John Waterstone

Complications of transvaginal ultrasound-directed follicle aspiration: a review of 2670 consecutive procedures

PurposeComplications following transvaginal ultrasound-directed follicle aspiration are rare, making it difficult to assess their true incidence. During a 4-year prospective study the complications arising from a series of 2670 consecutive procedures were monitored.ResultsVaginal hemorrhage occurred in 229 (8.6%) of the cases, with a significant loss (>100 ml) in 22 (0.8%). Postoperative pelvic infection occurred in 18 (0.6%) of the cases. Hemorrhage from the ovary with hemoperitoneum formation was seen on two occasions and necessitated emergency laparotomy in one instance. A single case of pelvic haematoma formation from a punctured iliac vessel was also recorded; this settled without intervention. Of the 18 cases with infection, 9 were severe with pelvic abscess formation; microbiological examination of the pus from these cases suggests that the most common route of infection in such cases is probably by direct inoculation of vaginal organisms into the peritoneal cavity by the collecting needle.ConclusionThe low incidence of pelvic infection questions the value of using prophylactic antibiotics. No increased risk of infection was demonstrated in cases with preexisting peritoneal damage.

Transvaginal color blood flow imaging of the periovulatory follicle

Objective To assess intrafollicular blood flow in relation to ovarian morphology and function during the periovulatory period. Design A prospective, longitudinal study of random, natural ovarian cycles. Setting The Ovarian Screening Clinic and Endocrine Laboratory of the Department of Obstetrics and Gynaecology, King’s College Hospital, London, United Kingdom. Patients Women with apparently normal ovarian function awaiting treatment for infertility by IVF-ET during subsequent natural cycles. Interventions All women were examined by transvaginal ultrasonography with color flow imaging and had a sample of peripheral venous blood taken at each scan for hormone analysis. Main Outcome Measures The minimum pulsatility index (PI) and maximum peak systolic velocity from vessels within the dominant follicle; the maximum follicular diameters (and hence volume); serum FSH, E2, LH, and P. Results The dominant follicle ruptured in 10 of 11 women. The median interval between the two scans that delineated the time of follicular rupture was 9.5 hours (range, 0.0 to 24.5 hours). These cycles appeared to be morphologically and endocrinologically normal. There was an apparent increase in intrafollicular blood flow over the periovulatory period with an insignificant trend toward lower values for the mean PI and a significant increase in the peak systolic velocity. These changes appeared to follow the rise in circulating LH. Conclusion Indexes of blood flow at a given site within the leading follicle can be monitored by transvaginal ultrasonography with color Doppler imaging over the periovulatory period. The increase in the peak systolic velocity and the relatively constant PI suggest a marked increase in blood flow at this time during the ovarian cycle.

A prospective randomized study comparing aspiration only with aspiration and flushing for transvaginal ultrasound-directed oocyte recovery

OBJECTIVE To compare aspiration only with aspiration and flushing of ovarian follicles during transvaginal ultrasound (US)-directed oocyte recovery. DESIGN Prospective randomized study. PATIENTS One hundred patients who were undergoing an in vitro fertilization (IVF) treatment cycle. INTERVENTIONS All patients underwent pituitary desensitization before the administration of gonadotropins. Monitoring of ovarian stimulation and the criteria for the administration of human chorionic gonadotropin were similar in both groups. In patients in whom aspiration alone was used, each follicle was aspirated until it was empty. The US probe was then rotated until every drop of follicular fluid had been aspirated before the next follicle was aspirated and the procedure repeated. For patients who had aspiration and flushing, each follicle was aspirated and then flushed up to a maximum of six times before moving to the next follicle. In both groups, all follicles greater than 10 mm were aspirated. RESULTS The indication for IVF and mean age of the patients were comparable in the two groups. There were no significant differences between the aspiration and the aspiration and flushing groups in terms of the number of oocytes retrieved (11 versus 9), the oocyte recovery rates (77.5% versus 77.0%), the fertilization rates (55.6% versus 60.0%), the number of embryos transferred (2 versus 2), or the number of clinical pregnancies (12 versus 13). The time taken for oocyte recovery was significantly shorter (15 versus 30 minutes, P less than 0.00001), and the dose of pethidine required significantly less (50 mg versus 100 mg, P less than 0.00001) in the aspiration only group. CONCLUSIONS Aspiration alone produces comparable oocyte recovery rates as aspiration and flushing while significantly reducing the length of the procedure and the dose of analgesia required. Aspiration alone suffices for virtually all cases during transvaginal US-directed oocyte recovery.

A prospective study to investigate the value of flushing follicles during transvaginal ultrasound-directed follicle aspiration *

In this study, 50 transvaginal US-directed follicle aspiration procedures were performed with follicle flushing using a double-channel needle. The origin of each oocyte was established according to whether it had been obtained in the initial part of the aspirate, in the dead space aspirate, in the first to third flushes, or in the fourth to sixth flushes. Seventeen percent of total oocytes were found in follicle flushes. Only 3.2% of total oocytes were found in the fourth to sixth flushes, and their fertilization rate was reduced. Flushing follicles with a double-channel needle may result in the recovery of 20% more oocytes than would be obtained by aspiration alone.

Two cases of cervical pregnancy following in vitro fertilization and embryo transfer to the lower uterine cavity

Cervical pregnancy is an uncommonly encountered form of ectopic pregnancy. The reported incidence following natural conception shows considerable geographical variation, with a range from 1:1000 pregnancies in Japan (1) to 1:95,000 pregnancies in Austria (2). This wide variation may reflect differences in gynecological practice since there is a welldocumented association with previous uterine instrumentation and, in particular, with termination of pregnancy performed by dilatation and sharp curettage (1). Other possible risk factors which have been proposed include structural uterine or cervical anomalies, uterine fibroids, endometrial atrophy, chronic endometritis, Ashermans syndrome, and the use of an intrauterine contraceptive device (3). It has been suggested that the site of embryo deposition within the uterine cavity may influence the subsequent pregnancy rates, with deposition of embryos in the lower uterine cavity leading to higher success rates than deposition in the fundal region (4). Over the past 12 months in this unit we have therefore adopted a policy of routine lower uterine transfer for all patients undergoing embryo replacement. Over the same time period we have also encountered two cases of cervical pregnancy and it is of considerable concern that the occurrence of this r a r e complication on two occasions within such a short space of time may have resulted from the technique of embryo transfer employed.

Laparoscopic zygote intrafallopian transfer using augmented local anesthesia

In this study, 29 laparoscopic ZIFTs were performed in 21 patients using local anesthesia augmented with intravenous analgesia. The technique was well tolerated; significant discomfort arose only when the fallopian tubes were manipulated and was minimized by transferring zygotes to one tube only. Seven pregnancies resulted, of which three have delivered and one is ongoing.

Sensitivity of pocket Doppler fetal heart detectors in early pregnancy: a comparative study

Anxiety about pregnancy viability is common in the first trimester. The cause may be vaginal bleeding or a history of miscarriage or of infertility. An immediate ultrasound scan is ideal but is often not available. Pocket Doppler fetal heart detectors are useful under these circumstances. These simple devices are relatively inexpensive and therefore easily available to clinicians. If fetal cardiac activity can be detected, reassurance can be provided immediately. The significance of failure to detect heart sounds is uncertain, because few data exists concerning the sensitivity of pocket Dopplers in early pregnancy (Brown & Robertson 1968; Kuah & Embrey 1968; Lloyd 1968; Brown 1971). Such failure may even increase rather than relieve the woman’s anxiety. In this study the sensitivity of three different pocket Doppler devices was compared at fixed gestational ages in in vitro fertilisation pregnancies.