Paracervical block with and without conscious sedation: a comparison of the pain levels during egg collection and the postoperative side effects

Pain Management during Ultrasound Guided Transvaginal Oocyte Retrieval - A Narrative Review

Transvaginal oocyte retrieval (TVOR), done for the purpose of assisted reproduction can instigate enormous pain and therefore requires adequate analgesia with the least adverse effects. As the procedure involves retrieving oocytes for in vitro fertilisation, the effect of the anaesthetic drugs on the oocyte quality should also be considered. This review focuses on the various modes of anaesthesia and the anaesthetic drugs which can be administered safely to provide effective analgesia in normal and in special conditions such as women with pre-existing comorbidities. Medline, Embase, PubMed and Cochrane electronic databases were searched according to modified Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. According to this review, conscious sedation appears to be the most preferred mode of anaesthesia in women undergoing TVOR owing to fewer adverse effects, faster recovery, better patient and specialist comfort and the least effect on oocyte quality and embryo development. Combining it with paracervical block resulted in lesser consumption of the anaesthetic drug, which may have a beneficial effect on the oocyte quality.

Effectiveness of music therapy as an adjuvant to conscious sedation in women undergoing transvaginal oocyte retrieval: A randomized controlled trial

AIM

Assisted reproductive technique (ART) has emerged as the highest form of treatment for infertile couples. Transvaginal oocyte retrieval is currently performed under conscious sedation in most centers. Since it is a relatively painful procedure, a number of adjuvant therapies have been tried to improve pain relief during the procedure. Music therapy is a nonpharmacological technique that has been successfully used for pain relief in perioperative and chronic pain of malignancy. However, studies evaluating its usefulness in ART-related procedures are limited. We evaluated the effectiveness of music therapy as an adjuvant for pain relief during oocyte retrieval.

METHODS

This was a randomized controlled trial conducted at a tertiary level teaching hospital in South India from September 2020 to March 2021. All women undergoing transvaginal oocyte retrieval were randomized to receive either music therapy along with conscious sedation (Group A) or conscious sedation alone (Group B). The primary outcome was postprocedure pain score assessed by the visual analog scale. Secondary outcomes included anxiety score.

RESULTS

A total of 109 women were randomized into Group A (54 women) and Group B (55 women). The postprocedure pain score was comparable between the two study groups (6.0, interquartile range [IQR] 4 to 6 vs. 6.0, IQR 4 to 6; p = 0.69). However, anxiety levels were found to be significantly lower in women who were offered music therapy (3.0, IQR 1 to 5 vs. 4.0, IQR 3 to 6; p = 0.004).

CONCLUSION

The use of music therapy as an adjuvant to conscious sedation was found to have no significant benefit in pain relief during oocyte retrieval.

Why do women choose to undergo oocyte aspiration without sedation or analgesia?

Objective

Oocyte pick-up (OPU) is a painful but essential part of in-vitro fertilization (IVF) that is usually performed under sedation and analgesia (SaA). Our aim was to study that why some women decide to undergo OPU without SaA?

Methods

This was a prospective study using patient questionnaires and the standardized 7-item generalized anxiety disorder (GAD-7) score. The patients were asked to assess the pain experienced during OPU using a visual analog scale (VAS). The study sample was a convenience sample of 100 healthy women undergoing OPU at our unit with or without SaA.

Results

Women who chose to undergo OPU without SaA were significantly more likely to express the fear of anesthesia. A high pain score (VAS ≥ 6) was reported by significantly more patients who underwent OPU without SaA than with SaA. Yet, 98% of the patients who underwent OPU without SaA stated that in future IVF cycles, they would still choose to undergo OPU without SaA. More patients had high anxiety scores among those who underwent OPU with than without SaA.

Conclusions

Women who chose to undergo OPU without SaA reported more often fear of anesthesia. Although these women experienced significantly more pain during OPU, almost all of them suggested that they would still choose to undergo OPU without SaA. Increased anxiety, as expressed by higher GAD-7 scores, was not associated with a tendency to choose SaA during OPU. The option of OPU without SaA seems to be an acceptable option for selected women.

Lay summary

Egg retrieval from the ovaries is a painful part of in vitro fertilization (IVF). It is, therefore, usually performed under sedation and pain relief (analgesia). The aim of this study was to investigate: Why some women decide to undergo egg retrieval without sedation? We prospectively studied 100 women using patient questionnaires and standardized scores in order to measure patient's pain and anxiety levels. We found that women who chose to undergo egg retrieval without sedation were significantly more likely to express fear of anesthesia. As expected, women who decided to forgo sedation experienced more pain during egg retrieval, yet, 98% of them decided that in future IVF cycles, they would still choose to undergo egg retrieval without sedation. Surprisingly, women who had high anxiety scores were not more likely to ask for sedation during egg retrieval. The option to undergo egg retrieval without sedation during IVF seems to be acceptable for some women.

OUP accepted manuscript

STUDY QUESTION

What is the methodological validity and usefulness of randomized controlled trials (RCTs) on pain relief during oocyte retrieval for IVF and ICSI?

SUMMARY ANSWER

Key methodological characteristics such as randomization, allocation concealment, primary outcome measure and sample size calculation were inadequately reported in 33–43% of the included RCTs, and a broad heterogeneity is revealed in the studied outcome measures.

WHAT IS KNOWN ALREADY

A Cochrane review on conscious sedation and analgesia for women undergoing oocyte retrieval concluded that the overall quality of evidence was low or very low, mainly owing to poor reporting. This, and heterogeneity of studied outcome measures, limits generalizability and eligibility of results for meta-analysis.

STUDY DESIGN, SIZE, DURATION

For this review, a systematic search for RCTs on pain relief during oocyte retrieval was performed on 20 July 2020 in CENTRAL CRSO, MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, WHO ICTRP, Web of Science, Portal Regional da BVS and Open Grey.

PARTICIPANTS/MATERIALS, SETTING, METHODS

RCTs with pain or patient satisfaction as an outcome were included and analysed on a set of methodological and clinical characteristics, to determine their validity and usefulness.

MAIN RESULTS AND THE ROLE OF CHANCE

Screening of 2531 articles led to an inclusion of 51 RCTs. Randomization was described inadequately in 33% of the RCTs. A low-risk method of allocation concealment was reported in 55% of the RCTs. Forty-nine percent of the RCTs reported blinding of participants, 33% of blinding personnel and 43% of blinding the outcome assessor. In 63% of the RCTs, the primary outcome was stated, but a sample size calculation was described in only 57%. Data were analysed according to the intention-to-treat principle in 73%. Treatment groups were not treated identically other than the intervention of interest in 10% of the RCTs. The primary outcome was intraoperative pain in 28%, and postoperative pain in 2%. The visual analogue scale (VAS) was the most used pain scale, in 69% of the RCTs in which pain was measured. Overall, nine other scales were used. Patient satisfaction was measured in 49% of the RCTs, for which 12 different methods were used. Occurrence of side-effects and complications were assessed in 77% and 49% of the RCTs: a definition for these was lacking in 13% and 20% of the RCTs, respectively. Pregnancy rate was reported in 55% of the RCTs and, of these, 75% did not adequately define pregnancy. To improve the quality of future research, we provide recommendations for the design of future trials. These include use of the VAS for pain measurement, use of validated questionnaires for measurement of patient satisfaction and the minimal clinically relevant difference to use for sample size calculations.

LIMITATIONS, REASONS FOR CAUTION

Consensus has not been reached on some methodological characteristics, for which we formulated recommendations. To prevent further heterogeneity in research on this topic, recommendations were formulated based on expert opinion, or on the most used method thus far. Future research may provide evidence to base new recommendations on.

WIDER IMPLICATIONS OF THE FINDINGS

Use of the recommendations given for design of trials on this topic can increase the generalizability of future research, increasing eligibility for meta-analyses and preventing wastefulness.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was obtained for this study. S.B. reports being the editor-in-chief of Human Reproduction Open. For this manuscript, he was not involved with the handling process within Human Reproduction Open, or with the final decision. Furthermore, S.B. reports personal fees from Remuneration from Oxford University Press as editor-in-chief of Human Reproduction Open, personal fees from Editor and contributing author, Reproductive Medicine for the MRCOG, Cambridge University Press. The remaining authors declare no conflict of interest in relation to the work presented.

TRIAL REGISTRATION NUMBER

Not applicable.

Acupuncture for pain relief of women undergoing transvaginal oocyte retrieval: A meta analysis and systematic review protocol

BACKGROUND

Pain during oocyte retrieval, which can make the in-vitro fertilization process an unpleasant experience, is becoming a common problem. Although there are many analgesic methods available in the clinical setting, they are not therapeutically equivalent, and some are associated with varying adverse reactions. In recent years, acupuncture analgesia has been used in the perioperative period of oocyte retrieval because of its perceived efficacy and safety. The purpose of this systematic review and meta-analysis is to provide evidence that acupuncture is effective in the treatment of vaginal oocyte retrieval pain.

METHODS

Electronic searches of the following six databases will be conducted by two qualified reviewers: MEDLINE, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Medicine database, VIP database and Wanfang database. Three clinical trial registries will also be searched: World Health Organization International Clinical Trial Registry Platform, Chinese Clinical Trial Registry, Cochrane Central Register of Controlled Trials and ClinicalTrials.Gov. All searches will cover the period from inception of the database/registry to March 2020 and will be limited to publications in English and Chinese. Data identification, data selection, data extraction, and bias risk assessment will be conducted independently by3ν two or more qualified reviewers, including those who selected the studies. Visual analogue scale scores will be calculated as the primary outcome. Secondary outcomes will include results of other subjective pain rating scales, including Likert scales or other defined numerical or non-numerical scales, self-assessed by patients before, during, and after oocyte retrieval. We will use STATA software (Version 16) to perform meta-analyses, and the Grading of Recommendations, Assessment, Development and Evaluations framework to grade the quality of evidence. If quantitative analysis is not available, a systematic narrative synthesis will be provided.

PROSPERO REGISTRATION NUMBER

CRD42020170095.

A randomized double-blinded non-inferiority trial comparing fentanyl and midazolam with pethidine and diazepam for pain relief during oocyte retrieval

RESEARCH QUESTION

Is fentanyl and midazolam non-inferior to pethidine and diazepam in pain relief during oocyte retrieval under conscious sedation?

DESIGN

A randomized double-blinded non-inferiority trial of 170 infertile women undergoing oocyte retrieval under conscious sedation in an assisted reproduction centre. The women were randomized to receive intravenously either 0.1 mg fentanyl and 5 mg midazolam or 25 mg pethidine and 5 mg diazepam, plus paracervical block with 10 ml 1% lignocaine. The primary outcome was abdominal pain level during retrieval assessed by linear visual analogue scale from 0-10. Secondary outcomes included vaginal pain levels during and after retrieval and postoperative abdominal pain levels and side-effects, satisfaction level, clinical pregnancy and ongoing pregnancy rates. A pre-defined non-inferiority margin of 1 for the difference in pain levels between two groups was set.

RESULTS

Vaginal and abdominal pain levels during retrieval were significantly lower in the fentanyl and midazolam group compared with the pethidine and diazepam group (per-protocol analysis, vaginal pain: 1.6 versus 4.3; mean difference: -2.7, 95% CI -3.7, -1.8; P < 0.001; abdominal pain: 2.9 versus 5.2; mean difference: -2.3, 95% CI -3.3 to -1.3; P < 0.001 for non-inferiority). No differences were observed in these pain levels after retrieval. Most women experienced no postoperative side-effects. The fentanyl and midazolam group had better sedation level, satisfaction level on pain relief and satisfaction on the overall retrieval procedure than the pethidine and diazepam group. No significant differences were found in clinical pregnancy and ongoing pregnancy rates between the two groups.

CONCLUSION

The fentanyl and midazolam group had significantly lower vaginal and abdominal pain levels during oocyte retrieval than the pethidine and diazepam group.

Randomized controlled trial of transcutaneous electrical nerve stimulation for pain relief during transvaginal oocyte retrieval using conscious sedation: study protocol for a randomized controlled trial

Background

Transvaginal oocytes retrieval is an essential step in in-vitro fertilization treatment. There are different pain relief methods, but none has been shown to be superior than the others. Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological and non-invasive pain relief method. This study aims to compare the pain levels experienced by the women using the conscious sedation and those who had TENS in addition to conscious sedation.

Methods and analysis

This is a double-blinded randomized trial that will be carried out in a university-assisted conception unit. Women who will undergo oocyte retrieval under conscious sedation will be recruited. After randomization, women will be allocated to either the active TENS group or placebo TENS group (the TENS machine will not emit active impulse), in addition to the paracervical block and conscious sedation. The primary outcome is pain levels of women during the retrieval assessed by the visual analog scale. Secondary outcomes include satisfaction of women and postoperative side effects.

Discussion

TENS is an effective non-pharmacological and non-invasive method for pain relief in a number of clinical conditions. Both women and assisted conception unit can benefit if the addition of non-invasive, simple, and low-cost TENS application is proven to be superior than using conscious sedation and paracervical block alone.

Trial registration

ClinicalTrials.gov, NCT03472430. Registered on 3 May 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3227-5) contains supplementary material, which is available to authorized users.

Pain relief for women undergoing oocyte retrieval for assisted reproduction

BACKGROUND

Various methods of conscious sedation and analgesia (CSA) have been used during oocyte retrieval for assisted reproduction. The choice of agent has been influenced by the quality of sedation and analgesia and by concerns about possible detrimental effects on reproductive outcomes.

OBJECTIVES

To assess the effectiveness and safety of different methods of conscious sedation and analgesia for pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval.

SEARCH METHODS

We searched; the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL, and trials registers in November 2017. We also checked references, and contacted study authors for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different methods and administrative protocols for conscious sedation and analgesia during oocyte retrieval.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were intraoperative and postoperative pain. Secondary outcomes included clinical pregnancy, patient satisfaction, analgesic side effects, and postoperative complications.

MAIN RESULTS

We included 24 RCTs (3160 women) in five comparisons. We report the main comparisons below. Evidence quality was generally low or very low, mainly owing to poor reporting and imprecision.1. CSA versus other active interventions.All evidence for this comparison was of very low quality.CSA versus CSA plus acupuncture or electroacupunctureData show more effective intraoperative pain relief on a 0 to 10 visual analogue scale (VAS) with CSA plus acupuncture (mean difference (MD) 1.00, 95% confidence interval (CI) 0.18 to 1.82, 62 women) or electroacupuncture (MD 3.00, 95% CI 2.23 to 3.77, 62 women).Data also show more effective postoperative pain relief (0 to 10 VAS) with CSA plus acupuncture (MD 0.60, 95% CI -0.10 to 1.30, 61 women) or electroacupuncture (MD 2.10, 95% CI 1.40 to 2.80, 61 women).Evidence was insufficient to show whether clinical pregnancy rates were different between CSA and CSA plus acupuncture (odds ratio (OR) 0.61, 95% CI 0.20 to 1.86, 61 women). CSA alone may be associated with fewer pregnancies than CSA plus electroacupuncture (OR 0.22, 95% CI 0.07 to 0.66, 61 women).Evidence was insufficient to show whether rates of vomiting were different between CSA and CSA plus acupuncture (OR 1.64, 95% CI 0.46 to 5.88, 62 women) or electroacupuncture (OR 1.09, 95% CI 0.33 to 3.58, 62 women).Trialists provided no usable data for other outcomes of interest.CSA versus general anaesthesia Postoperative pain relief was greater in the CSA group (0 to 3 Likert: mean difference (MD) 1.9, 95% CI 2.24 to 1.56, one RCT, 50 women).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 1.00, 95% CI 0.43 to 2.35, two RCTs, 108 women, I² = 0%).Evidence was insufficient to show whether groups differed in rates of vomiting (OR 0.46, 95% CI 0.08 to 2.75, one RCT, 50 women) or airway obstruction (OR 0.14, 95% CI 0.02 to 1.22, one RCT, 58 women). Fewer women needed mask ventilation in the CSA group (OR 0.05, 95% CI 0.01 to 0.20, one RCT, 58 women).Evidence was also insufficient to show whether groups differed in satisfaction rates (OR 0.66, 95% CI 0.11 to 4.04, two RCTs, 108 women, I² = 34%; very low-quality evidence).Trialists provided no usable data for outcomes of interest.2. CSA + paracervical block (PCB) versus other interventions.CSA + PCB versus electroacupuncture + PCB Intraoperative pain scores were lower in the CSA + PCB group (0 to 10 VAS: MD -0.66, 95% CI -0.93 to -0.39, 781 women, I² = 76%; low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.96, 95% CI 0.72 to 1.29, 783 women, I² = 9%; low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus general anaesthesiaEvidence was insufficient to show whether groups differed in postoperative pain scores (0 to 10 VAS: MD 0.49, 95% CI -0.13 to 1.11, 50 women; very low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.70, 95% CI 0.22 to 2.26, 51 women; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus spinal anaesthesiaPostoperative pain scores were higher in the CSA + PCB group (0 to 10 VAS: MD 1.02, 95% CI 0.48 to 1.56, 36 women; very low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.24 to 3.65, 38 women; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus PCBEvidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.44 to 1.96, 150 women; low-quality evidence) or satisfaction (OR 1.63, 95% CI 0.68 to 3.89, 150 women, low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus CSA only Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.62, 95% CI 0.28 to 1.36, one RCT, 100 women; very low-quality evidence). Rates of postoperative nausea and vomiting were lower in the CS + PCB group (OR 0.42, 95% CI 0.18 to 0.97, two RCTs, 140 women, I² = 40%; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.

AUTHORS' CONCLUSIONS

The evidence does not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte retrieval. Simultaneous use of sedation combined with analgesia such as the opiates, further enhanced by paracervical block or acupuncture techniques, resulted in better pain relief than occurred with one modality alone. Evidence was insufficient to show conclusively whether any of the interventions influenced pregnancy rates. All techniques reviewed were associated with a high degree of patient satisfaction. Women's preferences and resource availability for choice of pain relief merit consideration in practice.

IVF oocyte retrieval: prospective evaluation of the type of anesthesia on live birth rate, pain, and patient satisfaction

PURPOSE

Does the type of anesthesia (paracervical block (PCB) or general anesthesia (GA)) impact live birth rate, pain, and patient satisfaction?

METHODS

A non-randomized prospective cohort study was conducted in women treated for IVF. Two groups of patients were prospectively included: the PCB group (n = 234) and the GA group (n = 247). The type of anesthesia was determined by the patients. The primary endpoint was cumulative live birth rate by OR. Secondary endpoints were self-assessment of the patients' peri-operative abdominal and vaginal pain vs the doctors' evaluations during PCB, post-operative abdominal and vaginal pain level, and patient satisfaction in both groups. Pain levels were assessed with a numerical rating scale (NRS).

RESULTS

The live birth rate was similar in both groups (19.8% in the GA group vs 20.9% in the PCB group, P = 0.764). During oocyte retrieval in the PCB group, the physicians significantly under-estimated the vaginal pain experienced by the patients (3.04 ± 0.173 for patients vs 2.59 ± 0.113 for surgeons, P = 0.014). Post-operative vaginal and abdominal pain were significantly greater in the PCB group compared to the GA group (2.26 ± 0.159 vs 1.66 ± 0.123, respectively, P = 0.005, and 3.80 ± 0.165 vs 3.00 ± 0.148, respectively, P < 0.001). Patients were more significantly satisfied with GA than with PBC (P < 0.001).

CONCLUSION

Because the LBR was similar in both groups and patient satisfaction was high, the choice of anesthesia should be decided by the patients.

Predictors of pain during oocyte retrieval

INTRODUCTION

Pain during oocyte retrieval remains prevalent despite detailed and specific pain management protocols. Exploring the role of psychosocial risk factors of pain during the oocyte retrieval could identify possible targets for prevention. The present study assessed pain prevalence and possible risk factors for experiencing extreme pain levels in a large cohort of women receiving assisted reproductive technologies (ART) treatment.

METHODS

Participants were 810 first attendees about to begin treatment with ART. The participants completed questionnaires at three time points: at their 21st day of the cycle, during the waiting time before the oocyte retrieval surgery and after the oocyte retrieval.

RESULTS

Fifty-one (6.9%) of the women reported the oocyte retrieval to be very or extremely painful. The results of a multiple logistic regression indicated that the significant predictors of high pain intensity, measured before the oocyte retrieval, were negative gynecological experiences and side effects of hormonal treatment. Variables measured after the oocyte retrieval associated with pain intensity were higher levels of anxiety during the oocyte retrieval, lower levels of perceived control and longer duration of the procedure.

DISCUSSION

The findings of the present study may help to identify those women who are at increased risk of experiencing unacceptable pain levels during oocyte retrieval procedures and the medical staff is advised to take psychological factors into account.

A Prospective Randomized Trial Comparing Dexmedetomidine and Midazolam for Conscious Sedation During Oocyte Retrieval in An In Vitro Fertilization Program

Background:

Various sedative and analgesic techniques have been used for pain relief during oocyte retrieval which is the most painful part of in vitro fertilization (IVF) procedures.

Aim:

This study aimed at comparing dexmedetomidine and midazolam for conscious sedation in women undergoing transvaginal oocyte retrieval during an IVF program.

Settings and Design:

Prospective randomized double-blinded comparative study.

Patients and Methods:

Fifty-two patients undergoing oocyte retrieval in their first IVF cycle were randomly allocated into two equal groups. The intervention started with giving fentanyl1 mcg/kg intravenous (IV) followed by paracervical block in both groups. Then, subjects in group (D) received dexmedetomidine at a loading dose of 1 μg/kg IV over 10 min followed by 0.5 μg/kg/h infusion until Ramsay Sedation Scale (RSS) reached 3–4. Patients in group (M) received a loading dose of midazolam 0.06 mg/kg IV over 10 min followed by 0.5 mg incremental doses until RSS reached 3–4.

Statistical Analysis:

Statistical analysis was performed using SPSS program version 19 and EP 16 program.

Results:

Visual analog scale scores significantly decreased in group D than group M at 5 and 10 min during the procedure (P = 0.03 and 0.01, respectively), and at 20 min during postanesthesia care unit (PACU) time (P = 0.04). Intraoperative rescue sedation by propofol and postoperative rescue analgesia by acetaminophen showed a highly significant decrease (P < 0.01) in group D compared with group M. Furthermore, the time of PACU stay was significantly less (P < 0.01) in group D (49.03 ± 12.8 min) compared to group M (62.5 ± 18.34 min). Although significant bradycardia was noted in group D (23% of patients) during the procedure (P = 0.02), no cases were reported in group M. Patient satisfaction was significantly higher in group D (P < 0.1).

Conclusion:

Dexmedetomidine is an effective analgesic alternative to midazolam during oocyte retrieval for IVF. It offered not only a shorter PACU stay without significant side effects, but also better overall patient satisfaction scores.

[Patient's experience of topical anesthesia by lidocaine vaginal gel for oocyte retrieval]

A recent adverse effect of a paracervical block (cardiac arrest) occurred during an oocyte retrieval (OR), forcing us to reconsider our pain management during OR. Since then, we decided to use intravaginal lidocaine gel as analgesia during OR.

OBJECTIVES

To evaluate the pain during OR after intravaginal lidocaine gel analgesia and to evaluate the motivations of women choosing this technique.

METHODS

A monocentric observational study was performed on 200 patients. Pain was measured using a numeric pain scale during and after oocyte retrieval. The tolerance of the procedure was evaluated through a patient questionnaire.

RESULTS

Median maximal pain was 5±2.3 (0-10) per-retrieval and 3±2.2 (0-10) post-retrieval. The procedure was considered bearable by 85.5% of the patients and 81.5% of them would choose this method in case of new oocyte retrieval. No adverse effect occurred during the study.

CONCLUSION

The use of intravaginal lidocaine gel seems an acceptable analgesia alternative during oocyte retrieval.

Pain relief for women undergoing oocyte retrieval for assisted reproduction

BACKGROUND

Various methods of conscious sedation and analgesia have been used for pain relief during oocyte recovery in in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) procedures. The choice of agent has also been influenced by the quality of sedation and analgesia as well as by concerns about possible detrimental effects on reproductive outcomes.

OBJECTIVES

To assess the effectiveness and safety of different methods of conscious sedation and analgesia on pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval.

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL (from their inception to present); the National Research Register and Current Controlled Trials. We searched reference lists of included studies for relevant studies and contacted authors for information on unpublished and ongoing trials. There was no language restriction. The search was updated in July 2012.

SELECTION CRITERIA

Only randomised controlled trials comparing different methods of conscious sedation and analgesia for pain relief during oocyte recovery were included.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two review authors. Interventions were classified and analysed under broad categories or strategies of sedation and pain relief to compare different methods and administrative protocols of conscious sedation and analgesia. Outcomes were extracted and the data were pooled when appropriate.

MAIN RESULTS

With this update, nine new studies were identified resulting in a total of 21 trials including 2974 women undergoing oocyte retrieval. These trials compared five different categories of conscious sedation and analgesia: 1) conscious sedation and analgesia versus placebo; 2) conscious sedation and analgesia versus other active interventions such as general and acupuncture anaesthesia; 3) conscious sedation and analgesia plus paracervical block versus other active interventions such as general, spinal and acupuncture anaesthesia; 4) patient-controlled conscious sedation and analgesia versus physician-administered conscious sedation and analgesia; and 5) conscious sedation and analgesia with different agents or dosage. Evidence was generally of low quality, mainly due to poor reporting of methods, small sample sizes and inconsistency between the trials.Conflicting results were shown for women's experience of pain. Compared to conscious sedation alone, more effective pain relief was reported when conscious sedation was combined with electro-acupuncture: intra-operative pain mean difference (MD) on 1 to 10 visual analogue scale (VAS) of 3.00 (95% CI 2.23 to 3.77); post-operative pain MD in VAS units of 2.10 (95% CI 1.40 to 2.80; N = 61, one trial, low quality evidence); or paracervical block (MD not calculable).The pooled data of four trials showed a significantly lower intra-operative pain score with conscious sedation plus paracervical block than with electro-acupuncture plus paracervical block (MD on 10-point VAS of -0.66; 95% CI -0.93 to -0.39; N = 781, 4 trials, low quality evidence) with significant statistical heterogeneity (I(2) = 76%). Patient-controlled sedation and analgesia was associated with more intra-operative pain than physician-administered sedation and analgesia (MD on 10-point VAS of 0.60; 95% CI 0.16 to 1.03; N = 379, 4 trials, low quality evidence) with high statistical heterogeneity (I(2) = 83%). Post-operative pain was reported in only nine studies. As different types and dosages of sedative and analgesic agents, as well as administrative protocols and assessment tools, were used in these trials the data should be interpreted with caution.There was no evidence of a significant difference in pregnancy rate in the 12 studies which assessed this outcome, and pooled data of four trials comparing electro-acupuncture combined with paracervical block with conscious sedation and analgesia plus paracervical block showed an odds ratio (OR) of 0.96 (95% CI 0.72 to 1.29; N = 783, 4 trials) for pregnancy. High levels of women's satisfaction were reported for all modalities of conscious sedation and analgesia as assessed in 12 studies. Meta-analysis of all the studies was not attempted due to considerable heterogeneity.For the rest of the trials a descriptive summary of the outcomes was presented.

AUTHORS' CONCLUSIONS

The evidence from this review of 21 randomised controlled trials did not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte recovery. The simultaneous use of more than one method of sedation and pain relief resulted in better pain relief than one modality alone. The various approaches and techniques reviewed appeared to be acceptable and were associated with a high degree of satisfaction in women. As women vary in their experience of pain and in coping strategies, the optimal method may be individualised depending on the preferences of both the women and the clinicians and resource availability.

Effect of alfentanil dosage during oocyte retrieval on fertilization and embryo quality

OBJECTIVE

A possible negative effect of pain-relieving analgesics used during oocyte retrieval on fertilization and embryo development has been discussed. This study examines whether alfentanil dosage adversely affects fertilization and/or embryo quality.

STUDY DESIGN

In a retrospective observational study the effect of different doses of alfentanil on two primary endpoints, fertilization rate and good quality embryo (GQE) rate, were compared in 663 women.

RESULTS

In group A (<or=0.5mg alfentanil) and group B (>0.5mg alfentanil) mean fertilization rate was 0.6+/-0.3 versus 0.6+/-0.2 (P=0.678, adjusted P=0.937, 95% CI for the difference -0.041; 0.044) and mean GQE rate was 0.6+/-0.3 versus 0.5+/-0.3 (P=0.207, adjusted P=0.179, 95% CI for the difference -0.015; 0.078), respectively. A paired comparison of 65 women who underwent repeated IVF cycles found that, compared with <or=0.5mg alfentanil, doses of >0.5mg alfentanil had no adverse effects on fertilization rate (mean difference 0.05+/-0.3, P=0.231, 95% CI -0.02; 0.12) or GQE rate (mean difference -0.02+/-0.4, P=0.970, 95% CI -0.12; 0.09).

CONCLUSION

The amount of alfentanil is not associated with adverse effects on fertilization rate, embryo development, or clinical pregnancy rate, which is reassuring and indicates that women can be offered adequate pain relief.

Pain aspects in oocyte aspiration for IVF

The aim of this observational two-centre study was to investigate different aspects of pain in oocyte aspiration in conjunction with IVF, whether the preoperative information to women was sufficient, and which factor(s) influenced a woman's sense of security. The study group comprised 124 women who underwent IVF treatment. The visual analogue scale (VAS) was used to measure pain, and multiple-choice questions were used to evaluate satisfaction and sense of security. The women rated expected pain significantly higher than mean pain during surgery (P < 0.0001). They would have accepted significantly more pain than they experienced (P < 0.0001). In a stepwise linear regression analysis, total dose of alfentanil was the only variable that was independently associated with mean pain. Satisfaction with the preoperative information was high. Women considered staff competence to be important for their sense of security. In conclusion, women rated oocyte aspiration to be less painful than they expected before surgery. This is important information for women who are about to start IVF treatment, since it might reduce apprehension about the level of pain that could be expected during oocyte aspiration.

Pre-ovarian block versus paracervical block for oocyte retrieval

BACKGROUND

A pre-ovarian block (POB) technique can be used for pain relief during oocyte retrieval in IVF. The local anaesthetic is deposited in the vaginal wall and between the vaginal wall and the peritoneal surface near the ovary using ultrasound guidance. The aim of this study was to test whether analgesia with POB resulted in improved pain relief compared to paracervical block (PCB).

METHODS

A prospective, randomized, multicentre study of POB versus PCB (10 ml of 1% lidocaine each) with 183 patients randomized to POB (n = 96) or PCB (n = 87) was performed. Randomization (via a computer-generated list) was balanced for age, previously completed IVF cycles, degree of anxiety, estimated number of follicles, BMI, premedication and centre. Pain was measured using a visual analogue scale (VAS, 0-100 mm) and given as median values. The primary end-point of this study was overall VAS pain score for both sides during the oocyte retrieval procedure.

RESULTS

Overall pain during the entire oocyte retrieval was 22 (POB) and 16 (PCB) (P = 0.42). No differences were found in degree of anxiety, premedication, dose of alfentanil, fertilization rate, number of good-quality embryos or clinical pregnancy rate.

CONCLUSIONS

No differences were found in overall pain experienced during the entire oocyte retrieval procedure with POB compared to PCB.

Conscious sedation and analgesia for oocyte retrieval during IVF procedures: a Cochrane review

BACKGROUND

Various methods of sedation and analgesia have been used for pain relief during oocyte recovery during IVF.

OBJECTIVE

To compare conscious sedation and analgesia with alternative methods for pain relief and pregnancy outcomes.

METHODS

We searched the Specialised Register of the Menstrual Disorders and Subfertility Group, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, the National Research Register and Current Controlled Trials up to February 2004.

RESULTS

Twelve trials were included. Owing to considerable heterogeneity, regarding types and dosages of sedation or analgesia used, and tools used to assess pain, a meta-analysis was attempted only in trials where appropriate data were available. Clinical pregnancy rates per woman in individual trials were comparable. Data on pain showed conflicting results.

CONCLUSION

No single method or delivery system appeared superior for pregnancy rates and pain relief. Future studies need to be consistent in the choice of tools used to measure pain and the timing of such evaluations.

Conscious sedation and analgesia for oocyte retrieval during in vitro fertilisation procedures

BACKGROUND

Various methods of sedation and analgesia have been used for pain relief during oocyte recovery in IVF/ICSI procedures. The choice of agents has also been influenced by quality of analgesia as well as by concern about possible detrimental effects on reproductive outcome.

OBJECTIVES

To assess the efficacy of conscious sedation and analgesia versus alternative methods on pregnancy outcomes and pain relief in patients undergoing transvaginal oocyte retrieval.

SEARCH STRATEGY

We searched the Specialised Register of the Menstrual Disorders and Subfertility Group, The Central Register of Controlled Trials (CENTRAL) , MEDLINE (1966 to present), EMBASE (1980 to present), CINAHL (1982 to present), the National Research Register, and Current Controlled Trials. There was no language restriction. All references in the identified trials and background papers were checked and authors contacted to identify relevant published and unpublished data.

SELECTION CRITERIA

Only randomised controlled trials comparing conscious sedation and analgesia versus alternative methods for pain relief during oocyte recovery were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently scanned abstracts of the reports identified by electronic searching to identify relevant papers, extracted data and assessed trial quality. Interventions were classified and analysed under broad categories/strategies of pain relief comparing conscious sedation/analgesia with alternative methods and administration protocols.

MAIN RESULTS

Our search strategy identified 390 potentially eligible reports and 12 papers met our inclusion criteria. There were no significant differences in clinical pregnancy rates per woman and patient satisfaction between the methods compared. Women's perception of pain showed conflicting results. Due to considerable heterogeneity, in terms of types and dosages of sedation or analgesia used, and tools used to assess the principal outcomes of pain and satisfaction, a meta-analysis of all the studies was not attempted. Of the three trials which compared the effect of conventional medical analgesia plus paracervical block versus electro-acupuncture plus paracervical block, there was no significant difference in clinical pregnancy rates per woman in the two groups (OR 1.01; 95% CI 0.73 to 1.4). For intra-operative pain score as measured by visual analogue scale (VAS), there was a significant difference (WMD -4.95; 95% CI -7.84 to -2.07), favouring conventional medical analgesia plus paracervical block . There was also a significant difference in intra-operative pain by VAS between patient-controlled sedation and physician-administered sedation (WMD 5.98; 95% CI 1.63 to 10.33), favouring physician -administered sedation. However, as different types and dosages of sedative and analgesic agents were used in these trials, these data should be interpreted with caution. For the rest of the trials, a descriptive summary of the outcomes was presented.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effect of different methods of pain relief when compared with conscious sedation and analgesia used during oocyte recovery. In this review, no one particular pain relief method or delivery system appeared to be better than the other. In future, greater consensus is needed to determine both the tools used to evaluate pain and the timing of pain evaluation during and after the procedure. Pain assessment using both subjective and objective measures may merit consideration. In addition, future trials should include intra- and post-operative adverse respiratory and cardiovascular events as outcomes.

The pain-relieving effect of electro-acupuncture and conventional medical analgesic methods during oocyte retrieval: a systematic review of randomized controlled trials

OBJECTIVE

The primary objective of the present review was to determine what pain-relieving effect had been reported for acupuncture and other conscious sedation methods in assisted reproduction therapy since 1990. The secondary objective was to determine pregnancy rates, when possible.

METHODS

The data source was the Medline database of the National Library of Medicine covering the period January 1990-January 2004. Bibliographies of relevant publications and review articles were scanned. A systematic review and meta-analyses of randomized, controlled trials comparing the pain-relieving effect of acupuncture and other conscious sedation methods was carried out.

RESULTS

Of the 30 trials identified, 12 met the selection criteria for this systematic review and were included in the analysis. Five of the 12 studies reported differences in pain experiences during oocyte aspiration, but it was only possible to group the three trials evaluating the effect of electro-acupuncture (EA). The outcomes of these three studies were homogenous except from maximal and average pain.

CONCLUSION

No method could be regarded as being superior to another, and no consensus on which method is optimal for pain relief during oocyte retrieval was found. Low doses of lignocaine can, however, be recommended in paracervical block (PCB) as well as EA without pre-medication. The clinical pregnancy rates appeared to be similar between the studies. Since pain experience varies from individual to individual, the optimal method of conscious sedation may also be individualized.

Electro-acupuncture versus conventional analgesia: a comparison of pain levels during oocyte aspiration and patients' experiences of well-being after surgery

BACKGROUND

The primary aims were to compare the pain-relieving effect and post-operative well-being between electro-acupuncture analgesia (EA) and conventional analgesia (CA) comprising opiates. Further aims were to compare time for mobilization, and costs for time and drug consumption.

METHODS

In all, 160 women undergoing IVF were randomized, according to a computer-generated list, to EA or CA. Well-being was evaluated with the State Trait Anxiety Inventory (STAI). Pain and subjective expectations and experiences were recorded on a visual analogue scale (VAS). Time and drug consumption were recorded.

RESULTS

Although VAS pain ratings were significantly higher at oocyte aspiration (P < 0.0001) and after retrieval (P < 0.01) in the EA than in the CA group, they were similar 60 min after surgery. Both groups had similar STAI well-being scores. The EA group was significantly less tired and confused than the CA group after oocyte aspiration. No significant differences in time and costs for drug consumption were noted.

CONCLUSION

EA cannot generally be recommended as a pain-relieving method at oocyte aspiration but might be an alternative for women desiring a non-pharmacological method. An advantage of EA is less post-operative tiredness and confusion compared with CA.