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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
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Prof. Aboubakr Elnashar Benha university, Egypt
OOCYTE RETRIEVAL Prof. Aboubakr Elnashar Benha university, Egypt Aboubakr Elnashar
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6 CONTENTS APPROACH EQUIPMENTS TECHNIQUE PHYSICS DIFFICULTIES
PRECAUTIONS COMPLICATIONS PROFICIENCY 6 Aboubakr Elnashar
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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
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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
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Aboubakr Elnashar
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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}
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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
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Aboubakr Elnashar
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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
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(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
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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
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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.
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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
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7. COMPLICATIONS Bleeding Infection Pain Rare EFS Aboubakr Elnashar
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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
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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
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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
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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
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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
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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
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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
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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
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II. Infection Types: Incidence: Pelvic abscess ovarian abscess, or
infected endometriotic cyst. Incidence: 0.1-3% 0.6% Aboubakr Elnashar
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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
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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
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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
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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
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V. Unsuccessful oocyte retrieval
Empty follicle syndrome Incidence 1–7% of cycles Aboubakr Elnashar
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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).
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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)
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{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.
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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.
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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)
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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
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