transvaginal oocyte retrieval

Under ultrasound guidance, the operator inserts a 16.5 gauge × 11.8″ (1.6 mm × 300 mm outer diameter) needle through the vaginal wall and into an ovarian follicle, taking care not to injure nearby organs and blood vessels. The other end of the needle is attached to a suction device. Once the follicle is entered, suction is carefully applied to aspirate follicular fluid containing cellular material, including the oocyte. The suction device must maintain a pressure of -140 mmHg (necessary to aspirate rapidly, but not enough to damage the follicles) and a temperature of approximately 37 °C. The follicular fluid is delivered to a technician in the IVF laboratory to identify and quantify the ova. Once the ovarian follicles have been aspirated on one ovary, the needle is withdrawn and the procedure is repeated on the other ovary. It is not unusual to remove 20 oocytes as patients are generally hyperstimulated in advance of this procedure. After completion, the needle is withdrawn, and hemostasis is achieved. The procedure usually lasts 10{{ndash}}20 minutes. Once the extraction is done, the sample is analyzed in the microscope to select and carry out the oocyte decumulation, a process where the granulosa cells surrounding the oocyte are removed.

Initially performed using transabdominal ultrasonography, TVOR is currently performed with a transvaginal ultrasound transducer with an attached needle.{{cite book |last=Killick |first=S |editor-last=Bates |editor-first=J |title=Practical gynaecological ultrasound |edition=2nd |chapter=Ultrasound and fertility |pages=120–5 |publisher=Cambridge University Press |location=Cambridge, England |year=2006 |isbn=9780521674508 |chapter-url=https://books.google.com/books?id=5PV2RWOl42EC&q=%22Vaginal+ultrasound+is+the+method+of+choice%22&pg=PA123}} TVOR is performed in an operating room or a physician's office, with the subject in the lithotomy position. TVOR is usually performed under procedural sedation,{{cite journal |vauthors=Yasmin E, Dresner M, Balen A |title=Sedation and anaesthesia for transvaginal oocyte collection: an evaluation of practice in the UK |journal=Human Reproduction |volume=19 |issue=12 |pages=2942–5 |date=December 2004 |pmid=15388681 |doi=10.1093/humrep/deh526|url=http://humrep.oxfordjournals.org/content/19/12/2942.full.pdf}} general anesthesia,{{cite book |last=Sequeira |first=PM |veditors=Urman RD, Gross WL, Philip BK |title=Anesthesia outside of the operating room |edition=1st |chapter=Anesthesia for in vitro fertilization |pages=198–205 |publisher=Oxford University Press |location=Oxford, England |year=2011 |isbn=9780195396676|chapter-url=https://books.google.com/books?id=zrKAgG5nJUQC&q=%22anesthesia+for+transvaginal+oocyte+retrieval%22&pg=PA199}} paracervical block,{{cite journal |vauthors=Bumen S, Gunusen I, Firat V, Karaman S, Akdogan A, Tavmergen Goker EN |title=A comparison of intravenous general anesthesia and paracervical block for in vitro fertilization: effects on oocytes using the transvaginal technique |journal=Turkish Journal of Medical Sciences |volume=41 |issue=5 |pages=801–8 |year=2011 |doi=10.3906/sag-1009-1101 |doi-access=free }} or sometimes spinal anesthesia.{{cite journal |vauthors=Viscomi CM, Hill K, Johnson J, Sites C |title=Spinal anesthesia versus intravenous sedation for transvaginal oocyte retrieval: reproductive outcome, side-effects and recovery profiles |journal=International Journal of Obstetric Anesthesia |volume=6 |issue=1 |pages=49–51 |date=January 1997 |pmid=15321311 |doi=10.1016/S0959-289X(97)80052-0 }} Local anesthesia is not typically used because local anesthetic agents interfere with follicular cleavage and the technique requires multiple needle punctures.{{cite journal |vauthors=Saxena R, Sood J, Kumra VP |title=Comparison of various sedation techniques for transvaginal oocyte retrieval in a daycare set up |journal=Indian Journal of Anaesthesia |volume=49 |issue=2 |pages=16–21 |year=2005 |url=http://medind.nic.in/iad/t05/i2/iadt05i2p116.pdf}}

This technique must be done very delicately, without stimulating the uterus, so that contractions do not occur. Minimizing patient anxiety is desirable to favor efficacy.

Follicular flushing has not been found to increase pregnancy rates, nor result in an increase in oocyte yield. On the other hand, it requires a significantly longer operative time and more analgesia.{{Cite journal|last1=Farquhar|first1=Cindy|last2=Marjoribanks|first2=Jane|date=2018-08-17|editor-last=Cochrane Gynaecology and Fertility Group|title=Assisted reproductive technology: an overview of Cochrane Reviews|journal=Cochrane Database of Systematic Reviews|volume=2018|issue=8 |pages=CD010537|language=en|doi=10.1002/14651858.CD010537.pub5|pmid=30117155|pmc=6953328}}

Seminal fluid contains several proteins that interact with epithelial cells of the cervix and uterus, inducing active gestational immune tolerance. There are significantly improved outcomes when patients are exposed to seminal plasma around the time of oocyte retrieval, with statistical significance for clinical pregnancy, but not for ongoing pregnancy or live birth rates with the limited data available.{{cite journal |last1=Crawford |first1=G. |last2=Ray |first2=A. |last3=Gudi |first3=A. |last4=Shah |first4=A. |last5=Homburg |first5=R. |title=The role of seminal plasma for improved outcomes during in vitro fertilization treatment: review of the literature and meta-analysis |journal=Human Reproduction Update |volume=21 |issue=2 |date=Mar–Apr 2015 |pages=275–284 |issn=1355-4786 |doi=10.1093/humupd/dmu052 |pmid=25281684|doi-access=free }}

TVOR is typically performed after ovarian hyperstimulation, where oocytes are pharmacologically stimulated to mature. When the ovarian follicles have reached a certain degree of development, induction of final oocyte maturation is performed, generally by an intramuscular or subcutaneous injection of human chorionic gonadotropin (hCG).{{cite journal |vauthors=Stelling JR, Chapman ET, Frankfurter D, Harris DH, Oskowitz SP, Reindollar RH |title=Subcutaneous versus intramuscular administration of humanchorionicgonadotropin during an in vitro fertilization cycle |journal=Fertility and Sterility |volume=79 |issue=4 |pages=881–5 |year=2003 |pmid=12749424 |doi=10.1016/S0015-0282(02)04918-X |doi-access=free }} TVOR is typically performed 34{{ndash}}36 hours after hCG injection, when the eggs are fully mature but just prior to rupture of the follicles.{{cite web |last=Kovacs |first=P |title=HCG injection after ovulation induction with clomiphene citrate |publisher=Medscape |year=2004 |url=http://www.medscape.com/viewarticle/473515 |accessdate=2011-08-01}}

Injection of hCG as a trigger for ovulation confers a risk of ovarian hyperstimulation syndrome, especially in patients with polycystic ovary syndrome who have been hyperstimulated during previous assisted reproduction cycles.{{cite journal |vauthors=Oyawoye OA, Chander B, Hunter J, Gadir AA |title=Prevention of Ovarian Hyperstimulation Syndrome by Early Aspiration of Small Follicles in Hyper-responsive Patients With Polycystic Ovaries During Assisted Reproductive Treatment Cycles |journal=Medscape General Medicine |volume=7 |issue=3 |pages=60 |year=2005 |pmc=1681679 |pmid=16369286}}

Complications of TVOR include injury to pelvic organs, hemorrhage, and infection. Occurring more often in lean patients with polycystic ovary syndrome, ovarian hemorrhage after TVOR is a potentially catastrophic and not so rare complication.{{cite journal |vauthors=Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ |title=Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome |journal=Fertility and Sterility |volume=93 |issue=3 |pages=874–9 |year=2008 |pmid=19064264 |doi=10.1016/j.fertnstert.2008.10.028 |doi-access=free }} Additional complications may result from the administration of intravenous sedation or general anesthesia. These include asphyxia caused by airway obstruction, apnea, hypotension, and pulmonary aspiration of stomach contents.

Propofol-based anesthetic techniques result in significant concentrations of propofol in follicular fluid. As propofol has been shown to have deleterious effects on oocyte fertilization (in a mouse model), some authors have suggested that the dose of propofol administered during anesthesia should be limited, and also that the retrieved oocytes should be washed free of propofol.{{cite journal |last1=Christiaens |first1=F |last2=Janssenswillen |first2=C |last3=Verborgh |first3=C |last4=Moerman |first4=I |last5=Devroey |first5=P |last6=Van Steirteghem |first6=A |last7=Camu |first7=F |title=Propofol concentrations in follicular fluid during general anaesthesia for transvaginal oocyte retrieval |journal=Human Reproduction |volume=14 |issue=2 |pages=345–8 |date=February 1999 |pmid=10099976 |doi=10.1093/humrep/14.2.345 |url=http://humrep.oxfordjournals.org/content/14/2/345.full.pdf}} Anecdotal evidence suggests that certain airborne chemical contaminants and particles, especially volatile organic compounds (VOC), may be toxic to and impair the growth and development of embryos if present in sufficient concentrations in the ambient atmosphere of an IVF incubator.{{cite journal |vauthors=Cohen J, Gilligan A, Esposito W, Schimmel T, Dale B |title=Ambient air and its potential effects on conception in vitro |journal=Human Reproduction |volume=12 |issue=8 |pages=1742–9 |year=1997 |pmid=9308805 |doi=10.1093/humrep/12.8.1742 |doi-access=free }}{{cite journal |vauthors=Cohen J, Gilligan A, Willadsen S |title=Culture and quality control of embryos |journal=Human Reproduction |volume=13 |issue=Suppl 3 |pages=137–44 |date=June 1998 |pmid= 9755420|doi=10.1093/humrep/13.suppl_3.137 |doi-access=free }}

Endometriosis seems to cause a challenge for TVOR that may have reflection on individual surgeon's performance rates for the procedure, independently from the diameter of a pre-existing ovarian endometrioma (OMA) or ovarian adhesions. Obesity is another factor that may present a challenge for the procedure.{{Cite journal|last1=Kasapoğlu|first1=Işıl|last2=Türk|first2=Pınar|last3=Dayan|first3=Aylin|last4=Uncu|first4=Gürkan|date=September 2018|title=Does the presence of endometriosis cause a challenge for transvaginal oocyte retrieval? A comparison between patients with and without endometriosis|journal=Journal of the Turkish German Gynecological Association|volume=19|issue=3|pages=151–157|doi=10.4274/jtgga.2017.0146|issn=1309-0399|pmc=6085525|pmid=29545228}}

This technique was first developed by Pierre Dellenbach and colleagues in Strasbourg, France, and reported in 1984.{{cite journal |vauthors=Dellenbach P, Nisand I, Moreau L, Feger B, Plumere C, Gerlinger P, Brun B, Rumpler Y |title=Transvaginal, sonographically controlled ovarian follicle puncture for egg retrieval |journal=Lancet| pmid=6145902| volume=1 |issue=8392 |date=June 30, 1984 |pages=1467|doi=10.1016/s0140-6736(84)91958-5 |s2cid=41098471 }} Steptoe and Edwards used laparoscopy to recover oocytes when IVF was introduced, and laparoscopy was the major method of oocyte recovery until TVOR was introduced.

{{Reflist}}

• {{cite journal |author1=Bracha J. |author2=Lotan M. |author3=Zakut H. | year = 1988 | title = Ovarian abscess following cesarean section. A case report and review of the literature | journal = Clinical and Experimental Obstetrics & Gynecology | volume = 15 | issue = 4| pages = 134–6 |pmid=2976616 }}
• {{cite journal |author1=Coroleu B. |author2=Lopez-Mourelle F. |author3=Hereter L. | year = 1997 | title = Ureteral lesion secondary to vaginal ultrasound follicular puncture for oocyte recovery in in-vitro fertilization | journal = Human Reproduction | volume = 12 | issue = 5| pages = 948–50 | doi=10.1093/humrep/12.5.948|pmid=9194645 |display-authors=etal| doi-access=free }}
• {{cite journal |author1=Dicker D. |author2=Ashkenazi J. |author3=Feldberg D. | year = 1993 | title = Severe abdominal complications after transvaginal ultrasonographically guided retrieval of oocytes for in vitro fertilization and embryo transfer | journal = Fertility and Sterility | volume = 59 | issue = 6|pages=1313–1315 |display-authors=etal|doi=10.1016/S0015-0282(16)55997-4 |pmid=8495784 |doi-access=free }}
• {{cite journal |last=Tsen |first=LC |title=From Darwin to desflurane: anesthesia for assisted reproductive technologies |journal=IARS Review Course Lectures |pages=109–13 |publisher=International Anesthesia Research Society |location=San Francisco |year=2002 |url=http://www.iars.org/2002ReviewCourseLectures/pdfs/tsen2002.pdf}}

{{Assisted reproductive technology}}

Category:Fertility medicine