Transvaginal, sonographically controlled ovarian follicle puncture for egg retrieval

Recommendations for good practice in ultrasound: oocyte pick up†

STUDY QUESTION

What is good practice in ultrasound (US), and more specifically during the different stages of transvaginal oocyte retrieval, based on evidence in the literature and expert opinion on US practice in ART?

SUMMARY ANSWER

This document provides good practice recommendations covering technical aspects of US-guided transvaginal oocyte retrieval (oocyte pick up: OPU) formulated by a group of experts after considering the published data, and including the preparatory stage of OPU, the actual procedure and post-procedure care.

WHAT IS KNOWN ALREADY

US-guided transvaginal OPU is a widely performed procedure, but standards for best practice are not available.

STUDY DESIGN SIZE DURATION

A working group (WG) collaborated on writing recommendations on the practical aspects of transvaginal OPU. A literature search for evidence of the key aspects of the procedure was carried out. Selected papers (n = 190) relevant to the topic were analyzed by the WG.

PARTICIPANTS/MATERIALS SETTING METHODS

The WG members considered the following key points in the papers: whether US practice standards were explained; to what extent the OPU technique was described and whether complications or incidents and how to prevent such events were reported. In the end, only 108 papers could be used to support the recommendations in this document, which focused on transvaginal OPU. Laparoscopic OPU, transabdominal OPU and OPU for IVM were outside the scope of the study.

MAIN RESULTS AND THE ROLE OF CHANCE

There was a scarcity of studies on the actual procedural OPU technique. The document presents general recommendations for transvaginal OPU, and specific recommendations for its different stages, including prior to, during and after the procedure. Most evidence focussed on comparing different equipment (needles) and on complications and risks, including the risk of infection. For these topics, the recommendations were largely based on the results of the studies. Recommendations are provided on equipment and materials, possible risks and complications, audit and training. One of the major research gaps was training and competence. This paper has also outlined a list of research priorities (including clarification on the value or full blood count, antibiotic prophylaxis and flushing, and the need for training and proficiency).

LIMITATIONS REASONS FOR CAUTION

The recommendations of this paper were mostly based on clinical expertise, as at present, only a few clinical trials have focused on the oocyte retrieval techniques, and almost all available data are observational. In addition, studies focusing on OPU were heterogeneous with significant difference in techniques used, which made drafting conclusions and recommendations based on these studies even more challenging.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on the management of good laboratory practice in ART. Some useful troubleshooting/checklist recommendations are given for easy implementation in clinical practice. These recommendations aim to contribute to the standardization of a rather common procedure that is still performed with great heterogeneity.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the WG were funded by ESHRE. The other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NA.ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Production of piglets from in vitro-produced blastocysts by ultrasound-guided ovum pick-up from live donors

The objective of this research was to develop a system for piglet production by transvaginal ultrasound-guided ovum pick-up (OPU), in vitro production (IVP) of embryos and embryo transfer. First, to establish a culture system for a small number of oocytes or embryos, we evaluated the effect of different incubation volumes and culture densities on fertilizing ability and developmental competence in vitro. Porcine oocytes derived from slaughterhouse ovaries were matured, fertilized and then cultured in vitro in groups as follows: 50 oocytes in 500 μL medium for IVM, 20 oocytes in 100 μL medium for IVF and 20 embryos in 40 μL medium for IVC (Group I); 20 in 100 μL for IVM, 20 in 100 μL for IVF and 20 in 40 μL for IVC (Group II); and 10 in 100 μL for IVM, 10 in 100 μL for IVF and 10 in 40 μL for IVC (Group III). Percentages of sperm penetration, cleavage and blastocyst formation did not differ among the groups. Second, to increase the collection efficiency of porcine oocytes by transvaginal ultrasound-guided OPU, the effects of aspiration pressure on follicular oocyte collection were assessed. Oocytes were aspirated from ovaries of live sows using 80 or 100 mmHg. The recovered oocytes were divided into four categories according to the surrounding cumulus cells and quality of oocytes. The number of oocytes recovered using 100 mmHg pressure was significantly higher than with 80 mmHg pressure. However, there were no significant differences in the population of oocytes grouped by the morphological criteria, number of blastocysts per session and the total cell number in blastocysts between the two vacuum pressures. Finally, 81 oocytes obtained by OPU from five donor sows were subjected to IVP and 47 transferable embryos (9.4 ± 4.0 [mean ± SD] morulae/blastocysts per session) were obtained at 5 days after IVF. When they were transferred into five recipient gilts (5-16 embryos per recipient), three of five recipients became pregnant and farrowed a total of 12 live piglets. The present results demonstrate that porcine blastocysts can be produced by OPU-IVP and develop to full term after embryo transfer.

Analysis of Chromosome Segregation, Histone Acetylation, and Spindle Morphology in Horse Oocytes

The field of assisted reproduction has been developed to treat infertility in women, companion animals, and endangered species. In the horse, assisted reproduction also allows for the production of embryos from high performers without interrupting their sports career and contributes to an increase in the number of foals from mares of high genetic value. The present manuscript describes the procedures used for collecting immature and mature oocytes from horse ovaries using ovum pick-up (OPU). These oocytes were then used to investigate the incidence of aneuploidy by adapting a protocol previously developed in mice. Specifically, the chromosomes and the centromeres of metaphase II (MII) oocytes were fluorescently labeled and counted on sequential focal plans after confocal laser microscope scanning. This analysis revealed a higher incidence in the aneuploidy rate when immature oocytes were collected from the follicles and matured in vitro compared to in vivo. Immunostaining for tubulin and the acetylated form of histone four at specific lysine residues also revealed differences in the morphology of the meiotic spindle and in the global pattern of histone acetylation. Finally, the expression of mRNAs coding for histone deacetylases (HDACs) and acetyl-transferases (HATs) was investigated by reverse transcription and quantitative-PCR (q-PCR). No differences in the relative expression of transcripts were observed between in vitro and in vivo matured oocytes. In agreement with a general silencing of the transcriptional activity during oocyte maturation, the analysis of the total transcript amount can only reveal mRNA stability or degradation. Therefore, these findings indicate that other translational and post-translational regulations might be affected. Overall, the present study describes an experimental approach to morphologically and biochemically characterize the horse oocyte, a cell type that is extremely challenging to study due to low sample availability. However, it can expand our knowledge on the reproductive biology and infertility in monovulatory species.

Influence of transvaginal ultrasound-guided follicular punctures in the mare on heart rate, respiratory rate, facial expression changes, and salivary cortisol as pain scoring

Transvaginal ultrasound-guided follicular punctures are widely used in the mare for diagnosis, research, and commercial applications. The objective of our study was to determine their influence on pain, stress, and well-being in the mare, by evaluating heart rate, breath rate, facial expression changes, and salivary cortisol before, during, and after puncture. For this experiment, 21 pony mares were used. Transvaginal ultrasound-guided aspirations were performed on 11 mares. After injections for sedation, analgesia, and antispasmodia, the follicles from both ovaries were aspirated with a needle introduced through the vagina wall into the ovary. In the control group, 10 mares underwent similar treatments and injections, but no follicular aspiration. Along the session, heart rate and breath rate were evaluated by a trained veterinarian, ears position, eyelid closure, and contraction of facial muscles were evaluated, and salivary samples were taken for evaluation of cortisol concentration. A significant relaxation was observed after sedative injection in the punctured and control mares, according to ear position, eyelid closure, and contraction of facial muscles, but no difference between punctured and control animals was recorded. No significant modification of salivary cortisol concentration during puncture and no difference between punctured and control mares at any time were observed. No significant modification of the breath rate was observed along the procedure for the punctured and the control mares. Heart rate increased significantly but transiently when the needle was introduced in the ovary and was significantly higher at that time for the punctured mares than that for control mares. None of the other investigated parameters were affected at that time, suggesting discomfort is minimal and transient. Improving analgesia, e.g., through a multimodal approach, during that possibly more sensitive step could be recommended. The evaluation of facial expression changes and heart rate is easy-to-use and accurate tools to evaluate pain and well-being of the mare.

Ovum pick up, intracytoplasmic sperm injection and somatic cell nuclear transfer in cattle, buffalo and horses: from the research laboratory to clinical practice

Assisted reproductive techniques developed for cattle in the last 25 years, like ovum pick up (OPU), intracytoplasmic sperm injection (ICSI), and somatic cell nuclear transfer, have been transferred and adapted to buffalo and horses. The successful clinical applications of these techniques require both the clinical skills specific to each animal species and an experienced laboratory team to support the in vitro phase of the work. In cattle, OPU can be considered a consolidated technology that is rapidly outpacing conventional superovulation for embryo transfer. In buffalo, OPU represents the only possibility for embryo production to advance the implementation of embryo-based biotechnologies in that industry, although it is still mainly in the developmental phase. In the horse, OPU is now an established procedure for breeding from infertile and sporting mares throughout the year. It requires ICSI that in the horse, contrary to what happens in cattle and buffalo, is very efficient and the only option because conventional IVF does not work. Somatic cell nuclear transfer is destined to fill a very small niche for generating animals of extremely high commercial value. The efficiency is low, but because normal animals can be generated it is likely that advancing our knowledge in that field might improve the technology and reduce its cost.

Early Detection of Ovarian Tumors Using Ultrasound

Ovarian cancer can be treated with a very good prognosis if detected in the early stages, but not after it has advanced. Transvaginal ultrasound is capable of identifying changes in ovarian size and structure, and thereby detects early ovarian malignancies. This view has generated four major trials on transvaginal ultrasound detection: the Kentucky, PLCO, UKCTOCS, and SCSOCS trials. Each is sufficiently different to warrant examination. The Kentucky, UKCTOCS and SCSOCS trials report a shift to early stage detection. The Kentucky trial reports a survival benefit, while follow-up survival analysis is pending in the UKCTOCS and SCSOCS trials. Details of these trials are presented including definitions, inclusions/exclusions, analytic structure (intention-to-treat vs per protocol), performance (sensitivity, specificity, positive predictive value and negative predictive value), extent of screening-related treatment, time from screening to treatment, length of follow-up and survival versus mortality analysis. Questions are answered here about effectiveness, application, prevalence, cost and the potential for harm.

Ovarian function and morphology in the mare after multiple follicular punctures

REASONS FOR PERFORMING STUDY

In the mare, ultrasound-guided transvaginal oocyte recovery and transfer might offer a way to circumvent the demanding procedures of in vitro embryo production. Before clinical application, the possible consequences for subsequent fertility have to be considered.

OBJECTIVES

To examine ovarian function and morphology in mares after repeated follicular punctures.

METHODS

A total of 14-26 follicular puncture sessions were conducted on each of 4 Norwegian pony mares over a period of 8 years. The ovaries of these mares were recovered by bilateral ovariectomy or at post mortem and subjected to macroscopic inspection and histology. For comparison, ovaries were collected from 7 nonaspirated control mares and processed for histology.

RESULTS

In all experimental mares, ovarian function, defined as the ability regularly to ovulate preovulatory follicles and develop corpora lutea, remained normal during their last breeding season. Gross examination and histology showed that normal follicular and corpus luteum development was accompanied by the formation of condensed reparative fibrosis and normal local haemosiderosis of the ovarian stroma in all experimental mares. In one mare, an ovary contained several foci of chronic apostematous oophoritis, while a cystic structure lined with a single layer of epithelial-like cells and surrounded by a cartilaginous capsule was present in the other ovary.

CONCLUSIONS AND POTENTIAL RELEVANCE

Repeated follicular aspirations do not hamper future folliculogenesis, ovulation and corpus luteum formation. However, ovarian puncture induces reparative fibrosis in the ovarian stroma and involves a risk of inducing abscess formation within the ovarian tissue which may impair fertility.

Ovum Pick Up and In Vitro Production in the bovine after use in several generations: A 2005 status

The first In Vitro Produced (IVP) calf was born in 1981 and the non-surgical Ovum Pick Up (OPU) technique for the bovine was adapted from the human in 1987. Since then, considerable research has been aimed at improving both technologies in the bovine. Both OPU and IVP can now be seen as mature technologies. It can be estimated that more than 200,000 IVP calves have been born world wide to date, and when the two technologies are combined they are capable of producing over 50 calves per donor cow per year, albeit with a large variation between donors. Not many new breakthroughs are expected for OPU. For IVP however, automation and miniaturization as well as a greater understanding of the embryo through the application of gene based technologies such as micro-arrays, may provide an in vitro environment that is more in vivo-like than traditional micro drop/well systems. This improved environment should result in higher embryo developmental rates as well as improved quality and welfare of subsequent offspring. The application of OPU/IVP has progressed from treating infertile high genetic multiple ovulation and embryo transfer (MOET) cows in commercial situations to enhancing breeding scheme designs. With the bovine genome being rapidly sequenced and bovine genes for traits of economic interest becoming available in the coming years, OPU/IVP will prove invaluable in rapidly multiplying rare genes or Quantitative Trait Loci (QTL) of high value. In due course, it is anticipated that Marker Assisted Selection or Gene Assisted Selection (MAS/GAS) schemes will be more widely implemented. In addition, OPU, and particularly IVP, provide the basis for more advanced technologies such as cloning and transgenics. This paper is dedicated to celebrate and recognize the significant contributions made by Theo Kruip (1939-2003) to the wide area of bovine OPU and IVP.

The early days of IVF outside the UK

In this article the history of IVF in geographical regions outside the UK are traced by pioneers of that time. Following the birth of Louise Brown in 1978, live births after IVF occurred in Australia in 1980, in the USA in 1981 and in Sweden and France in 1982. Following the first IVF birth in Australia, the Government of Victoria established a review of IVF research and practice which led to the proclamation of the Infertility (Medical Procedures) Act 1984, the first legislation to regulate IVF and its associated human embryo research. Despite such restriction, IVF doctors and scientists from Victoria, especially those under the leadership of Carl Wood, Alan Trounson and Ian Johnston continued to initiate new treatments for infertility and new methods for delivering this treatment. In the USA IVF research began on animals as early as the 1930s, when Pincus and Enzmann at Harvard were involved in attempts at IVF in the rabbit. In the 1940s, John Rock attempted human IVF with 138 human oocytes without success. In 1965, Bob Edwards was with Georgeanna and Howard Jones at Johns Hopkins where attempts were made to fertilize oocytes in vitro. Clinical IVF began in earnest in the USA in 1980 with the first birth in 1981 achieved by the use of HMG--a first successful use with IVF. In France, two groups Frydman and Testart (Clamart) and Cohen, Mandelbaum and Plachot (Sevres) focused their research in particular directions. In 1981, the Clamart group developed a plasma assay for the initial rise in LH. The Sevres group developed a transport technique. Plachot produced a long series of cytogenetic analyses of oocytes and human embryos. Mandelbaum described the microstructures of the human oocyte. The start of IVF in France benefited from the help of animal researchers from the Institut National de la Recherche Agronomique. The first babies were born in Clamart in February 1982 and in Sèvres in June 1982. Important contributions to the development of IVF from the Nordic countries include techniques for ovarian stimulation, sonographic techniques for monitoring and vaginal oocyte retrieval and also unique possibilities for monitoring IVF safety. These developments, in combination with relatively permissive laws for the practice of reproductive medicine and relatively generous reimbursement policies, as well as a general public confidence in IVF, have led to an exceptionally high availability of IVF, within international comparison.

Complications of assisted reproductive techniques

OBJECTIVE

To review and appreciate the relevant data on assisted reproduction techniques and their potential complications.

DATA RESOURCES

Major publications on assisted reproduction that include the information concerning complications associated with this practice.

RESULTS

Assisted reproduction is a common practice in modern reproductive medicine. Complications are associated with ovulation induction and the extracorporeal methods that are used for IVF-ET, GIFT, and zygote intrafallopian transfer (ZIFT). These complications are associated with laparoscopy, anesthesia, oocyte retrieval, and laboratory facilities. Pregnancies resulting from assisted reproduction are more complicated than spontaneous pregnancies. There are higher rates of ectopic, heterotopic, and multifetal pregnancies; abortions; and premature deliveries. Increased rates of perinatal mortality and morbidity result from prematurity, and higher rates of maternal diseases in pregnancy (preeclampsia, diabetes mellitus, bleeding, anemia) contribute to fetal intra-uterine growth restriction and maternal morbidity.

CONCLUSIONS

Assisted reproduction practice should be well controlled in view of the potential for complications before and during pregnancies.

Gamete intrafallopian transfer by hysteroscopy as an alternative treatment for infertility

OBJECTIVE

To evaluate efficacy and safety of the hysteroscopic cannulation by flexible catheter of the fallopian tubes for gamete intrafallopian transfer (GIFT).

DESIGN

We studied the pregnancy rate (PR) and the safety of this new technique.

SETTING

All patients were enlisted for GIFT at our Reproductive Medicine Unit.

PATIENTS

We treated 26 patients whose infertility causes were terminal tubal damage, male factors, unexplained factors, and endometriosis. Patients with uterine tubal ostia unsuitable for gamete transfer or cervical incontinence were not included in the group.

INTERVENTIONS

The patients underwent ovulation induction and oocyte retrieval by transvaginal ultrasonically guided puncture. The gamete transfers were carried out by hysteroscopic procedure using a flexible catheter put through the operating channel.

MAIN OUTCOME MEASURE

The efficacy was evaluated by the PR (25.9%).

RESULTS

Seven clinical pregnancies were obtained, but two patients aborted during the first weeks of pregnancy. No ectopic pregnancies were observed.

CONCLUSIONS

Our results indicate that hysteroscopic GIFT is an alternative, safe, effective, and not invasive technique for fertility problems.

A case of human pregnancy after microinjection of capacitated sperm into the perivitelline space

Microinjection of capacitated sperm into the perivitelline space of oocyte was offered to one couple with persistent infertility of mixed origin. The husband's semen was subnormal, whereas his wife had definitive tubal occlusion and polycystic ovaries. Four previous in vitro fertilization (IVF) attempts were performed but no fertilization was obtained. After superovulation, 13 oocytes were collected. Ten were submitted to microinjection and two were damaged during the procedure. One of the remaining eight had two pronuclei 18 hr after microinjection and progressed to a four-cell embryo after 48 hr. After reimplantation, a normal pregnancy was initiated, caryotype (46XX) was checked at 17 weeks. A normal and healthy girl has been delivered at term.

Ovarian stimulation with gonadotropin-releasing hormone (GnRH) analogue improves the in vitro fertilization (IVF) pregnancy rate with both transvaginal and laparoscopic oocyte recovery

The relative impact of ovarian stimulation protocol and oocyte retrieval technique on success rates of in vitro fertilization program was studied in 200 patients. Sixty-three patients received gonadotropin-releasing hormone analogue (GnRHa) with human menopausal gonadotropin (hMG), and 137 received hMG only. The GnRHa + hMG protocol resulted in higher pregnancy rates than the hMG-only protocol (19.0 vs 9.5%, respectively; P less than 0.01) despite a lower cleavage rate. Oocyte retrieval was performed via laparoscopy in 100 patients and transvaginally in 100 patients. The number of oocytes recovered per cycle was 6.1 +/- 3.9 with laparoscopy and 7.0 +/- 3.1 transvaginally. Pregnancy rates were similar for both retrieval techniques (13 and 12%, respectively). A breakdown of these results showed that the advantage for the GnRHa + hMG protocol was not affected by the oocyte retrieval technique. A comparison of simultaneous blood and follicular fluid pH measured every 10 min during laparoscopy and transvaginal oocyte recovery revealed a constant decline in follicular fluid pH during laparoscopy, while no changes were observed during the vaginal procedure. We conclude that the improvement in in vitro fertilization results during the period of our study is due primarily to the introduction of GnRHa + hMG protocol rather than the method of oocyte retrieval.

Ovarian cyst aspiration prior to initiating ovarian hyperstimulation for in vitro fertilization

Twenty-three consecutive patients presenting for in vitro fertilization were evaluated with transvaginal sonography on cycle day 3, prior to initiating ovarian hyperstimulation. Three of these patients were noted to have large ovarian cysts. All three underwent transvaginal aspiration of the cysts, followed immediately by initiation of ovarian hyperstimulation. Following oocyte retrieval, in vitro fertilization, and embryo transfer, all three women achieved pregnancy. We conclude that cyst aspiration is not contraindicated when an ovarian cyst is encountered in the follicular phase of an in vitro fertilization cycle.

Ultrasound directed follicle aspiration for oocyte collection using the perurethral technique

Our experience in 242 consecutive ultrasound directed follicle aspirations using the perurethral technique is reported. The mean number of follicles punctured per patient was 9.6 (range 20 to 35), resulting in a mean oocyte yield of 6.1 (range 0 to 31) per patient. It was necessary to change to another ultrasound directed route in 20 patients, and we failed to retrieve oocytes in a further 6 patients. There were no serious complications. The fertilization and cleavage rates were 68% and 91%, respectively. Embryo transfer was performed in 178 cases, resulting in 39 clinical pregnancies (21.9%). Ultrasound directed follicle aspiration by the perurethral route is an efficient way of collecting oocytes and is acceptable to patients. There is no need for general anaesthesia, so this technique is well suited to in vitro fertilization programs based on outpatient procedures.

Uterine and ovarian flow velocity waveforms in the normal menstrual cycle: a transvaginal Doppler study

A combined transvaginal 2D real-time and pulsed Doppler method was used for recording flow velocity waveforms in the uterine and ovarian arteries from 16 healthy women during the follicular and luteal phase of the normal menstrual cycle. Continuous forward end-diastolic flow velocities were documented in 74% of the ovarian artery and 96.5% of the uterine artery flow velocity waveforms. Comparison of the pulsatility index from the left and right ovarian artery revealed a significantly lower pulsatility index on the side of the ovary bearing the developing corpus luteum, suggesting reduced down-stream impedance or increased blood flow. The pulsatility index from the uterine artery only seems to be marginally involved in the observed impedance changes during the luteal phase of the menstrual cycle.

Comparison between laparoscopically and ultrasonographically guided transvaginal follicular aspiration methods in an in vitro fertilization program in the same patients using the same stimulation protocol

Oocyte recovery from 43 patients undergoing ultrasound-guided transvaginal oocyte retrieval was compared to a previous laparoscopic oocyte retrieval cycle from the same patient. Gonadotropin stimulation in both cycles was performed using the same protocol. There were no statistically significant differences in the mean day of oocyte retrieval or the mean daily estradiol level up to the day of oocyte retrieval between laparoscopic and transvaginal cycles. The total number of follicles aspirated per cycle, preovulatory oocytes aspirated per cycle, and number of concepti of preovulatory origin transferred per cycle were not statistically different. The number of immature oocytes aspirated per cycle was statistically decreased in transvaginal retrieval cycles, which resulted in an increased total number of concepti transferred per transfer in laparoscopic retrieval cycles. Twelve pregnancies resulted from the transvaginal retrieval cycles (27.9%), seven of which are ongoing or delivered. Ultrasound-guided transvaginal follicular aspiration yields results comparable to laparoscopic retrieval in the same patients and should be the method of choice for oocyte pickup because of its many advantages.

Complications and problems in transvaginal sector scan-guided follicle aspiration

Complications and problems in the first 181 transvaginal sector scan-guided follicle aspirations in a recently established in vitro fertilization (IVF) unit were studied. No major complications occurred and, in only 3% of patients, it appeared impossible to aspirate the follicles because of method-related problems (i.e., localization of ovaries too high above the vaginal top and/or ovaries too mobile). The method is easily mastered and the oocyte yield of this method is already high, even though it is early in the learning phase of the procedure. The mean duration of the procedure decreased from more than 30 minutes to less than 20 minutes in the first 7 months after the introduction of this technique in the IVF program. The authors believe this method soon will be the choice for follicle aspiration in all major IVF programs.

Transvaginal sector scan sonography for needle guided transvaginal follicle aspiration and other applications in gynecologic routine and research

A transvaginal sector scanner probe has been developed for precise needle-guided transvaginal follicle aspiration under sonographic control. The first results of transvaginal needle-guided follicle aspiration are presented. A high recovery rate was obtained (86% /follicle). The pregnancy rate after in vitro fertilization and embryo replacement was remarkably high (21.3%/cycle). Because exceptionally high-quality images of the organs in the pelvis are obtained, there are numerous other potential applications for the trans-vaginal sector scanner.

An experience of laparoscopic and transvesical oocyte retrieval in an in vitro fertilization program

Successful pregnancies have been achieved after in vitro fertilization of oocytes obtained by an ultrasound-guided transvesical approach, as well as with the traditional laparoscope. With the use of the same laboratory facilities, success rates for each retrieval method were evaluated in an established in vitro fertilization program. There was a significantly increased cancellation rate and a decrease in oocyte/follicle rate in the transvesical group, but there was a greater fertilization rate with possible improved embryo quality. Although the transfer rates were similar, the pregnancy rate appeared lower in the transvesical group. A valid comparison of these data is not possible because the two groups are dissimilar for factors known to influence oocyte development and recovery. Different criteria were applied to patient selection and treatment, and operation expertise differed between the two groups.

Transvaginal sonographically controlled follicle puncture for oocyte retrieval

Transvaginal sonographically guided follicle aspiration under local anesthesia was performed on more than 100 patients and compared favorably with the other techniques that have been proposed to retrieve oocytes for in vitro fertilization. Sonography employs a sector scanner placed on the abdomen, and the needle is introduced through the posterior fornix of the vagina into the cul-de-sac and the ovary. In case of a high ovary, a transvaginal-transvesical variation may be used. The method is not painful and is easy to learn and perform. The sole adverse incidents have involved inadvertent venous puncture with no sequelae. The number and quality of recovered oocytes are good, and five normal children conceived after this method of retrieval were recently born. The technique permits substantial simplification of egg recovery for in vitro fertilization, which can now be performed in an outpatient setting without the risk and expense of laparoscopy and general anesthesia or the discomfort of transabdominal-transvesical ultrasound-guided aspiration.

Contributions of Ultrasound to In Vitro Fertilization Programs

The process of in vitro fertilization (IVF) and embryo transfer (ET) has gained worldwide attention since the birth of the first "test-tube baby" in 1978. Many couples with a history of infertility have elected to undergo this procedure. This article examines the process of IVF/ET and the role of ultrasound in monitoring follicular growth and in the retrieval of the oocytes by laparoscopy or sonographically guided transvesical or transvaginal needle aspiration.