Complacency Is the Enemy in Transvaginal Follicle Aspiration



SANTA BARBARA, CALIF. – A third of the audience attending a specialty conference on in vitro fertilization reported hospitalizing a patient for pelvic infection following transvaginal follicle aspiration, and the same percentage reported performing a laparoscopy or laparotomy for bleeding following the procedure.

Bowel and ureteral injuries and retroperitoneal hematomas also were reported, but at far lower rates, Dr. David R. Meldrum said at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

While the instant survey was unscientific and represented complications only among specialists who perform many transvaginal procedures, the high rate of serious complications was noteworthy, said Dr. Meldrum, scientific director of Reproductive Partners Medical Group in Redondo Beach, Calif., and director of the annual course on in vitro fertilization and embryo transfer.

"I’ve talked to several people who feel that complications of this procedure are underreported," he said.

"The last thing you want to be is complacent," Dr. Meldrum continued. "As a pilot, I know ... if you ever get complacent about something you should be paying maximal attention to," it will "bite you in the bottom."

Dr. Meldrum noted that transvaginal oocyte retrieval is highly efficacious and generally well tolerated under intravenous sedation. It is not, however, a risk-free procedure.

To reduce the potential for complications, he recommended using a 16- or 17-gauge needle with a very sharp tip and rinsing both the needles and collection tubing before use.

The ovary should be positioned very close to the transducer. Use "firm, constant pressure" of the probe, abdominal pressure, and a tenaculum, he suggested.

During the procedure, the needle should be rotated during movement to avoid bending the needle in any direction.

The ovary should be entered high, away from lower structures. "Don’t have a hint of anything between the ovary and the posterior pelvic wall," he said. In case of positioning difficulties, "keep in mind you can come across from the other side."

"Keep the needle tip well visualized and within the ovary," he said.

Dr. Meldrum reminded the audience that retroperitoneal bleeding can usually be managed by pressure from above when it is recognized during a procedure, but that symptoms may develop hours after the procedure. Abscesses may present up to 6 weeks following a transvaginal follicle aspiration.

Even during normal, successful aspirations, severe pain may occur during the procedure and for several days afterward, in a small percentage of patients.

Dr. Meldrum noted that Tylenol with codeine, a commonly prescribed analgesic, will be ineffective in approximately 1 of 10 patients who don’t metabolize codeine.

He reported that he had no relevant conflicts of interest.

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