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We report a case of ultrasound-guided ex vivo oocyte retrieval for fertility preservation in a woman with bilateral borderline ovarian tumor, for whom conventional transvaginal oocyte retrieval was deemed unsafe because of the increased risk of malignant cell spillage. Ovarian stimulation with gonadotropins was performed. Surgery was scheduled according to the ovarian response to exogenous gonadotropic stimulation; oophorectomized specimens were obtained by laparoscopy, and oocyte retrieval was performed ∼ 37 hours after the ovulatory trigger. The sum of 20 ovarian follicles were aspirated, and 16 oocytes were obtained. We performed vitrification of 12 metaphase II oocytes and 3 oocytes matured in vitro. Our result emphasizes the viability of ex vivo mature oocyte retrieval after controlled ovarian stimulation for those with high risk of malignant dissemination by conventional approach.Relatamos um caso de obtenção ex vivo de óvulos, guiada por ultrassonografia, para preservação da fertilidade em uma mulher com tumor ovariano borderline bilateral, para quem a recuperação transvaginal convencional foi considerada insegura, devido ao aumento do risco de disseminação de células malignas. Foi realizada estimulação ovariana com gonadotrofinas. A cirurgia foi agendada de acordo com a resposta ovariana à estimulação gonadotrófica exógena; após ooforectomia por laparoscopia, ∼ 37 horas após a maturação folicular, procedeu-se à recuperação extracorpórea de oócitos. Um total de 20 folículos ovarianos foi aspirado e 16 complexos cumulus foram obtidos, resultando na vitrificação de 12 oócitos maduros e de 3 oócitos imaturos amadurecidos in vitro. Nosso resultado enfatiza a viabilidade da recuperação ex vivo de oócitos maduros após estimulação ovariana controlada para mulheres com alto risco de disseminação maligna pela captação oocitária realizada convencionalmente pela via transvaginal.

We report the pregnancy and live birth achieved after in vitro maturation (IVM) of oocytes and PGT-A in a 23-year-old patient suffering from ovarian gonadotropin resistance. A woman with resistant ovary syndrome (ROS) had secondary amenorrhea, high FSH levels (25.34 mIU/mL) and LH (29.6 mIU/mL), low estradiol levels (15.2 pg/mL), and high serum AMH levels (38.0 ng/mL), associated with an increased antral follicle count (AFC) of 45. Without gonadotropin priming and HCG trigger, ultrasound-guided transvaginal oocyte retrieval was performed. Aspiration of antral-stage follicles allowed the retrieval of 15 immature oocytes. After oocyte collection, immature oocytes were cultured in the IVM medium. Following IVM, six of them reached metaphase II stage. Resultant matured oocytes were fertilized by intracytoplasmic sperm injection (ICSI). Embryos obtained were cultured to the blastocyst stage. On day 5, three embryos reached blastocyst stage. Trophectoderm biopsy and PGT-A were performed on two better quality embryos on day 5 after fertilization. Two biopsied embryos were reported to be euploid. PGT-A was performed utilizing next-generation sequencing (NGS\MPS). One embryo was transferred in an artificial thaw cycle and resulted in a viable intrauterine pregnancy and live birth. Our experience indicates that there is no requirement for gonadotropin stimulation and use of b-hCG trigger prior to IVM in patients with ROS. The results suggest that oocytes obtained with IVM in patients with ROS are capable of meiotic and mitotic division, fertilization, and generation of euploid embryos. IVM appears to be a valuable approach in patients with ROS, allowing them to have genetically connected offspring.

Background Oocyte retrieval is the most important procedure in in vitro fertilization (IVF). Various anesthetic methods are used to control a patient’s anxiety and pain during IVF; however, there are no recommended anesthetic methods at present. In this study, we retrospectively investigated chemical pregnancy rates according to the anesthetic method used for oocyte retrieval. Methods We reviewed records of patients who underwent oocyte retrieval between January 1, 2012 and December 31, 2017. Patients were divided into the spinal anesthesia (SA) and monitored anesthesia care (MAC) groups. The primary outcome was chemical pregnancy rate after IVF. Results The study included 95 patients. SA was administered in 77 (81%) and MAC in 18 (19%). The overall chemical pregnancy rate was 32.6% (31/95). According to the anesthetic method, the pregnancy rate was 32.5% (25/77) in the SA group and 33.3% (6/18) in the MAC group. There was no statistical difference in the pregnancy rate between the groups (P = 0.575). The procedural time was significantly shorter in the SA group than in the MAC group (P < 0.001). Conclusions Chemical pregnancy rates were not significantly different between the SA and MAC groups. However, the procedure duration was shorter in the SA group than in the MAC group.

Objective: Anesthesia for assisted reproductive technology is very important to provide less stressful and painful environment for patients, with minimal side effects on oocytes. In the present study, we aimed to evaluate hemodynamic parameters, recovery time and intracytoplasmic sperm injection (ICSI) outcome among patients underwent anesthesia with fentanyl, remifentanil or alfentanil. Material and methods: This randomized double-blinded clinical trial was conducted in patients undergoing anesthesia for transvaginal ultrasound guided oocyte retrieval (TUGOR). Patients were randomly allocated to alfentanil (A; 15 μg/kg), fentanyl (F; 1.5 μg/kg) or remifentanil (R; 1.5 μg/kg) groups. Results: Three hundred forty patients were assessed for eligibility and randomized for transvaginal oocyte retrieval following general anesthesia and 105 were lost to follow up. No statistically significant differences were noted among groups regarding basic characteristics. Although, time to respond to verbal command was significantly different among groups (A: 1.99 ± 1.64, F: 2.56 ± 1.72, R: 1.78 ± 1.34, P = 0.014). There were no significant differences among groups with respect to the first and second postoperative pain intensity, patient satisfaction, pre-induction and post-induction systolic and diastolic blood pressure (BP). Terminal systolic (A: 101.61 ± 9.15, F: 105.29 ± 12.61, R: 102 ± 12.91, P = 0.01) and diastolic (A: 59.97 ± 9, F: 65.63 ± 9.13, R: 63.69 ± 11.01, P = 0.003) BP was significantly different among groups. The fertilization rate was significantly different among groups (A: 51.6%, F: 54.4%, R: 62.2%, P = 0.018). Implantation rate, biochemical and clinical pregnancy rate was similar among groups. Conclusions: The results of present study demonstrated that all three opioids have the same efficiency, in regards to patient satisfaction and pregnancy outcome. However, Anesthesia with alfentanil compared with fentanyl and remifentanil, seems to be inferior for TUGOR due to higher effect on fertilization rate and less hemodynamic stability. Registration number: IRCT201410258677N4. Keywords: Alfentanil, Fentanyl, Remifentanil, General anesthesia, Intracytoplasmic sperm injections

(1) Background: There has been various reports on the potential impact of anesthetic agents used during oocyte retrieval (OR) on the impairment of the capacity of the oocyte for fertilization and subsequent embryo quality, results have been conflicting, (2) Methods: The effects of two different sedation protocols during OR in two groups of patients undergoing In Vitro Fertilization/Intra-Cytoplasmic Sperm Injection IVF/ICSI, were compared on propofol consumption and on in vitro fertilization (IVF)/ICSI success. The study group received dexmedetomidine and fentanyl, while the control remifentanil and midazolam. In a prospective cohort study, we encompassed 72 cycles/patients. The administered dose of propofol per patient and fertilization rates were the primary outcomes, while anesthesiological parameters and IVF/ICSI outcomes were the secondary endpoints, (3) Results: We found a significant increase in propofol consumption in the study compared to the control group (77.0 ± 10.6 mg vs. 12.1 ± 6.1, p &lt, 0.001), but fertilization rates were similar (p = 0.469). From the secondary anesthesiological outcomes, the post anesthesia discharge scores were better in the control group (15.0 (13.5 min) vs. 5.0 (10.0 min), p = 0.028). From the IVF/ICSI secondary outcome parameters, we found a higher quality of embryos on day three in the study compared to the control group (p = 0.040). The comparison of the other secondary outcomes yielded non-significant differences, (4) Conclusions: The use of dexmedetomidine, as an alternative agent during OR, was associated with higher propofol consumption as a rescue dose compared to remifentanil but was linked with similar fertilization rates and higher quality of embryos produced.

Research Question: In the early stages of the COVID-19 pandemic, IVF clinics stopped the majority of patient treatment cycles to minimize the risk of disease transmission. The risk of SARS-CoV-2 viral exposure and potential cross contamination within the IVF lab remains largely unclear. To that end, the objective of this study was to examine follicular fluid (FF), culture media (M) and vitrification solution (VS) for SARS-CoV-2 in an IVF lab. Design: Prospective clinical study. All females undergoing transvaginal oocyte retrieval (TVOR) were required to have a negative SARS-CoV-2 RNA test 3-4 days prior to the procedure. Male partners were not tested. All cases utilized intracytoplasmic sperm injection (ICSI). The first tube of FF aspirated during oocyte retrieval, M drops following removal of embryos on day 5, and VS after blastocyst cryopreservation were analyzed for SARS-CoV-2 RNA. Results: In total, M from 61 patients, VS from 200 patients, and FF from 300 patients were analyzed. All samples were negative for SARS-CoV-2 viral RNA. Conclusion(s): With stringent safety protocols in place, including female patient testing and symptom-based screening of men, the presence of SARS-CoV-2 RNA was not detected in FF, M or VS. This work demonstrates the possibility of implementing a rapid laboratory screening assay for SARS-CoV-2 and has implications for safe laboratory operations, including cryostorage recommendations.

Background Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following hysterectomy with an estimated incidence of 0.14–1.4%. There is a wide range of risk factors thought to contribute to VCD, but due to its rare occurrence, much still remains to be learned about the true impact of risk factors leading to dehiscence. We present here the second known report of VCD to occur in a patient undergoing transvaginal oocyte retrieval during her fertility treatment. This case highlights what may become a more common clinical scenario as more premenopausal women are diagnosed with reproductive tract cancers and access assisted reproductive therapies to preserve fertility. Case presentation Our patient is a 35-year-old G1 P0 A1 who had undergone ovary-sparing total laparoscopic hysterectomy (TLH) following diagnosis of endometrial adenocarcinoma. She underwent two in-vitro fertilization (IVF) cycles after TLH to bank frozen blastocysts, the first vaginal oocyte retrieval (VOR) taking place 12 weeks following hysterectomy. She experienced VCD during her second VOR that occurred 17 weeks after TLH, the second case of VCD to be reported in the literature during fertility preservation treatment following hysterectomy. The patient underwent an emergent and uncomplicated repair of the defect vaginally the same day. Conclusions Currently there are no guidelines in place for women who have undergone hysterectomy with regard to when they can begin fertility treatment in the post-operative period. Based on now two case reports, it is worth considering extension of the typical 6-week timeline of avoidance of vaginal procedures to allow for full cuff healing. Infertility providers should also be mindful of limiting transvaginal ultrasounds where possible to reduce force along the cuff.

Objective: The aim of the study was to compare patients with and without endometriosis regarding performance rates, difficulties, and complications associated with transvaginal oocyte retrieval (TVOR) procedures. Material and Methods: A prospective cohort study was conducted at the In Vitro Fertilization Unit of the Division of Reproductive Endocrinology and Infertility Department of a university hospital. Fifty-eight patients with endometriosis and 61 patients without endometriosis underwent TVOR procedures consecutively. Primary outcome measures were; number of needle entries per patient and performance rating defined as the total number of oocytes retrieved per vaginal needle entry. The requirement for manual compression of the abdominal wall (assistance) to reach the ovaries, procedure-related pain, and procedural complications were also evaluated. Results: The median number of needle entries through the vaginal wall per patient was comparable between the two groups (p=0.45). Performance rates were higher in the control group (p=0.001). Performance rates and total number of the needle entries through the vaginal wall were not significantly correlated with ovarian endometrioma (OMA) diameter (r=0.28; p=0.68; r=0.275, p=0.068, respectively) in the endometriosis group. Body mass index (BMI) scores were found to be correlated with the number of the needle entries and higher BMI scores were associated with higher numbers of vaginal wall punctures (p

Transvaginal oocyte retrieval (TVOR) for in vitro fertilization (IVF) is a standard procedure with very few complications. Although a relatively safe procedure immediate complications like bleeding from the vaginal vault, hemoperitoneum and trauma to the adjoining structures like the bladder, ureter etc and delayed complications like pelvic abscess and fistulas have been reported in literature. We report a case of 29 year old women with past history of pelvic inflammatory disease (PID) who underwent TVOR for IVF and later on presented with right side pyosalpingx, a delayed complication of TVOR. The patient had to undergo salpingectomy. Late manifestation of pyosalpingx supports the notion that the presence of PID is a high risk for infective complications following any pelvic procedure as it provides a culture medium for bacteria to grow slowly after transvaginal inoculation.

Transvaginal oocyte retrieval is a frequently used procedure during IVF cycles worldwide, as it has many advantages such as acceptable safety and effectiveness. However, some serious complications can occur, including hemorrhage, infection, and injury to adjacent pelvic structures. Certain rare complications, including ureteral obstruction, ureterovaginal fistula, and vertebral osteomyelitis have been observed in some case reports. Although these complications are rare, they can lead to life-threatening conditions. Therefore, preventive strategies should be seriously considered, including sterilization, adequate equipment, and proper training of staff. The aim of this chapter is to discuss both common and rare complications of oocyte pick-up and propose some recommendations for making the procedure safer.

Background: This study seeks to evaluate concurrent use of clomiphene to block spontaneous LH surge in controlled ovarian stimulation in patients with good ovarian reserve. Methods: Thirty five fertile donors with good antral count were stimulated from day 1 or 2 of spontaneous or withdrawal bleeds with clomiphene citrate and recombinant FSH. Transvaginal oocyte retrieval was done after 34 hours of trigger. An LH surge was defined as an LH level ≥10 mIU/ml with progesterone elevation (≥1.0 ng/ml). Fertilization and Embryo quality was assessed from day 2 onwards. Each recipient was transferred a maximum of 3 embryos and remaining were cryopreserved. Results: After an average stimulation of 8.65 days, 15.4 oocytes were retrieved per stimulation. LH surge was noted in 3 cases (9.68%) though oocyte retrieval was done in all cases. Fresh embryo transfer was done in respective recipients of all cases with an implantation rate of 61.29% and a cumulative live birth rate of 42%. Conclusions: Controlled ovarian stimulation using clomiphene and gonadotropin is a viable option to prevent LH surge without additional use of antagonist.

Objective We sought to identify patients at risk of incomplete transvaginal oocyte retrieval, develop a risk assessment formula to identify patients who would benefit from a transabdominal approach, and compare complication and pregnancy rates between these two approaches. Materials and Methods In this retrospective case control study in a private in vitro fertilization center, 95 cases of women undergoing transabdominal follicular aspiration for oocyte retrieval (15 transabdominal only and 80 transabdominal and vaginal combined) were compared with 278 controls of women undergoing the transvaginal aspiration only. Transabdominal oocyte retrieval was performed when one or more ovaries could not be retrieved via the transvaginal approach. Main study outcomes included need for transabdominal retrieval, pregnancy rates, and complications. Results A risk assessment scoring system was developed as follows: difficulty seeing ovaries on ultrasound (+4), history of pelvic surgery (+3), and body mass index of 30 kg/m 2 or greater (+2). With a cutoff score of 4 or greater, the overall sensitivity is 75%, specificity is 80%, positive predictive value is 57%, and negative predictive value is 90%. No statistically significant differences were found for pregnancy rates or complications. Conclusion The transabdominal approach is an alternative option that would increase the total number of oocytes retrieved with no statistical difference in complication or pregnancy rates. We also developed a scoring system that can serve as a useful screening tool for identifying women at increased risk of transabdominal oocyte retrieval.

Objective Pelvic abscess during pregnancy is an uncommon complication, but can lead to adverse perinatal outcomes during pregnancy. Case report We present a patient who developed rupture of a tubo-ovarian abscess during pregnancy following in vitro fertilization and embryo transfer. Thirty-eight reported cases are reviewed, and transvaginal oocyte retrieval, genital tract infections, endometrioma, and previous pelvic surgery are considered as risk factors for pelvic abscess during pregnancy. Conclusion Prolonging gestational duration when an infection situation is allowed is the principle of treatment.

Purpose To report a case of a 34-year-old female with endometriosis and a complication presented with gross hematuria due to bladder injury after transvaginal oocyte retrieval for in vitro fertilization. Case Report A 34-year-old woman with endometriosis presented with gross hematuria 4 days after oocyte retrieval and was conservatively followed up. Results As an uncommon emerging situation after oocyte retrieval for in vitro fertilization procedure, gross hematuria is pointed as a complication with an endometriosis patient. Conclusions Although a transvaginal approach is accepted as a safe and simpler technique for oocyte retrieval, complications like adjacent organ injury should be kept in mind. Especially in patients with endometriosis, in whom pelvic anatomy is distorted due to adhesions, oocyte pick-up procedure should be carried out more carefully.

Reproductive biology has witnessed substantial technological developments to cure infertility, which is a major concern worldwide affecting more than 10% of the couples. The combined effort of basic and applied medical research led to the development of a technique popularly known as in vitro fertilization (IVF) to alleviate infertility. It is a technique by which an egg is fertilized by a sperm in in vitro conditions. It has emerged as a safe and effective technique that overcomes the limitation of other methods. In general, damage of fallopian tubes is the major reason for female infertility as it obstructs the contact between the egg and the sperm, whereas male infertility is mainly due to impaired sperm quality and quantity. In 1978 the technique of IVF was successfully adopted by Dr. Edwards and Dr. Steptoe resulting in a normal, healthy, and fit baby from a human oocyte. The technique is performed by collecting the contents of female fallopian tube after natural ovulation and mixing it with sperm followed by implantation. The ovarian hyperstimulation, transvaginal oocyte retrieval from ovary, egg and sperm preparation, and selection of resulting embryos before implantation are important considerations for IVF. By the application of applied reproductive technologies, the IVF success rate is now substantially improved. There are many potential factors that might influence the success or failure of pregnancy rate through IVF. Although IVF has proved to be a boon for many couples suffering from infertility, it poses serious moral, ethical, social, and religious controversies.

Since the birth of the first IVF baby, a baby girl ?Louise Joy Brown? in 25th July 1978 [1] and the first IVF boy ?Alastair MacDonald? in 14th January 1979 [2], millions of successful IVF births took place till date. Initially oocyte retrieval was a real challenge and people had taken oocyte by laparotomy and/or by other laparoscopic techniques. These techniques were very difficult and in many cases unsuccessful because of severe tubal disease, multiple adhesions or hidden ovaries. The overall success rate was less than 50% [2]. Improvement in the success rate of OPU to 60-80% per follicle occurred between 1979 and 1980 when a foot-controlled fixed aspiration pressure control was introduced [3] and specially designed Teflon-lined aspiration needles with beveled points were used [4]. Transvaginal oocyte retrieval (TVOR) technique was first developed by Pierre Dellenbach and colleagues in Strasbourg, France, and reported in 1984 [5]. OPU or TVOR is usually done under general anesthesia (GA) with the help of transvaginal sonography (TVS) after 34 to 36 hours of trigger i.e. human chorionic gonadotropin (hCG) administration [6].

Background The rates of serious complications from IVF with transvaginal oocyte retrieval are low. However, as the usage of IVF continues to increase, more complications are presenting to acute care and physicians should be aware of management issues. Case A 36-year-old, gravida 4, para 1 woman presented to the emergency department with significant vaginal hemorrhage and severe abdominal pain after undergoing a routine transvaginal oocyte retrieval. She was taken to the operating room and found to have extensive lacerations of the posterior vaginal mucosa and a large vaginal hematoma tracking to the retroperitoneal space. Conclusion This case represents a previously unreported but possible complication of oocyte retrieval. Although oocyte retrieval complications are not frequently reported, significant vaginal and pelvic vascular injury and hemorrhage can occur. Physicians should be cognizant of trauma that can occur secondary to vaginal instruments and not just intraperitoneal injuries.

Here we investigate whether the presence of germinal vesicle-stage oocytes (GV&minus, oocytes) reflects poor oocyte developmental competence (or quality). This was a prospective, non-randomised, cohort pilot-study involving 60 patients undergoing in vitro fertilization/ intracytoplasmic sperm injection for whom complete pregnancy outcome data were available. Patients in whom GV&minus, oocytes were retrieved (GV+) at transvaginal oocyte retrieval (TVOR) were compared with those from whom no GVs were retrieved (GV&minus, ). We found that GV+ (n = 29) and GV&minus, (n = 31) patients were similarly aged (35.4 vs. 36.4 years, p = 0.446). GV+ patients had a mean of 2.41 &plusmn, 2.03 GVs and comparable yields of MII oocytes to GV&minus, patients (11 &plusmn, 6.88 vs. 8.26 &plusmn, 4.84, p = 0.077). Compared with GV&minus, patients, GV+ patients had markedly lower implantation rates (11.8% vs. 30.2%, p = 0.022) as well as oocyte utilisation rates for clinical pregnancy (2.3% vs. 6.8%, p = 0.018) and live-birth (1.9% vs. 5.7%, p = 0.029). DNA damage levels measured using &gamma, H2AX immunostaining were not different in oocytes from women &lt, 36 years versus those &ge, 36 years (p = 0.606). Thus, patients who have GV&minus, stage oocytes at TVOR exhibit poor oocyte quality reflected in reduced per-oocyte pregnancy success rates and uniformly high levels of oocyte DNA damage.

A case series of haematoperitoneum caused by ovarian bleeding after transvaginal oocyte retrieval (TVOR) is presented and all published cases summarized. In a retrospective case series, four patients with ovarian bleeding after TVOR were included. In addition, a pooled analysis of all published cases (n = 32) who underwent surgical intervention for severe haematoperitoneum caused by ovarian bleeding after TVOR was carried out. Main outcome measures were incidence, risk factors, course and intraoperative findings. In the pooled analysis, the incidence was 0.08%. The first sign of haematoperitoneum was evident in 33.3% within the first postoperative hour, and, cumulatively, in 93.3% within 24 h. The median time between TVOR and surgical intervention was 10 h. In four patients, the ovary could not be preserved, which was associated with a longer time interval between TVOR and the onset of symptoms (median 18 h versus 2.5 h; P = 0.004) as well as between TVOR and surgical intervention (median 21.5 h versus 8.5 h; 0.004). In conclusion, severe haematoperitoneum occurs in 0.08% after TVOR. Late-onset bleeding is common. A longer time interval between TVOR and surgical intervention might put a patient at risk of ovariectomy.

Objectives: To evaluate the effect of acupuncture as an adjunct treatment to increase the success rate of in vitro fertilisation (IVF). Methods: A review of the English and Korean literature was conducted to identify studies on acupuncture as an adjunct treatment to IVF. The main outcome measures were the biochemical pregnancy rate (BPR), the implantation rate (IR), the clinical pregnancy rate (CPR), the miscarriage rate (MR), the on-going pregnancy rate (OPR) and the live birth rate (LBR). Results: Nine meta-analyses of 11 systematic reviews (SRs) were included in this review. In four SRs, the overall IVF outcomes regardless of the procedural steps were documented; two of these SRs reported a significant effect on the CPR. One SR reported that acupuncture at the time of controlled ovarian hyperstimulation had a significant effect on the BPR. Seven SRs reported that acupuncture had no significant impact on transvaginal oocyte retrieval (TVOR). In eight SRs, significant impacts on the CPR, LIBR and OPR were reported when acupuncture was performed around the time of embryo transfer (ET). The results of repeated acupuncture after ET were included in two SRs, which included the same primary studies. The results of the SRs showed that acupuncture had a positive effect on the CPR. Conclusions: When the complete IVF procedure is analysed, there is conflicting evidence in that some reviews have found that acupuncture leads to an increased CPR but others have not. In addition, the reviews presented no evidence to suggest that acupuncture has any specific risks.

Objectives To measure the level of sFas in serum and follicular fluid (FF) from infertile women undergoing exogenous gonadotropin stimulation as a part of IVF/ICSI cycles and to study its correlation with oocyte maturation, fertilization, and embryo quality. Materials and methods Serum and FF samples were obtained from 55 patients at the time of transvaginal oocyte retrieval after ovulation induction for assisted reproduction. sFas levels in the serum and FF were measured in duplicate by a solid phase enzyme-linked immunosorbent assay (ELISA). E2 levels were measured by an enzyme immunoassay. Results There was no statistically significant correlation between age and sFas levels in serum ( p =0.84, r =−0.35) or follicular fluid ( p =0.75, r =−0.36). It was observed that the levels of sFas in serum and FF vary with different patients’ diagnosis. There was a statistically significant increase in sFas levels in both serum ( p =0.023, r =0.08) and FF ( p =0.014, r =0.01) in patients with uterine causes of infertility (subseptate uterus and previous myomectomy) compared with those having other causes of infertility. sFas were detected in low concentration in serum and FF in patients with male factor and idiopathic causes of infertility ( Fig. 1 ). A positive correlation was found between the sFas levels in the serum and those in the FF ( p =0.01, r =0.91) ( Fig. 2 ). However, no correlation was found between the levels of sFas and the levels of estradiol in the serum ( p =0.427, r =−0.03). There was a significant correlation between the number of fertilized oocytes and the level of sFas in the serum ( p =0.013, r =−0.42) ( Fig. 3 ). There was no correlation between the number of fertilized oocytes and the level of sFas in FF ( p =0.168, r =−0.40). However, a significant correlation between the levels of sFas in the serum of pregnant ( n =11) and non-pregnant women ( n =44) was observed ( p =0.045, r =0.90) ( Fig. 4 ). Conclusions A lower level of sFas in serum was associated with a higher pregnancy rates. This may be attributed to the presence of good fertilized oocytes. The above phenomena may suggest that low levels of sFas in serum may be associated with improved implantation of fertilized oocytes or may prevent damage to the embryo. Lower levels of sFas seem to support embryo implantation.

Background Numerous randomised studies have reported pregnancy outcome in women who received acupuncture during their in vitro fertilisation (IVF) treatment cycle. Objective The objective of this study was to conduct a systematic review with meta-analysis of the trials of acupuncture during IVF treatment on the outcomes of clinical pregnancy and live birth rates. Search strategy Searches were conducted in MEDLINE, EMBASE, Cochrane Library, ISI Proceedings and SCISEARCH. Selection criteria All randomised controlled trials that evaluated the effects of acupuncture compared with no treatment or sham acupuncture in women undergoing IVF–intracytoplasmic sperm injection treatment were included. Data collection and analysis Study selection, quality appraisal and data extraction were performed independently and in duplicate. A sensitivity analysis was conducted where the meta-analysis was restricted to trials in which sham acupuncture was used in the control group. Meta-regression analysis was used to explore the association between study characteristics and pregnancy rates. Main results Thirteen relevant trials, including a total of 2500 women randomised to either acupuncture or control group, were identified. No evidence of publication bias was found (Begg’s test, P = 0.50). Five trials (n = 877) evaluated IVF outcome when acupuncture was performed around the time of transvaginal oocyte retrieval, while eight trials (n = 1623) reported IVF outcome when acupuncture was performed around the time of embryo transfer (ET). Meta-analysis of the five studies of acupuncture around the time of egg collection did not show a significant difference in clinical pregnancy (relative risks [RR] = 1.06, 95% CI 0.82–1.37, P = 0.65). Meta-analysis of the eight studies of acupuncture around the time of ET showed no difference in the clinical pregnancy rate (RR = 1.23, 95% CI 0.96–1.58, P = 0.1). Live birth data were available from five of the eight studies of acupuncture around the time of ET. Meta-analysis of these studies did not show a significant increase in live birth rate with acupuncture (RR = 1.34, 95% CI 0.85–2.11). Using meta-regression, no significant association between any of the studied covariates and clinical pregnancy rate was found (P > 0.05 for all covariates). Conclusion Currently available literature does not provide sufficient evidence that adjuvant acupuncture improves IVF clinical pregnancy rate.

Ultrasonically guided transvaginal oocyte retrieval is a relatively short procedure that is performed on an outpatient basis. Any anaesthetic technique may interfere with certain aspects of human oocyte fertilisation or embryo implantation. The optimal anaesthetic technique should allow good surgical anaesthesia with minimal side effects, a short recovery time and high rate of successful pregnancy.We present our experience and evaluation of the various techniques studied to carry out this technique.Amongst the various available total intravenous anaesthesia options, propofol/ remifentanil or fentanyl technique of sedation appears to be safe and effective.

Second-trimester amniocentesis is a common procedure for prenatal diagnosis. Sepsis is a rare complication after amniocentesis and may rapidly deteriorate if prompt treatment, including broad-spectrum antibiotics and removal of the infected abortus, is delayed. In vitro fertilization and embryo transfer (IVF-ET) is a standard final treatment for infertile women. Transvaginal oocyte retrieval is necessary for such women; this procedure potentially causes Escherichia coli attaching and effacing in the abdominal cavity. Here we report that two pregnant women by IVF-ET developed sepsis after second-trimester amniocentesis. The cause of sepsis after amniocentesis is still unknown. We provided the possibility of the causation of the E. coli infection associated with the previous intra-abdominal procedure, but it needs more evidence to prove it.

Background Oocyte (egg) retrieval for in-vitro fertilization is a relatively short procedure, usually performed as an outpatient. Propofol is a suitable anesthetic agent. Target-controlled infusion is a recently developed system that aids rapid recovery from propofol anesthesia. This study sought to determine the target concentration of propofol required to prevent movement in 50% (Cp50) and 95% (Cp95) of women during oocyte retrieval, and investigated whether supplemental nitrous oxide (N 2 O) modified the Cp50 and Cp95. Methods Forty-seven women scheduled for oocyte retrieval were randomly selected to receive either O 2 -air mixture (control group; n =23) or 50% O 2 -N 2 O mixture (Nitrous oxide group; n =24). Propofol was infused using a target-controlled infusion system with the concentration determined by up-down sequential allocation using 0.5μg/mL step size. Transvaginal oocyte retrieval was performed after reaching target blood concentration. Patient responses to oocyte retrieval were noted as either no movement or movement . Results Using target-controlled infusion the Cp50 was 4.1μg/mL in the control group and 3.3μg/mL in the nitrous oxide group. Calculated Cp95 values were 4.0μg/mL and 5.1μg/mL with and without 50% nitrous oxide respectively. Conclusions The Cp50 value for target-controlled infusion propofol during oocyte retrieval was significantly reduced by a factor of 1.24 (95% CI 1.07-1.44) with the use of 50% nitrous oxide.

We report a case of ureteral injury with delayed hematuria after transvaginal oocyte retrieval. A 28-year-old infertile patient with a history of previous laparoscopic resection of endometriotic nodes of both sacrouterine ligaments presented with abdominal pain one day after oocyte retrieval. Four days after oocyte retrieval, she presented with massive hematuria that reappeared 6 days after oocyte retrieval. Monopolar coagulation with wire electrode and insertion of a double-J-stent was performed during operative cystoscopy. The patient recovered completely after transfusion and had no signs of renal impairment after ureteric stent removal. This is the first report of ureteral injury after oocyte retrieval presenting itself with delayed massive hematuria and no signs of renal dysfunction or urinary leakage into retroperitoneal space.

Background Transvaginal ultrasound guided oocyte retrieval during in vitro fertilization is performed routinely around the world and has reduced the occurrence of intra-abdominal injury considerably over laparoscopic procedures. Despite this, injuries do occur. Case We report a case of a 37-year-old patient who underwent IVF and encountered a ureteric injury during oocyte retrieval, which was recognized early and treated with ureteral stents with full resolution. During a subsequent IVF cycle, stenting of the ureters allowed better visualization, resulting in an uneventful retrieval and subsequent pregnancy. Conclusion Ureteric injury can occur during transvaginal ultrasound guided egg retrieval. Prompt recognition is vital to successful treatment. Stenting of the ureters is the most common therapeutic modality and can be used in subsequent retrievals to identify the ureters.

Objective To investigate the role of matrix metalloproteinase-9 (MMP-9) in the pre-ovulatory follicular fluid and culture media during in vitro fertilisation (IVF) cycle and to develop the zymographic pre-diagnosis marker for successful implantation and pregnancy in human IVF. Design Controlled clinical study. Setting IVF Laboratory, Women's Hospital Infertility Clinic and Dongguk University, Korea. Sample Women undergoing in vitro fertilisation treatment. Methods Experiments were designed for controlled clinical study with women undergoing IVF treatment. MMP-9 expressions in follicular fluid and culture media samples that had been collected during transvaginal oocyte retrieval were measured using zymography. MMP-9 activities and expressions were strongly correlated to a higher rate of fertilisation and pregnancy. Main outcome measures Fertilisation rates and ultrasonic evidence of intrauterine pregnancy by four weeks after embryo transfer. Result MMP-9 activity was significantly higher in the pregnant group than in the non-pregnant group (P < 0.01). In contrast, MMP-2 activity was present in the follicular fluid and culture media of all women, and no difference in its expressions was found between the pregnant and non-pregnant groups. No correlation was found between the MMP-9 expression in follicular fluid and culture media and the fertilisation rates. Conclusion The expression of MMP-9 in the follicular fluid and culture media is a prerequisite for successful pregnancy in IVF cycle. The zymography of MMP-9 activity in follicular fluids of human and culture media was developed as a pre-diagnostic method and zymographic diagnosis marker for successful fertilisation, implantation and pregnancy in human IVF.

In human IVF, the concept of 'low responders' is well known and generally defined as women with poor-response to gonadotrophin stimulation in a previous induction cycle. The objective of this retrospective study is to describe and characterise the concepts of 'low-, medium-, and high-response' and 'low, medium, and high responders' in bovine-assisted reproduction by analysing the OPU-IVF results obtained following 665 gonadotrophin-stimulated sessions conducted in 112 animals, nearly all of which were previously unsuccessful in traditional multiple ovulation and embryo transfer (MOET) programs. They were submitted to OPU and IVP between 1999 and 2003. In reference to these 665 OPU sessions, categories of response were defined based on the overall mean+/-S.D. follicles aspirated and COC obtained i.e., for follicles 14.7+/-9.8 and for COCs 11.7+/-8.1. So arbitrary cut-off values to define the categories of sessions were for follicles 5 and 25, and for COC 4 and 20. The three categories for follicles punctured in one session were therefore follicle low-response (FLR)or=5 follicles, follicle medium-response (FMR) 6-24 follicles or follicle high-response (FHR)or=25 follicles and for COCs recovered in one session COC low-response (CLR)or=4 COC, COC medium-response (CMR) 5-19 COC or COC high-response (CHR)or=20 COC. In addition, four categories of animals were also defined: (1) a low responder animal (LRA) had at least one OPU session in which FLR and CLR were observed (genuine low-response, see Section ); these animals did not have any high-response sessions, (2) a medium responder animal (MeRA) had only medium-responses, (3) a high responder animal (HRA) had at least one OPU session in which FHR and CHR were observed; these animals did not have any low-response sessions, and (4) mixed responder animals (MiRA) had both low and high-responses. Finally, we distinguished biological (animals) and technical (recovery rate and ultrasound resolution) causes of response differences. In 'low, high, medium and mixed reponders,' different results were obtained (p0.05): mean follicle numbers (8.8+/-4.8a, 22.4+/-10.5c, 13.2+/-5.2b,15.1+/-10.2d), COC numbers (6.3+/-3.9a, 18.5+/-8.2c, 10.4+/-4b, 12.0+/-8.3d), embryo numbers (1.8+/-2.1a, 5.6+/-4.9c, 2.5+/-2.7b, 3.5+/-3.8d) and also for recovery rate (72%a, 83%b,79%, 79%) and percentage embryo development (29%, 30%a, 24%b, 29%). In conclusion, the results of this study demonstrate that variability in OPU results has technical (ultrasound resolution and recovery rate) as well as biological (animal) aspects. Selection of animals with extreme (high or low) follicle and COC production results allows us to distinguish three populations: 'low, medium, and high responders' to FSH stimulation.

We describe the first case of bacteremia due to Actinomyces urogenitalis . Bacteremia was secondary to a tubo-ovarian abscess following transvaginal oocyte retrieval. Identification was established by matrix-assisted desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and confirmed by 16S rRNA gene sequencing. A. urogenitalis should be considered as a potential causative agent of infection after gynecological procedures.

Background and Aims: Oocyte retrieval is the only vital aspect of in vitro fertilization requiring anesthesia. Previous studies have shown the inconclusive role of paracervical block (PCB) in transvaginal oocyte retrieval (TVOR) under ultrasound guidance. This study was planned to observe the role and efficacy of PCB as measured by the amount of propofol used as rescue in patients undergoing TVOR and grading it on the basis of body mass index (BMI). Methods: This prospective, comparative study, conducted over 1 year, recruited 140 American Society of Anesthesiologists I and II patients and divided into two groups as follows: Group A received PCB with 20 ml of 1% lignocaine and Group B received no PCB. Total propofol consumed, BMI, time taken, oocytes retrieved, postprocedure visual analog scale score, and complications were noted. In both the groups, patients were then divided into underweight, normal, overweight, and obese according to BMI. Statistical analysis was done using Statistical Package Mini Tab Version 17.0. The primary objective was to study the efficacy of PCB as estimated by amount of propofol required during the procedure. The secondary aim was to assess the effect of BMI on the efficacy of PCB. Results: Propofol requirement was found to be significantly more (P < 0.05) in Group B patients (172.14 ± 64.15) in comparison to Group A (132.14 ± 66.11). Amount of propofol required in normal BMI and overweight patients was significantly higher in Group B. No significant difference was observed in underweight, and obese patients in both the groups. Conclusion: PCB reduces the consumption of propofol in normal BMI patients. Underweight and obese population do not benefit from PCB.

There are little systematic data reported in the literature on complications observed after transvaginal oocyte retrieval (OR) guided by ultrasound. We report our experience in 542 in vitro fertilisation cycles. The frequency of severe complications in our patients was 0.72%; of these, two cases were bronchospasm during anaesthesia (0.36%) and two were cases of intraperitoneal bleeding (0.36%); minor vaginal bleeding was the most frequent complication (18.08%), which was treated easily. Through this retrospective analysis, it is evident that clinical suspicion is of particular importance in detecting post-OR complications on one hand, but on the other these complications are rare and most are treated conservatively.

Drug-induced immune thrombocytopenia has been associated with hundreds of medications and can lead to devastating consequences for the patient. We present a case of a healthy 33-year-old female undergoing in vitro fertilization who developed a severe drug-induced thrombocytopenia, petechiae, and a large hemoperitoneum after receiving Cefazolin antibiotic prophylaxis for a transvaginal oocyte retrieval. The patient was admitted to the intensive care unit for resuscitation with blood products. The presence of drug-dependent platelet antibodies to Cefazolin was confirmed serologically.

Study Objectives: To compare the outcome of assisted reproductive technology procedures in women who undergo monitored anesthesia care (MAC) with remifentanil versus general anesthesia. Design: Retrospective data analysis. Setting: University hospital. Patients: 251 ASA physical status I and II women participating in an in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) program. Interventions: During the first phase of the study, all patients underwent general anesthesia induction with alfentanil, propofol, and nitrous oxide, which was maintained with isoflurane or propofol infusion. In the second phase of the study, all patients received a standardized MAC technique with a remifentanil infusion; local anesthetics were not used. Measurements: The primary endpoint was pregnancy rate per transfer. The number of oocytes collected, fertilized, and cleaved was recorded, as was the number of oocytes transferred. Main Results: Patients who underwent MAC had a greater pregnancy rate with IVF (28.2 vs. 16.3%), with ICSI (32.2% vs. 18.8%), and overall (30.6% vs. 17.9%). Conclusions: Pregnancy rates in women undergoing transvaginal oocyte retrieval for assisted reproductive technologies were significantly higher with a remifentanil-based MAC technique than with a general anesthetic technique.

Objective: In compare the use of purified follicle-stimulating hormone with that of a preparation containing follicle-stimulating hormone and luteinizing hormone in infertile females undergoing IVF. Design: Open-labelled prospective controlled single-center study. Setting: Nile Badrawy IVF unit. Participants: 153 infertile females undergoing their first cycle of IVF divided into 2 groups. Interventions: Ovarian stimulation was done with either highly purified FSH for group 1 (n = 75) or human menopausal gonadotrophin group 2 (n = 78) after pituitary desensitization commenced in the midluteal phase of the preceding cycle. Monitoring was performed by ultrasound transvaginal oocyte retrieval followed by IVF and transfer of three embryos. Outcomes: Number of oocytes >18 mm at day of hCG, fertilization rate, embryo transfer rate, clinical pregnancy rate and incidence of ovarian hyperstimulation syndrome. Results: The response to ovarian hyperstimulation was similar in both groups. The number of follicles >18 mm achieved at day of hCG was 12.3 ± 0.9 (mean ± SEM) following stimulation with 38.3 ± 0.9 ampoules of Fostimon The Menogon-treated group needed 39.1 ± 0.8 ampoules to produce 11.6 ± 0.7 follicles. Fertilization rate (2PN/cell) was 58.6 vs. 64.2% in the Fostimon and Menogon group, respectively (p > 0.05). The number of embryos transferred per woman was 3.1 ± 0.1 in the Fostimon group and 3.6 ± 0.1 in the Menogon group. The pregnancy rate per woman was 33.3 vs. 25.6% in the Fostimon- and Menogon-treated groups, respectively (p > 0.05). Miscarriage rate was 16 vs 20%, respectively. However, the incidence of multiple pregnancies was significantly higher in the Fostimon-treated group (32%) vs. 10% only in the Menogon-treated group (p < 0.01). Conclusion: Purified FSH yields similar clinical outcome to hMG in terms of oocytes retrieved and clinical pregnancies in a standard IVF regimen.

Objective: To investigate the role of interleukin-12 (IL-12) and IL-8 in the periovulatory follicular fluid during in vitro fertilization cycles. Design: A prospective study. Setting: Reproductive Medicine Unit, Liverpool Women's Hospital, United Kingdom. Patient(s): Women undergoing in vitro fertilization treatment. Intervention(s): IL-8 and IL-12 concentrations in follicular fluid samples that had been collected during transvaginal oocyte retrieval were measured using an enzyme-linked immunosorbent assay (ELISA). Cytokine concentrations were correlated to fertilization rates and treatment outcome. Main Outcome Measure(s): Fertilization rates and ultrasonographic evidence of intrauterine pregnancy by 4 weeks after embryo transfer. Result(s): Failed fertilization in women with detectable IL-12 was significantly higher (45.5%) than in the IL-12 negative group (6.1%), P =.01. None of the women with detectable IL-12 achieved a pregnancy at the end of the treatment ( P =.01). IL-8 was present in the follicular fluid of all women, and no difference in its concentrations was found between the pregnant and nonpregnant groups. No correlation was found between the follicular fluid concentrations of IL-8 and fertilization rates. Conclusion(s): The presence of IL-12 in the follicular fluid appears to be associated with a negative outcome in IVF treatment. Interleukin-8 appears to be an essential part of folliculogenesis, although its concentration is not associated with fertilization or implantation rates.

Infertility patients with malpositioned ovaries have considerable difficulty conceiving naturally because of extended fallopian tubes and ovarian malposition; such patients turn for help to assisted reproductive technology (ART) treatment. For most of these patients, ovarian malposition prevents transvaginal oocyte retrieval, so the transabdominal approach for oocyte retrieval is required. One of our infertility patients presented with ovarian malposition, and laparoscopy-assisted transabdominal oocyte retrieval was performed. We performed a Gonadotropin-releasing hormone agonist (GnRH-a) long protocol with human menopausal gonadotropin (hMG) ovarian stimulation, and used a standard transvaginal probe through the anterior abdominal wall for ovarian imaging and monitoring of the growing follicles. The patient underwent laparoscopically-assisted transabdominal oocyte retrieval-9 oocytes were recovered, and 5 were fertilized, and 2 embryos were transferred to the patient's uterus. The patient became pregnant and a gestational sac was detectable by transvaginal ultrasonography, but she spontaneously miscarried. The patient then received several laparoscopically-assisted transabdominal oocyte retrievals and finally became pregnant following a thawed embryo transfer during a hormone replacement cycle, and now her pregnancy is going well.

Summary Objective Ovarian hyperstimulation syndrome (OHSS) is more severe when pregnancy occurs, as the developing pregnancy produces human chorionic gonadotropin, which stimulates the ovary's persistent growth. If no pregnancy occurs, the syndrome will typically resolve within 1 week. In a maintained pregnancy, slow resolution of symptoms usually occurs over 1-2 months. Case Report A 31-year-old woman, gravida 2, para 1, aborta 1, with polycystic ovary syndrome underwent in vitro fertilization (IVF) with clomiphene citrate and follicle-stimulating hormone/gonadotropin releasing hormone-antagonist stimulation. During transvaginal oocyte retrieval, enlarged bilateral ovaries were noted. She had an episode of OHSS after IVF/embryo transfer, for which paracentesis was performed three times. Pregnancy was achieved. Throughout antenatal examinations, bilateral ovaries were enlarged. She delivered a healthy baby by cesarean section at term. However, 1 month after delivery, the bilateral ovary had not shrunk, and levels of tumor markers CA125 and CA199 were 50.84 and 41.34 U/mL, respectively. At laparotomy for suspected malignancy, both adnexae formed "kissing ovaries", which were multinodulated with yellow serous fluid. Specimens from wedge resection submitted for frozen section showed a benign ovarian cyst. The final pathology report showed bilateral follicle cysts. Conclusion With the increasing use of gonadotropins in the management of infertility, ovarian enlargement secondary to hyperstimulation is common. Generally, symptoms appear between the 6 th and 13 th weeks of pregnancy and disappear thereafter. The hyperstimulated ovary often subsides after the first trimester. This case is unusual as the megalocystic ovary persisted after delivery. To the best of our knowledge, we report the first case of enlarged bilateral ovaries persisting 2 months after delivery.

ObjectiveTo observe the analgesic effect of acupuncture at Hegu (LI 4) in vitro fertilization-embryo transfer (IVF-ET) transvaginal oocyte retrieval using ultrasonography and explore its mechanism.MethodsNinety patients undergoing IVF-EF oocyte retrieval were randomly divided into three groups: an acupuncture group with needles inserted into bilateral Hegu (LI 4) points, a placebo group given placebo needles, and a control group with routine oocyte retrieval. Each group had an indometacin enema 30 min before the operation. We compared the pain-rated index (PRI), visual analogy scale (VAS), and present pain intensity (PPI) immediately after operation and 1 h after operation. We also determined the neuropeptide Y (NPY) level of the follicular fluid.ResultsPRI, VAS, and PPI after operation and 1 h after operation in the acupuncture group were significantly lower than those in the control group (P< 0.01). No obvious difference (P>0.05) was observed in PRI, VAS, and PPI after operation and 1 h after operation between the placebo group and the control group. The NPY level of the follicular fluid in the acupuncture group was significantly higher than that in the control group (P0.05) was observed in the NPY level of the follicular fluid between the placebo group and the control group.ConclusionThe analgesic effect of acupuncture at Hegu in transvaginal oocyte retrieval using ultrasonography may be related to the increase in the NPY level of the follicular fluid.

Background Pethidine with midazolam-induced conscious sedation for pain relief during transvaginal oocyte retrieval for in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) procedures is associated with residual pain and oversedation. Patient-controlled analgesia (PCA) with remifentanil may serve as an alternative for pethidine. We investigated whether PCA remifentanil with diclofenac was associated with improved periprocedural pain relief than pethidine analgesia during IVF/ICSI procedures, with sedation scores, safety profiles, and patient satisfaction as secondary endpoints. Methods Seventy-six women were randomized to receive pethidine (2 mg/kg i.m.) and midazolam (7.5 mg)-induced conscious sedation (n = 40) or PCA with remifentanil and diclofenac (50 mg; n = 36). The Numeric Rating Scale, McGill Pain Questionnaire (MPQ), Ramsey Sedation Scale, and a 5-day pain-and-discomfort diary were used to evaluate pain and sedation levels. Results There were no differences in baseline characteristics and reproductive outcomes between both groups. Periprocedural pain scores were comparable for remifentanil and pethidine groups (4 [3 to 7] vs. 6 [4 to 8]; P = 0.13). Pain scores in the pethidine group were significantly lower at 30 minutes after the procedure (1 [0 to 3] vs. 2 [1 to 5]; P = 0.016), but at cost of higher sedation levels when compared to remifentanil (4 [2 to 4] vs. 2 [2 to 2]; P

Objective To report a case of pelvic actinomycosis presenting as large, multiloculated abscesses after an in vitro fertilization (IVF) cycle for male factor infertility. Design A case report and literature review. Setting University hospital. Patient(s) A 31-year-old nulligravid woman presenting with urinary retention, pelvic pain, and fever 6 days after transvaginal oocyte retrieval and an embryo transfer for male factor infertility. Intervention(s) Intravenous and oral antimicrobial therapy, and computed tomography (CT)-guided drainage of pelvic abscesses. Main Outcome Measure(s) Clinical and radiologic resolution of symptoms and infection. Result(s) The CT scan revealed several large, multiloculated pelvic and tuboovarian abscesses. The patient defervesced after 6 days of intravenous antibiotics, but the pelvic pain did not improve. After CT-guided drainage of the pelvic abscesses, the patient's symptoms improved. The drained material was cultured, and the patient was diagnosed with pelvic actinomycosis tuboovarian abscesses, an infrequent cause of tuboovarian abscess and a rare complication of assisted reproductive technology (ART). The patient was switched from intravenous to oral antibiotics and discharged home. Conclusion(s) Pelvic Actinomyces israelii presenting as pelvic abscesses may occur as a rare complication of ART. Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer.

The aim of this study is to report a case of acute ureterovaginal fistula (UVF) formation with immediate symptomatic presentation after transvaginal ultrasound-guided oocyte retrieval (TVOR) for in vitro fertilization (IVF) and to perform a systematic literature review of ureteral injuries during TVOR. A 33-year-old woman with a history of anovulatory infertility presented with severe abdominal pain and vaginal leakage immediately following TVOR for IVF. We systematically reviewed the current literature regarding ureteral injury resulting from TVOR and present a case of timely identification and management of a UVF followed by a successful pregnancy. Computed tomography cystogram with intravenous contrast and left retrograde pyelogram confirmed the diagnosis of UVF which was managed by placement of the left ureteral stent. The IVF cycle was converted to a freeze-all cycle. The ureteral stent was removed 4 weeks later, and a subsequent frozen embryo transfer cycle resulted in pregnancy. We present the 13th case of ureteral injury and the fourth case of UVF following TVOR. UVF formation is a rare complication after TVOR and may result in serious long-term morbidity if it is not identified and treated promptly. Clinicians must exercise a high degree of suspicion and prompt evaluation for potential ureteral injuries in women presenting with abdominal pain, urinary symptoms, or vaginal leakage following TVOR.

Objective To present the first report of massive hemoperitoneum in a case of essential thrombocythemia after transvaginal oocyte retrieval for IVF and review the relevant literature related to the management of patients with this condition. Design Case report. Setting Assisted conception unit of a tertiary care university hospital in the United Kingdom. Patient(s) A 37-year-old woman with essential thrombocythemia who developed massive intra-abdominal bleeding after transvaginal oocyte retrieval for IVF. Intervention(s) Emergency laparotomy and right salpingoophorectomy. Result(s) Resuscitation of the patient. Main outcome measure(s) Overall management of the patient is discussed. Conclusion(s) The management of patients with essential thrombocythemia at the childbearing period poses a difficult problem. Fertility may be reduced, and an adverse outcome of pregnancy due to thrombotic or bleeding complications is a matter of concern. A multidisciplinary approach with close and early cooperation with the hematologists before initiation of IVF therapy for patients with essential thrombocythemia is essential. Efforts should be made to reduce the platelet count and assess the platelet function before embarking on IVF, keeping in mind the double jeopardy from bleeding and thrombosis in these cases.

BACKGROUND: Various methods of conscious sedation and analgesia (CSA) have been used during oocyte retrieval for assisted reproduction. The choice of agent has been influenced by the quality of sedation and analgesia and by concerns about possible detrimental effects on reproductive outcomes. OBJECTIVES: To assess the effectiveness and safety of different methods of conscious sedation and analgesia for pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval. SEARCH METHODS: We searched; the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL, and trials registers in November 2017. We also checked references, and contacted study authors for additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing different methods and administrative protocols for conscious sedation and analgesia during oocyte retrieval. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcomes were intraoperative and postoperative pain. Secondary outcomes included clinical pregnancy, patient satisfaction, analgesic side effects, and postoperative complications. MAIN RESULTS: We included 24 RCTs (3160 women) in five comparisons. We report the main comparisons below. Evidence quality was generally low or very low, mainly owing to poor reporting and imprecision. 1. CSA versus other active interventions. All evidence for this comparison was of very low quality. CSA versus CSA plus acupuncture or electroacupuncture Data show more effective intraoperative pain relief on a 0 to 10 visual analogue scale (VAS) with CSA plus acupuncture (mean difference (MD) 1.00, 95% confidence interval (CI) 0.18 to 1.82, 62 women) or electroacupuncture (MD 3.00, 95% CI 2.23 to 3.77, 62 women). Data also show more effective postoperative pain relief (0 to 10 VAS) with CSA plus acupuncture (MD 0.60, 95% CI ‐0.10 to 1.30, 61 women) or electroacupuncture (MD 2.10, 95% CI 1.40 to 2.80, 61 women). Evidence was insufficient to show whether clinical pregnancy rates were different between CSA and CSA plus acupuncture (odds ratio (OR) 0.61, 95% CI 0.20 to 1.86, 61 women). CSA alone may be associated with fewer pregnancies than CSA plus electroacupuncture (OR 0.22, 95% CI 0.07 to 0.66, 61 women). Evidence was insufficient to show whether rates of vomiting were different between CSA and CSA plus acupuncture (OR 1.64, 95% CI 0.46 to 5.88, 62 women) or electroacupuncture (OR 1.09, 95% CI 0.33 to 3.58, 62 women). Trialists provided no usable data for other outcomes of interest. CSA versus general anaesthesia Postoperative pain relief was greater in the CSA group (0 to 3 Likert: mean difference (MD) 1.9, 95% CI 2.24 to 1.56, one RCT, 50 women). Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 1.00, 95% CI 0.43 to 2.35, two RCTs, 108 women, I(2) = 0%). Evidence was insufficient to show whether groups differed in rates of vomiting (OR 0.46, 95% CI 0.08 to 2.75, one RCT, 50 women) or airway obstruction (OR 0.14, 95% CI 0.02 to 1.22, one RCT, 58 women). Fewer women needed mask ventilation in the CSA group (OR 0.05, 95% CI 0.01 to 0.20, one RCT, 58 women). Evidence was also insufficient to show whether groups differed in satisfaction rates (OR 0.66, 95% CI 0.11 to 4.04, two RCTs, 108 women, I(2) = 34%; very low‐quality evidence). Trialists provided no usable data for outcomes of interest. 2. CSA + paracervical block (PCB) versus other interventions. CSA + PCB versus electroacupuncture + PCB Intraoperative pain scores were lower in the CSA + PCB group (0 to 10 VAS: MD ‐0.66, 95% CI ‐0.93 to ‐0.39, 781 women, I(2) = 76%; low‐quality evidence). Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.96, 95% CI 0.72 to 1.29, 783 women, I(2) = 9%; low‐quality evidence). Trialists provided no usable data for other outcomes of interest. CSA + PCB versus general anaesthesia Evidence was insufficient to show whether groups differed in postoperative pain scores (0 to 10 VAS: MD 0.49, 95% CI ‐0.13 to 1.11, 50 women; very low‐quality evidence). Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.70, 95% CI 0.22 to 2.26, 51 women; very low‐quality evidence). Trialists provided no usable data for other outcomes of interest. CSA + PCB versus spinal anaesthesia Postoperative pain scores were higher in the CSA + PCB group (0 to 10 VAS: MD 1.02, 95% CI 0.48 to 1.56, 36 women; very low‐quality evidence). Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.24 to 3.65, 38 women; very low‐quality evidence). Trialists provided no usable data for other outcomes of interest. CSA + PCB versus PCB Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.44 to 1.96, 150 women; low‐quality evidence) or satisfaction (OR 1.63, 95% CI 0.68 to 3.89, 150 women, low‐quality evidence). Trialists provided no usable data for other outcomes of interest. CSA + PCB versus CSA only Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.62, 95% CI 0.28 to 1.36, one RCT, 100 women; very low‐quality evidence). Rates of postoperative nausea and vomiting were lower in the CS + PCB group (OR 0.42, 95% CI 0.18 to 0.97, two RCTs, 140 women, I(2) = 40%; very low‐quality evidence). Trialists provided no usable data for other outcomes of interest. AUTHORS' CONCLUSIONS: The evidence does not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte retrieval. Simultaneous use of sedation combined with analgesia such as the opiates, further enhanced by paracervical block or acupuncture techniques, resulted in better pain relief than occurred with one modality alone. Evidence was insufficient to show conclusively whether any of the interventions influenced pregnancy rates. All techniques reviewed were associated with a high degree of patient satisfaction. Women’s preferences and resource availability for choice of pain relief merit consideration in practice.

A cohort study was undertaken to compare the effect at the time of oocyte retrieval of the i.v. administration of either 1000 ml of lactated Ringer's solution or 1000 ml of a 5% solution of human albumin on in-vitro fertilization patients at risk for severe ovarian hyperstimulation syndrome (OHSS). A total of 207 patients with an oestradiol concentration > 10,000 pmol/l and/or > 15 follicles (> 10 mm diameter) on the day of human chorionic gonadotrophin (HCG) injection were reviewed. Of these, 158 women received 500 ml of lactated Ringer's solution both before and after egg retrieval, and 49 women received two infusions of 500 ml of 5% human albumin in normal saline at the time of egg retrieval. Severe OHSS developed in two patients who received human albumin and in 10 women who did not receive the albumin. This difference was not statistically significant. There were no differences between the two groups in terms of age, number of follicles punctured at transvaginal oocyte retrieval or oestradiol concentration at the time of HCG injection. The administration of a 5% human albumin solution does not prevent the development of severe OHSS in at risk patients. It does appear to blunt the severity of the condition.

To investigate the potential advantages of epidural anesthesia in an in vitro fertilization and embryo transfer program. Between January 1991 and December 1992, 148 infertile patients underwent transvaginal ultrasound guided oocyte retrieval. A total of 44 patients (group A) had 50 retrievals under epidural anesthesia, and 104 patients (group B, control group) 112 retrievals under intravenous sedation (propofol) with mask-assisted ventilation (nitrous oxide). In group A satisfactory anesthesia was achieved in 49 of the 50 cases (98%); one patient required additional intravenous administration of propofol owing to extreme anxiety. No complications were observed. Adversely, in group B nausea was observed in 16 cases (14%) and nausea and vomiting in 7 cases (6%). In group A the fertilization, cleavage and pregnancy rates were 67.2%, 92% and 20% respectively, while in group B the rates were 69.3%, 93% and 19.6% respectively; the differences are not statistically significant. Epidural anesthesia is an effective method for transvaginal oocyte retrieval but does not improve the treatment outcome as compared to an intravenous sedation with mask-assisted ventilation using propofol and nitrous oxide.

We report a case of a recurrent empty follicle syndrome. The patient was admitted to our intracytoplasmic injection program because of her partner's azoospermia. Ovarian stimulation was accomplished using gonadotrophin therapy after treatment with oral contraceptive pills followed by gonadotrophin-releasing hormone agonist. Thirty-six hours after the administration of HCG (human chorionic gonadotrophins), transvaginal oocyte retrieval yielded no oocytes despite the aspiration and flushing of all available follicles. Two years later, a second treatment cycle was started using the same pituitary desensitisation and ovarian stimulation regimens. HCG from a different batch with respect to that used in the first treatment cycle was administered. Aspiration and repeated flushing of all follicles of one ovary failed to yield any identifiable oocyte. The β-HCG and progesterone serum concentrations on the day of retrieval were 181 mIU/mL and 3.79 ng/mL, respectively. New oocyte retrieval was planned 6 h after the first attempt for aspiration of follicles. Again, no ova were obtained at this second trial despite the aspiration of the all follicles. As to our knowledge this is the first report of recurrent EFS (empty follicle syndrome) and managed without repeating the HCG injection on the day of unsuccessful oocyte retrieval.

The main goal of the present retrospective study is to compare four analgesic methodologies (EMLA cream, propofol, thiopental sodium, sevoflurane) for in vitro fertilization (IVF) oocyte retrieval. We found that most anaesthetic parameters were not significantly different among all treatments. In contrast, significant differences were revealed in all groups for total number of oocytes retrieved per patient, rate of mature oocytes at metaphase II stage (MII) and percentage of fertilization and embryo development. In the EMLA cream and thiopental sodium groups we observed the highest percentage of MII oocytes (P < 0.001). Fertilization rate in the EMLA and sevoflurane groups were similar but significantly higher than the propofol and thiopental sodium groups (P < 0.001). The highest rate of anomalous fertilization was observed in the propofol group. Rate of embryo development was similar in all groups but sevoflurane group had a lower percentage of good embryos. In conclusion, by comparing different anaesthetic techniques with different mechanisms of action and administration, potential negative effects of these drugs on the initial stages of human IVF procedure were revealed. Therefore, a local anaesthetic cream is proposed as an acceptable alternative option for anaesthesia during transvaginal oocyte retrieval.

This case study presents an unusual finding of filarial infection within follicular fluid obtained during an in vitro fertilization (IVF) oocyte retrieval procedure.A 41 year-old G4P1030 immigrant from western Africa underwent in vitro fertilization (IVF). At the time of inspection of the follicular fluid obtained at oocyte retrieval, mobile worm-like organisms were observed and identified as Wuchereria bancrofti microfilariae (filariasis). The patient successfully underwent treatment for filariasis and Onchocerciasis co-infection. Following treatment, the patient underwent embryo transfer that failed to result in a pregnancy.Recent years have seen an increase in international travel and immigration. Therefore, practitioners must become familiar not only with illnesses that are endemic to their geographic region but also diseases that are more common in remote regions of the world. The infertility evaluation and treatment offers physicians a unique opportunity to identify and initiate treatment for diseases that might otherwise go undiagnosed.