >2 h 0.1% vaginal ≥100 mL: 0.8% Risk factors: anticoagulant therapy Rarely a major problem(coagulopathy ) Treatment: 1. local pressure 2. oversewing. 3. laparoscopy or laparotomy: in the case of heavy bleeding

11. 2. Intra-abdominal Hemorrhage: 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

12. 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

13. 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.

14. 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

15. Infection Types: Pelvic abscess ovarian abscess, or infected endometriotic cyst. Incidence: 0.1-3% 0.6%

16. 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

17. 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: -Lower abdominal pain more than a week after OR -Dysuria - Fever

18. 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.

19. Rare complications 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