Immediate ureterovaginal fistula secondary to oocyte retrieval--a case report

Ureterovaginal fistula: a case report and review of an unexpected contemporary complication secondary to transvaginal ultrasound-guided oocyte retrieval

Despite the widespread use of transvaginal ultrasound-guided oocyte retrieval in assisted reproductive technology procedures, there is a lack of systematic data on the incidence and nature of its complications. This makes it difficult for healthcare providers to fully understand and manage the risks associated with the procedure, and for patients to make informed decisions about their care. Ureteral injuries and other complications during oocyte retrieval are important to consider and manage appropriately. Early ureterovaginal fistula is a rare but serious complication that can occur after oocyte collection by transvaginal ultrasound. It is important for medical professionals to be aware of this potential complication and to take appropriate measures to prevent and manage it. Minimally invasive treatments for ureterovaginal fistula can be effective in resolving the condition and minimize the risk of further complications. However, early diagnosis and prompt intervention are critical in achieving a successful outcome.

Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review

Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Rare Surgical Complication of In Vitro Fertilisation Treatment: Bladder Injury During Oocyte Retrieval

Current literature suggests that surgical complications from oocyte retrievals (ORs) are uncommon. Here, we present a rare case of bladder injury during OR and its subsequent management. A 37-year-old nulliparous woman underwent assisted reproductive therapy (ART) for primary infertility secondary to anovulatory cycle. During OR, there was an inadvertent puncture of the bladder, with active intra-bladder bleeding seen on transvaginal ultrasound. Bladder washout followed by continuous drainage was instituted with antibiotic coverage over several days. Bladder integrity ascertained through computer tomography urogram and cystoscopy were unremarkable. She was discharged well and continued with her fertility treatment. Transvaginal OR is associated with few complications. Bladder injury, albeit rare, can present with massive hematuria and hemodynamic instability. Early identification of the injury is key to management with insertion of the indwelling urinary catheter, hemodynamic resuscitation and bladder irrigation. With a urological multi-disciplinary approach, most bladder injuries can be resolved non-invasively.

The Maribor consensus: report of an expert meeting on the development of performance indicators for clinical practice in ART

STUDY QUESTION

Is it possible to define a set of performance indicators (PIs) for clinical work in ART, which can create competency profiles for clinicians and for specific clinical process steps?

SUMMARY ANSWER

The current paper recommends six PIs to be used for monitoring clinical work in ovarian stimulation for ART, embryo transfer, and pregnancy achievement: cycle cancellation rate (before oocyte pick-up (OPU)) (%CCR), rate of cycles with moderate/severe ovarian hyperstimulation syndrome (OHSS) (%mosOHSS), the proportion of mature (MII) oocytes at ICSI (%MII), complication rate after OPU (%CoOPU), clinical pregnancy rate (%CPR), and multiple pregnancy rate (%MPR).

WHAT IS KNOWN ALREADY

PIs are objective measures for evaluating critical healthcare domains. In 2017, ART laboratory key PIs (KPIs) were defined.

STUDY DESIGN, SIZE, DURATION

A list of possible indicators was defined by a working group. The value and limitations of each indicator were confirmed through assessing published data and acceptability was evaluated through an online survey among members of ESHRE, mostly clinicians, of the special interest group Reproductive Endocrinology.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The online survey was open for 5 weeks and 222 replies were received. Statements (indicators, indicator definitions, or general statements) were considered accepted when ≥70% of the responders agreed (agreed or strongly agreed). There was only one round to seek levels of agreement between the stakeholders.

Indicators that were accepted by the survey responders were included in the final list of indicators. Statements reaching less than 70% were not included in the final list but were discussed in the paper.

MAIN RESULTS AND THE ROLE OF CHANCE

Cycle cancellation rate (before OPU) and the rate of cycles with moderate/severe OHSS, calculated on the number of started cycles, were defined as relevant PIs for monitoring ovarian stimulation. For monitoring ovarian response, trigger and OPU, the proportion of MII oocytes at ICSI and complication rate after OPU were listed as PIs: the latter PI was defined as the number of complications (any) that require an (additional) medical intervention or hospital admission (apart from OHSS) over the number of OPUs performed. Finally, clinical pregnancy rate and multiple pregnancy rate were considered relevant PIs for embryo transfer and pregnancy. The defined PIs should be calculated every 6 months or per 100 cycles, whichever comes first. Clinical pregnancy rate and multiple pregnancy rate should be monitored more frequently (every 3 months or per 50 cycles). Live birth rate (LBR) is a generally accepted and an important parameter for measuring ART success. However, LBR is affected by many factors, even apart from ART, and it cannot be adequately used to monitor clinical practice. In addition to monitoring performance in general, PIs are essential for managing the performance of staff over time, and more specifically the gap between expected performance and actual performance measured. Individual clinics should determine which indicators are key to the success in their organisation based on their patient population, protocols, and procedures, and as such, which are their KPIs.

LIMITATIONS, REASONS FOR CAUTION

The consensus values are based on data found in the literature and suggestions of experts. When calculated and compared to the competence/benchmark limits, prudent interpretation is necessary taking into account the specific clinical practice of each individual centre.

WIDER IMPLICATIONS OF THE FINDINGS

The defined PIs complement the earlier defined indicators for the ART laboratory. Together, both sets of indicators aim to enhance the overall quality of the ART practice and are an essential part of the total quality management. PIs are important for education and can be applied during clinical subspecialty.

STUDY FUNDING/COMPETING INTEREST(S)

This paper was developed and funded by ESHRE, covering expenses associated with meetings, literature searches, and dissemination. The writing group members did not receive payment.

Dr G.G. reports personal fees from Merck, MSD, Ferring, Theramex, Finox, Gedeon-Richter, Abbott, Biosilu, ReprodWissen, Obseva, PregLem, and Guerbet, outside the submitted work. Dr A.D. reports personal fees from Cook, outside the submitted work; Dr S.A. reports starting a new employment in May 2020 at Vitrolife. Previously, she has been part of the Nordic Embryology Academic Team, with meetings were sponsored by Gedeon Richter. The other authors have no conflicts of interest to declare.

DISCLAIMER

This document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation.

The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

Furthermore, ESHREs recommendations do not constitute or imply the endorsement, recommendation, or favouring of any of the included technologies by ESHRE.

Bladder hematoma: a complication from an oocyte retrieval procedure

INTRODUCTION

More than one million fertilization cycles are performed every year. The incidence of serious complications associated with transvaginal oocyte pick-up is low, but the procedure is not risk-free. Risks are inherent to procedures in which thin needles and sharp instruments are introduced into the vaginal wall and ovarian capsule to access the ovaries.

CASE DESCRIPTION

A 45-year-old patient reported urinary discomfort and difficulty urinating after her second cycle, 12 hours after oocyte pick-up. She had visible hematuria with small blood clots. Transvaginal ultrasound examination performed 24 hours after pick-up showed a heterogeneous intravesical image suggestive of a clot; her bladder measured 23x19mm. She was afebrile and in good condition. The patient was managed conservatively and offered fluids. The clot was expelled within a matter of hours. This case of a bladder hematoma was the first in the 21 years of a clinic where all procedures are guided by ultrasonography with clear visualization of the tip of the needle throughout the 15-20 minutes of the procedure. Patients submitted to ultrasound-guided transvaginal oocyte pick-up procedures in IVF protocols must be informed of this rare potential complication.

Immediate ureterovaginal fistula following oocyte retrieval: A case and systematic review of the literature

The aim of this study is to report a case of acute ureterovaginal fistula (UVF) formation with immediate symptomatic presentation after transvaginal ultrasound-guided oocyte retrieval (TVOR) for in vitro fertilization (IVF) and to perform a systematic literature review of ureteral injuries during TVOR. A 33-year-old woman with a history of anovulatory infertility presented with severe abdominal pain and vaginal leakage immediately following TVOR for IVF. We systematically reviewed the current literature regarding ureteral injury resulting from TVOR and present a case of timely identification and management of a UVF followed by a successful pregnancy. Computed tomography cystogram with intravenous contrast and left retrograde pyelogram confirmed the diagnosis of UVF which was managed by placement of the left ureteral stent. The IVF cycle was converted to a freeze-all cycle. The ureteral stent was removed 4 weeks later, and a subsequent frozen embryo transfer cycle resulted in pregnancy. We present the 13^th case of ureteral injury and the fourth case of UVF following TVOR. UVF formation is a rare complication after TVOR and may result in serious long-term morbidity if it is not identified and treated promptly. Clinicians must exercise a high degree of suspicion and prompt evaluation for potential ureteral injuries in women presenting with abdominal pain, urinary symptoms, or vaginal leakage following TVOR.

Ureteral Injury with Delayed Massive Hematuria after Transvaginal Ultrasound-Guided Oocyte Retrieval

We report a case of ureteral injury with delayed hematuria after transvaginal oocyte retrieval. A 28-year-old infertile patient with a history of previous laparoscopic resection of endometriotic nodes of both sacrouterine ligaments presented with abdominal pain one day after oocyte retrieval. Four days after oocyte retrieval, she presented with massive hematuria that reappeared 6 days after oocyte retrieval. Monopolar coagulation with wire electrode and insertion of a double-J-stent was performed during operative cystoscopy. The patient recovered completely after transfusion and had no signs of renal impairment after ureteric stent removal. This is the first report of ureteral injury after oocyte retrieval presenting itself with delayed massive hematuria and no signs of renal dysfunction or urinary leakage into retroperitoneal space.

Ureteral injury after transvaginal ultrasound-guided oocyte retrieval: a complication of in vitro fertilization-embryo transfer that may lurk undetected in women presenting with severe ovarian hyperstimulation syndrome

OBJECTIVE

To report a case of ureteral injury after transvaginal ultrasound-guided oocyte retrieval, initially misdiagnosed as an ovarian hyperstimulation syndrome (OHSS).

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 26-year-old patient with a history of primary infertility due to polycystic ovary syndrome (PCOS) presented with acute pelvic pain after transvaginal ultrasound-guided oocyte retrieval for in vitro fertilization-embryo transfer.

INTERVENTION(S)

Initial clinical presentation, context, and imaging results were consistent with the diagnosis of mild OHSS. Recurrence of the pelvic pain with radiation to the right lumbar region suggested the possibility of a urinary complication.

MAIN OUTCOME MEASURE(S)

Successful detection and management of unilateral ureteral injury in a patient with PCOS.

RESULT(S)

Uro-computed tomography scan helped with the diagnosis of right pelvic-ureter lesion. Patient underwent cystoscopy with uncomplicated right ureteral stent placement and delivered a healthy baby at term.

CONCLUSION(S)

Although ureteral injury after transvaginal ultrasound-guided oocyte retrieval is a rare complication of IVF-ET, it could have serious sequelae such as fistula formation and renal dysfunction if untreated. Clinicians must be aware that it may lurk undetected in women presenting OHSS.

Clinical complications after transvaginal oocyte retrieval in 7,098 IVF cycles

We report the complications observed after transvaginal oocyte retrieval guided by ultrasound in 7,098 IVF cycles. The frequency of severe complications in our patients was 0.08%, of which four cases were intraperitoneal bleeding (0.06%) and two were cases of ovarian abscess (0.003%).