Skip Navigation


Hum. Reprod. Advance Access originally published online on September 23, 2004
Human Reproduction 2004 19(12):2942-2945; doi:10.1093/humrep/deh526
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF ) Freely available
Right arrow All Versions of this Article:
19/12/2942    most recent
deh526v1
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by Yasmin, E.
Right arrow Articles by Balen, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Yasmin, E.
Right arrow Articles by Balen, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Human Reproduction vol. 19 no. 12 © European Society of Human Reproduction and Embryology 2004; all rights reserved

Sedation and anaesthesia for transvaginal oocyte collection: an evaluation of practice in the UK

Ephia Yasmin1, Martin Dresner2 and Adam Balen1,3

1 Reproductive Medicine Unit and 2 Department of Anaesthesia, Leeds General Infirmary, Leeds LS2 9NS, UK

3 To whom correspondence should be addressed. Email: adam.balen{at}leedsth.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 Appendix. The questionnaire
 References
 
BACKGROUND: The objective of the survey was to evaluate sedation and anaesthetic practice employed for oocyte collection in the different assisted conception units in the UK and whether the guidelines of safe sedation were adhered to. METHODS: A survey was carried out by means of a postal questionnaire sent out to the 100 reproductive medicine units of the UK, and 67 of the units responded. RESULTS: A response rate of 67% was achieved. Seventy-seven percent of responding units were part of hospitals with resuscitation facilities; 23% were free-standing without an in-house resuscitation team. Intravenous sedation was the preferred method of sedation for oocyte collection, being used in 62.4% of units. General anaesthesia was the primary method in 24.6% of units. A total of 47.4% of units used a medical member of the reproductive medicine team for administering sedation; 69% of cases were performed in a facility within the unit. One-hundred percent of respondents had oxygen, suction and tilting trolleys. It was reported that 23% of units were free standing, without cover from a resuscitation team. Sedation was performed by non-anaesthetic doctors in 46% and by nurses in 8.2%. In 69%, collections were performed outside of a general operating theatre environment. Also, 4.8% of units had no resuscitation trolley and 21.4% no defibrillator. CONCLUSION: Though most units complied with the guidelines of safe sedation and anaesthesia, gaps have been observed in the safe provision of sedation services for women undergoing oocyte retrieval in some units.

Key words: anaesthesia/conscious sedation/oocyte retrieval


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Conclusion
 Appendix. The questionnaire
 References
 
Oocyte retrieval forms one of the most vital aspects of IVF. Great efforts have been made to make the procedure safe and as comfortable for the patient as possible. The replacement of laparoscopic retrieval by the transvaginal route under ultrasound guidance was a great step forward. The use of ‘conscious sedation’ as a means of pain control and anxiolysis, with or without local anaesthesia/paracervical block, reduces some of the risks associated with deep sedation or general anaesthesia. However, conscious sedation is still not without its hazards, and appropriate precautions must be taken to minimize risk.

In the huge volume of literature on assisted reproduction technology, there is a paucity of studies on the evaluation of the different methods of pain relief during oocyte retrieval. The ideal method of pain relief would be one that is (i) safe, providing adequate pain relief with minimal side effects and complications; (ii) easy to administer and monitor; (iii) short acting and easily reversible; and (iv) without deleterious effects on oocytes and embryos.

The primary concern of safety is governed by the type, number and quantity of drugs, the personnel administering them and monitoring the patients, and the kind of infrastructure available at the site of oocyte collection.

In November 2001, the Academy of Royal Colleges published a report on safe sedation practices on health care in adults. Previously published guidelines were reviewed and evidence of continued poor standards in sedation was discussed. Some general recommendations and new measures were proposed. The rationale for this report was a history of deaths during and after procedures under sedation typified by one survey of 14 000 endoscopic procedures that revealed a 30-day mortality of 1 in 2000 from cardio-respiratory problems (Bell et al., 1991Go).

Is this topic important to workers in reproductive medicine? The patient population presenting for procedures under sedation in reproductive medicine is relatively young and healthy, and serious morbidity, let alone mortality, appears to be rare. However, just one critical incident due to sedation would be a disaster for all involved, and the consequences for the specialty far reaching. A previous survey (Elkington et al., 2003Go) noted a great deal of variation in personnel present during the procedure, the use of drugs, the degree of monitoring and the availability of emergency drugs. Given the renewed focus on safe sedation, we aimed to produce a basic description of current practice and facilities used for sedation in UK reproductive medicine, and to assess the deficits highlighted in the earlier surveys from which further enquiries can be targeted and recommendations considered. We also wanted to evaluate the drugs that were being used for anaesthesia/sedation. Concentrations of the drugs have been demonstrated in the follicular fluid at the time of oocyte retrieval (Christiaen et al., 1999Go; Ben Shlomo et al., 2000Go).


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Conclusion
 Appendix. The questionnaire
 References
 
A questionnaire (Appendix) was mailed to all 100 UK Reproductive Medicine Units listed with the Human Fertilization and Embryology Authority (HFEA), to be returned anonymously in a stamped addressed envelope. Sixty-seven replies were received.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Conclusion
 Appendix. The questionnaire
 References
 
Four questionnaires were excluded from analysis because the responding units did not perform oocyte retrievals.

Seventy-seven percent of responding units were part of a hospital with resuscitation facilities; 23% of the units responding were free-standing units without an in-house resuscitation team.

I.v. sedation was the preferred method of sedation for oocyte collection, being used in 62.4% of units. General anaesthesia was the primary method in 24.6% of units, 2.8% used either general or i.v. sedation, and another 5% combined i.v. sedation with a paracervical block. One respondent (1.6%) used spinal anaesthesia with i.v. sedation and 3.6% used i.m. analgesics with i.v. sedation.

Of those units using i.v. sedation, 39 out of the 46 (84.8%) employed a combination of two drugs, usually midazolam in combination with fentanyl, alfentanil, pethidine or propofol. More than two sedative drugs were used in 10.85% of units (Figure 1).



View larger version (10K):
[in this window]
[in a new window]
  		Figure 1. Number of different drugs preferred for i.v. sedation.

 
A total of 47.4% of units had a medical member of the reproductive medicine team administering sedation, sometimes working with a nurse or supervising a nurse; 44.4% used anaesthetists and 8.2% of units indicated that a nurse independently administered sedation (Figure 2). One unit did not respond to this question.



View larger version (9K):
[in this window]
[in a new window]
  		Figure 2. Person/persons performing anaesthesia/sedation: (1) medical member; (2) anaesthetist; (3) nurse.

 
Most oocyte retrievals were performed within assisted conception units (69%). However, the remaining 31% were performed within an operating theatre complex. Two units used both places for their egg collections.

Units were asked if oxygen, suction, a tilting operating table, resuscitation trolley and a defibrillator were available to them at the site of oocyte collection. All units possessed oxygen, suction and a tilting operating table, with 78.6% having all five facilities. However, 4.8% had no resuscitation trolley and 21.4% had no defibrillator (Figure 3).



View larger version (14K):
[in this window]
[in a new window]
  		Figure 3. Type of facilty in the oocyte collection areas: (1) oxygen; (2) suction; (3) tilting operating table; (4) resuscitation trolley; (5) defibrillator.

 
Units were asked if oxygen, suction and a tilting trolley were available for each patient in recovery, and if the attending nurses had formal recovery or resuscitation training. The results are shown in Figure 4 and indicate that 3.3% of units had none of these facilities.



View larger version (10K):
[in this window]
[in a new window]
  		Figure 4. Type of facility in recovery area: (1) oxygen for every patient; (2) suction for every patient; (3) tilting bed or trolley; (4) nurse with formal recovery or resuscitation training; (5) no facility.

 

   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Conclusion
 Appendix. The questionnaire
 References
 
Conscious sedation has gained acceptance in the short-term management of pain in the field of internal medicine and dentistry (Bell et al., 1991Go; Quine et al., 1995Go; Independent Expert Working Group, 2000Go) with well established guidelines. It has also evolved as a popular method of pain control for oocyte collection in IVF (Ben Shlomo et al., 1992Go; Gohar et al., 1993Go; Ditkoff et al., 1997Go; Bokhari and Pollard, 1999Go). Trout et al. (1998)Go have strongly advocated the use of conscious sedation as it has so far proved appropriate in terms of safety as well as ease of administration. The present survey has revealed that the variability in use of sedation and anaesthesia and type of personnel administering it present during the earlier surveys (Bokhari and Pollard, 1999Go; Elkington et al., 2003Go) still persists.

When these findings are compared with the practical recommendations in many of the published guidelines, it shows some obvious deficiencies. Free-standing units and those isolated from operating theatre departments may not have the in-house skill to deal with serious cardio-respiratory complications of sedation, unless anaesthetists are present. This is not always a practical or economically viable solution for many units, so existing staff, training and facilities need to be improved in some units. Formal training in sedation and resuscitation, the availability of appropriate equipment, and on-going audit of complications and compliance with protocols are vital. Even within hospitals where resuscitation staff are available, shortfalls in basic resuscitation equipment, particularly in the recovery area, cannot be treated with complacency.

The Intercollegiate Report on Safe Sedation Practice made several new recommendations, which include the following:

  • Royal Colleges in association with the relevant subspecialty organizations should develop guidelines on sedation methods appropriate to clinical practice in the sphere of influence.
  • Royal Colleges and their Faculties should incorporate necessary instruction and assessment into training and revalidation programmes of those specialties that use sedation techniques.
  • The clinical governance framework should deliver safe sedation practice at hospital level by enabling a patient-centred culture in which:
    multidisciplinary team training ensures that all staff understand their roles;
    those who actually administer sedative drugs are aware of the possible adverse consequences and are able to deal with these; and
    audit of adverse incidence, complications (particularly severe ones such as admission to intensive care) and adherence to agreed national and local protocols promotes continuous quality improvement.
  • Each hospital should nominate two consultants, one an anaesthetist and the other a user of sedation, to collaborate in the local implementation of guidelines and the provision of a specialist service for patients with particular problems.

The second issue governing mode of pain control is the effect of the agents used on outcome such as number of oocytes retrieved, fertilization and cleavage rates, and pregnancy outcome. Use of halothane and neuroleptic analgesia has been studied and deemed unfit for oocyte retrieval (Naito et al., 1989Go). Use of general anaesthesia with NO2 is also considered to have an adverse outcome leading to reduced pregnancy rates (Gonen et al., 1995Go). During paracervical blocks, the concentrations of lidocaine found in follicular fluid have not revealed any detrimental effect on oocytes (Wikland et al., 1990Go). A prospective randomized, placebo-controlled study by Ng et al. (1999)Go has observed lower abdominal pain scores without any negative effect on pregnancy rates when paracervical block with lignocaine is combined with i.v. sedation. The effect of propofol has been a matter of debate. Concentration of propofol has been demonstrated in the follicular fluid in a number of studies (Coetsiev et al., 1992; Christiaen et al., 1999Go; Ben-Shlomo et al., 2000Go). Ben-Shlomo et al. (2000)Go found no difference in fertilization, cleavage and embryo cell number, while Vincent et al. (1995)Go demonstrated lower pregnancy rates with propofol than with isoflurane for laparoscopic embryo transfer. Ben-Shlomo et al. (1999) compared general anaesthesia with sedation and found a comparable number of oocytes retrieved and no difference in rate of embryo transfers and pregnancies. Studies of human and non-human oocytes have revealed no deleterious effects with the drugs generally used in conscious sedation such as fentanyl and midazolam (Bruce et al., 1985Go; Swanson and Leavitt, 1992Go; Chopineau et al., 1993Go). There remains the possibility that anaesthetic during oocyte retrieval can influence the results of IVF, and more studies are required in this field.


   Conclusion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
Appendix. The questionnaire
 References
 
Conscious sedation is an accepted mode of pain control during oocyte retrievals. Trout et al. (1998)Go strongly advocate the use of conscious sedation for oocyte retrieval taking into consideration its safety and ease of administration. Our survey has revealed a good level of facilities in reproductive medicine units that perform sedation, with some indication of deficiencies. Generally conscious sedation precludes the need for highly sophisticated and expensive equipment, but we suggest that, despite the probable lower level of risk compared with sedation in some other clinical areas, there is an urgent need to comply with the recommendations above. Once specific standards are published, and scrutiny takes place at the local level, small equipment shortfalls will be rapidly addressed. Training issues are more complicated and will require significant resources. The involvement of anaesthetists may also not be straight forward, in that the majority have no experience or current input into reproductive medicine.


   Appendix. The questionnaire
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 Appendix. The questionnaire
References
 

  1. Is your unit free-standing, without an in-house resuscitation team YES/NO
  2. Is your unit part of a hospital with resuscitation facilities YES/NO
  3. What is your routine, principal method of increasing comfort during egg collection?
    1. General anaesthesia
    2. Oral or intramuscular sedatives and analgesics
    3. Intravenous sedation
    4. Local anaesthetic techniques such as spinal anaesthesia
    5. Other (please specify)

  4. If answered (ii) or (iii), which are the drugs employed





  5. Who usually performs the technique in question 3?
    1. A medical member of the infertility team
    2. A nurse
    3. An anaesthetist
    4. Other (please specify)

  6. Where are your egg collections performed?
    1. An operating theatre within a larger theatre block
    2. In a facility within the assisted conception unit

  7. If you ticked (ii) for the last question, which of the following facilities are available
    1. Oxygen
    2. Suction
    3. A tilting operating table
    4. A resuscitation trolley
    5. A defibrillator

  8. In the recovery area, which of the following criteria are satisfied?
    1. Oxygen available for every patient
    2. Suction available for every patient
    3. A tilting bed or trolley
    4. A nurse with formal recovery or resuscitation training


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 Appendix. The questionnaire
 References
 
Academy of Medical Royal Colleges (2001) Report of an intercollegiate Working Party Chaired by the Royal College of Anaesthetists. Implementing and Ensuring Safe Sedation practice for Healthcare Procedures in adults AOMRC, London.

Bell GD, McCloy RF, Charlton JE, Campbell D, Dent NA, Gear MWL and Logan RFA (1991) Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. Gut 32, 823–827.[Abstract/Free Full Text]

Ben Shlomo I, Amodai I, Levran D, Dor J, Echkin A and Perl AZ (1992) Midazolam–fentanyl sedation in conjunction with local anaesthesia during oocyte retrieval for in vitro fertilization. J Assist Reprod Genet 9, 83–85.[CrossRef][Web of Science][Medline]

Ben Shlomo I, Moskovich R, Golan J, Eyali V, Tabak A and Shalev E (2000) The effect of propofol anaesthesia on oocyte fertilization and early embryo quality. Hum Reprod 15, 2197–2199.[Abstract/Free Full Text]

Ben Shlomo I, Moskovich R, Katz Y and Shalev E (1999) Midazolam/ketamine sedative combination compared with fentanyl/propofol/isoflurane anaesthesia for oocyte retrieval. Hum Reprod 14, 1757–1759.[Abstract/Free Full Text]

Bokhari A and Pollard BJ (1999) Anaesthesia for assisted conception: a survey of UK practice. Eur J Anaesthesiol 16, 225–230.[CrossRef][Web of Science][Medline]

Bruce DL, Hinkley R and Norman PF (1985) Fentanyl does not inhibit fertilization or early development of sea urchin eggs. Anesth Analg 64, 498–500.[Abstract/Free Full Text]

Chopineau J, Bazin JE, Terrisse MP, Sautou V, Janny L, Schoeffler P et al. (1993) Assay for midazolam in liquor folliculi during in vitro fertilization under anesthesia. Clin Pharm 12, 770–773.[Web of Science][Medline]

Christiaens F, Janssenswillen C, Verborgh C, Moerman I, Devroey P, Van Steirteghem A and Camu F (1999) Propofol concentrations in follicular fluid during general anaesthesia for transvaginal oocyte retrieval. Hum Reprod 14, 345–348.[Abstract/Free Full Text]

Costier T, Dhont M, De Sutter P, Merchiers E, Versichelen L and Rosseel MT (1992) Propofol anaesthesia for ultrasound guided oocyte retrieval: accumulation of the anaesthetic agent in follicular fluid. Hum Reprod 7, 1422–1424.[Abstract/Free Full Text]

Ditkoff EC, Plumb J, Selick A and Sauer MV (1997) Anesthesia practices in the United States common to in vitro fertilization (IVF) centers. J Assist Reprod Genet 14, 145–147.[Web of Science][Medline]

Elkington NM, Kehoe J and Acharya U (2003) Intravenous sedation in assisted conception units: a UK survey. Hum Fertil 6, 74–76.

Gohar J, Lunenfield E, Potashik G and Glezerman M (1993) The use of sedation only during oocyte retrieval for in vitro fertilization: patient's pain self assessments versus doctor's evaluations. J Assist Reprod Genet 10, 476–478.[CrossRef][Web of Science][Medline]

Gonen O, Shulman A, Ghelter Y, Shapiro A, Judeiken R, Beyth Y, Ben-Nun I (1995) The impact of different types of anaesthesia on in vitro fertilization-embryo transfer treatment outcome. J Assist Reprod Genet 12, 678–682.[CrossRef][Web of Science][Medline]

Independent Expert Working Group (2000) Standards in Conscious Sedation for Dentistry.

Naito Y, Tamai S, Fukata J, Seo N, Nakai Y, Imura H, Mori K (1989) Comparison of endocrinological stress response associated with transvaginal ultrasound oocyte pick-up under halothane anaesthesia and neuroleptanaesthesia. Can J Anaesth 36, 633–636.[Web of Science][Medline]

Ng Yu Hung Ernest, Tang Shan Oi, Chui Chi Kwai David and Ho Chung Pak (1999) A prospective, randomized, double-blind and placebo controlled study to assess the efficacy of paracervical block in the pain relief during egg collection in IVF. Hum Reprod 14, 2783–2787.[Abstract/Free Full Text]

Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB and Hopkins A (1995) A prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing and sedation methods. Gut 36, 462–467.[Abstract/Free Full Text]

Report of an Independent Expert Working Group, October 2000. Standards in Conscious Sedation for Dentistry. Published by Society for the Advancement of Anaesthesia in Dentistry, London.

Robinson JN, Forman RG, Lockwood GM, Hickey JB, Chapman MG and Barlow DH (1991) A comparison of the transient hyperprolactinaemic stress response obtained using two different methods of analgesia for ultrasound guided transvaginal oocyte retrieval. Hum Reprod 6, 1291–1293.[Abstract/Free Full Text]

Swanson RJ and Leavitt MG (1992) Fertilization and mouse embryo development in the presence of midazolam. Anesth Analg 75, 549–554.[Abstract/Free Full Text]

Trout SW, Vallerand AH and Kemmann E (1998) Conscious sedation for in vitro fertilization. Fertil Steril 69, 799–808.[CrossRef][Web of Science][Medline]

Vincent RD, Syrop CH, Van Voorhis BJ, Chestnut DH, Sparks AE, McGrath JM et al. (1995) An evaluation of the effect of anaesthetic technique on reproductive success after laparoscopic pronuclear stage transfer. Propofol/nitrous oxide versus isoflurane/nitrous oxide. Anaesthesiology 82, 352–358.[CrossRef][Web of Science][Medline]

Wikland M, Evers H, Jakobsson AH, Sandqyist U, Sioblom P (1990) The concentration of lidocaine in follicular fluid when used for paracervical block in a human IVF-ET programme. Hum Reprod 5, 920–923.[Abstract/Free Full Text]

Submitted on June 3, 2004; accepted on August 20, 2004.


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF ) Freely available
Right arrow All Versions of this Article:
19/12/2942    most recent
deh526v1
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by Yasmin, E.
Right arrow Articles by Balen, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Yasmin, E.
Right arrow Articles by Balen, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?