Minimising the risk of infection and bleeding at trans-vaginalultrasound guided ovum pick-up

This survey was composed by Dr Harish M Bhandari, Clinical Research Fellow, Center for Reproductive Medicine, University Hospitals of Coventry and Warwickshire NHS Trust, and Warwick Medical School, University of Warwick.
Dr Rina Agrawal, Consultant Specialist & Hon Associate Professor in Reproductive Medicine / Obstetrics & Gynaecology, Centre for Reproductive Medicine, University Hospitals of Coventry and Warwickshire NHS Trust, Warwick Medical School, University of Warwick.

Dr Rina Agrawal	Dr Harish M Bhandari

Introduction:
Trans-vaginal ovum pick-up (TV-OPU) or oocyte retrieval (OR) under ultrasound guidance as a part of assisted reproductive technique is a relatively straight forward and safe procedure compared with the original laparoscopic approach, but it is associated with a risk of minor vaginal bleeding (0.5% - 18.4%), severe intra-abdominal bleeding (0.02% – 0.7%), pelvic infection (0.4% - 1.3%) and accidental injury to other pelvic organs. The most common causes of bleeding are injury to the vaginal mucosa and damage to fine vascular network of blood vessels on the ovarian surface and theca interna. Rarely, severe bleeding may occur as a result of injury to pelvic vessels or generalized clotting disorders.
TV-OPU was first described in 1985 by Wikland et al., (Annals of New York Academy of Sciences) and the first results were presented by Wilfried Feichtinger and Peter Kemeter (Fertility Sterility, 1986). Since then TV-OPU has gained an extensive popularity. However, the practice of pre-procedural preparation, the actual procedure and the subsequent management varies considerably among practitioners due to a lack of published guidelines.

The objective of this survey was to identify the world-wide clinical practice of recognizing at-risk women of excessive vaginal bleeding or of developing pelvic infection following OPU, measures taken to minimise these risks and the management of these complications.

Results:

We received completed survey forms from 155 IVF clinics, originating from 52 countries, from six continents. These clinics performed 97,200 IVF cycles annually.

Do you routinely undertake the following investigations before OPU?

Surgical preparation in the pre-operative period is essential for a safe and successful procedural outcome. Full blood count to assess haemoglobin concentration and platelet count is an important and invaluable test as anaemia and thrombocytopenia increase the risk of bleeding. Some studies have emphasized the importance of performing coagulation profile before OPU (Qiao et al., 2009, International Journal of Gynecology and Obstetrics), but it is interesting to observe that only a third of the clinicians who responded to the survey investigate for coagulation abnormalities.
There is a potential risk of causing iatrogenic pelvic infection from an existing vaginal infection. Nevertheless, only about 30% of responding practitioners perform routine screening tests for vaginal infections. Consideration should be given to screen for vaginal and cervical infections, particularly that of Chlamydia trachomatis.

In your practice, which of the following women have increased risk of bleeding complications following OPU?

A retrospective study (Liberty et al., Fertility Sterility, 2010) reported that lean (BMI 19 – 21 kg/m2) PCOS women were at an increased risk of acute ovarian haemorrhage. Obesity may predispose to technical difficulties during the procedure. A further retrospective study (Qiao et al., 2009, International Journal of Gynecology and Obstetrics) observed that women who had severe bleeding produced significantly fewer number of oocytes compared with women who had mild bleeding. However, the number of cases of severe ovarian bleeding in this observational study over a four year period was five, out of whom four have had previous pelvic surgery.

Do you clean the vagina before OPU to minimise the risk of infection?

There is conflicting evidence on the use of antiseptics for vaginal cleaning before OPU. In a prospective randomized study, van Os et al., (Human Reproduction, 1992) reported no significant difference in the fertilization and pelvic infection rates, but a significantly increased clinical pregnancy rates when the normal saline was used. In a further prospective randomized study, Hannoun et al., (Gynecologic and Obstetric Investigation, 2008) proposed that vaginal preparation using betadine did not affect the IVF outcome. In this survey, a majority of the clinicians (58%) preferred to clean the vagina with sterile water, but a third of them use both sterile water and antiseptics.

Do you routinely give antibiotics?

Use of antibiotic prophylaxis is debatable with conflicting evidence in the literature. We too observed a wide variation in the practice with 15% of the clinicians not administering antibiotics and 34% administered antibiotics to only high risk women. Consideration should be given to the use of prophylactic antibiotics in women with a high risk of infection if not routinely, since severe pelvic infections is associated with significant morbidity.

If you give antibiotics, how many doses?

There is no uniform agreement in the duration and type of antibiotics used. A Single dose of a single antibiotic is the preferred antibiotic prophylaxis used by 43% clinicians, but 9% preferred to use antibiotics for 5 days.

Which aspiration needle do you prefer to use for OPU?

A Single lumen needle is technically easier to use and in the survey it is the most preferred needle used for follicular aspiration. There is no evidence to suggest that the single lumen needle is superior over the double lumen needle in minimizing the risk of bleeding or infection.

What needle size do you prefer to use for follicle aspiration?

A Majority of the clinicians prefer to use 17 gauge needles for follicular aspiration since there is evidence to suggest that the use of a 17 gauge needle is associated with reduced pain when compared with a 15 or 16 gauge needles, but there is no evidence on minimising bleeding and infection.

Do you use Doppler ultrasound routinely at OPU?

Smaller studies have suggested that the use of Doppler may detect and reduce the risk of hemorrhage, but it does not eliminate the risk of moderate or severe bleeding (Risquez and Confino, 2010, Reproductive BioMedicine Online). It is very interesting to observe that Doppler ultrasound is routinely used by 20% of the clinicians and by 18% in difficult or specific cases.

Do you routinely use ultrasound scan before discharge the patient home to check for pelvic collection?

Pelvic collection increases the risk of pelvic infection and measuring the fluid pockets at post OPU ultrasound may offer a measure of intra-abdominal bleeding, though an accurate assessment may be difficult and is time consuming. Twelve percent of the clinicians world-wide routinely perform post-OPU ultrasound scan to check for pelvic collection before the women are discharged home.

For how many hours is the patient being observed in the unit before discharge after OPU?

There is no consensus in the duration of recovery time, but a majority (57%) of women were discharged home within two hours of OPU procedure, but 13% of the clinicians prefer to keep women for up to 6 hours of observation following OPU.

Who discharges the patient after OPU?

A Majority of the clinicians (59%) who responded to the survey opined that recovery nurses have adequate competence to discharge a woman following OPU.

Do you routinely do a blood count before discharge after OPU?

The blood loss is estimated to be 230 ml in the first 24 hours after OPU (Dessole et al., Fertility and Sterility, 2001) and Haemoglobin and haematocrit measurement may not be accurate in the estimation of mild intra-abdominal bleeding. In this survey, most clinicians (98%) do not feel that a full blood count post-OPU and before discharge would be beneficial in identifying women with intra-abdominal bleeding.

For a diagnosed haemoperitoneum which of following interventions would you prefer to undertake?

Intra-abdominal bleeding is a rare, but a serious complication following a trans-vaginal OPU. 74% of the clinicians who responded to the survey prefer to take a conservative approach with a close monitoring in the hospital, but a quarter of the clinicians feel a diagnostic laparoscopy and proceed to laparotomy would be the preferred approach for managing intra-abdominal bleeding.

In case vaginal bleeding not responding to vaginal compression, which of the following interventions do you undertake?

Several methods could be used to arrest continued vaginal bleeding not responding to initial vaginal compression. A firm vaginal compression for 3 - 5 minutes (>60%) and suturing of the bleeding area (>50%) are the most preferred methods followed by vaginal packing for 2 or more hours (40%).

Conclusions:

There is a wide variation in the practice of minimising the risk of infection and bleeding complications following OPU and in the subsequent management. There is clearly a need for us to formulate uniform guidelines based on the available good quality evidence to enable clinicians to undertake safer practices during TV-OPU.