Consequences of Superovulation and ART Procedures
Consequences of Superovulation and ART Procedures
Although when initially performed, oocyte retrieval was accomplished via laparoscopy with the associated potential complications of laparoscopy, including hemorrhage from initial entry, intestinal lacerations, and complications from increased intra-abdominal pressure, complications have been reduced since the advent of ultrasound-guided transvaginal oocyte aspiration, first described in 1985. Overall, transvaginal oocyte retrieval is a safe procedure, with a low rate of major complications, generally <0.5%. Potential injuries from transvaginal aspiration include bleeding, infection, and injury to surrounding intra-abdominal structures including the intestine, uterus, fallopian tubes, or vessels ( Table 2 ).
In a review of 92 transvaginal ultrasound-guided oocyte aspirations, Howe et al in 1988 reported three major complications, one of which required a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Dicker et al in 1993 reported two ruptured endometriomas and three cases of intra-abdominal bleeding out of 3656 retrievals (0.13%). In a Dutch review in 1996, of 2495 cycles, the authors reported one bowel injury (a perforated appendix that required laparotomy and appendectomy), and six cases of pelvic inflammatory disease following retrieval (0.24%). In these cases, prophylactic antibiotics were not used, but the vagina had been sterilely prepped prior to aspiration. In a more recent study from 2011, Aragona et al reviewed 7098 oocyte retrievals performed from 1987 to 2009 and found four cases of severe peritoneal bleeding (0.06%) and two cases of pelvic abscess (0.03%). All patients had received antibiotic prophylaxis, generally with 1 g of ceftazidime. In a study of 9175 retrievals in Finland, Klemetti et al found an infection rate of 0.11% and a significant bleeding rate of 0.24%. A study from the Netherlands that reviewed 100,000 IVF cycles from 1984 to 2008 found a total of six deaths from IVF, two of which were from sepsis. In our institution, antibiotic prophylaxis is not routinely used except in patients with known hydrosalpinx, endometrioma, or history of pelvic inflammatory disease; however, a sterile solution is placed in the vagina prior to instrumentation.
Although significant intraperitoneal bleeding does occur during transvaginal oocyte retrieval, it rarely requires surgery. Of the cases discussed in the study by Aragona et al, all four were taken to the operating room for laparoscopy and were found to have a range of 750 to 1000 mL of hemoperitoneum. However, less clinically significant bleeding (≤200 mL) occurs more frequently and does not require surgical intervention. A recent study by Rísquez et al studied Doppler ultrasound as a potential means of reducing hemorrhagic complications from oocyte retrieval; they found that Doppler ultrasound was accurate in identifying moderate or severe peritoneal bleeding but not mild bleeding.
Complications of Retrieval
Although when initially performed, oocyte retrieval was accomplished via laparoscopy with the associated potential complications of laparoscopy, including hemorrhage from initial entry, intestinal lacerations, and complications from increased intra-abdominal pressure, complications have been reduced since the advent of ultrasound-guided transvaginal oocyte aspiration, first described in 1985. Overall, transvaginal oocyte retrieval is a safe procedure, with a low rate of major complications, generally <0.5%. Potential injuries from transvaginal aspiration include bleeding, infection, and injury to surrounding intra-abdominal structures including the intestine, uterus, fallopian tubes, or vessels ( Table 2 ).
In a review of 92 transvaginal ultrasound-guided oocyte aspirations, Howe et al in 1988 reported three major complications, one of which required a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Dicker et al in 1993 reported two ruptured endometriomas and three cases of intra-abdominal bleeding out of 3656 retrievals (0.13%). In a Dutch review in 1996, of 2495 cycles, the authors reported one bowel injury (a perforated appendix that required laparotomy and appendectomy), and six cases of pelvic inflammatory disease following retrieval (0.24%). In these cases, prophylactic antibiotics were not used, but the vagina had been sterilely prepped prior to aspiration. In a more recent study from 2011, Aragona et al reviewed 7098 oocyte retrievals performed from 1987 to 2009 and found four cases of severe peritoneal bleeding (0.06%) and two cases of pelvic abscess (0.03%). All patients had received antibiotic prophylaxis, generally with 1 g of ceftazidime. In a study of 9175 retrievals in Finland, Klemetti et al found an infection rate of 0.11% and a significant bleeding rate of 0.24%. A study from the Netherlands that reviewed 100,000 IVF cycles from 1984 to 2008 found a total of six deaths from IVF, two of which were from sepsis. In our institution, antibiotic prophylaxis is not routinely used except in patients with known hydrosalpinx, endometrioma, or history of pelvic inflammatory disease; however, a sterile solution is placed in the vagina prior to instrumentation.
Although significant intraperitoneal bleeding does occur during transvaginal oocyte retrieval, it rarely requires surgery. Of the cases discussed in the study by Aragona et al, all four were taken to the operating room for laparoscopy and were found to have a range of 750 to 1000 mL of hemoperitoneum. However, less clinically significant bleeding (≤200 mL) occurs more frequently and does not require surgical intervention. A recent study by Rísquez et al studied Doppler ultrasound as a potential means of reducing hemorrhagic complications from oocyte retrieval; they found that Doppler ultrasound was accurate in identifying moderate or severe peritoneal bleeding but not mild bleeding.
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