Bladder Haematoma: A Rare but Serious Complication of Oocyte Retrieval.

A 30-year-old nulligravida with primary infertility presented to our hospital after 3 years of married life. The patient had a regular menstrual cycle and no significant medical and surgical history except one laparoscopy, performed as part of infertility investigations, which showed bilateral distal tubal block. Her hormonal profile showed: Follicle stimulating hormone (FSH) = 6.4 μ/mL, Luteinising hormone (LH) = 2.8 μ/mL, prolactin = 18.9 ng/mL and Anti mullerian hormone (AMH) = 4.24 ng/mL. The male partner was 33 years old with normozoospermia. The patient was counselled for assisted reproductive technology (ART) in view of a bilateral tubal block to which she agreed. Controlled ovarian stimulation using a flexible antagonist protocol was followed. She received recombinant-FSH (folisurge 150 IU, Intas pharmaceuticals) for 12 days. Recombinant LH (luveris 75 IU, Merck Serono) was added on day 7 of stimulation. The antagonist (cetrorelix-cetrofirst, Gufic biosciences) was started by day 6 of stimulation and continued till the day of trigger. Final triggering was achieved by recombinant human chorionic gonadotropin (ovitrelle, Merck, London, UK). Oocyte retrieval was performed by most senior specialists. The bladder was emptied before the procedure. Both ovaries were punctured using a single-lumen aspiration needle (17G, Cook, William A. COOK Australia) attached to a closed suction system. Oocyte aspiration was done at a pressure of minus 100 mmHg and 10 oocytes (7 metaphase II, 2 metaphase I and 1 germinal vesicle) were aspirated. The procedure was uneventful. The patient was discharged in satisfactory condition 4 h later. The patient presented in an emergency on the 5 th day post-TVOR with lower abdominal pain, urinary frequency, dysuria and visible haematuria. Vital signs were normal. On abdominal examination, she had suprapubic tenderness. Per speculum examination showed a healthy cervix and vagina. A pelvic ultrasound was performed, which showed a big bladder haematoma measuring 5.1 cm × 2.5 cm [ Figure 1 ]. The haematoma was moving with a change of position of the patient. Tranexamic acid was given intravenously to control bleeding. It was administered to reduce any active bleeding with a clear understanding that it would not aid in resolving the already-formed haematoma. The bladder was catheterised with a self-retaining 16 French Foley catheter and 900 mL of blood-tinged urine was drained. Fluid rush was given with 500 mL of normal saline (0.9%) along with 1 mL of injection furosemide. A catheter was removed after 4 h and the patient passed about 20 g of clots spontaneously [ Figure 2 ]. Repeat ultrasound showed an empty bladder. The patient was discharged the next day in good condition. Bladder haematoma post TVOR The haematoma expelled as clots A 35 - year old nulligravida presented to our hospital with primary infertility with history of prolonged married life. She had a regular menstrual cycle. There was no significant medical and surgical history except six failed intrauterine inseminations. Her hormonal profile showed: FSH = 8.4 μ/mL, LH = 6.8 μ/mL, prolactin = 20.9 ng/mL and AMH = 2.14 ng/mL. The male partner was 38 years old with normozoospermia. The patient was counselled for ART in view of prolonged married life with unexplained infertility. Controlled ovarian stimulation using a flexible antagonist protocol was followed in the same manner as described for the previous patient. Oocyte retrieval was performed by the same senior specialist. Oocyte aspiration was done at a pressure of minus 100 mmHg and 8 oocytes (6 metaphase II, 2 metaphase I) were aspirated. The procedure went uncomplicated. The patient was discharged in satisfactory condition 4 h later. The patient presented in the emergency outpatient department 7 th day post-TVOR with lower abdominal pain and visible haematuria. Pelvic ultrasound showed a bladder haematoma, which measured 6.1 cm × 5.6 cm × 4.2 cm [ Figure 3 ]. Tranexamic acid was given intravenously to control bleeding. The bladder was catheterised and 1200 mL of blood-tinged urine was drained. Fluid rush was given with 500 mL normal saline (0.9%) along with 1 ml of injection furosemide. After 4 h catheter was removed in the hope of self-passage of clots. After 1 h, the patient again complained of lower abdominal pain and dysuria with an inability to pass urine. The bladder was re-catheterised and fluid therapy was given. After 48 h, repeat scan did not reveal any change in the size of the clot. The decision to irrigate the bladder with hydrogen peroxide was taken because of the persistence of haematoma and the symptomatic state of the patient. We used 6% hydrogen peroxide solution which was mixed with 0.9% normal saline. The solution was put with a 20-Fr three-cavity Foley catheter with side holes. Irrigation fluid was 1:10 mixture of 6% hydrogen peroxide and 0.9% saline. Using three-cavity Foley decreases the chances of catheter blockage. The solution was maintained in the bladder for 1 min each in a total of two cycles. Clots were evacuated after two cycles of bladder irrigation. Repeat ultrasound showed an empty bladder. The patient was discharged the next day in satisfactory condition. Big bladder haematoma post TVOR

Since the introduction of transvaginal oocyte retrieval (TVOR) in 1983, it has become the standard method for oocyte retrieval due to its simplicity.[ 1 ] Stimulated ovaries being heavier tend to remain easily accessible in the pelvis thus adding on to simplicity of the procedure. Despite being a simple procedure, TVOR can lead to challenging complications sometimes, as is inherent to any invasive procedure that involve sharp instrumentation. A few rare complications include haemorrhage, bladder and bowel damage, ureteric injuries, adnexal torsion, endometriotic or dermoid cyst rupture, vertebral osteomyelitis, pelvic abscess formation, pelvic vessel injury with retroperitoneal haematomas formation and ruptured pelvic kidney.[ 2 ] Women with known pelvic pathologies such as a history of complicated abdominal pelvic surgeries, severe endometriosis, tuberculosis, abdominal or pelvic inflammatory diseases and Mullerian abnormalities, a history of previous difficult oocyte retrievals and morbid obesity are more prone to TVOR-related complications. Patients with known bleeding disorders, hemoglobinopathies and those on anticoagulant therapy are especially at risk of haemorrhage. Here, we present two rare cases of bladder haematoma formation post-TVOR and their conservative management.

TVOR being a simple procedure, complication like bladder hematoma can be avoided if it is kept under consideration. Complications arising intraoperatively are easy to diagnose, but those arising in post-operative period tend to get missed if proper follow-up is not done post-procedure. A high index of suspicion in post-operative period can prevent further serious implications. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. RV - Concept and manuscript writing; SD and SD - Procedure and data contribution; all authors have critically reviewed the manuscript. Nil. There are no conflicts of interest. Not applicable.

Complications post-oocyte retrieval procedures can be both minor and major. Minor complications include nausea, vomiting, abdominal pain, bloating and distension. The rate of major complications, as reported by Sauer[ 3 ] in a study of over 1000 cases was 0.7%. Bladder haematoma is a rare complication of TVOR. Souza et al .[ 4 ] reported a urological complications rate of 0.03% in over 2739 procedures, which was similar to our rate of 0.04% in over 4835 procedures. The need to apply inward pressure by ultrasound probe against the vaginal wall and the direct relationship of the bladder with a site of puncture makes it more vulnerable to injury. Since the bladder is emptied before the procedure, it becomes difficult to visualise any inadvertent intravesical bleeding if this complication is not kept into consideration. Perfetto and Milki[ 6 ] showed a similar case of bladder haematoma in which the patient presented very next day of oocyte retrieval with visible haematuria. Ultrasound showed 82 mm × 70 mm bladder haematoma, which was managed with bladder irrigation using a Bard 26-Fr 6-eye catheter. Xu et al .[ 5 ] used hydrogen peroxide solution for resolution of bladder haematomas formed due to various urological causes. The study showed the successful use of hydrogen peroxide in 27 out of 31 cases of bladder haematoma. In a case report by Souza et al .[ 4 ] patient presented within 12 h of oocyte retrieval with complaints of haematuria along with blood clots. TVS revealed a heterogeneous intravesical mass suggestive of clot 22 mm × 19 mm, which was managed conservatively. Jayakrishnan et al .[ 7 ] described a case of visible haematuria with hemodynamic instability as a complication of oocyte retrieval. The patient presented 7 days after oocyte retrieval. Cystoscopy revealed a bleeding pseudoaneurysm which was resected and cauterised. Bladder haematomas, pseudoaneurysms and arteriovenous fistulas must always be kept in mind when the patient presents with haematuria post-oocyte aspiration. The presentation of bladder haematomas can be both early as well as late onset. The delay in presentation can be attributed to the time which is takes for the haematomas to form and attain a considerable size, ultimately to present either in the form of urinary retention, increased frequency or dysuria. Damage to pelvic structures can be avoided by using colour Doppler imaging in case of doubt about the vascularity of the structure.[ 8 ] Keeping the ultrasound probe with needle guide in a lateral position before vaginal puncture and keeping the needle tip always under visibility can prevent many otherwise avoidable complications. Multiple vaginal punctures must always be avoided keeping a maximum number of punctures one per ovary.