1) I am not sure that the description of the problem is accurate. An ovary in the POD per se should be readily accessible unless there is pelvic pathology. (In pre-historic times - in the early days of laparoscopy and before the introduction of real time ultrasound scanning - the aspiration of peritoneal fluid through a needle inserted in the POD was an important tool in the diagnosis of intraperitoneal bleeding as in cases of ectopic pregnancy. Fertiloscopy is also done in a similar way in appropriate cases with no problems).

2) When the ovary in not accessible (be it in the POD or elsewhere) and there is an increased risk of damage to internal organs or large vessels oocyte retrieval from the inaccessible ovary should not be performed. Oocyte retrieval should be performed on the accessible side and the inaccessible one should not be attempted.

3) If, on pre-treatment scan, both ovaries are inaccessible transvaginally, the possibility of laparoscopic oocyte retrieval should be explored, although this may also not be possible due to the pelvic pathology. In selected cases a Diagnostic Laparoscopy before IVF treatment starts may be indicated.

4) Inaccessible ovaries are usualy not in the POD but above (cranial to) the uterus. In these cases they may be accessible for transabdominal oocyte retieval.

5) Finally, transmyometrial approach is another option in some rare and selected cases (with patient's prior informed consent). This should not be attempted where there is a uterine pathology. The endometrium should be well away from the needle.

6) On a few rare occasions I was able to turn an apparently inaccessible ovary into an accessible one by gentle bimanual manipulation. This will probably not work when the reason of the inaccessibility is a pelvic pathology (i.e. adhesions) and should not be attempted.

7) It is important that inaccessible ovaries are identified prior to the start of the treatment so that the patient is well informed of possible problems before treatment starts.

Dr. Ariel Zosmer, UK

It is not often that the ovaries cannot be pressured against the vaginal vault or the uterus. If it is clear on the ultrasound examination that there will be intervening blood vessels or bowel, you can still manipulate with abdominal pressure, finding the right areas to push the ovary to become "adhere" to the needle entry point, so to speak.
Once you find this spot, you can do the puncturing. Color doppler flow will help in this. I have no reservation going through the uterus, and a very fast passage would not cause significant bleeding. I will likely no transfer in the same cycle though, especially when the endometrium was traversed. More of a problem is when the ovary is far away, sometimes adherent to the uterus, but worse is if it is adherent to adhesions or bowel, and is closer to the abdominal wall then the vaginal vault. Then still using the transvaginal transducer and the same US guide, one can do a transabdominal follicle aspiration that way.

Unfortunately, neither of these situations can be helped if the patient is very big because then the ovary will be too far away to be within the transducer's focal length if after all these manipulation the ovary is more than 10 centimeters away.

Hope this is of help.

Milton Leong, HK

The most simple and straight forward oocyte retrieval is when the ovaries are in the pouch of Douglas. The stimulated ovary is often heavy because of the multiple fluid-filled large follicles, then it simply slides to the pouch of Douglas, where it is most accessible, and the needle only has to pass the vaginal wall. The retrieval might be more problematic when the ovaries are outside of the pouch of Douglas. In that case there are several things you can do:
1. External abdominal manual pressure by an assistant is often all that is necessary.
2. Grasping the cervix with a tenaculum and pulling the uterus is extremely helpful in difficult cases.
3. Rarely you have to pass through the uterus to reach the ovary
4. Even more rarely, when there is no other choice, you can reach the ovaries transabdominally.

Ariel Weissman, Israel

John's very comprehensive answer leaves little room for additional comment. I always require a pre-treatment scan to assess ovarian access even in patients who have had 'easy' TVOA before as bleeding, scarring, evolving endometriosis and pregnancy can all transform a previously 'easy' pelvis. Chronic constipation is a frequent finding and persuading overweight women to lose weight often clears the fat deposits that seem to 'wrap around' the pelvic organs.

Gillian Lockwood, UK

TVOA - difficult ovarian access:

Do you mean high ovary (at pelvic brim) or ovary in Utero-Vesical position or ovary adherent lateral on broad ligament?

Ovary in POD always OK to access unless stuck lateral to U/S ligament (? overlying ureter).

At my clinics (PIVET and CFC) TVOA is performed under i.v. sedation as follows:

1. All cases have Bisacodyl supp. X1 at 4pm ± 8pm previous day
2. If known to have high or difficult access ovaries, give Picolax bowel clearance 4pm previous day
3. Pelvic belt (like IVP compression belt) placed when sedated on table
4. All patients placed in slight Trendelenburg position ~20 degrees
5. If one or other ovary not accessible between U/S ligaments, hand manipulate after removing belt i.e. bimanual manipulation
6. Can even tilt bed - up down or lateral tilt to gain optimum access
7. Repositioned ovary "held in place" by support nurse pushing strongly into pelvis with "blunt fist" compression
8. Continue ovary pressure from above until all follicles aspirated
9. If difficult TVOA check POD 2or 3 mins after TVOA; aspirate any pool of blood if present
10. Do not knowingly needle through suspected bowel or possible ureteric region.
11. Can aspirate by percutaneous needling, or trans-urethral with partially filled bladder if appropriate.
12. Ovary can be accessed via Uterine body (Terumo & Kato technique) but I do not favour this, bleeding can be a significant problem.
12. If recalcitrant ovary, consider laparoscopic adhesiolysis before next TVOA
13. If still a problem revert to laparoscopic follicle aspiration "like the early days" - my first 50 IVF babies

Difficult cases are usually predicted by history and preliminary scans; good to have an experienced colleague in support.

John Yovich, Australia