{"paper_id":"4379e656-fee4-48b5-902e-115583e02be7","body_text":"Transvaginal ultrasound-guided follicular aspiration was first described in 1983 and\nrapidly became widely accepted because of its simplicity and effectiveness ( Gleicher  et al ., 1983 ;  Bennett  et al ., 1993 ). In 2013,\nthe International Committee Monitoring Assisted Reproductive Technologies (ICMART)\nestimated that 6.5 million children were born in the world from  in\nvitro  fertilization (IVF) procedures and that more than one million\nannual follicular punctures were performed in at least 60 countries ( Adamson  et al. , 2017 ).\nAccording to the literature, the incidence of serious complications associated with\ntransvaginal oocyte pick-up is low, but the procedure is not risk-free. Risks are\ninherent to procedures in which thin needles and sharp instruments are introduced\ninto the vaginal wall and ovarian capsule to access the ovaries. A transvaginal\nprobe equipped with a needle guide is introduced into the vaginal canal and\npositioned in the lateral vaginal fornix on the same side of the ovary to be\naspirated. This is done in order to reach the gonad with the end of the probe as\nclosely as possible ( Seyhan  et al .,\n2014 ). The needle is then connected to a suction pump, and introduced\ninto the follicles after perforation of the vaginal wall and ovarian capsule. Only\nthen the aspiration of the follicular fluid begins.\nAs a precaution, the number of vaginal and ovarian perforations is kept to a minimum.\nTherefore, greater numbers of follicles are aspirated without withdrawing the needle\ntip from inside the ovary ( el Hussein  et\nal ., 1992 ). After all ovarian follicles have been aspirated,\nthe needle is withdrawn and the procedure is repeated in the contralateral ovary.\nThe tip of the needle must be visualized by ultrasound throughout the entire\nprocedure in order to avoid damaging adjacent pelvic structures ( Gleicher  et al ., 1983 ).\n\nThe patient described in this paper consented to having her case published. A single\nnulliparous woman was first seen in our clinic in April 2014. She was seeking\ninformation on oocyte cryopreservation and  in vitro  fertilization.\nShe did not have a partner at the time. She had no record of comorbidities and her\nmenstrual cycles were regular. The antimullerian hormone (AMH) level measured after\nher first appointment was 3.4 ng/mL and her antral follicle count (AFC) was 12. She\nreturned to the clinic in September 2015 with a partner (age 38). At the beginning\nof the cycle, her FSH dosage was 6 mIU/mL; her estradiol (E2) level was 43 ng/dL;\nand her AFC was 17. Her prospects in relation to age were discussed and she was\noffered an IVF/ICSI cycle with genetic testing for aneuploidies of the resulting\nblastocysts.\nThe protocol and total amount of gonadotropins administered were as follows:\nGonalF ®  (recombinant FSH, Merck, Aubonne, Switzerland) 1050 IU\nand Menopur ®  (Ferring Pharmaceuticals, Kiel, Germany) 1050 IU.\nThis patient was prescribed an antagonist cycle with Orgalutran ® \n(Merck Sharp & Dohme, Ravensburg, Germany), 4 vials. The LH trigger utilized was\nOvidrel ®  250 mcg (recombinant HCG, Merck, Aubonne,\nSwitzerland). The transvaginal ultrasound-guided oocyte retrieval procedure was\nperformed in September 2015 with a standard Wallace ®  (UK) 25-cm\n17-G single-lumen needle attached to a closed suction system with a continuous\npressure pump at 90 mmHg, as per the protocol in place in our Center. Ten oocytes\nwere harvested, 4 of which were Metaphase II; two embryos were vitrified on day\n3.\nThe patient underwent a second cycle in April 2016, at age 45, with\nPergoveris ®  (recombinant FSH plus recombinant LH, Merck,\nAubonne, Switzerland), using a total gonadotropin dose of 1350 IU of FSH and 670 IU\nof LH, and an additional 1200 IU of FSH with Fostimon M ®  (IBSA\nInstitut Biochimique S.A. Lamone, Switzerland). The patient was again prescribed an\nantagonist cycle with Orgalutran ®  (Merck Sharp & Dohme,\nRavensburg, Germany), 5 vials. This time the LH trigger was performed with\nGonapeptyl daily ®  0.1mg (Ferring Pharmaceuticals, Kiel, Germany),\n2 vials. However, during the second cycle she decided to only cryopreserve her\noocytes. All pre-procedure examinations were normal. Follicle aspiration was done 35\nhours after the LH trigger. Both ovaries were punctured without complications. A\nKitazato ® , Japan, 17-G needle was used in the procedure and\nnine metaphase II oocytes were harvested. Immediately prior to aspiration, the\npatient was instructed to void her bladder to reduce the contact area with the\npuncture zone. An experienced team carried out the aspiration procedure and no\nissues were detected.\nThe patient reported urinary discomfort and difficulty voiding her bladder 12 hours\nafter follicular puncture. She reported seeing blood and small blood clots in her\nurine. However, she only contacted the clinic the following day. She was asked to\nreturn immediately to the clinic. Despite the complaints, the patient was in good\ngeneral condition and without signs of fever within 24 hours of the pick-up\nprocedure. Transvaginal ultrasound examination performed 24 hours after pick-up\nshowed a heterogeneous intravesical image ( Figure\n1 ) suggestive of a clot; her bladder measured 23x19mm. The urologist with\nthe team recommended an expectant approach with increased fluid intake. The patient\nreported discomfort throughout the day. She expelled the clot in the evening, and\nsymptoms subsided. She has not recurred in the months following this episode.\nFigure 1 A and B. Transvaginal ultrasound examination performed one day after\noocyte retrieval, showing a heterogeneous intravesical image and a\nwell-defined bladder measuring 23x19mm in its larger diameter\nA and B. Transvaginal ultrasound examination performed one day after\noocyte retrieval, showing a heterogeneous intravesical image and a\nwell-defined bladder measuring 23x19mm in its larger diameter\n\nThis was the only case of a bladder hematoma in more than 2739 procedures (0.03%),\nwhich now appear alongside one case of a hematoma of the parametrium and another\ncase of hemoperitoneum. All oocyte pick-up procedures were ultrasound guided.\nAdditionally, clear visualization of the needle tip is mandatory throughout the\nprocedure.\nThe patient described in this case had no history of pelvic or abdominal surgery.\nAlthough the rate of complications associated with vaginal oocyte pick-up is low,\ncare and attention are mandatory in order to minimize potential harm. Patients must\nbe checked for prior pelvic surgery, sequelae from pelvic inflammatory disease, and\nhistory of endometriosis.\nAccording to  Bennett  et al .\n(1993) , vascular lesions of the vaginal and ovarian walls, accidental\ninjuries to pelvic organs such as the bowel, bladder, ureters and pelvic blood\nvessels, and pelvic infection by microorganisms from the vaginal canal are a few of\nthe possible complications arising from this procedure. These authors reviewed 2670\ncases of oocyte retrieval and described vaginal bleeding (8.6%) as the most frequent\ncomplication, followed by hemoperitoneum (0.7%), pelvic infection (0.6%), and\naccidental puncture of pelvic vessels (0.04%).\nLudwig  et al.  (2006) \ndescribed similar findings. The authors examined the peri- and postoperative\ncomplications of 1058 oocyte retrieval procedures and found vaginal bleeding (2-3%)\nas the most frequent complication, followed by hemoperitoneum (1 %). They did not\nreport cases of pelvic infection, although it appears to occur in 0.2 to 0.6% of the\ncases ( Dicker  et al .,\n1993 ).\nSeyhan  et al . (2014)  reported\nsimilar findings in a comparison between complication rates and pain score\ndefinitions after oocyte retrieval for  in vitro  maturation and IVF\ncycles. Vaginal and ovarian bleedings were the most frequent complications. Their\nfindings were in agreement with previous studies, in which vaginal bleeding occurred\nin 0.5-7.5% of the cases and pelvic pain was the most frequent complication ( el Hussein  et al. , 1992 ;  El-Shawarby  et al ., 2004 ).\n El-Shawarby  et al . (2004) \nalso described other complications including adnexal torsion, ruptured endometriotic\ncysts, issues with anesthesia, and vertebral osteomyelitis.\nThe literature has been unanimous in showing that complications arising from oocyte\nretrieval are rare. In this context, accidental urinary tract injuries are\napparently even less frequent.  von Eye Corleta\n et al.  (2008)  reported a case of immediate\nureterovaginal fistula secondary to oocyte retrieval, which improved spontaneously\nafter six weeks. Similarly,  Jones  et\nal . (1989)  reported three other cases of ureteral injury.\n Coroleu  et al . (1997)  and\n Fugita & Kavoussi (2001)  described\ncases in which patients were diagnosed with complications between five days and four\nmonths after the retrieval procedure, involving a combination of irritative voiding\nsymptoms, leukocytosis, and negative urine culture, which, according to them,\nindicated urinary tract injury. These authors also emphasized the importance of\nearly diagnosis. In fact,  Miller  et\nal . (2002)  reported a case of acute ureteral obstruction\nfollowing a seemingly uncomplicated oocyte retrieval procedure, in which prompt\ndiagnosis and ureteral stenting led to rapid recovery with no long-term urinary\ntract sequelae.\nOne might assume that bladder injury occurs more frequently than ureter lesions on\naccount of the local anatomy, although this idea has not been supported by\nliterature reports. The topographic characteristics of the bladder and its direct\nrelationship with the site of puncture might increase the risk of injury when the\nneedle is inserted, while the pressure exerted by the probe causes its walls to\ncollapse, thus making visualization more difficult.\nPreventing damage to pelvic structures during oocyte retrieval includes using\nColor-Doppler velocimetry to identify blood vessels in cases of doubt ( Bhandari  et al ., 2015 ).\nAdditionally, it is wise to keep the end of the needle guide always in a lateral\nposition before puncturing to avoid being too close to blood vessels, the bladder,\nand the ureter. Finally, oocyte pick-up should only commence after complete bladder\nvoiding ( Miller  et al .,\n2002 ).\nAs pointed out by  von Eye Corleta  et\nal . (2008) , given the elective nature of transvaginal\nultrasound-guided oocyte retrieval in IVF cycles, patients should be informed about\nthese potential, albeit rare, risks and complications.","source_license":"CC-BY-4.0","license_restricted":false}