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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Follicular flushing
More than 50% of IVF practitioners employ a technique of flushing each follicle with culture media, with the goal of
increasing oocyte yield.
26
This is accomplished with a double-lumen retrieval needle and one or more flushes of the follicle
with repeated aspiration.
27
Initial studies showed a potential increase in oocyte yield, but subsequent randomized trials have
not demonstrated this.
28–30
Flushing increases procedural time by a range of 3 to 15 minutes.
24,29
It has been postulated
that flushing may be of benefit in certain patient populations with anticipated low oocyte yield, including poor responders and
those undergoing natural cycle IVF, but prospective data is limited and has not borne this out.
24,31,32
There does not appear
to be a difference in fertilization or implantation rates between oocytes obtained from aspiration before or after
flushing.
24,26
Ultimately, follicular flushing may not be practical in high volume fertility centers performing many oocyte
aspirations per day.
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Identification of oocytes
The tubes of culture media containing aspirate are passed through to the embryology lab. They are poured onto culture
plates where the embryologist identifies and grades the oocytes.
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Concluding the procedure
The needle is removed and flushed with culture media. The posterior cul-de-sac should be inspected for collection of free
fluid that may indicate bleeding prior to the removal of the probe. A speculum should be placed and the vaginal puncture
sites inspected for hemostasis.
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PEARLS AND PITFALLS
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POSTOPERATIVE CARE
The patient should be monitored in a recovery area after the procedure. IVF staff should note any vital sign derangements,
heavy vaginal bleeding, or intractable abdominal pain. Postoperative pain should be treated, with up to 3% of patients
reporting severe pelvic pain following the procedure. Up to 20% of patients will report moderate pain 2 hours
postprocedure, and this is directly related to number of oocytes retrieved.
34
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OUTCOMES
PRs in IVF cycles are highly correlated with number of oocytes initially retrieved.
7
This outcome depends upon many
patient characteristics, including response to ovarian hyperstimulation, adequate sedation, habitus, or other anatomic
challenges.
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COMPLICATIONS
Vaginal bleeding:
Vaginal bleeding is reported in 2% to 10% of patients following TVOR.
34
The vast majority of this can be managed by
holding direct pressure to the puncture sites in the vagina for >1 minute. Rarely, a suture will need to be placed in the
vagina. Vaginal bleeding exceeds 100 mL in <1% of cases.
15
Intra-abdominal bleeding:
Significant intra-abdominal bleeding is a rare complication of TVOR, occurring in 0.1% of cases.
15,34
This can be caused
by small follicular vessels on the ovary or injury to iliac vessels or sacral veins.
35,36
Patients present in the postoperative
period with pain out of proportion to the procedure and possible signs of hypovolemia. Ultrasound may show free fluid in
the cul-de-sac, but absence of fluid does not rule out a retroperitoneal bleed.
6,36
Further imaging with CT scan may be
necessary in a stable patient. Most intra-abdominal bleeding following TVOR is self-limiting and the patient can be
managed conservatively with serial exam and hemoglobin measurement.
7
Rarely, laparoscopy or laparotomy may be
indicated to identify and treat the source of bleeding. If the IVF team is not performing the surgery, it is important that
they communicate with the surgical team. Many gynecologists may not be familiar with the appearance of
hyperstimulated ovaries, and unnecessary cystectomies and oophorectomies have been performed.
6
All patients should be
consented for possible oophorectomy in the case of ovarian source bleeding that cannot be controlled. If the enlarged
ovaries are anterior to the uterus, an open laparoscopic entry or left upper quadrant entry should be considered to avoid
ovarian trauma.
37
Pelvic infection:
The rate of pelvic infection following TVOR is exceptionally low.
15
Some patients are at higher risk for infectious
complications. Women with endometriomas that are entered at the time of TVOR may be a nidus for infection and
extended antibiotic coverage should be considered.
6,38
In our practice we routinely prescribe triple therapy, single
preoperative doses of ampicillin, gentamicin, and clindamycin. If possible, endometriomas should be avoided during TVOR
given infection risk and high rate of recurrence.
39
Women with significant tubal disease may also be predisposed, although
the majority with clinically evident hydrosalpinges will have been removed prior to IVF.
Empty follicle syndrome:
Empty follicle syndrome (EFS) occurs when there is normal follicular development but oocytes cannot be aspirated at the
time of TVOR. This is postulated to be due to low bioavailability or bioactivity of hCG, which causes luteinization of the
follicles allowing the cumulus–oocyte complexes to detach from the follicular wall.
40
The timing of TVOR should be 36 to
38 hours following hCG administration, follicular rupture occurs at 39 to 41 hours following injection.
41
In patients with
EFS in a prior cycle, options include switching from urinary to recombinant hCG or using an antagonist cycle to allow a
GnRH agonist trigger.
42,43
If hCG is used, the patient can check a sensitive urine pregnancy test to confirm bioavailability
12 hours following trigger injection. If the test is negative, an additional injection can be given and the TVOR timing
adjusted.
44
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KEY REFERENCES
1. Wikland M, Enk L, Hamberger L. Transvesical and transvaginal approaches for the aspiration of follicles by use of
ultrasound. Ann N Y Acad Sci. 1985;442:182–194.
2. Seifer DB, Collins RL, Paushter DM, et al. Follicular aspiration: a comparison of an ultrasonic endovaginal transducer with
fixed needle guide and other retrieval methods. Fertil Steril. 1988;49(3):462–467.
3. Deutinger J, Reinthaller A, Csaicsich P, et al. Follicular aspiration for in vitro fertilization: sonographically guided
transvaginal versus laparoscopic approach. Eur J Obstet Gynecol Reprod Biol. 1987;26(2):127–133.
4. Lavy G, Diamond MP, Nero F, et al. Transvaginal and transabdominal ultrasound for monitoring of follicular development
in an in vitro fertilization and embryo transfer program: patient response. J In Vitro Fert Embryo Transf. 1987;4(5):293–
295.
5. Lavy G, Restrepo-Candelo H, Diamond M, et al. Laparoscopic and transvaginal ova recovery: the effect on ova quality.
Fertil Steril. 1988;49(6):1002–1006.
6. Sharif KW, Coomarasamy A. Assisted Reproduction Techniques : Challenges and Management Options. Chichester,
West Sussex; Hoboken, NJ: Wiley-Blackwell; 2012:215–242.
7. Ginsburg ES, Racowsky C. In Vitro Fertilization: a Comprehensive Guide. New York, NY: Springer; 2012:55–60.
8. Vlahos NF, Giannakikou I, Vlachos A, et al. Analgesia and anesthesia for assisted reproductive technologies. Int J
Gynaecol Obstet. 2009;105(3):201–205.
9. Hammarberg K, Wikland M, Nilsson L, et al. Patients’ experience of transvaginal follicle aspiration under local anesthesia.
Ann N Y Acad Sci. 1988;541:134–137.
10. Yasmin E, Dresner M, Balen A. Sedation and anaesthesia for transvaginal oocyte collection: an evaluation of practice in
the UK. Hum Reprod. 2004;19(12):2942–2945.
11. Ben-Shlomo I, Moskovich R, Katz Y, et al. Midazolam/ketamine sedative combination compared with
fentanyl/propofol/isoflurane anaesthesia for oocyte retrieval. Hum Reprod. 1999;14(7):1757–1759.
12. Blayney MR, Ryan JD, Malins AF. Propofol target-controlled infusions for sedation–a safe technique for the non-
anaesthetist? Br Dent J. 2003;194(8):450–452; discussion 43.
13. Christiaens F, Janssenswillen C, Van Steirteghem AC, et al. Comparison of assisted reproductive technology performance
after oocyte retrieval under general anaesthesia (propofol) versus paracervical local anaesthetic block: a case-controlled
study. Hum Reprod. 1998;13(9):2456–2460.
14. Ben-Shlomo I, Moskovich R, Golan J, et al. The effect of propofol anaesthesia on oocyte fertilization and early embryo
quality. Hum Reprod. 2000;15(10):2197–2199.
15. Bennett SJ, Waterstone JJ, Cheng WC, et al. Complications of transvaginal ultrasound-directed follicle aspiration: a review
of 2670 consecutive procedures. J Assist Reprod Genet. 1993;10(1):72–77.
16. Egbase PE, al-Sharhan M, al-Othman S, et al. Incidence of microbial growth from the tip of the embryo transfer catheter
after embryo transfer in relation to clinical pregnancy rate following in-vitro fertilization and embryo transfer. Hum
Reprod. 1996;11(8):1687–1689.
17. Moore DE, Soules MR, Klein NA, et al. Bacteria in the transfer catheter tip influence the live-birth rate after in vitro
fertilization. Fertil Steril. 2000;74(6):1118–1124.
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18. Fanchin R, Harmas A, Benaoudia F, et al. Microbial flora of the cervix assessed at the time of embryo transfer adversely
affects in vitro fertilization outcome. Fertil Steril. 1998;70(5):866–870.
19. Egbase PE, Udo EE, Al-Sharhan M, et al. Prophylactic antibiotics and endocervical microbial inoculation of the
endometrium at embryo transfer. Lancet. 1999;354(9179):651–652.
20. Davis LB, Ginsburg ES. Transmyometrial oocyte retrieval and pregnancy rates. Fertil Steril. 2004;81(2):320–322.
21. Damario MA. Transabdominal-transperitoneal ultrasound-guided oocyte retrieval in a patient with mullerian agenesis.
Fertil Steril. 2002; 78(1):189–191.
22. Barton SE, Politch JA, Benson CB, et al. Transabdominal follicular aspiration for oocyte retrieval in patients with ovaries
inaccessible by transvaginal ultrasound. Fertil Steril. 2011;95(5):1773–1776.
23. Kumaran A, Narayan PK, Pai PJ, et al. Oocyte retrieval at 140-mmHg negative aspiration pressure: A promising
alternative to flushing and aspiration in assisted reproduction in women with low ovarian reserve. J Hum Reprod Sci.
2015;8(2):98–102.
24. Levens ED, Whitcomb BW, Payson MD, et al. Ovarian follicular flushing among low-responding patients undergoing
assisted reproductive technology. Fertil Steril. 2009;91(4 Suppl):1381–1384.
25. Mok-Lin E, Brauer AA, Schattman G, et al. Follicular flushing and in vitro fertilization outcomes in the poorest responders:
a randomized controlled trial. Hum Reprod. 2013;28(11):2990–2995.
26. Knight DC, Tyler JP, Driscoll GL. Follicular flushing at oocyte retrieval: a reappraisal. Aust N Z J Obstet Gynaecol.
2001;41(2):210–213.
27. Haines CJ, Emes AL, O’Shea RT, et al. Choice of needle for ovum pickup. J In Vitro Fert Embryo Transf.
1989;6(2):111–112.
28. Wongtra-Ngan S, Vutyavanich T, Brown J. Follicular flushing during oocyte retrieval in assisted reproductive techniques.
Cochrane Database Syst Rev. 2010;(9):CD004634.
29. Tan SL, Waterstone J, Wren M, et al. A prospective randomized study comparing aspiration only with aspiration and
flushing for transvaginal ultrasound-directed oocyte recovery. Fertil Steril. 1992;58(2):356–360.
30. Scott RT, Hofmann GE, Muasher SJ, et al. A prospective randomized comparison of single- and double-lumen needles for
transvaginal follicular aspiration. J In Vitro Fert Embryo Transf. 1989;6(2):98–100.
31. Lozano DH, Fanchin R, Chevalier N, et al. Optimising the semi natural cycle IVF: the importance of follicular flushing. J
Indian Med Assoc. 2006;104(8):423–427.
32. Mendez Lozano DH, Brum Scheffer J, Frydman N, et al. Optimal reproductive competence of oocytes retrieved through
follicular flushing in minimal stimulation IVF. Reprod Biomed Online. 2008;16(1):119–123.
33. Licciardi FL, Schwartz LB, Schmidt-Sarosi C. A tenaculum improves ovarian accessibility during difficult transvaginal
follicular aspiration: a novel but simple technique. Fertil Steril. 1995;63(3):677–679.
34. Ludwig AK, Glawatz M, Griesinger G, et al. Perioperative and post-operative complications of transvaginal ultrasound-
guided oocyte retrieval: prospective study of >1000 oocyte retrievals. Hum Reprod. 2006;21(12):3235–3240.
35. Bergh T, Lundkvist O. Clinical complications during in-vitro fertilization treatment. Hum Reprod. 1992;7(5):625–626.
36. Azem F, Wolf Y, Botchan A, et al. Massive retroperitoneal bleeding: a complication of transvaginal ultrasonography-guided
oocyte retrieval for in vitro fertilization-embryo transfer. Fertil Steril. 2000;74(2):405–406.
37. Hasson HM, Rotman C, Rana N, et al. Open laparoscopy: 29-year experience. Obstet Gynecol. 2000;96(5 Pt 1):763–766.
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38. Padilla SL. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval. Hum
Reprod. 1993;8(8):1282–1283.
39. Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum
Reprod. 2009; 24(3):496–501.
40. Meniru GI, Craft IL. Evidence from a salvaged treatment cycle supports an aetiology for the empty follicle syndrome that
is related to terminal follicular developmental events. Hum Reprod. 1997;12(11):2385–2387.
41. Andersen AG, Als-Nielsen B, Hornnes PJ, et al. Time interval from human chorionic gonadotrophin (HCG) injection to
follicular rupture. Hum Reprod. 1995;10(12):3202–3205.
42. Penarrubia J, Balasch J, Fabregues F, et al. Recurrent empty follicle syndrome successfully treated with recombinant
human chorionic gonadotrophin. Hum Reprod. 1999;14(7):1703–1706.
43. Lok F, Pritchard J, Lashen H. Successful treatment of empty follicle syndrome by triggering endogenous LH surge using
GnRH agonist in an antagonist down-regulated IVF cycle. Hum Reprod. 2003;18(10):2079–2081.
44. Ndukwe G, Thornton S, Fishel S, et al. ‘Curing’ empty follicle syndrome. Hum Reprod. 1997;12(1):21–23.
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