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
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