OVUM PICK UPEMBRYO TRANSFER

jaideep malhotranarendra malhotra

mnmhagra3@gmail.comGLOBAL RAINBOW HEALTH CARE

HISTORY OF OOCYTE RETRIEVAL

• initial oocytes were studied by removing ovaries by laparotomy

• 1970 steptoe and edwards laparoscopic method (yielded oocytes from one third of follicles)

• by 1980 a commercial opu needle and pump was available(teflon needle retrival rates became 90%)

• steptoe and goswamy devised the ultrasound guided oocyte retrival

PHYSICS OF OOCYTE RETRIEVAL

• a no. of factors affect oocyte collection and damage to ova

• pump vacuum flow,velocity,needle lumen size and length,follicular pressure and size,collection techniques

COOK MEDICAL TECHNOLOGY STUDY FROM BRISBANE

PHYSICS AND EGG

VACUUM APPLIED AFTER NEEDLE ENTRY IN FOLLICLE

VACUUM DEACTIVATE BEFORE EXIT FROM FOLLICLE

VACUUM ACTIVATED AND DEACTIVATED OUTSIDE FOLLICLE

DAMAGE TO OOCYTESVACUUM PRESSURESDAMAGE WITHIN THE NEEDLE/VACUUM LINESDAMAGE WITHIN THE FOLLICLEDAMAGE TO THE CUMULUS

PHYSICS OF OPU• MAINTAINANCE OF SUCTION(IF THIS IS NOT MAINTAINED

THE FOLLICULAR FLUID WILL BE LOST AT ENTRY AND EXIT)

• MOVEMENT OF THE NEEDLE TIP IN THE FOLLICLE MAY DAMAGE THE OOCYTE PARTICULARLY TO THE CUMULUS

• IT IS A COMMON PRACTICE TO SPIN THE NEEDLE TIP AS YOU WILL SEE IN THE SYDNEY IVF VIDEO

• ALSO SOME PEOPLE SCRAPE THE FOLLICLE WALLS BY THE EDGE OF THE NEEDLE.. THIS MAY CAUSE SIGNIFICANT DAMAGE TO OOCYTE SPECIALLY IN SMALL FOLLICLES

• STUDY IS GOING ON TO COMPARE SPINNING THE NEEDLE TIP AND BLASTOCYST FORMATION (A POSSIBLE SOLUTION FOR MORE RETRIVAL WITHOUT SPINNING IS MAY BE TO USE FLUSHING THE FOLLICLES WITH LOWER SUCTION VACCUMS)

CLINICAL ASPECTS OF OPU• TIMING:34-36 HRS

AFTER THE HCG TRIGGER

• MORE M2 OOCYTES

OVARIAN ACCESSIBILITY ASSESSMENT

• IN DUMMY CYCLE• ON REGISTRATION• DURING STIMULATION

MONITORING• VERY HIGH AND VAGINALLY

UNAPPROACHABLE OVARIES MAY POSE DIFFICULTY FOR TVS OPU AND MAY NEED LAPAROSCOPY

PRE PICK UP SCAN

EGG PICK UP TECHNIQUE

• analgesia(vaginal and cervical blocks)(mild analgesia)

• anaesthesia (mild gen anaesthesia propofol/pentothal)

• preop counselling and physical check up

• it is a low risk surgical procedure hence no need for a detailed preop assessment

ANAESTHETIC PROTOCOL

• FENTANYL: 1-2 g/kg i.v.(AVERAGE DOSE 100g)

• MIDAZOLAM:0.05-0.1mg/kg i.v.(AVERAGE DOSE 2-5mg)

• ADD PROPOFOL IF NEEDED 1-2mg/kg• Monitor oxygen saturation and administer

oxygen as indicated• Local anaesthesia• No anaesthesia(only some pain and

sedation)(councelling)

OT SETUPS

MAMC DELHI

MNMH AGRA

Rainbow IVF

MATERIAL CHECKLIST FOR OPU

• DRY BLOCK HEATER AND WARM BLOCKS

• FALCON TESTUBES• GLASS SYRINGE WITH BLUNT

NEEDLE(COMES WITH THE NEEDLE)• BEAKERS,PETRIDISHES/FOUR WELL

DISHES/PIPETTES/PIPETTE PUMPS ETC

• SUCTION PUMP(COOK/ROCKET/INDIAN MAKE:SHIVANI)

• NEEDLES(COOK/REPROLINE/OTHERS)

• TUBINGS• ULTRASOUND MACHINE : TVS

PROBE

TEMPERATURE CONTROL• warm blocks for test

tubes• hand held test tube

warmer• heated laminar

table(integrated table available now made in india)

GETTING READY

GETTING READY

LOCAL ANAESTHETIC INJECTION

SHEFALI AND DINESH JAIN CENTRE INDORE

ASPIRATION NEEDLE

• 17 GAUZE• SINGLE LUMEN OR

DOUBLE LUMEN• DOUBLE LUMEN MAY BE

USED IN LESSER FOLLICLE AND WHERE MULTIPLE FOLLICLE FLUSHING IS NEEDED

• CONNECTING TEFLON TUBING TO THE BUNGE (SPECIAL DESIGN BUNGES)

TECHNIQUE

• clean the vagina and wash off all particulate matter with normal saline

• vaginal ultrasound(use of cover and jelly???)

• focus and fix the target ovary in the centre of the biopsy line

• enter with a sharp jab• enter the follicle at

maximum diameter

needle entry

TECHNIQUE CONT…

• SUCTION VACUUM APPLIED BEFORE ENTERING THE FOLLICLE TO PREVENT LEAKING

• ASPIRATION PRESSURE AROUND 100(NEVER MORE THAN 130)• IF FLUSHING IS BEING DONE IT SHOULD BE AT LOW PRESSURE• AFTER ASPIRATION OF FIRST FOLLICLE IT MAY BE A GOOD

PRACTICE TO FLUSH THE NEEDLE OF ANY VAGINAL MUCUS OR TISSUE

• THE FOLLICLE SHOULD BE ASPIRATED TILL TOTALLY COLLAPSED• SPINNING ACTION IS NOW DEBATABLE• THE MOBILE OVARY CAN BE NEARED TO THE PROBE TIP AND

FIXED BY THE ASSISTANT PUSHING IT DOWN• A CO ORDINATION OF EYE/ HAND AND FOOT PRESSURE IS

NEEDED

Eye Hand and Foot Co-ordination

OOCYTE ASPIRATION

FOLLICLE ASPIRATION

LOOSE CAP AND BLOCKED NEEDLE

CHANGING CAPS/PUMP PRESSURE

FLUSHING• value is debatable• only may be used in natural

cycle/less eggs/poor responders/small follicle(ivm)

• if more than 10 follicles are seen then flushing not required and this may prolong the procedure and discomfort

• flushing follicle 6 times may increase the yield by 20%

• it is rather better to aspirate completely (as the follicle retrieved in the first aspirate and last aspirate is same)

TUBES AND PETRI DISHES

OOCYTE CUMULUS COMPLEX SCREENING

DIFFICULTIES IN OPU

• ovary stuck behind the cervix and uterus (may have to go thru)

• endomeriomas • (contamination of the follicle aspiration) • try not to aspirate till opu completed..but if

punctured then aspirate completely, flush them and flush the needle many times

• bleeding : if ovarian vessel.. just remove the needle and bleeding will stop..if iliac is hit remove needle gently and bleeding may stop,but if there is rapid bleeding,laparotomy may be needed..

• vaginal and cervical bleeding usually stops with pressure , if does not suture

DIFFICULTIES IN OPU

• ovary stuck on the fundus

• vaginal vessels• thru cervix• endometrioma • too near major blood

vessels • hydrosalpinx

COMPLICATIONS

VAGINAL BLEEDING 1.4-18.4% IF THE PROBE IS

ROTATED WITH NEEDLE INSIDE(CAN TEAR VAGINA,OVARIAN SURFACE AND INTRA ABDOMINAL ORGANS)

INTRAPERITONEAL BLEEDING

• RARE• 0-1.3%• INTRAPERITONEAL OR RETROPERITONEAL• IF HAEMODYNAMIC DISTURBANCE.. URGENT LIFE

SAVING MEASURES AND LAPAROTOMY OR LAPROSCOPY

• RETROPERITONEAL HAEMATOMAS PRESENT AFTER SOME TIME (ABOUT 10 HRS POS OPU)

INFECTION

• PID :0.2-0.55 %• BECAUSE THE VAGINAL FLORA IS CARRIED

INTO THE PERITONEUM WITH THE NEEDLE PUNCTURE.

• PUNCTURE OF INFECTED HYDROSALPINX AND OOPHERITIS

• MAY PRESENT AS ACUTE INFECTION AND ENDOTOXEMIA

• LOCAL INFLAMMATORY REACTION• ROLE OF PROPHYLACTIC BROAD

SPECTRUM ANTIBIOTIC• FOR TREATMENT COVERAGE WITH

ANTIBIOTICS AND MONITORING IS NEEDED

TAKE HOME MESSAGE

• SIMPLE AND EFFICIENT PROCEDURE• HOWEVER CARE SHOULD BE TAKEN(THE

COMPLICATIONS ARE POTENTIALLY DANGEROUS)

• HAS A LEARNING CURVE

CONGRATULATIONS ON 35 YEARS OF ART

THANK YOU