1. You can get: This lecture from: My scientific page on Face book:
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ABOUBAKR ELNASHAR

2. Prof. Aboubakr Elnashar Benha university, Egypt
OOCYTE RETRIEVAL
Prof. Aboubakr Elnashar
Benha university, Egypt
Aboubakr Elnashar

3. 6 CONTENTS APPROACH EQUIPMENTS TECHNIQUE PHYSICS DIFFICULTIES
PRECAUTIONS
COMPLICATIONS
PROFICIENCY 6
Aboubakr Elnashar

4. 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)
Aboubakr Elnashar

5. 2. EQUIPMENTS 1. Ultrasound machine: Frequency: Transducer:
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.
Aboubakr Elnashar

6. Aboubakr Elnashar

7. Single Lumen Ovum Aspiration Needle
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
Aboubakr Elnashar

8. 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).
Aboubakr Elnashar

9. Aspirating mature follicles. 90–120mmHg:
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.
Aboubakr Elnashar

10. 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.
Aboubakr Elnashar

11. 4. TECHNIQUE Check patient's name, her husband's name
time and date of the trigger
equipment, lines and aspirator
Make sure the bladder is fully drained.
Bladder is easily and unnoticedly punctured if it is not empty.
Aboubakr Elnashar

12. a. General anesthesia. 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.
Aboubakr Elnashar

13. 1. An aspirating needle is introduced through a guide attached to TV probe
Avoid contaminating the needle tip
2. The ovary should lined up to the most accessible position on the screen
focus and fix the ovary in the centre of the biopsy line
Line the most accessible follicle up against the biopsy lines.
Try to aspirate follicles through the least number of vaginal and ovarian punctures
Put plan how to do this through the least possible punctures before you start aspiration.
The optimum
one vaginal puncture and
one ovarian puncture for each ovary.

14. 3. Push the probe against the ovary
Insert the needle through the lateral or posterior fornices. Try to avoid the anterior fornix as far as possible.
Do not insert the needle through the cervix or the uterus as far as possible
unless you try all maneuvers to overcome this.
If you have appropriate number of retrieved oocyte-cumulus complexes, you may even "sacrifice" those remaining ones behind or above the uterus.
Aboubakr Elnashar

15. 4. insert the needle inside the follicle Enter The path of the needle
with a sharp jab
the follicle at maximum diameter
The path of the needle
is guided into each ovarian follicle by a biopsy guideline imposed on the ultrasound screen
The highly reflective walls of the needle identify its path
The needle tip can be observed as it is maneuvered within the ovaries and into each follicle.
Never puncture any hypoechoic something
unless you are quite confident it is a follicle.
Bowel and blood vessels resemble follicles in their cross sections.
90-degree rotation of the ultrasound probe clearly differentiates.
Aboubakr Elnashar

16. Aspiration pressure around 100
5. The follicular fluid containing the oocyte/cumulus complex is aspirated by application of suction:
Aspiration pressure around 100
(never more than 130)
Suction applied before entering the follicle
to prevent leaking
The walls of the follicle collapse
Ensure that all the follicular fluid is withdrawn
Aboubakr Elnashar

17. 6. Advance the needle into an adjacent follicle or
withdraw to the edge of the ovary
Realign
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.
All follicles should be aspirated
Follicles should only be left if
they are difficult to reach
{large pelvic blood vessels and the bowel are not perforated}

18. 8. If significant blood loss during the procedure
7. The needle should be flushed between the 2 ovaries of any potential blockage caused by blood clots
If the aspirated fluid is too bloody
change the collecting tube rapidly to avoid clotting of the fluid
8. If significant blood loss during the procedure
steady loss vaginally:
Speculum is inserted: bleeding points identified:
Pressure to the bleeding point with a gauze swab held in the end of sponge holding forceps.
Vaginal pack may be inserted
Video: OR1
Aboubakr Elnashar

19. Aboubakr Elnashar

20. Presence of fluid in endometrium Presence of ascites
5. DIFFICULTIES
Ovary
High
Stuck behind the cervix and uterus
Ovary stuck on the fundus
Endomeriomas
Hydrosalpinx
Blood vessels
In vagina
Too near
Presence of fluid in endometrium
Presence of ascites

21. (in very selected cases with very high ovaries).
Ovary is high
a. Raise the head of the table. b. Ask someone to push the ovary downwards
The direction of this "push" is an art.. It should be in a caudalad direction towards the aspirating gynecologist..
c. Insert the probe deeply in the posterior fornix and push it to reach the high ovary. d. Abdominal oocyte retrieval
(in very selected cases with very high ovaries).
This is rarely needed with skilled hands.
Aboubakr Elnashar

22. If inadvertently punctured: Antibiotic
Endometrioma
Do not aspirate
{Unacceptably high rates of infection}
If inadvertently punctured:
Antibiotic
Cephalosporin or broad-spectrum penicillin + metronidazole for 5 days
Aspirate completely
Flush them
Flush the needle many times or
Change the needle
Aboubakr Elnashar

23. Fluid in endometrial cavity after OR and before ET
usually associated with a poor prognosis.
It could be present due to
Excessive cervical mucus that ascends into the endometrial cavity
Fluid reflux from a hydrosalpinx
Subclinical uterine infection
Abnormal endometrial development.
Persistent fluid accumulation at ET:
Freezing of all embryos and transfer in a subsequent cycle.

24. 6. PRECAUTIONS CBC Anaemia and thrombocytopenia:
increase 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)
Aboubakr Elnashar

25. 7. COMPLICATIONS
Bleeding
Infection
Pain
Rare
EFS
Aboubakr Elnashar

26. 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)
Aboubakr Elnashar

27. TT: vaginal and cervical bleeding
  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: vaginal and cervical bleeding
usually stops with pressure, if does not suture
laparoscopy or laparotomy: in the case of heavy bleeding.
Aboubakr Elnashar

28. Compression is almost always enough for control of bleeding punctures, even those who show a "pulsating" bleeder
The latter may, however, need prolonged vaginal packing for 2-4 hours...
Aboubakr Elnashar

29. 2. Intra-abdominal hge: From: High risk S and S ovarian vessels
capsule puncture sites
other pelvic vessels
High risk
Lean patients with PCOS: 4.5%.
(Liberty et al, 2010)
2. History of surgery
S and S
weakness, dizziness
dyspnea, abdominal pain,
tachycardia, low blood pressure
Aboubakr Elnashar

30. Management Early hemodynamic monitoring: 2. Transfusion
if ovarian vessel
remove the needle and bleeding will stop..
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
Aboubakr Elnashar

31. Prevention of bleeding:
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
Aboubakr Elnashar

32. 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)
Aboubakr Elnashar

33. 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)
Aboubakr Elnashar

34. II. Infection Types: Incidence: Pelvic abscess ovarian abscess, or
infected endometriotic cyst.
Incidence:
0.1-3%
0.6%
Aboubakr Elnashar

35. Technique of vaginal puncture
Depend upon
Technique of vaginal puncture
Presence or absence of pelvic infection or pelvic endometriosis
Puncture of hydrosalpinx or bowel during the procedure
Preoperative vaginal preparation by 10% povidone iodine or normal saline
Prophylactic antibiotics are used or not.
The presence of pelvic adhesions may be associated with pelvic infections after TVOR
Aboubakr Elnashar

36. Routes for pelvic infection:
Reactivation of latent infection
Contamination after trauma to the bowel
Direct inoculation of vaginal organisms
Puncture of a hydrosalpinx.
Symptoms:
Lower abdominal pain more than a week after OR
Dysuria
Fever
Aboubakr Elnashar

37. Prevention: History of pelvic infection: antibiotic prophylaxis
Antibiotics and antimycotics for all OR: data do not support
Signs of clinical infection before ET: cryopreservation& ET in a future cycle
Before starting stimulation: culture for vaginal infections: if negative to proceed.
Aboubakr Elnashar

38. 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.
Aboubakr Elnashar

39. V. Unsuccessful oocyte retrieval
Empty follicle syndrome
Incidence
1–7% of cycles
Aboubakr Elnashar

40. Failure to retrieve oocytes in
DEFINITION
EFS
Failure to retrieve oocytes in
patients undergoing COS with at least 5 mature follicles (≥15 mm) on the day of hCG
(Coskun et al. 2010)
Borderline form of EFS
Retrieval of very few (mature or immature) oocytes
from several mature follicles
(Isik and Vicdan, 2000; Nikolettos et al., 2004; Duru et al.,2007; Desai et al., 2009; Vutyavanich et al., 2010).

41. No response to the rescue HCG. 0–1.1%.
TYPES
1. Genuine: 33%
Failure to retrieve oocytes despite optimal hCG levels on the day of OR.
No response to the rescue HCG.
0–1.1%.
(Beck-Fruchter et al, 2012)
2. False: 67%
Failure to retrieve oocytes in the presence of low hCG
(Stevenson and Lashen, 2008)

42. {No single tt is known to be universally effective}
MANAGEMENT
{No single tt is known to be universally effective}
If the embryologist does not get any eggs after aspiration of 3 mature follicles:
Stop the procedure
Ensure patient has taken the trigger injection at the right time
urine pregnancy test
(obtained by catherisation or aspirated follicular fluid)
a. Positive pregnancy test: rules out False EFS: continue egg collection.

43. b. Pregnancy test is negative: False EFS
Stop the procedure
HMG injection {support follicular growth}
E2 and HCG levels.  (Remember that we will get the results of the blood tests only after a few hrs)
HCG injection
OR 36h after this 2nd HCG shot.

44. If we are worried about the quality of the hCG injection:
RecHCG (Ovitrelle)
Increase the dose of hCG to IU (instead of the  standard IU)

45. You can get: This lecture from: My scientific page on Face book:
Aboubakr Elnashar Lectures.
Slide share web site
All lectures from:
My clinic, 3 Althawra St. Almansura
ABOUBAKR ELNASHAR