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Objective To obtain evidence-based conclusions about the effect of acupuncture on pain relief in women undergoing oocyte retrieval, the results of randomized controlled trials (RCTs) that met the criteria were assessed on the Pain Assessment Scale and pregnancy indicators. Search Methods References were retrieved in MEDLINE, EMBASE, CNKI database, CBM database, VIP database, and Wanfang database from inception to June 26, 2021. Unpublished ongoing trials were searched in the Clinical Trials Registries. This review included RCTs that investigated the acupuncture analgesic effects during oocyte retrieval in women undergoing in vitro fertilization. Results Fourteen RCTs (2503 women in total) with six types of comparisons were finally included. The quality of concluding evidence was generally low or very low. Performance bias and outcome assessment bias was the main risk of bias of the included studies. Acupuncture combined with conscious sedation and analgesia (CSA) was associated with less intraoperative (SMD=−1.03; 95% CI: −1.71 to −0.36) and postoperative (SMD = −1.11; 95% CI: −1.51 to −0.71) pain compared to receive CSA alone in oocyte retrieval. Acupuncture with non-steroidal anti-inflammatory drugs (NSAIDs) was more effective than using NSAIDs alone for postoperative analgesia (MD = −1.76; 95% CI: −2.08 to −1.44). Conclusion Acupuncture complex analgesic therapy is more effective than utilizing CSA or NSAIDs alone. Furthermore, there is no significant consensus on whether there is an analgesic effect of applying acupuncture alone during oocyte retrievals, which needs further research. The overall results should be interpreted with caution due to the high risk of bias/low-GRADE scores among these studies. Protocol and Registration PROSPERO registration number: CRD42020170095.

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.

Objective To assess the level of satisfaction of women undergoing transvaginal oocyte retrieval (TOR) without anesthesia as well as the comfort of the gynecologists. Design Single-center, prospective cohort study of women undergoing TOR from July 2017 to January 2018. Setting This study was conducted in an academic public hospital. Patient(s) Women with ≤15 follicles for retrieval were eligible. Women with body mass index > 35, difficult vaginal approach, endometrioma > 5 cm, or pelvic inflammatory disease were excluded. Intervention(s) None. Main Outcome Measure(s) Our primary endpoint was patient satisfaction. Secondary endpoints were women’s willingness to recommend or undergo the procedure again without anesthesia, anxiety levels before the procedure, expected level of pain, actual pain levels during the procedure, and gynecologist’s level of difficulty or technical compromise. Result(s) During the study period, 500 TORs were performed, of which 402 (80%) were screened for study eligibility. Overall, data were analyzed for 50 eligible women who had their first in vitro fertilization cycle (participating in the study) without anesthesia. High rates of satisfaction were reported, and 90% would recommend the procedure without anesthesia to their friends. Physicians graded the difficulty of the procedure as very easy in 35 procedures; in only two procedures was difficulty reported. Conclusion(s) TOR without anesthesia is feasible, with a relatively high satisfaction rate from both patients and gynecologists, suggesting that it should be considered in selected women.

Study objectiveThe most important limitation for spinal anesthesia in the ambulatory setting is the prolonged motor blockade and delayed postoperative ambulation. The current study was conducted to compare spinal mepivacaine–fentanyl combination versus conventional combination of spinal bupivacaine with fentanyl for surgical anesthesia of ultrasound-guided transvaginal oocyte retrieval for in vitro fertilization (IVF).Patients and methodsSixty female patients undergoing ultrasound-guided transvaginal oocyte retrieval for in vitro fertilization on ambulatory basis were enrolled in the current study. Patients were randomly distributed in to one of two equal groups: mepivacaine group (group M) and bupivacaine group (group B). Patients in group M received intrathecal 37.5 mg of isobaric mepivacaine 1.5% plus 10 μg fentanyl while patients in group B received intrathecal 12.5 mg of hyperbaric bupivacaine 0.5% plus 10 μg fentanyl. Primary outcome measure was the time to complete motor block regression. Secondary outcome measures included the peak sensory blockade level achieved, the times for sensory block regression to S1 dermatome, post-anesthesia stable ambulation, 1st voiding, and hospital discharge. The incidence of perioperative adverse events was also recorded.ResultsTwo patients (one in each group) were excluded from the study due to failed block and conversion to general anesthesia. The peak sensory blockade levels (T6–T10) were satisfactory for procedural anesthesia in the remaining patients of both groups. Patients in group M had significantly faster sensory block regression to S1 and motor block resolution when compared with group B (P< 0.05). Times to steady ambulation, voiding and hospital discharge were significantly shorter in group M when compared with group B (P< 0.05). There was no intergroup significant difference as regards the incidence of perioperative adverse events, and none of the patients reported transient neurological symptoms (TNS) or postdural puncture headache in both groups.ConclusionThe mepivacaine–fentanyl combination was superior to bupivacaine–fentanyl combination for spinal anesthesia of ultrasound-guided transvaginal oocyte retrieval on ambulatory basis because of faster sensory and motor block resolution and the shorter time to ambulation and hospital discharge with reliability of surgical anesthesia and no difference in the incidence of perioperative adverse events between both groups.

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.

Previous preclinical and preliminary clinical data suggest an appetite-stimulating effect of propofol compared with halogenated drugs. This study compared the effects of propofol with those of sevoflurane on recovery of hunger during the postoperative period.Patients undergoing outpatient transvaginal oocyte retrieval were randomized to propofol-remifentanil (propofol group) or sevoflurane-remifentanil (sevoflurane group) anesthesia. The primary endpoint was the time before feeling hungry (≥ 50/100 mm on a visual analogue scale). Secondary endpoints included plasma levels of ghrelin, leptin, and insulin (ten minutes, one hour, and two hours after anesthesia), caloric intake at first feed, and discharge readiness time.In the 58 patients allocated to either the propofol or sevoflurane group, there was no difference in the median [interquartile range] recovery time of hunger (97 [75-138] vs 97 [80-140] min, respectively; median difference, 1; 95% confidence interval [CI], - 15 to 14; P = 0.91); caloric intake (245 [200-343] vs 260 [171-314] kcal; P = 0.39); or discharge readiness time (125 [85-153] vs 125 [95-174] min, P = 0.29). The groups showed no difference in crude plasma levels of ghrelin, leptin, and insulin at any time-point. When peptide plasma levels were expressed as a % change from baseline, there was a higher insulin plasma level one hour after anesthesia in the sevoflurane group (median difference, 4.9%; 95% CI, - 16.2 to 43.4) compared with the propofol group (median difference, - 21.2%; 95% CI, - 35.7 to 9.1; adjusted P = 0.01).Propofol did not accelerate the recovery of hunger compared with sevoflurane after outpatient minor surgery. Moreover, propofol did not have distinguishable effects on other clinical or biological parameters associated with food intake.www.ClinicalTrials.gov (NCT02272166); registered 22 October, 2014.RéSUMé: OBJECTIF: Des données précliniques et cliniques préliminaires suggèrent un effet de stimulation de l’appétit du propofol par rapport aux gaz halogénés. Cette étude a comparé les effets du propofol à ceux du sévoflurane sur le rétablissement de la faim en période postopératoire. MéTHODE: Des patientes subissant un prélèvement des ovocytes par voie transvaginale ont été randomisées à recevoir une anesthésie à base de propofol et rémifentanil (groupe propofol) ou de sévoflurane et rémifentanil (groupe sévoflurane). Le critère d’évaluation principal était la période de temps avant de ressentir de la faim (≥ 50/100 mm sur une échelle visuelle analogique). Les critères d’évaluation secondaires comprenaient les taux plasmatiques de ghréline, de leptine et d’insuline (à dix minutes, une heure et deux heures après l’anesthésie), l’apport calorique lors du premier repas, et le moment où les patientes étaient prêtes à recevoir leur congé. RéSULTATS: Chez les 58 patientes allouées aux groupes propofol ou sévoflurane, aucune différence n’a été observée dans le temps médian [écart interquartile (ÉIQ)] jusqu’à retour de la faim (97 [75–138] vs 97 [80–140] min, respectivement; différence médiane, 1; intervalle de confiance [IC] 95 %, − 15 à 14; P = 0,91), ni dans l’apport calorique (245 [200–343] vs 260 [171–314] kcal; P = 0,39) ou le moment où elles étaient prêtes à recevoir leur congé (125 [85-153] vs 125 [95-174] min, P = 0,29). Les groupes n’ont démontré aucune différence en matière de taux plasmatiques de ghréline, de leptine et d’insuline à quelque point dans le temps que ce soit. Lorsque les taux plasmatiques de peptides étaient exprimés en % de changement par rapport aux taux de base, on a observé un taux plasmatique plus élevé d’insuline une heure après l’anesthésie dans le groupe sévoflurane (différence médiane, 4,9 %; IC 95 %, − 16,2 à 43,4) par rapport au groupe propofol (différence médiane, − 21,2 %, IC 95 %, − 35,7 à 9,1; P ajusté = 0,01). CONCLUSION: Le propofol n’a pas accéléré le retour de la faim par rapport au sévoflurane après une chirurgie ambulatoire mineure. De plus, le propofol n’a pas démontré d’effets distinctifs sur d’autres paramètres cliniques ou biologiques associés à l’ingestion de nourriture. ENREGISTREMENT DE L’éTUDE: www.ClinicalTrials.gov (NCT02272166); enregistrée le 22 octobre 2014.

Background: A variety of anesthetic techniques have been used to make transvaginal oocyte retrieval (TVOR) safe and efficient. The optimal anesthetic technique during TVOR should provide safe, effective analgesia, few side effects, a short recovery time, and be nontoxic to the oocytes that are being retrieved. The concept of conscious sedation is widely accepted for the short-term management of pain. Objective: This study assessed patient's perception of pain using conscious sedation and in-vitro fertilization (IVF) outcomes. Materials and Methods: A cross sectional study of 71 eligible patients that underwent assisted reproduction program in our facility. All clients were treated with antagonist protocol for controlled ovarian hyperstimulation. Self-administered questionnaires were used as the research instrument. Pain was assessed using a 10 cm visual analogue scale (VAS), while client's overall satisfaction was rated using Likert scoring system. Results: Client aged 33.2 ± 4.2 years. Most of them had primary infertility with mean duration of 4.5 ± 2.9 years. Unexplained infertility was the commonest cause of infertility. The pregnancy rate per embryo transfer was 47.9%, miscarriage rate was 5.6%, while the live birth rate was 42.3%. The mean VAS scores at 1 h, 6 h, 24 h and at embryo transfer were 4.9 ± 1.7, 2.5 ± 1.2, 1.3 ± 0.9, and 0.5 ± 0.6, while the Likert score was 3.8 ± 1.1. Conclusion: Conscious sedation with Midazolam and Pethidine is a safe, effective, and acceptable method of analgesia/anesthesia for TVOR. However randomized prospective studies with larger sample sizes are recommended.

Ultrasound-guided oocyte retrieval is a standard procedure for ovum pick up (OPU) during in vitro fertilization. Possible complications include tubo-ovarian abscesses (TOAs) in the fallopian tubes, and endometriosis may be associated with increasing the severity of pelvic infection. A 35-year-old woman who had been treated for infertility and endometriosis presented with abdominal pain that appeared several days after OPU. There were no significant changes in the size of both ovaries and fallopian tubes. A week later, transvaginal echography revealed right oviduct enlargement. Because conservative treatment with antibiotics before this revelation had not been successful, laparoscopy was performed for abscess drainage and/or excision of the adnexa. Intraoperative findings were an abscess in the right adnexa involving the ovary and fallopian tube. Preservation of the right fallopian tube was difficult due to the risk of prolonged infection, and a right appendectomy was performed. The diagnosis was a right TOA. Severe cases of pelvic infection after OPU may cause infertility. The presence of endometriosis may aggravate the infection, but the relationship between the extent of the endometriosis and the severity of the infection is not known. Even if the endometriosis is mild, as it was in this patient, surgical treatment should be considered if a severe infection occurs after OPU and conservative treatment is not effective.

Objective: Transvaginal oocyte retrieval has become the common method for infertility couples undergoing artificial reproductive technology. Although it was considered to be safe, rare complications including urinary bladder injury were reported. Case report: We described two cases of bladder injury with refractory blood clots after oocyte retrieval, for whom conservative treatment failed. Diagnostic cystoscopy was performed and an Ellik evacuator was used for clot dissolution successfully. Conclusion: Urinary bladder injury with clots retention is a rare complication following ovary puncture. When tenacious clots become organized, the removal with traditional bladder irrigation may be difficult. We introduce Ellik evacuator as an effective and reliable procedure for evacuating tenacious clots in the urinary bladder. Keywords: Transvaginal oocyte retrieval (TVOR), Bladder injury, Hematuria, Tenacious clot, Ellik

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

PURPOSE OF REVIEW The objective of this review is to analyze and summarize the current anesthetic methods used to alleviate pain and discomfort during transvaginal oocyte retrieval procedures (TORP), to try to reach practical recommendations, based on the evidence, which will translate into daily practice, the knowledge on the anesthetic management of patients scheduled for TORP. RECENT FINDINGS There is no strong evidence to recommend the avoidance of any technique or drug for TORP, including nitrous oxide or halogenated agents. Women should be offered any available technique. The evidence available up to date is not convincing enough to recommend avoiding any anesthetic technique in terms of pregnancy and birth rates. SUMMARY TORP is painful for women and different techniques may be used for pain relief in day case surgery. The other important outcome to consider is the pregnancy rate, and any anesthetic technique or drug which would improve this pregnancy rate should be recommended. Conscious sedation and general anesthesia proved to be well tolerated for woman and the oocytes, despite the use of propofol, opioids, benzodiacepines, nitrous oxide, or other drugs. Spinal anesthesia and paracervical block are also acceptable options, and can be combined with conscious sedation. Nevertheless, more studies are needed to find out the ideal drug or technique combination for the woman and the oocyte.

Conscious sedation is a commonly used approach to provide pain relief during transvaginal oocyte retrieval. It has been shown to be effective with high levels of acceptability and patient satisfaction. Fundamental Standards and Development Standards in safe sedation practice have been set out by the Royal College of Anaesthetists and they recommend that Royal Colleges, in association with the relevant sub-specialty organizations, should develop guidelines on sedation methods appropriate to clinical practice in their sphere of influence. This Policy and Practice paper outlines the human resources and equipment necessary to optimize patients' safety for the administration of intravenous (I.V.) sedation in assisted conception units, based on the most current evidence and guidance available.

(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.

STUDY QUESTION What is the reproductive potential following combinations of ovarian stimulation, IVM and ovarian tissue cryopreservation (OTC) in female patients seeking fertility preservation (FP)? SUMMARY ANSWER In selected patients, combining different FP procedures is a feasible approach and reproductive outcomes after FP in patients who return to attempt pregnancy are promising. WHAT IS KNOWN ALREADY FP is increasingly performed in fertility clinics but an algorithm to select the most suitable FP procedure according to patient characteristics and available timeframe is currently lacking. Vitrification of mature oocytes (OV) and OTC are most commonly performed, although in some clinical scenarios a combination of procedures including IVM, to spread the sources of gametes, may be considered in order to enhance reproductive options for the future. STUDY DESIGN, SIZE, DURATION Retrospective, observational study in a university-based, tertiary fertility centre involving all female patients who underwent urgent medical FP between January 2012 and December 2018. Descriptive analysis of various FP procedures, either stand-alone or combined, was performed, and reproductive outcomes of patients who attempted pregnancy in the follow-up period were recorded. PARTICIPANTS/MATERIALS, SETTING, METHODS In total, 207 patients underwent medical FP. Patient-tailored strategies and procedures were selected after multidisciplinary discussion. When deemed feasible, FP procedures were combined to cryopreserve different types of reproductive tissue for future use. The main primary outcome measure was the number of mature oocytes. Live birth rates were evaluated in patients who returned for reproductive treatment. MAIN RESULTS AND THE ROLE OF CHANCE Among patients seeking FP, 95/207 (46%) had breast cancer, 43/207 (21%) had haematological malignancies and 31/207 (15%) had a gynaecological tumour. Mean ± SD age was 27.0 ± 8.3 years. Eighty-five (41.1%) patients underwent controlled ovarian stimulation (COS), resulting in 10.8 ± 7.1 metaphase II (MII) oocytes for vitrification. Eleven (5.3%) patients had multiple COS cycles. Transvaginal oocyte retrieval for IVM was performed in 17 (8.2%) patients, yielding 9.2 ± 10.1 MII oocytes. Thirty-four (16.4%) patients underwent OTC combined with IVM of oocytes retrieved from ovarian tissue ‘ex vivo’ (OTO-IVM), yielding 4.0 ± 4.3 MII oocytes in addition to ovarian fragments. Seventeen (8.2%) patients had OTC combined with OTO-IVM and transvaginal retrieval of oocytes for IVM from the contralateral ovary, resulting in 13.5 ± 9.7 MII oocytes. In 13 (6.3%) patients, OTC with OTO-IVM was followed by controlled stimulation of the contralateral ovary, yielding 11.3 ± 6.6 MII oocytes in total. During the timeframe of the study, 31/207 (15%) patients have returned to the fertility clinic with a desire for pregnancy. Of those, 12 (38.7%) patients had preserved ovarian function and underwent ART treatment with fresh oocytes, resulting in nine (75%) livebirth. The remaining 19 (61.3%) patients requested warming of their cryopreserved material because of ovarian insufficiency. Of those, eight (42.1%) patients had a livebirth, of whom three after OTO-IVM. To date, 5/207 patients (2.4%) achieved an ongoing pregnancy or livebirth after spontaneous conception. LIMITATIONS, REASONS FOR CAUTION Our FP programme is based on a patient-tailored approach rather than based on an efficiency-driven algorithm. The data presented are descriptive, which precludes firm conclusions. WIDER IMPLICATIONS OF THE FINDINGS Combining different FP procedures is likely to enhance the reproductive fitness of patients undergoing gonadotoxic treatment but further follow-up studies are needed to confirm this. STUDY FUNDING/COMPETING INTEREST(S) No external funding was used for this study and the authors have no competing interests. TRIAL REGISTRATION NUMBER N/A.

Background: Pain during oocyte retrieval, which can make the in-vitro fertilization process an unpleasant experience, is becoming a common problem. Although there are many analgesic methods available in the clinical setting, they are not therapeutically equivalent, and some are associated with varying adverse reactions. In recent years, acupuncture analgesia has been used in the perioperative period of oocyte retrieval because of its perceived efficacy and safety. The purpose of this systematic review and meta-analysis is to provide evidence that acupuncture is effective in the treatment of vaginal oocyte retrieval pain. Methods: Electronic searches of the following six databases will be conducted by two qualified reviewers: MEDLINE, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Medicine database, VIP database and Wanfang database. Three clinical trial registries will also be searched: World Health Organization International Clinical Trial Registry Platform, Chinese Clinical Trial Registry, Cochrane Central Register of Controlled Trials and ClinicalTrials.Gov. All searches will cover the period from inception of the database/registry to March 2020 and will be limited to publications in English and Chinese. Data identification, data selection, data extraction, and bias risk assessment will be conducted independently by3ν two or more qualified reviewers, including those who selected the studies. Visual analogue scale scores will be calculated as the primary outcome. Secondary outcomes will include results of other subjective pain rating scales, including Likert scales or other defined numerical or non-numerical scales, self-assessed by patients before, during, and after oocyte retrieval. We will use STATA software (Version 16) to perform meta-analyses, and the Grading of Recommendations, Assessment, Development and Evaluations framework to grade the quality of evidence. If quantitative analysis is not available, a systematic narrative synthesis will be provided. PROSPERO registration number: CRD42020170095.

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.

ContextThe H19 long noncoding RNA (lncRNA) belongs to a highly conserved, imprinted gene cluster involved in embryonic development and growth control. We previously described a novel mechanism whereby the Anti-mullerian hormone (Amh)appears to be regulated byH19.However, the relationship between circulatingH19and markers of ovarian reserve including AMH not been investigated.ObjectiveTo determine whetherH19expression is altered in women with decreased ovarian reserve.DesignExperimental study.SettingYale School of Medicine (New Haven, USA) and Gazi University School of Medicine (Ankara, Turkey).Patients or other participantsA total of 141 women undergoing infertility evaluation and treatment.InterventionCollection of discarded blood samples and cumulus cells at the time of baseline infertility evaluation and transvaginal oocyte retrieval, respectively.Main outcome measureSerum and cumulus cellH19expression.ResultsWomen with diminished ovarian reserve (as determined by AMH) had significantly lower serum H19 expression levels as compared to controls (p p ConclusionIn this study, we show that downregulation ofH19in serum and cumulus cells is closely associated with decreased ovarian reserve, as measured by decreased AMH levels and reduced oocyte yield at oocyte retrieval. Further study with expanded sample sizes is necessary to determine whetherH19may be of use as a novel biomarker for diminished ovarian reserve.

This study aimed to identify the anesthetic-sparing effect of different intraoperative sound on sedated patients under propofol target controlled infusion anesthesia (TCI). 90 patients scheduled for transvaginal oocyte retrieval surgery (TVOR) were available and randomized into three groups: patients isolated from background noise(S), patients listened to a voice calling their names (CN), or patients listened to the classical music (CM). The main outcome was the value of total propofol consumption/surgical time. In the result, the value of total propofol consumption/surgical time for the CM group was 22.48% lower than CN group. The value of ΔEntropy and ΔCE for the CM group were also lower than that for the CN group (-2.17 ± 4.13 vs. 1.33 ± 3.43, P-value0.001) (-0.17 ± 0.28 vs. 0.07 ± 0.25, P-value0.001). We concluded that participants under propofol TCI who were listening to classical music had lower CE value, Entropy level and reduced 22.48% total propofol consumption/surgical time compared to those called by their names.

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

BACKGROUND In this prospective double-blind randomized study, we evaluated the analgesic effect and potential effect on pregnancy rate of the nonsteroidal anti-inflammatory drug flurbiprofen axetil in patients undergoing ultrasound-guided transvaginal oocyte retrieval under propofol-remifentanil anesthesia. METHODS A total of 200 patients scheduled to undergo ultrasound-guided transvaginal oocyte retrieval were randomly allocated to receive 1.5 mg/kg of flurbiprofen axetil (FA group) or placebo (control group) 30 minutes before the procedure. Postoperative pain scores, embryo implantation rate, and pregnancy rate were recorded. Neuroendocrine biomarkers and prostaglandin E2 levels in follicular fluid were tested after oocyte retrieval. RESULTS Patients in the FA group awakened earlier after surgery than patients in the control group (3.3 ± 2.6 vs 5.3 ± 3.4 minutes, P < .05) and had lower pain scores than patients in the control group (2.0 [0.0, 2.8] vs 5.0 [3.0, 5.0], P< .001). The difference in pregnancy rates between the 2 groups (44%-44%) was 0% (conventional 2-sided 95% confidence interval, -13.8% to 13.8%). The lower limit of the 90% 1-sided confidence interval for this difference was -9.0%, which was within the predefined noninferiority margin of -15.0%. The concentration of prostaglandin E2 in follicular fluid was decreased in the FA group (24.51 ± 1.52 vs 25.15 ± 1.49 pg/mL, P = .039), although the difference does not appear to be clinically important. CONCLUSIONS Flurbiprofen axetil given before ultrasound-guided transvaginal oocyte retrieval for patients under propofol-remifentanil general anesthesia relieves pain without any detrimental effect on clinical pregnancy rate.

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 during assisted reproductive technologies (ARTs) was first introduced in 1981, replacing both surgical egg collection and laparoscopic retrieval but also previous different approaches such as the transurethral ultrasound-guided route. It is well known that the number of oocytes retrieved depends on many factors: type of aspiration needle (wide or narrow bore or single or double channel), aspiration pressure, follicular flushing, timing of HCG triggering, and experience and skills of the surgeon.

Background: Total intravenous anaesthesia (TIVA) using propofol is one of the commonest techniques used for TVOR as a day care procedure by virtue of its adequate sedation and speedy clear headed recovery. Monitors like BIS or entropy help us to effectively titrate the drug so as to maintain optimal depth of anaesthesia and minimise drug consumption. Subjects and Methods: After obtaining Institutional Review Board approval, this prospective randomised controlled study was conducted in the Department of Anaesthesiology and Intensive care, Medical College Hospital. All ASA Grade I and II female patients of reproductive age group coming for oocyte retrieval under general anaesthesia who can understand the informed consent form were included in the study. Results: There is a statistically significant difference observed between group P1 and P3 with regard to Proportion of patients not requiring rescue boluses. No significant difference was observed between P1 – P2 and P2-P3 groups. There was a statistically significant difference observed between groups P1 and P3 in respect to total propofol consumption. No significant difference observed between P1-P2 and P2-P3. Conclusion: Bolus dose of propofol can be an induction dose of choice in oocyte retrieval patients as it requires less rescue boluses compared to 1.0mg/kg and and overall propofol consumption was less than 2 mg/kg but more than1 mg/kg.

Background: The patients undergoing IVF treatment are thoroughly evaluated for the cause of infertility, appropriate treatment instituted and the associated co morbidity. Another major challenge for the anaesthetists is to allay the anxiety. The patients presenting in the IVF clinic are under high degree of social and psychological stress. Detailed pre anaesthetic check up was done a day prior to surgery and appropriate investigations were carried out. Subjects and Methods: The anaesthetic technique and the questionnaire were explained to the patients and an informed written consent was taken from all the patients.Patients were kept fasting overnight prior to surgery and were premedicated with Tab. Ranitidine 150 mg and Tab. Alprazolam 0.25 mg on the night before surgery and repeated on the next day one hour prior to surgery with sip of water. Results: On table recovery time was found to be 6.12 minutes in group P1 (2mg/kg), 5.32 minutes in group P2 (1.5mg/kg) and 5.32 minutes in group P3 (1mg/kg). No statistical difference observed between the 3 groups. Time to discharge was found to be 37.08 minutes in group P1 (2mg/kg), 33.48minutes in group P2 (1.5mg/kg) and 28.88minutes in group P3 (1mg/kg). Conclusion: On table recovery time was found to be 6.12 minutes in group P1 (2mg/kg), 5.32 minutes in group P2 (1.5mg/kg) and 5.32 minutes in group P3 (1mg/kg). No statistical significant difference was observed between the three groups.

Objectives Assisted reproductive technology is commonly used for women with infertility. We report a case of acute intermittent porphyria associated with in vitro fertilization treatment. Case Report A 35-year-old woman with tubal factor infertility presented to our clinic with persistent low abdominal pain and hyponatremia after transvaginal oocyte retrieval. During admission, she experienced a generalized tonic–clonic seizure attacked following by dark brown color urine. Urinary tests showed elevated porphobilinogen, 5-aminolevulinic acid, uroporphyrin, and coproporphyrin, confirming the diagnosis of acute intermittent porphyria. The patient's condition continued to improve after hemin treatment and rehabilitation. Conclusion Newly onset acute intermittent porphyria during the course of controlled ovarian hyperstimulation for in vitro fertilization is a rare but possible complication. Acute intermittent porphyria should be taken into consideration for persisted unexplained abdominal pain and seriously alerted if accompanied with neurological symptoms. Special tests for acute intermittent porphyria should be taken into consideration for the differential diagnosis of lower abdominal pain after oocyte retrieval.