Hum. Reprod. Advance Access originally published online on August 29, 2006
Human Reproduction 2006 21(11):2969-2971; doi:10.1093/humrep/del252
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Uro-retroperitoneum after ultrasound-guided transvaginal follicle puncture in an oocyte donor: A Case Report
1 Service de Gynécologie Obstétrique et Médecine de la Reproduction and 2 Service de Radiologie, Hôpital Tenon, Paris, France
3 To whom correspondence should be addressed at: Service de Gynécologie Obstétrique et Médecine de la Reproduction, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France. E-mail: ofiori{at}freesurf.fr and olivia.fiori{at}tnn.ap-hop-paris.fr
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Abstract |
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Ultrasound-guided transvaginal follicle aspiration is the standard technique for oocyte retrieval prior to IVF. Complications are rare, but some are potentially serious. We report a case of ureteral injury with acute-onset uro-retroperitoneum in a volunteer oocyte donor. The patient recovered rapidly after ureteral stenting. This case underlines the need for all candidate oocyte donors to receive proper information on serious procedure-related complications.
Key words: IVF/oocyte retrieval/transvaginal follicle aspiration/ultrasound/uro-retroperitoneum
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Introduction |
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Ultrasound-guided transvaginal follicle aspiration is the standard oocyte retrieval procedure for IVF. Although less invasive than laparoscopic retrieval, it is not devoid of potentially serious complications such as haemorrhage, pelvic infection and injury of pelvic structures (El-Shawarby et al., 2004
). We report a case of ureteral injury following transvaginal follicle puncture in an unpaid volunteer oocyte donor.
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Case report |
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A 33-year-old woman with a history of two spontaneous pregnancies, delivered twice by Caesarean section, gave her informed consent to participate in an anonymous voluntary unpaid oocyte donation program in the IVF department of our institution. She had no other relevant medical history, especially no endometriosis or renal pathology.
Ovarian stimulation was based on a short flare regimen with daily injection of a GnRH agonist (triptorelin, Decapeptyl; Beaufour Ipsen Pharma, Paris, France) and recombinant FSH (Puregon; Organon, France). Ovulation was triggered with recombinant hCG (Ovitrelle 250 µg; Serono, France) after 13 days of GnRH treatment, with a peak serum estradiol level of 2030 pg/ml. After bladder probing, ultrasound-guided transvaginal follicular puncture was performed under general anaesthesia. No prophylactic antibiotic therapy was used. No intraoperative complications were noted, and ten oocytes were retrieved.
Two hours after the procedure, the patient complained of severe abdominal pain and dysuria. The central temperature and blood pressure were normal, and she had mild tachycardia. Abdominal and pelvic examinations were normal. There was no vaginal bleeding and no vesical globe. Abdomino-pelvic sonography showed two enlarged multicystic ovaries, with no significant fluid in the pouch of Douglas. Intravenous analgesia was started (paracetamol), and she was kept in hospital overnight for observation. The next day, she was febrile (38.4°C) and had nausea, vomiting, urinary urgency and bladder tenesmus. Physical examination disclosed abdominal guarding in the right iliac fossa. Laboratory analysis showed leukocytosis (18 300/mm3) and a normal C-reactive protein level and haematocrit. Intravenous antibacterial therapy was started with ofloxacin and metronidazole. Her temperature normalized on day 2, but the leukocyte count had increased further (23 200/mm3), and the C-reactive protein level was also elevated (108 mg/ml). On day 3, magnetic resonance imaging (MRI) showed two enlarged ovaries, a right latero-uterine collection in the broad ligament and dilation of the right urinary tract collection system (Figure 1). Abdomino-pelvic helical computerized tomography (CT) confirmed the right-sided latero-uterine collection and dilation of the pyelocaliceal cavities. Delayed helical CT showed marked leakage of contrast medium through a right pelvic-ureter lesion near the vesico-ureteral junction (Figure 2).
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Cystoscopy and right ureteral stenting led to significant pain relief. The patient was discharged on post-operative day 8, and the ureteral stent was removed 10 weeks later.
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Discussion |
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Ultrasound-guided transvaginal oocyte retrieval was first described in 1985 by Wikland (Wikland et al., 1985
), and a large series subsequently confirmed its simplicity, efficacy and safety (El-Shawarby et al., 2004). The main complications of this minimally invasive technique are haemorrhage and pelvic abscess, which occur in 0.08 and 0.6% of procedures, respectively (Bennett et al., 1993; Dicker et al., 1993). Injuries of the bowel, bladder and pelvic vessels have occasionally been reported (Bergh and Lundkvist, 1992; Van Hoorde et al., 1992; Schenker and Ezra, 1994; Akman et al., 1995; Azem et al., 2000).
Among the four previously reported cases of ureteral damage during follicular puncture in infertile women (Jones et al., 1989; Coroleu et al., 1997; Fugita and Kavoussi, 2001; Miller et al., 2002), only one was diagnosed in the immediate post-operative period (Miller et al., 2002). Acute or persistent abdominal pain after follicular puncture, as in our patient, is suggestive of haemoperitoneum, which is confirmed by the presence of free peritoneal fluid on sonography. If this latter sign is absent, and especially if the patient has digestive and/or urinary disorders, differential diagnoses include damage to retroperitoneal anatomical structures such as a vessel or ureter. However, in the IVF setting, pelvic ultrasound is hindered by changes in ovarian volume and structure due to superovulation and follicular puncture.
In the other three cases reported in the literature (Jones et al., 1989; Coroleu et al., 1997; Fugita and Kavoussi, 2001), the diagnosis of ureteral injury was made between 5 days and 4 months. A combination of immediate irritative urinary symptoms, leukocytosis and negative urine culture is suggestive of urinary tract injury. In addition to renal sonography, uro-CT and MRI can help with the diagnosis, thereby permitting immediate conservative management by ureteral stenting. Late diagnosis can lead to infection and renal dysfunction. More extensive surgery may be required, such as ureteral reimplantation into the bladder or nephrectomy (Jones et al., 1989; Coroleu et al., 1997; Fugita and Kavoussi, 2001).
This risk of rare but potentially severe complications of follicular puncture raises specific ethical and medico-legal issues, especially when the donor is an unpaid volunteer. In France, no financial compensation is offered to blood or tissue donors. Most donors are motivated by the plight of a family member or close friend, whose only chance to conceive is through an oocyte donation. Proper information on the risks of such procedures must be given to volunteer oocyte donors, who have no direct benefit other than the personal satisfaction of helping an infertile couple (Jordan et al., 2004).
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References |
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Akman MA, Katz E, Damewood MD, Ramzy AI, Garcia JE. (1995) Perforated appendicitis and ectopic pregnancy following in-vitro fertilization. Hum Reprod 10:3325–3326.
Azem F, Wolf Y, Botchan A, Amit A, Lessing JB, Kluger Y. (2000) Massive retroperitoneal bleeding: a complication of transvaginal ultrasonography-guided oocyte retrieval for in vitro fertilization-embryo transfer. Fertil Steril 74:405–406.[CrossRef][Web of Science][Medline]
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Van Hoorde GJ, Verhoeff A, Zeilmaker GH. (1992) Perforated appendicitis following transvaginal oocyte retrieval for in-vitro fertilization and embryo transfer. Hum Reprod 7:850–851.
Wikland M, Enk L, Hamberger L. (1985) Transvesical and transvaginal approaches for the aspiration of follicles by use of ultrasound. Ann N Y Acad Sci 442:182–194.[Web of Science][Medline]
Submitted on February 23, 2006; resubmitted on May 20, 2006; accepted on May 25, 2006.
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