Bladder hematoma: a complication from an oocyte retrieval procedure
Bladder hematoma: a complication from an oocyte retrieval procedure
Souza, Maria do Carmo Borges de;Souza, Marcelo Marinho de;Antunes, Roberto de Azevedo;Tamm, Maria Augusta;Silva, Joyce Barreto da;Mancebo, Ana Cristina Allemand;
2019-01-01 00:00:00
JBRA Assisted Reproduction 2019;23(1):75-78 doi: 10.5935/1518-0557.20180086 Case report Bladder hematoma: a complication from an oocyte retrieval procedure 1 1 1 Maria do Carmo Borges de Souza , Marcelo Marinho de Souza , Roberto de Azevedo Antunes , Maria Augusta 1 1 1 Tamm , Joyce Barreto da Silva , Ana Cristina Allemand Mancebo Fertipraxis-Centro de Reprodução Humana- RJ, Brazil As a precaution, the number of vaginal and ovarian per- ABSTRACT forations is kept to a minimum. Therefore, greater numbers Introduction: More than one million fertilization cy- of follicles are aspirated without withdrawing the needle tip cles are performed every year. The incidence of serious from inside the ovary (el Hussein et al., 1992). After all complications associated with transvaginal oocyte pick-up ovarian follicles have been aspirated, the needle is with- is low, but the procedure is not risk-free. Risks are inherent drawn and the procedure is repeated in the contralateral to procedures in which thin needles and sharp instruments ovary. The tip of the needle must be visualized by ultra- are introduced into the vaginal wall and ovarian capsule to sound throughout the entire procedure in order to avoid access the ovaries. damaging adjacent pelvic structures (Gleicher et al., 1983). Case description: A 45-year-old patient reported urinary discomfort and difficulty urinating after her sec - ond cycle, 12 hours after oocyte pick-up. She had visible CASE REPORT hematuria with small blood clots. Transvaginal ultrasound The patient described in this paper consented to having examination performed 24 hours after pick-up showed a her case published. A single nulliparous woman was first seen heterogeneous intravesical image suggestive of a clot; her in our clinic in April 2014. She was seeking information on bladder measured 23x19mm. She was afebrile and in good oocyte cryopreservation and in vitro fertilization. She did not condition. The patient was managed conservatively and of- have a partner at the time. She had no record of comorbidi- fered fluids. The clot was expelled within a matter of hours. ties and her menstrual cycles were regular. The antimullerian This case of a bladder hematoma was the first in the 21 hormone (AMH) level measured after her first appointment years of a clinic where all procedures are guided by ultra- was 3.4 ng/mL and her antral follicle count (AFC) was 12. sonography with clear visualization of the tip of the needle She returned to the clinic in September 2015 with a partner throughout the 15-20 minutes of the procedure. Patients (age 38). At the beginning of the cycle, her FSH dosage was submitted to ultrasound-guided transvaginal oocyte pick- 6 mIU/mL; her estradiol (E2) level was 43 ng/dL; and her up procedures in IVF protocols must be informed of this AFC was 17. Her prospects in relation to age were discussed rare potential complication. and she was offered an IVF/ICSI cycle with genetic testing for aneuploidies of the resulting blastocysts. Keywords: Hematoma, urinary tract, in vitro fertilization, The protocol and total amount of gonadotropins adminis- complications. ® tered were as follows: GonalF (recombinant FSH, Merck, Au- bonne, Switzerland) 1050 IU and Menopur (Ferring Pharma- ceuticals, Kiel, Germany) 1050 IU. This patient was prescribed INTRODUCTION an antagonist cycle with Orgalutran (Merck Sharp & Dohme, Transvaginal ultrasound-guided follicular aspiration was Ravensburg, Germany), 4 vials. The LH trigger utilized was first described in 1983 and rapidly became widely accept - Ovidrel 250 mcg (recombinant HCG, Merck, Aubonne, Swit- ed because of its simplicity and effectiveness (Gleicher et zerland). The transvaginal ultrasound-guided oocyte retrieval al., 1983; Bennett et al., 1993). In 2013, the International procedure was performed in September 2015 with a standard Committee Monitoring Assisted Reproductive Technologies Wallace (UK) 25-cm 17-G single-lumen needle attached to a (ICMART) estimated that 6.5 million children were born in closed suction system with a continuous pressure pump at 90 the world from in vitro fertilization (IVF) procedures and mmHg, as per the protocol in place in our Center. Ten oocytes that more than one million annual follicular punctures were were harvested, 4 of which were Metaphase II; two embryos performed in at least 60 countries (Adamson et al., 2017). were vitrified on day 3. According to the literature, the incidence of serious The patient underwent a second cycle in April 2016, at complications associated with transvaginal oocyte pick-up age 45, with Pergoveris (recombinant FSH plus recombi- is low, but the procedure is not risk-free. Risks are inherent nant LH, Merck, Aubonne, Switzerland), using a total go- to procedures in which thin needles and sharp instruments nadotropin dose of 1350 IU of FSH and 670 IU of LH, and are introduced into the vaginal wall and ovarian capsule to an additional 1200 IU of FSH with Fostimon M (IBSA In- access the ovaries. A transvaginal probe equipped with a stitut Biochimique S.A. Lamone, Switzerland). The patient needle guide is introduced into the vaginal canal and po- was again prescribed an antagonist cycle with Orgalutran sitioned in the lateral vaginal fornix on the same side of (Merck Sharp & Dohme, Ravensburg, Germany), 5 vials. the ovary to be aspirated. This is done in order to reach This time the LH trigger was performed with Gonapeptyl the gonad with the end of the probe as closely as possible daily 0.1mg (Ferring Pharmaceuticals, Kiel, Germany), (Seyhan et al., 2014). The needle is then connected to a 2 vials. However, during the second cycle she decided to suction pump, and introduced into the follicles after perfo- only cryopreserve her oocytes. All pre-procedure examina- ration of the vaginal wall and ovarian capsule. Only then tions were normal. Follicle aspiration was done 35 hours the aspiration of the follicular fluid begins. after the LH trigger. Both ovaries were punctured without Received May 22, 2018 Accepted November 22, 2018 Case report 76 complications. A Kitazato , Japan, 17-G needle was used DISCUSSION in the procedure and nine metaphase II oocytes were har- This was the only case of a bladder hematoma in more vested. Immediately prior to aspiration, the patient was than 2739 procedures (0.03%), which now appear along- instructed to void her bladder to reduce the contact area side one case of a hematoma of the parametrium and anoth- with the puncture zone. An experienced team carried out er case of hemoperitoneum. All oocyte pick-up procedures the aspiration procedure and no issues were detected. were ultrasound guided. Additionally, clear visualization of The patient reported urinary discomfort and difficulty void- the needle tip is mandatory throughout the procedure. ing her bladder 12 hours after follicular puncture. She report- The patient described in this case had no history of pelvic ed seeing blood and small blood clots in her urine. However, or abdominal surgery. Although the rate of complications as- she only contacted the clinic the following day. She was asked sociated with vaginal oocyte pick-up is low, care and attention to return immediately to the clinic. Despite the complaints, are mandatory in order to minimize potential harm. Patients the patient was in good general condition and without signs must be checked for prior pelvic surgery, sequelae from pelvic of fever within 24 hours of the pick-up procedure. Transvag- inflammatory disease, and history of endometriosis. inal ultrasound examination performed 24 hours after pick- According to Bennett et al. (1993), vascular lesions of up showed a heterogeneous intravesical image (Figure 1) the vaginal and ovarian walls, accidental injuries to pel- suggestive of a clot; her bladder measured 23x19mm. The vic organs such as the bowel, bladder, ureters and pelvic urologist with the team recommended an expectant approach blood vessels, and pelvic infection by microorganisms from with increased fluid intake. The patient reported discomfort the vaginal canal are a few of the possible complications throughout the day. She expelled the clot in the evening, and arising from this procedure. These authors reviewed 2670 symptoms subsided. She has not recurred in the months fol- cases of oocyte retrieval and described vaginal bleeding lowing this episode. (8.6%) as the most frequent complication, followed by Figure 1. A and B. Transvaginal ultrasound examination performed one day after oocyte retrieval, showing a heterogeneous intravesical image and a well-defined bladder measuring 23x19mm in its larger diameter JBRA Assist. Reprod. | v.23 | nº1 | Jan-Feb-Mar / 2019 Bladder hematoma after oocyte retrieval - Souza, MCB. hemoperitoneum (0.7%), pelvic infection (0.6%), and ac- REFERENCES cidental puncture of pelvic vessels (0.04%). Adamson G, De Mouzon J, Dyer S, Chambers G, Ishihara O, Ludwig et al. (2006) described similar findings. The authors examined the peri- and postoperative complica- Banker M, Mansour R, Vanderpoel S, Zegers-Hochschild F. ICMART World Report 2013. Hum Reprod. 2017;32:i64-5. tions of 1058 oocyte retrieval procedures and found vag- inal bleeding (2-3%) as the most frequent complication, followed by hemoperitoneum (1 %). They did not report Bennett SJ, Waterstone JJ, Cheng WC, Parsons J. Com- cases of pelvic infection, although it appears to occur in 0.2 plications of transvaginal ultrasound-directed follicle as- to 0.6% of the cases (Dicker et al., 1993). piration: a review of 2670 consecutive procedures. J Seyhan et al. (2014) reported similar findings in a com- Assist Reprod Genet. 1993;10:72-7. PMID: 8499683 parison between complication rates and pain score definitions DOI: 10.1007/BF01204444 after oocyte retrieval for in vitro maturation and IVF cycles. Vaginal and ovarian bleedings were the most frequent com- Bhandari H, Agrawal R, Weissman A, Shoham G, Leong M, plications. Their findings were in agreement with previous Shoham Z. Minimizing the Risk of Infection and Bleeding studies, in which vaginal bleeding occurred in 0.5-7.5% of the at Trans-Vaginal Ultrasound-Guided Ovum Pick-up: Results cases and pelvic pain was the most frequent complication (el of a Prospective Web-Based World-Wide Survey. J Obstet Hussein et al., 1992; El-Shawarby et al., 2004). El-Shawarby Gynaecol India. 2015;65:389-95. PMID: 26663998 DOI: et al. (2004) also described other complications including ad- 10.1007/s13224-014-0619-z nexal torsion, ruptured endometriotic cysts, issues with anes- thesia, and vertebral osteomyelitis. Coroleu B, Lopez Mourelle F, Hereter L, Veiga A, Calderón The literature has been unanimous in showing that G, Martinez F, Carreras O, Barri PN. Ureteral lesion second- complications arising from oocyte retrieval are rare. In this ary to vaginal ultrasound follicular puncture for oocyte re- context, accidental urinary tract injuries are apparently covery in in-vitro fertilization. Hum Reprod. 1997;12:948- even less frequent. von Eye Corleta et al. (2008) reported 50. PMID: 9194645 DOI: 10.1093/humrep/12.5.948 a case of immediate ureterovaginal fistula secondary to oocyte retrieval, which improved spontaneously after six Dicker D, Ashkenazi J, Feldberg D, Levy T, Dekel A, weeks. Similarly, Jones et al. (1989) reported three other Ben-Rafael Z. Severe abdominal complications af- cases of ureteral injury. Coroleu et al. (1997) and Fugita ter transvaginal ultrasonographically guided retriev- & Kavoussi (2001) described cases in which patients were al of oocytes for in vitro fertilization and embryo trans- diagnosed with complications between five days and four fer. Fertil Steril. 1993;59:1313-5. PMID: 8495784 months after the retrieval procedure, involving a combi- DOI: 10.1016/S0015-0282(16)55997-4 nation of irritative voiding symptoms, leukocytosis, and negative urine culture, which, according to them, indicat- el Hussein E, Balen AH, Tan SL. A prospective study com- ed urinary tract injury. These authors also emphasized the paring the outcome of oocytes retrieved in the aspirate importance of early diagnosis. In fact, Miller et al. (2002) with those retrieved in the flush during transvaginal ultra- reported a case of acute ureteral obstruction following a sound directed oocyte recovery for in-vitro fertilization. Br seemingly uncomplicated oocyte retrieval procedure, in J Obstet Gynaecol. 1992;99:841-4. PMID: 1419996 DOI: which prompt diagnosis and ureteral stenting led to rapid 10.1111/j.1471-0528.1992.tb14417.x recovery with no long-term urinary tract sequelae. One might assume that bladder injury occurs more fre- quently than ureter lesions on account of the local anato- El-Shawarby S, Margara R, Trew G, Lavery S. A review my, although this idea has not been supported by literature of complications following transvaginal oocyte retrieval for reports. The topographic characteristics of the bladder and in-vitro fertilization. Hum Fertil (Camb). 2004;7:127-33. its direct relationship with the site of puncture might in- PMID: 15223762 DOI: 10.1080/14647270410001699081 crease the risk of injury when the needle is inserted, while the pressure exerted by the probe causes its walls to col- Fugita OE, Kavoussi L. Laparoscopic ureteral reimplanta- lapse, thus making visualization more difficult. tion for ureteral lesion secondary to transvaginal ultra- Preventing damage to pelvic structures during oocyte sonography for oocyte retrieval. Urology. 2001;58:281. retrieval includes using Color-Doppler velocimetry to iden- PMID: 11489721 DOI: 10.1016/S0090-4295(01)01147-5 tify blood vessels in cases of doubt (Bhandari et al., 2015). Additionally, it is wise to keep the end of the needle guide Gleicher N, Friberg J, Fullan N, Giglia RV, Mayden K, Kesky T, always in a lateral position before puncturing to avoid be- Siegel I. EGG retrieval for in vitro fertilisation by sonographi- ing too close to blood vessels, the bladder, and the ureter. cally controlled vaginal culdocentesis. Lancet. 1983;2:508- Finally, oocyte pick-up should only commence after com- 9. PMID: 6136659 DOI: 10.1016/S0140-6736(83)90530-5 plete bladder voiding (Miller et al., 2002). As pointed out by von Eye Corleta et al. (2008), given Jones WR, Haines CJ, Matthews CD, Kirby CA. Traumatic the elective nature of transvaginal ultrasound-guided oo- ureteric obstruction secondary to oocyte recovery for in vi- cyte retrieval in IVF cycles, patients should be informed tro fertilization: a case report. J In Vitro Fert Embryo Transf. about these potential, albeit rare, risks and complications. 1989;6:185-7. PMID: 2794736 DOI: 10.1007/BF01130786 CONFLICT OF INTEREST Ludwig AK, Glawatz M, Griesinger G, Diedrich K, Ludwig M. The authors disclose no potential conflict of interest. Perioperative and post-operative complications of transvag- inal ultrasound-guided oocyte retrieval: prospective study Corresponding author: of >1000 oocyte retrievals. Hum Reprod. 2006;21:3235- Maria do Carmo Borges de Souza 40. PMID: 16877373 DOI: 10.1093/humrep/del278 Fertipraxis-Centro de Reprodução Humana Rio de Janeiro, Brazil Miller PB, Price T, Nichols JE Jr, Hill L. Acute ureteral ob- E-mail: mcborgesss@yahoo.com.br, struction following transvaginal oocyte retrieval for IVF. mariadocarmo@fertipraxis.com.br Hum Reprod. 2002;17:137-8. PMID: 11756377 DOI: 10.1093/humrep/17.1.137 JBRA Assist. Reprod. | v.23 | nº1 | Jan-Feb-Mar / 2019 Case report 78 Seyhan A, Ata B, Son WY, Dahan MH, Tan SL. Compar- von Eye Corleta H, Moretto M, D'Avila AM, Berger M. Im- ison of complication rates and pain scores after trans- mediate ureterovaginal fistula secondary to oocyte retriev - vaginal ultrasound-guided oocyte pickup procedures al--a case report. Fertil Steril. 2008;90:2006.e1-3. PMID: for in vitro maturation and in vitro fertilization cy- 18440002 DOI: 10.1016/j.fertnstert.2008.03.005 cles. Fertil Steril. 2014;101:705-9. PMID: 24424363 DOI: 10.1016/j.fertnstert.2013.12.011 JBRA Assist. Reprod. | v.23 | nº1 | Jan-Feb-Mar / 2019
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Bladder hematoma: a complication from an oocyte retrieval procedure
Bladder hematoma: a complication from an oocyte retrieval procedure
Abstract
JBRA Assisted Reproduction 2019;23(1):75-78 doi: 10.5935/1518-0557.20180086 Case report Bladder hematoma: a complication from an oocyte retrieval procedure 1 1 1 Maria do Carmo Borges de Souza , Marcelo Marinho de Souza , Roberto de Azevedo Antunes , Maria Augusta 1 1 1 Tamm , Joyce Barreto da Silva , Ana Cristina Allemand Mancebo Fertipraxis-Centro de Reprodução Humana- RJ, Brazil As a precaution, the number of vaginal and ovarian per- ABSTRACT forations is kept to a minimum. Therefore, greater numbers Introduction: More than one million fertilization cy- of follicles are aspirated without withdrawing the needle tip cles are performed every year. The incidence of serious from inside the ovary (el Hussein et al., 1992). After all complications associated with transvaginal oocyte pick-up ovarian follicles have been aspirated, the needle is with- is low, but the procedure is not risk-free. Risks are inherent drawn and the procedure is repeated in the contralateral to procedures in which thin needles and sharp instruments ovary. The tip of the needle must be visualized by ultra- are introduced into the vaginal wall and ovarian capsule to sound throughout the entire procedure in order to avoid access the ovaries. damaging adjacent pelvic structures (Gleicher et al.,
JBRA Assisted Reproduction 2019;23(1):75-78 doi: 10.5935/1518-0557.20180086 Case report Bladder hematoma: a complication from an oocyte retrieval procedure 1 1 1 Maria do Carmo Borges de Souza , Marcelo Marinho de Souza , Roberto de Azevedo Antunes , Maria Augusta 1 1 1 Tamm , Joyce Barreto da Silva , Ana Cristina Allemand Mancebo Fertipraxis-Centro de Reprodução Humana- RJ, Brazil As a precaution, the number of vaginal and ovarian per- ABSTRACT forations is kept to a minimum. Therefore, greater numbers Introduction: More than one million fertilization cy- of follicles are aspirated without withdrawing the needle tip cles are performed every year. The incidence of serious from inside the ovary (el Hussein et al., 1992). After all complications associated with transvaginal oocyte pick-up ovarian follicles have been aspirated, the needle is with- is low, but the procedure is not risk-free. Risks are inherent drawn and the procedure is repeated in the contralateral to procedures in which thin needles and sharp instruments ovary. The tip of the needle must be visualized by ultra- are introduced into the vaginal wall and ovarian capsule to sound throughout the entire procedure in order to avoid access the ovaries. damaging adjacent pelvic structures (Gleicher et al., 1983). Case description: A 45-year-old patient reported urinary discomfort and difficulty urinating after her sec - ond cycle, 12 hours after oocyte pick-up. She had visible CASE REPORT hematuria with small blood clots. Transvaginal ultrasound The patient described in this paper consented to having examination performed 24 hours after pick-up showed a her case published. A single nulliparous woman was first seen heterogeneous intravesical image suggestive of a clot; her in our clinic in April 2014. She was seeking information on bladder measured 23x19mm. She was afebrile and in good oocyte cryopreservation and in vitro fertilization. She did not condition. The patient was managed conservatively and of- have a partner at the time. She had no record of comorbidi- fered fluids. The clot was expelled within a matter of hours. ties and her menstrual cycles were regular. The antimullerian This case of a bladder hematoma was the first in the 21 hormone (AMH) level measured after her first appointment years of a clinic where all procedures are guided by ultra- was 3.4 ng/mL and her antral follicle count (AFC) was 12. sonography with clear visualization of the tip of the needle She returned to the clinic in September 2015 with a partner throughout the 15-20 minutes of the procedure. Patients (age 38). At the beginning of the cycle, her FSH dosage was submitted to ultrasound-guided transvaginal oocyte pick- 6 mIU/mL; her estradiol (E2) level was 43 ng/dL; and her up procedures in IVF protocols must be informed of this AFC was 17. Her prospects in relation to age were discussed rare potential complication. and she was offered an IVF/ICSI cycle with genetic testing for aneuploidies of the resulting blastocysts. Keywords: Hematoma, urinary tract, in vitro fertilization, The protocol and total amount of gonadotropins adminis- complications. ® tered were as follows: GonalF (recombinant FSH, Merck, Au- bonne, Switzerland) 1050 IU and Menopur (Ferring Pharma- ceuticals, Kiel, Germany) 1050 IU. This patient was prescribed INTRODUCTION an antagonist cycle with Orgalutran (Merck Sharp & Dohme, Transvaginal ultrasound-guided follicular aspiration was Ravensburg, Germany), 4 vials. The LH trigger utilized was first described in 1983 and rapidly became widely accept - Ovidrel 250 mcg (recombinant HCG, Merck, Aubonne, Swit- ed because of its simplicity and effectiveness (Gleicher et zerland). The transvaginal ultrasound-guided oocyte retrieval al., 1983; Bennett et al., 1993). In 2013, the International procedure was performed in September 2015 with a standard Committee Monitoring Assisted Reproductive Technologies Wallace (UK) 25-cm 17-G single-lumen needle attached to a (ICMART) estimated that 6.5 million children were born in closed suction system with a continuous pressure pump at 90 the world from in vitro fertilization (IVF) procedures and mmHg, as per the protocol in place in our Center. Ten oocytes that more than one million annual follicular punctures were were harvested, 4 of which were Metaphase II; two embryos performed in at least 60 countries (Adamson et al., 2017). were vitrified on day 3. According to the literature, the incidence of serious The patient underwent a second cycle in April 2016, at complications associated with transvaginal oocyte pick-up age 45, with Pergoveris (recombinant FSH plus recombi- is low, but the procedure is not risk-free. Risks are inherent nant LH, Merck, Aubonne, Switzerland), using a total go- to procedures in which thin needles and sharp instruments nadotropin dose of 1350 IU of FSH and 670 IU of LH, and are introduced into the vaginal wall and ovarian capsule to an additional 1200 IU of FSH with Fostimon M (IBSA In- access the ovaries. A transvaginal probe equipped with a stitut Biochimique S.A. Lamone, Switzerland). The patient needle guide is introduced into the vaginal canal and po- was again prescribed an antagonist cycle with Orgalutran sitioned in the lateral vaginal fornix on the same side of (Merck Sharp & Dohme, Ravensburg, Germany), 5 vials. the ovary to be aspirated. This is done in order to reach This time the LH trigger was performed with Gonapeptyl the gonad with the end of the probe as closely as possible daily 0.1mg (Ferring Pharmaceuticals, Kiel, Germany), (Seyhan et al., 2014). The needle is then connected to a 2 vials. However, during the second cycle she decided to suction pump, and introduced into the follicles after perfo- only cryopreserve her oocytes. All pre-procedure examina- ration of the vaginal wall and ovarian capsule. Only then tions were normal. Follicle aspiration was done 35 hours the aspiration of the follicular fluid begins. after the LH trigger. Both ovaries were punctured without Received May 22, 2018 Accepted November 22, 2018 Case report 76 complications. A Kitazato , Japan, 17-G needle was used DISCUSSION in the procedure and nine metaphase II oocytes were har- This was the only case of a bladder hematoma in more vested. Immediately prior to aspiration, the patient was than 2739 procedures (0.03%), which now appear along- instructed to void her bladder to reduce the contact area side one case of a hematoma of the parametrium and anoth- with the puncture zone. An experienced team carried out er case of hemoperitoneum. All oocyte pick-up procedures the aspiration procedure and no issues were detected. were ultrasound guided. Additionally, clear visualization of The patient reported urinary discomfort and difficulty void- the needle tip is mandatory throughout the procedure. ing her bladder 12 hours after follicular puncture. She report- The patient described in this case had no history of pelvic ed seeing blood and small blood clots in her urine. However, or abdominal surgery. Although the rate of complications as- she only contacted the clinic the following day. She was asked sociated with vaginal oocyte pick-up is low, care and attention to return immediately to the clinic. Despite the complaints, are mandatory in order to minimize potential harm. Patients the patient was in good general condition and without signs must be checked for prior pelvic surgery, sequelae from pelvic of fever within 24 hours of the pick-up procedure. Transvag- inflammatory disease, and history of endometriosis. inal ultrasound examination performed 24 hours after pick- According to Bennett et al. (1993), vascular lesions of up showed a heterogeneous intravesical image (Figure 1) the vaginal and ovarian walls, accidental injuries to pel- suggestive of a clot; her bladder measured 23x19mm. The vic organs such as the bowel, bladder, ureters and pelvic urologist with the team recommended an expectant approach blood vessels, and pelvic infection by microorganisms from with increased fluid intake. The patient reported discomfort the vaginal canal are a few of the possible complications throughout the day. She expelled the clot in the evening, and arising from this procedure. These authors reviewed 2670 symptoms subsided. She has not recurred in the months fol- cases of oocyte retrieval and described vaginal bleeding lowing this episode. (8.6%) as the most frequent complication, followed by Figure 1. A and B. Transvaginal ultrasound examination performed one day after oocyte retrieval, showing a heterogeneous intravesical image and a well-defined bladder measuring 23x19mm in its larger diameter JBRA Assist. Reprod. | v.23 | nº1 | Jan-Feb-Mar / 2019 Bladder hematoma after oocyte retrieval - Souza, MCB. hemoperitoneum (0.7%), pelvic infection (0.6%), and ac- REFERENCES cidental puncture of pelvic vessels (0.04%). Adamson G, De Mouzon J, Dyer S, Chambers G, Ishihara O, Ludwig et al. (2006) described similar findings. The authors examined the peri- and postoperative complica- Banker M, Mansour R, Vanderpoel S, Zegers-Hochschild F. ICMART World Report 2013. Hum Reprod. 2017;32:i64-5. tions of 1058 oocyte retrieval procedures and found vag- inal bleeding (2-3%) as the most frequent complication, followed by hemoperitoneum (1 %). They did not report Bennett SJ, Waterstone JJ, Cheng WC, Parsons J. Com- cases of pelvic infection, although it appears to occur in 0.2 plications of transvaginal ultrasound-directed follicle as- to 0.6% of the cases (Dicker et al., 1993). piration: a review of 2670 consecutive procedures. J Seyhan et al. (2014) reported similar findings in a com- Assist Reprod Genet. 1993;10:72-7. PMID: 8499683 parison between complication rates and pain score definitions DOI: 10.1007/BF01204444 after oocyte retrieval for in vitro maturation and IVF cycles. Vaginal and ovarian bleedings were the most frequent com- Bhandari H, Agrawal R, Weissman A, Shoham G, Leong M, plications. Their findings were in agreement with previous Shoham Z. Minimizing the Risk of Infection and Bleeding studies, in which vaginal bleeding occurred in 0.5-7.5% of the at Trans-Vaginal Ultrasound-Guided Ovum Pick-up: Results cases and pelvic pain was the most frequent complication (el of a Prospective Web-Based World-Wide Survey. J Obstet Hussein et al., 1992; El-Shawarby et al., 2004). El-Shawarby Gynaecol India. 2015;65:389-95. PMID: 26663998 DOI: et al. (2004) also described other complications including ad- 10.1007/s13224-014-0619-z nexal torsion, ruptured endometriotic cysts, issues with anes- thesia, and vertebral osteomyelitis. Coroleu B, Lopez Mourelle F, Hereter L, Veiga A, Calderón The literature has been unanimous in showing that G, Martinez F, Carreras O, Barri PN. Ureteral lesion second- complications arising from oocyte retrieval are rare. In this ary to vaginal ultrasound follicular puncture for oocyte re- context, accidental urinary tract injuries are apparently covery in in-vitro fertilization. Hum Reprod. 1997;12:948- even less frequent. von Eye Corleta et al. (2008) reported 50. PMID: 9194645 DOI: 10.1093/humrep/12.5.948 a case of immediate ureterovaginal fistula secondary to oocyte retrieval, which improved spontaneously after six Dicker D, Ashkenazi J, Feldberg D, Levy T, Dekel A, weeks. Similarly, Jones et al. (1989) reported three other Ben-Rafael Z. Severe abdominal complications af- cases of ureteral injury. Coroleu et al. (1997) and Fugita ter transvaginal ultrasonographically guided retriev- & Kavoussi (2001) described cases in which patients were al of oocytes for in vitro fertilization and embryo trans- diagnosed with complications between five days and four fer. Fertil Steril. 1993;59:1313-5. PMID: 8495784 months after the retrieval procedure, involving a combi- DOI: 10.1016/S0015-0282(16)55997-4 nation of irritative voiding symptoms, leukocytosis, and negative urine culture, which, according to them, indicat- el Hussein E, Balen AH, Tan SL. A prospective study com- ed urinary tract injury. These authors also emphasized the paring the outcome of oocytes retrieved in the aspirate importance of early diagnosis. In fact, Miller et al. (2002) with those retrieved in the flush during transvaginal ultra- reported a case of acute ureteral obstruction following a sound directed oocyte recovery for in-vitro fertilization. Br seemingly uncomplicated oocyte retrieval procedure, in J Obstet Gynaecol. 1992;99:841-4. PMID: 1419996 DOI: which prompt diagnosis and ureteral stenting led to rapid 10.1111/j.1471-0528.1992.tb14417.x recovery with no long-term urinary tract sequelae. One might assume that bladder injury occurs more fre- quently than ureter lesions on account of the local anato- El-Shawarby S, Margara R, Trew G, Lavery S. A review my, although this idea has not been supported by literature of complications following transvaginal oocyte retrieval for reports. The topographic characteristics of the bladder and in-vitro fertilization. Hum Fertil (Camb). 2004;7:127-33. its direct relationship with the site of puncture might in- PMID: 15223762 DOI: 10.1080/14647270410001699081 crease the risk of injury when the needle is inserted, while the pressure exerted by the probe causes its walls to col- Fugita OE, Kavoussi L. Laparoscopic ureteral reimplanta- lapse, thus making visualization more difficult. tion for ureteral lesion secondary to transvaginal ultra- Preventing damage to pelvic structures during oocyte sonography for oocyte retrieval. Urology. 2001;58:281. retrieval includes using Color-Doppler velocimetry to iden- PMID: 11489721 DOI: 10.1016/S0090-4295(01)01147-5 tify blood vessels in cases of doubt (Bhandari et al., 2015). Additionally, it is wise to keep the end of the needle guide Gleicher N, Friberg J, Fullan N, Giglia RV, Mayden K, Kesky T, always in a lateral position before puncturing to avoid be- Siegel I. EGG retrieval for in vitro fertilisation by sonographi- ing too close to blood vessels, the bladder, and the ureter. cally controlled vaginal culdocentesis. Lancet. 1983;2:508- Finally, oocyte pick-up should only commence after com- 9. PMID: 6136659 DOI: 10.1016/S0140-6736(83)90530-5 plete bladder voiding (Miller et al., 2002). As pointed out by von Eye Corleta et al. (2008), given Jones WR, Haines CJ, Matthews CD, Kirby CA. Traumatic the elective nature of transvaginal ultrasound-guided oo- ureteric obstruction secondary to oocyte recovery for in vi- cyte retrieval in IVF cycles, patients should be informed tro fertilization: a case report. J In Vitro Fert Embryo Transf. about these potential, albeit rare, risks and complications. 1989;6:185-7. PMID: 2794736 DOI: 10.1007/BF01130786 CONFLICT OF INTEREST Ludwig AK, Glawatz M, Griesinger G, Diedrich K, Ludwig M. The authors disclose no potential conflict of interest. Perioperative and post-operative complications of transvag- inal ultrasound-guided oocyte retrieval: prospective study Corresponding author: of >1000 oocyte retrievals. Hum Reprod. 2006;21:3235- Maria do Carmo Borges de Souza 40. PMID: 16877373 DOI: 10.1093/humrep/del278 Fertipraxis-Centro de Reprodução Humana Rio de Janeiro, Brazil Miller PB, Price T, Nichols JE Jr, Hill L. Acute ureteral ob- E-mail: mcborgesss@yahoo.com.br, struction following transvaginal oocyte retrieval for IVF. mariadocarmo@fertipraxis.com.br Hum Reprod. 2002;17:137-8. PMID: 11756377 DOI: 10.1093/humrep/17.1.137 JBRA Assist. Reprod. | v.23 | nº1 | Jan-Feb-Mar / 2019 Case report 78 Seyhan A, Ata B, Son WY, Dahan MH, Tan SL. Compar- von Eye Corleta H, Moretto M, D'Avila AM, Berger M. Im- ison of complication rates and pain scores after trans- mediate ureterovaginal fistula secondary to oocyte retriev - vaginal ultrasound-guided oocyte pickup procedures al--a case report. Fertil Steril. 2008;90:2006.e1-3. PMID: for in vitro maturation and in vitro fertilization cy- 18440002 DOI: 10.1016/j.fertnstert.2008.03.005 cles. Fertil Steril. 2014;101:705-9. PMID: 24424363 DOI: 10.1016/j.fertnstert.2013.12.011 JBRA Assist. Reprod. | v.23 | nº1 | Jan-Feb-Mar / 2019
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