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Transvaginal oocyte retrieval is an outpatient procedure performed under local anaesthesia. Hypno-analgesia could be effective in managing comfort during this procedure. This study aimed to assess the effectiveness of a virtual reality headset as an adjunct to local anaesthesia in managing nociception during oocyte retrieval. This was a prospective, randomized single-centre study including patients undergoing oocyte retrieval under local anaesthesia. Patients were randomly assigned to the intervention group (virtual reality headset + local anaesthesia) or the control group (local anaesthesia). The primary outcome was the efficacy on the ANI ® , which reflects the relative parasympathetic tone. Secondary outcomes included pain, anxiety, conversion to general anaesthesia rate, procedural duration, patient's and gynaecologist's satisfaction and virtual reality headset tolerance. ANI was significantly lower in the virtual reality group during the whole procedure (mean ANI: 79 95 CI [77; 81] vs 74 95 CI [72; 76]; p < 0.001; effect size Cohen's d -0.53 [-0.83, -0.23]), and during the two most painful moments: infiltration (mean ANI: 81 +/- 11 vs 74 +/- 13; p < 0.001; effect size Cohen's d -0.54[-0.85, -0.24]) and oocytes retrieval (mean ANI: 78 +/- 11 vs 74.40 +/- 11; p = 0.020; effect size Cohen's d -0.37 [-0.67, -0.07]).There was no significant difference in pain measured by VAS. No serious adverse events related were reported. The integration of virtual reality as an hypnotic tool during oocyte retrieval under local anaesthesia in assisted reproductive techniques could improve patient's comfort and experience., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Study Question: Can we monitor post-oocyte retrieval infections in the French national health data system to complement the French ART vigilance system?, Summary Answer: Medico-administrative databases provide a more comprehensive view of post-oocyte retrieval infections and can be used to detect abnormal increases in frequency and outlier ART centers as a complementary tool to the ART vigilance system., What Is Known Already: The various studies of ART complications are reassuring, showing relatively low overall complication rates. Nonetheless, the European Union has set up a vigilance system to monitor these complications. However, this system is not an exhaustive source of information and does not provide a complete overview of post-ART complications., Study Design, Size, Duration: The study population was identified from the comprehensive French national hospital discharge database. It included women under 46 years of age undergoing an oocyte retrieval in 2019, classified into three population subgroups according to the indication of oocyte retrieval: infertility (IF) , fertility preservation (FP), and oocyte donation (OD) . The study population included 52 098 women who had undergone 65 948 oocyte retrievals in 2019., Participants/materials, Setting, Methods: Hospital stays and delivery of antibiotics within 31 days after oocyte retrieval were analyzed. Women and infections were characterized according to various characteristics (age, comorbidities, indication of oocyte retrieval, type of hospital stay, length of hospital stay, type of antibiotherapy, etc.). Multivariate analysis was performed to determine the relation between the occurrence of infection and women's characteristics, and results are expressed as odds ratios (ORs) and 95% CI. A funnel plot and a box plot were used to compare the infection rate per center with the national average and to detect outliers., Main Results and the Role of Chance: Infections in the month following the oocyte retrieval represented 6.9% of the procedures in 2019 (n = 4522). Of these infections, 112 were hospitalized (0.2% of oocyte retrievals), and 4410 were non-hospitalized (6.7% of oocyte retrievals). The hospitalized infections were essentially gynecological infections (40.9%) and urinary tract infections (23.5%). In 87.9% of non-hospitalized infections, a single antibiotic therapy was prescribed. Mixed-effect model analysis showed that the risk of infection was significantly higher in women under 30 years of age, in the FP population, in supplementary universal health coverage (CMU-C) beneficiaries, and women with endometriosis. Funnel plot and box plot analysis showed that three ART centers have an infection rate significantly higher than the national average. In the three centers that stand out from all the others, the objective is to return to these centers to understand the possible reasons for this observed rate and to implement corrective measures., Limitations, Reasons for Caution: Despite all its advantages, the French national health data system presents some limitations, such as the risk of inappropriate coding. Another limitation of this study is that we cannot confirm an attributable relation between the infection and the ART procedure, even if the delay of 31 days after oocyte retrieval is consistent with the occurrence of a post-retrieval complication. In addition, antibiotics may be prescribed as a 'precautionary' measure in certain situations (women with a susceptibility to infection, complicated procedures), or as antibiotic prophylaxis for embryo transfer., Wider Implications of the Findings: Despite the limits in identifying post-ART infections in medico-administrative databases, this approach is a promising way to complement the ART vigilance reporting system. This concept developed for infections will also be generalized to other complications with regular feedback to professionals., Study Funding/competing Interest(s): No specific funding was sought for the study. The study was supported by the Agence de la biomédecine, France. The authors declare that they have no conflict of interest., Trial Registration Number: N/A., (© The Author(s) 2023. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Transvaginal oocyte retrieval is frequently followed by adverse events related to anesthesia and the procedure. Some research showed that transcutaneous electrical acupoint stimulation (TEAS) can relieve intraoperative pain and postoperative nausea., Objective: This study examined whether TEAS can alleviate pain and relieve adverse symptoms after oocyte retrieval., Design, Setting, Participants and Interventions: Altogether 128 patients were randomly divided into the TEAS group and the mock TEAS group. The two groups received a 30-minute-long TEAS or mock TEAS treatment that began 30 min after oocyte retrieval., Main Outcome Measures: The primary outcome was the visual analog scale (VAS) pain score. Secondary outcomes were pressure pain threshold, McGill score, pain rating index (PRI), present pain intensity (PPI), VAS stress score, VAS anxiety score, and postoperative adverse symptoms., Results: The baseline characteristics of the two groups were comparable (P > 0.05). The VAS pain scores of the TEAS group were lower than those of the mock TEAS group at 60 and 90 min after oocyte retrieval (P < 0.05). The McGill score, PRI and PPI in the TEAS group were significantly lower than those in the control group at 60 min after oocyte retrieval (P < 0.05). However, the two groups had equivalent beneficial effects regarding the negative emotions, such as nervousness and anxiety (P > 0.05). The TEAS group was superior to the mock TEAS group for relieving postoperative adverse symptoms (P < 0.05)., Conclusion: TEAS treatment can relieve postoperative pain and postoperative adverse symptoms for patients undergoing oocyte retrieval. Please cite this article as: Liu LY, Su Y, Wang RR, Lai YY, Huang L, Li YT, Tao XY, Su MH, Zheng XY, Huang SC, Wu YN, Yu SY, Liang FR, Yang J. Transcutaneous electrical acupoint stimulation benefits postoperative pain relief of oocyte retrieval: A randomized controlled trial. J Integr Med. 2024; 22(1): 32-38., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Shanghai Yueyang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. Published by Elsevier B.V. All rights reserved.)

Transvaginal ultrasound-guided oocyte retrieval is the gold-standard technique for oocyte retrieval that has few associated procedural and post-procedural complications. Rarely, severe complications can occur including haemoperitoneum, for which the incidence reported in the literature is approximately 0.08-0.22%. In this report, we present the case of a nulliparous woman in her late 30s who presented to the hospital with severe abdominal pain following transvaginal ultrasound-guided oocyte retrieval and was found to have extensive haemoperitoneum attributed to ovarian rupture., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Obesity is one of the main concerns for public health and is becoming an increasingly widespread problem worldwide. Women are more likely to require a cesarean section and have a longer hospital stay after delivery. Excess body weight can interfere with ovulation and make it more difficult for embryos to implant in the uterus. A high body mass index (BMI) has controversial effects on the outcomes of medically assisted reproduction treatments (IVF) and, if careful counseling is not performed, medical-legal risks may be incurred. While some researchers argue that obesity does not particularly affect ART outcomes, other studies claim that a high BMI does not interfere with embryonic development. Both the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) has stated that there is no clear evidence supporting a BMI limit for IVF treatment and that each patient should be evaluated on an individual basis. The purpose of our study was to evaluate whether performing in vitro fertilization on these patients increases the risk of medical, surgical, and anesthetic complications of oocyte retrieval., Patients and Methods: From January 2011 to December 2022, all patients with BMI higher than 25 were enrolled in the study (n=766). Complications and risks related to oocyte retrieval were evaluated, and patients were divided according to BMI groups., Results: With the one-way ANOVA test, all groups were compared with the control group, and none showed statistically significant differences, only the number of produced embryos in the BMI group between 30-34.9 was lower and statistically significant., Conclusions: Only one study has analyzed these aspects, mainly focusing on the need for anesthesia drugs and any related complications, and the same author reported greater difficulty in performing oocyte retrieval. The same study recorded an increase in incomplete oocyte retrievals. Our work does not confirm any of these impressions.

General anesthesia is frequently administered during oocyte retrieval. Its effects on the outcomes of IVF cycles are uncertain. This study investigated whether administration of general anesthesia (specifically propofol) during oocyte retrieval affects IVF outcomes. A total of 245 women undergoing IVF cycles were included in this retrospective cohort study. IVF outcomes of 129 women who underwent oocyte retrieval under propofol anesthesia and 116 without anesthesia were compared. Data were adjusted for age, BMI, estradiol on triggering day and total gonadotropin dose. The primary outcomes were fertilization, pregnancy and live birth rates. A secondary outcome was the efficiency of follicle retrieval associated with the use of anesthesia. Fertilization rate was lower in retrievals under anesthesia compared to without (53.4% ± 34.8 vs. 63.7% ± 33.6, respectively; p = 0.02). There was no significant difference in the ratio of expected to retrieved oocytes between retrievals with and without anesthesia (0.8 ± 0.4 vs. 0.8 ± 0.8, respectively, p = 0.96). The differences in pregnancy and live birth rates between the groups were not statistically significant. General anesthesia administered during oocyte retrieval may have adverse effects on the fertilization potential of oocytes. This impact on the developmental potential of oocytes may lead to negative IVF outcomes and should be investigated further., (© 2023. The Author(s).)

Outpatient procedures and flexible staffing models have become prevalent within the ambulatory surgical and procedural spaces of reproductive endocrinology and infertility practice. High volumes of outpatients are treated daily by rotating nurses, surgeons, and anesthesia staff, often with the added layer of trainees present. "Teaming" can allow stable units and ad hoc groups to partner better for enhanced efficiency, effectiveness, and patient experience in routine procedural activities. These skills then can be parlayed into the rare moments of crisis to improve safety outcomes. Teaming concepts, applied in routine and acute scenarios, can optimize clinical operations, patient experience, and outcomes in our reproductive endocrinology and infertility ambulatory procedural and surgical spaces., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the effect of preoperative intravenous (IV) acetaminophen versus oral (PO) acetaminophen or placebo on postoperative pain scores and the time to discharge in women undergoing oocyte retrieval., Design: Randomized, double-blind, placebo-controlled trial., Setting: Single academic fertility center., Patient(s): Women aged 18-43 years undergoing oocyte retrieval., Intervention(s): Randomization to preoperative 1,000 mg IV acetaminophen and PO placebo (group A), IV placebo and 1,000 mg PO acetaminophen (group B), or IV and PO placebo (group C) MAIN OUTCOME MEASURE(S): Difference in patient-reported postoperative visual analog scale pain scores from baseline and the time to discharge., Result(s): Of the 159 women who completed the study, there were no differences in the mean postoperative pain score differences or the time to discharge. Although not statistically significant, the mean postoperative opioid dose requirement in group A was lower than that in groups B and C (0.24 vs. 0.59 vs. 0.58 mg IV morphine equivalents, respectively) due to fewer women in group A requiring rescue pain medication (8% vs. 19% vs. 15%, respectively). Group A also reported less constipation when compared with groups B and C (19% vs. 33% vs. 40%, respectively). The rates of postoperative nausea were similar, and there were no differences in embryology or early pregnancy outcomes between the study groups., Conclusion(s): Preoperative IV acetaminophen for women undergoing oocyte retrieval did not reduce postoperative pain scores or shorten the time to discharge when compared with PO acetaminophen or placebo and, thus, cannot currently be recommended routinely in this patient population., Clinical Trial Registration Number: NCT03073980., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the ooplasm granulation patterns of donor oocytes, like those of oocytes from poor-prognosis patients, are predictive of in vitro fertilization (IVF) outcomes., Design: Retrospective cohort study., Setting: Academically affiliated private clinical infertility and research center., Patient(s): 770 fresh and 381 vitrified-thawed metaphase II oocytes from young donors (aged 21.0-34.6 years) used for IVF during 2017-2020., Intervention(s): Determination of granulation patterns in every oocyte during intracytoplasmic sperm injection as fine, central, uneven, dispersed, and peripheral (thawed only)., Main Outcome Measure(s): Fertilization, pregnancy, and live birth rates in fresh and thawed donor oocytes. Both overall and known-outcome analyses were performed for pregnancy and live birth., Result(s): In fresh donor oocytes, 2 pronuclei rates trended down from 96.1% to 90.2%, 88.9%, and 69.7% from fine to central, uneven, and dispersed granulations; overall pregnancy rates trended down from 50.4% to 29.0%, 17.7%, and 6.9%, as well as live birth rates (43.4%, 21.6%, 12.5%, and 6.4%), from fine to uneven, central, and dispersed granulations. Known pregnancy and known-live birth analyses showed similar findings. Thawed donor oocytes demonstrated similar trends in differences in fertilization, pregnancy, and live birth analyses with relatively worse outcomes. Peripheral granulation, unique to vitrification and thawing, always demonstrated the worst IVF outcomes. Moreover, granulation patterns were relatively disassociated from embryo morphological grades in fresh and largely disassociated in thawed donor oocytes., Conclusion(s): Predictive values of oocyte granulation patterns for fertilization, pregnancy, and live birth in IVF cycles are even more pronounced in young donors than results in older poor-prognosis patients, further supporting integration of oocyte granulation patterns into embryo selection., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To provide evidence-based recommendations to practicing physicians and others regarding the efficacy of oocyte cryopreservation (OC) for donor oocyte in vitro fertilization and planned OC., Methods: The American Society for Reproductive Medicine conducted a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1986 to 2018. The American Society for Reproductive Medicine Practice Committee and a task force of experts used available evidence and through consensus developed evidence-based guideline recommendations., Main Outcome Measure(s): Outcomes of interest included live birth rate, clinical pregnancy rate, obstetrical and neonatal outcomes, and factors predicting reproductive outcomes., Result(s): The literature search identified 30 relevant studies to inform the evidence base for this guideline., Recommendation(s): Evidence-based recommendations were developed for predicting the likelihood of live births after planned OC, autologous OC in infertile women, and donor OC, as well as factors that may impact live birth rates. Recommendations were developed regarding neonatal outcomes after using fresh vs. cryopreserved oocytes in cases of autologous or donor oocytes., Conclusion(s): There is insufficient evidence to predict live birth rates after planned OC. On the basis of limited data, ongoing and live birth rates appear to be improved for women who undergo planned OC at a younger vs. older age. Although there are no significant differences in per transfer pregnancy rates with cryopreserved vs. fresh donor oocytes, there is insufficient evidence that the live birth rate is the same with vitrified vs. fresh donor oocytes. Neonatal outcomes appear similar with cryopreserved oocytes compared with fresh oocytes. Future studies that compare cumulative live birth rates are needed., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the outcomes of planned oocyte cryopreservation patients most likely to have a final disposition., Design: Retrospective cohort study of all patients who underwent at least 1 cycle of planned oocyte cryopreservation between Jan 2005 and December 2009., Setting: Large urban University-affiliated fertility center PATIENT(S): All patients who underwent ≥1 cycle of planned oocyte cryopreservation in the study period., Intervention(s): None MAIN OUTCOME MEASURE(S): Primary outcome was the disposition of oocytes at 10-15 years. Secondary outcomes included thaw/warming types, laboratory outcomes, and live birth rates. Outcomes and variables treated per patient., Result(s): A total of 231 patients with 280 cycles were included. The mean age at the first retrieval was 38.2 years (range 23-45). A total of 3,250 oocytes were retrieved, with an average of 10 metaphase II frozen/retrieval. To date, the oocytes of 88 patients (38.1%) have been thawed/warmed, 109 (47.2%) remain in storage, 27 (11.7%) have been discarded, and 7 (3.0%) have been transported elsewhere. The return rate (patients who thawed/warmed oocytes) was similar by Society for Assisted Reproductive Technology age group. The mean age of patients discarding oocytes was 47.4 years (range, 40-57). Of the 88 patients who thawed/warmed oocytes, the mean age at the time of thaw/warming was 43.9 years (range, 38-50) with a mean of 5.9 years frozen (range, 1-12). Nine patients (10.2%) thawed/warmed for secondary infertility. A total of 62.5% of patients created embryos with a partner, and 37.5% used donor sperm. On average, 14.3 oocytes were thawed/warmed per patient, with 74.2% survival (range, 0%-100%) and a mean fertilization rate of 68.8% of surviving oocytes. Of 88 patients, 39 (44.3%) planned a fresh embryo transfer (ET); 36 of 39 patients had at least 1 embryo for fresh ET, and 11 had a total of 14 infants. Forty-nine of 88 patients (55.7%) planned for preimplantation genetic testing for aneuploidy, with a mean of 4.2 embryos biopsied (range, 0-14) and a euploidy rate of 28.9%. Of the 49 patients, 17 (34.7%) had all aneuploidy or no embryos biopsied. Twenty-four patients underwent a total of 36 single euploid ET with 18 live births from 16 patients. Notably, 8 PGT-A patients had a euploid embryo but no ET, affecting the future cumulative pregnancy rate. Overall, 80 patients with thaw/warming embryos had a final outcome. Of these, 20 had nothing for ET (arrested/aneuploid), and of the 60 who had ≥1 ET, 27 had a total of 32 infants, with a live birth rate of 33.8% (27/80)., Conclusion(s): We report the final outcomes of patients most likely to have returned, which is useful for patient counseling: a utilization rate of 38.1% and a no-use rate of 58.9%, similar across age groups. Further studies with larger cohorts as well as epidemiologic comparisons to patients currently cryopreserving are needed., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

We report a case of 33-year-old female with underlying genetic susceptibility for familial porphyria cutanea tarda due to novel UROD variant (c.636 + 2 dupT) unmasked by transient exposure to supraphysiological oestrogen concentrations following a single cycle of successful controlled ovarian stimulation for oocyte retrieval. Use of oral oestrogen in the form of oral contraceptive pills and hormone replacement therapy has been well known to trigger active porphyria cutanea tarda phenotype in susceptible women. However, to date, the emergence of clinically overt porphyria cutanea tarda has not been reported in association with fertility treatment in the literature before.

The aim of this study was to compare the effects of starting progesterone (P4) luteal support (LS) on day of egg retrieval (ER) or day of embryo transfer (ET) on the ratio of difficult ET and cycle outcome. This was a RCT ( ClinicalTrials.gov Identifier: NCT03040830) carried out at Mansoura Integrated Fertility Center (MIFC), Mansoura, Egypt, from November 2015 to January 2017. A total of 171 eligible long agonist ICSI cases were randomly allocated on day of ER into group A (86) starting LS as daily IM 100 mg P4 on day of ER and group B (85) starting P4-LS on day of ET. Difficult ET was defined as blood on ET catheter and/or sounding or dilating the cervix. Primary outcome was the overall ratio of difficult ET and ratios on day 3 and 5 ET. Secondary outcome was the ongoing pregnancy rate (OPR) and implantation rate (IR). The results are presented as % for groups A and B respectively: overall difficult ET (44.1, 24.7) (p = 0.009); day 3 difficult ET (23.2, 24.4) (p = 0.45); day 5 difficult ET (62.7, 25.6) (p = 0.001); overall OPR (38.3, 44.7) (p = 0.43); day 3 ET OPR (41.8, 33.3) (p = 0.51); day 5 ET OPR (34.8, 57.5) (p = 0.048); overall IR (20.0, 22.5) (p = 0.62); day 3 ET IR (17.8, 13.4) (p = 0.44); day 5 ET IR (22, 34.1) (p = 0.09). In conclusion, starting P4 luteal support on egg retrieval day is associated with significantly higher ratio of difficult embryo transfer and lower ongoing pregnancy rate and tendency to lower IR in day 5 ET, so starting P4-LS on day of ET is recommended.

Objective: To study pain in women undergoing oocyte retrieval with a reduced needle (20/17 gauge) compared to a standard needle (16 gauge)., Design: Single-center randomized controlled trial., Setting: Fertility clinic., Patients: Women undergoing their first oocyte retrieval for in vitro fertilization or intracytoplasmic sperm injection., Interventions: Oocyte retrieval with a reduced needle (20/17 gauge) or with a standard needle (16 gauge)., Main Outcome Measures: The primary outcome measure was intraoperative pain on an 11-point visual analogue scale (VAS). Secondary outcome measures included the following: dosage of fentanyl requested; pain at 5, 15 and 30 minutes after retrieval; and pain and analgesia until 4 days after retrieval., Results: A total of 47 women were randomized for the reduced needle (RN) and 48 for the standard needle (SN). Pain scores were significantly lower during and after retrieval with the RN. During retrieval, mean VAS scores in the RN group were 4.3 versus 6.3 in the SN group. Pain remained significantly lower in the RN group after retrieval, with VAS-scores of 1.2 vs. 2.1 directly after retrieval, 0.0 versus 2.0 5 minutes after retrieval, and 0.0 versus 1.0 30 minutes after retrieval. In the RN group, three patients (6.4%) requested more fentanyl during the procedure, versus 16 (33.3%) in the SN group. A total of 79 patients submitted their follow-up questionnaire (response rate 83%). Pain on the first 2 days following retrieval was significantly less in the RN group, with VAS scores of 1.6 versus 2.4 in the SN group, and 1.2 versus 2.5. In line with this finding, fewer patients in the RN group took analgesia on the days after the procedure. This difference was statistically significant only on day 3., Conclusion: Use of a thinner needle results in significantly and clinically relevant lower pain scores during oocyte retrieval, and patients in the reduced needle group requested significantly less analgesia during oocyte retrieval than patients in the standard needle group. Pain scores remained significantly lower up until 2 days after the procedure., Dutch Trial Registration Number: NTR6064 (www.trialregister.nl)., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of seasons on the incidence of high risk of ovarian hyperstimulation syndrome (OHSS) after in oocyte retrieval in patients with polycystic ovarian syndrome (PCOS) and to establish a nomogram to predict the risk of OHSS., Design: Single-center, retrospective study., Setting: University-affiliated reproductive medicine center., Patients: A total of 2,030 infertility patients with PCOS underwent the follicular phase long-acting long protocol IVF/ICSI in the reproductive medicine center from January 2017 to December 2019., Interventions: None., Main Outcome Measures: Logistic regression analysis was used to analyze the factors associated with a high risk of OHSS. We established a nomogram to predict the risk of OHSS in infertility patients with PCOS after oocyte retrieval., Results: The incidence of patients at high risk of OHSS was significantly different from season-to-season and was especially higher in the summer and winter. Multivariate logistic analysis showed that gonadotropin dosage, number of retrieved oocytes, estradiol level, average bilateral ovarian diameter on the day human chorionic gonadotropin was administered, type of infertility, and average temperature were independent risk factors for OHSS after oocyte retrieval in PCOS patients. Based on the above independent risk factors, we constructed a prediction model for OHSS risk. To evaluate the efficiency of the prediction model, we calculated the C-index (0.849), area under the receiver operating characteristic curve (0.849), and internal validation C-index (0.846). Decision curve analysis suggested that the prediction model exhibited significant net benefits., Conclusions: The incidence of PCOS patients at high risk for OHSS after oocyte retrieval fluctuated with seasonal temperature changes, and was significantly higher in extreme climates. The prediction model had favorable predictive performance and clinical application value., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Cao, Shi, Ma, Ma and Zhai.)

Research Question: What are the risk factors affecting the incidences of moderate-to-severe ovarian hyperstimulation syndrome (OHSS) and severe hemoperitoneum in assisted reproductive technology (ART) treatment cycles?, Design: A retrospective cohort study was conducted on 1,435,108 oocyte retrieval cycles among Japanese ART registry data between 2007 and 2015. The study included 11,378 cycles with moderate-to-severe OHSS, 1182 cycles with severe hemoperitoneum, including 27 cycles with both conditions, and 1,422,575 cycles without moderate-to-severe OHSS and severe hemoperitoneum., Results: The incidences of moderate-to-severe OHSS and severe hemoperitoneum were 0.79% and 0.08%, respectively, and decreased by 0.57-fold and 0.29-fold from 2007 to 2015, respectively. In cycles with OHSS and cycles with hemoperitoneum women were younger (odds ratios [OR] 0.91 and 0.95, respectively) and had more retrieved oocytes (OR 1.09 and 1.01, respectively) compared with cycles without both complications. The use of a gonadotrophin-releasing hormone (GnRH) agonist protocol for ovarian stimulation was the highest risk factor in cycles with OHSS and hemoperitoneum (OR 1.83 and 1.24, respectively), followed by GnRH antagonist protocol (reference), gonadotrophin with or without oral medicine (OR 0.45 and 0.56, respectively) and natural or oral medicine (OR 0.02 and 0.19, respectively). In fresh embryo transfer, clinical pregnancy was associated with an increased risk of OHSS and hemoperitoneum (OR 1.19 and 2.34, respectively)., Conclusions: The highest risk factors affecting OHSS and hemoperitoneum were the use of a GnRH agonist protocol and clinical pregnancy following fresh embryo transfer. The incidences of OHSS and hemoperitoneum have decreased yearly with a reduction of GnRH agonist use and fresh embryo transfer., (Copyright © 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Transvaginal Ultrasound-Guided Oocyte Retrieval (TUGOR) is a painful procedure, which often requires the application of anesthesia agents. There is a controversy in the literature about the effects of administrated anesthetics for TUGOR on patients & pregnancy outcomes., Objective: The current study aimed to compare the effects of remifentanil with or without propofol, administrated for TUGOR, on pregnancy and anesthesia outcomes., Method: In a double-blind randomized controlled trial, 180 candidates of TUGOR, aged 18-40 years old, were included in the study. All study women received midazolam 0.03 mg/kg and remifentanil 1 ug/kg as anesthesia induction; Later on, they were randomly assigned in two equalsize groups in terms of anesthesia maintenance, as the intervention group received remifentanil infusion 0.25 μg/kg/min and the control group received remifentanil infusion 1ug/kg/min with propofol 50-150 ug/kg/min. Hemodynamic symptoms, operation outcomes, including the side effects, and pregnancy outcomes, were compared between the study groups. The study is registered with the Iranian Clinical Trials Registry, number IRCT201611177013N15., Results: Although the hemodynamic symptoms showed significantly better ranges in the remifentanil group, however, the study groups were not significantly different in durations of operation, anesthesia, and recovery. However, the anesthesia side effects during and after the operation were not significantly different between the groups; they were more common in control one. The reproductive outcomes (numbers of collected oocytes, fertilized oocytes and transferred embryos, pregnancy rates) showed better but non-significant ranges in the remifentanil group., Conclusion: Using remifentanil alone in comparison to remifentanil & propofol in the TUGOR procedure can be achieved better pregnancy outcomes without imposing the side effects of propofol; therefore, it is not recommended to use propofol as an anesthesia agent for a TUGOR procedure., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

This study aimed to assess whether basal hormonal levels can predict the levels of progesterone (P4) on the day of oocyte retrieval (OR) and examine the impact of P4 levels on the day of OR on the outcome of assisted reproduction. One hundred sixty-four patients that were enrolled in the assisted reproduction procedure were classified according to their P4 levels on the OR day (< 2 ng/ml vs. ≥ 2 ng/ml). Patients who had P4 levels < 2 ng/ml had significantly higher follicle stimulating hormone (FSH) levels and significantly lower anti-Mullerian hormone (AMH) levels. More than half of patients with P4 levels < 2 ng/ml on the OR day got pregnant and delivered healthy infants. There was a significant correlation between lower FSH values and higher P4 values at OR and between higher AMH values and higher P4 values on the day of OR. Regression analysis showed that high FSH levels are the most important factor that can reliably imply lower P4 levels on OR day. Our study confirmed that lower basal FSH levels can predict the levels of P4 on the OR day. Moreover, lower levels of P4 on the day of OR are associated with a positive outcome in assisted reproduction.

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.

Objectives: To assess trends, predictors, and perinatal outcomes of ovarian hyperstimulation syndrome (OHSS) associated with in vitro fertilization (IVF) cycles in the United States., Design: Retrospective cohort study using National Assisted Reproductive Technology Surveillance System (NASS) data., Setting: Not applicable., Patient(s): Fresh autologous and embryo-banking cycles performed from 2000 to 2015., Interventions(s): None., Main Outcome Measure(s): OHSS, first-trimester loss, second-trimester loss, stillbirth, low birth weight, and preterm delivery., Result(s): The proportion of IVF cycles complicated by OHSS increased from 10.0 to 14.3 cases per 1,000 from 2000 to 2006, and decreased to 5.3 per 1,000 from 2006 to 2015. The risk of OHSS was highest for cycles with more than 30 oocytes retrieved (adjusted risk ratio [aRR] 3.85). OHSS was associated with a diagnosis of ovulatory disorder (aRR 2.61), tubal factor (aRR 1.14), uterine factor (aRR 1.17) and cycles resulting in pregnancy (aRR 3.12). In singleton pregnancies, OHSS was associated with increased risk of low birth weight (aRR 1.29) and preterm delivery (aRR 1.32). In twin pregnancies, OHSS was associated with an increased risk of second-trimester loss (aRR 1.81), low birth weight (aRR 1.06), and preterm delivery (aRR 1.16)., Conclusion(s): Modifiable predictive factors for OHSS include number of oocytes retrieved, pregnancy following fresh embryo transfer, and the type of medication used for pituitary suppression during controlled ovarian hyperstimulation. Patients affected by OHSS had a higher risk of preterm delivery and low birth weight. Clinicians should take measures to reduce the risk of OHSS whenever possible., (Copyright © 2020 American Society for Reproductive Medicine. All rights reserved.)

Objective: To assess the level of satisfaction of women undergoing transvaginal oocyte retrieval (TOR) without anesthesia as well as the comfort of the gynecologists., Design: Single-center, prospective cohort study of women undergoing TOR from July 2017 to January 2018., Setting: This study was conducted in an academic public hospital., Patient(s): Women with ≤15 follicles for retrieval were eligible. Women with body mass index > 35, difficult vaginal approach, endometrioma > 5 cm, or pelvic inflammatory disease were excluded., Intervention(s): None., Main Outcome Measure(s): Our primary endpoint was patient satisfaction. Secondary endpoints were women's willingness to recommend or undergo the procedure again without anesthesia, anxiety levels before the procedure, expected level of pain, actual pain levels during the procedure, and gynecologist's level of difficulty or technical compromise., Result(s): During the study period, 500 TORs were performed, of which 402 (80%) were screened for study eligibility. Overall, data were analyzed for 50 eligible women who had their first in vitro fertilization cycle (participating in the study) without anesthesia. High rates of satisfaction were reported, and 90% would recommend the procedure without anesthesia to their friends. Physicians graded the difficulty of the procedure as very easy in 35 procedures; in only two procedures was difficulty reported., Conclusion(s): TOR without anesthesia is feasible, with a relatively high satisfaction rate from both patients and gynecologists, suggesting that it should be considered in selected women., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

We report the first case of OHSS following GnRH agonist trigger for final follicular maturation in random start ovarian stimulation for egg-donation cycles during inadvertent concomitant early pregnancy. As an additional note, the sustained activity exerted by the increasing endogenous hCG production seemed to be responsible for the suboptimal performance in terms of oocyte yield in the current case. OHSS can occur in random-start stimulations protocols even after the use of a GnRH agonist for triggering in case of concomitant unnoticed early pregnancy especially if stimulation is commenced in the periovulatory/luteal phase. The present case report introduces a note of extreme caution when proceeding with this protocol in an otherwise fertile population (egg-donors, elective or oncologic oocyte cryopreservation).

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., (Copyright © 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Tubo-ovarian abscess may develop in women with endometrioma following assisted reproductive technology (ART). The infection, though rare, is typically late in onset and may present several months after the procedure, and in pregnancy-with the risks of abortion and premature labor. It is thought that transcutaneous oocyte retrieval during ART is the route for bacterial contamination resulting in infection of the endometrioma. Pathogens reported in the literature include Escherichia coli ( E. coli ) and Group B streptococcus (GBS) but Staphylococcus lugdunensis ( S. lugdunensis ), a coagulase-negative staphylococcus (CoNS), and groin and perineal skin commensal was isolated from the endometrioma in this case. We discuss the challenges in diagnosis and treatment of this rare condition and the implications of the discovery that an organism previously dismissed as a contaminant has emerged as a causative organism in severe, deep-seated infections of soft tissues in recent literature., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2019 Shimon Edelstein et al.)

Objective: Transvaginal oocyte retrieval has become the common method for infertility couples undergoing artificial reproductive technology. Although it was considered to be safe, rare complications including urinary bladder injury were reported., Case Report: We described two cases of bladder injury with refractory blood clots after oocyte retrieval, for whom conservative treatment failed. Diagnostic cystoscopy was performed and an Ellik evacuator was used for clot dissolution successfully., Conclusion: Urinary bladder injury with clots retention is a rare complication following ovary puncture. When tenacious clots become organized, the removal with traditional bladder irrigation may be difficult. We introduce Ellik evacuator as an effective and reliable procedure for evacuating tenacious clots in the urinary bladder., (Copyright © 2019. Published by Elsevier B.V.)

Study Question: Is there any association between the number of oocytes retrieved and neonatal outcomes following IVF/ICSI treatment for patients using a freeze-all strategy?, Summary Answer: There was no increased risk of adverse neonatal outcomes in cycles with high number of oocytes retrieved (≥ 16) compared to those with 10-15 oocytes retrieved in freeze-all cycles., What Is Known Already: Recent studies have found that there is an increased risk of preterm birth (PTB, <37 weeks gestation) and low birth weight (LBW, <2500 g) following IVF in women with a high number (>20) of oocytes retrieved in fresh embryo transfer (ET) cycles. Other studies have found that there is an association between the number of oocytes retrieved and placenta praevia. However, the association between the number of oocytes retrieved and neonatal outcomes when using a freeze-all strategy is unknown., Study Design, Size, Duration: This retrospective cohort study included 14 170 women with singleton deliveries achieved by a freeze-all strategy performed between November 2006 and December 2017 in China. Only the first delivery from one episode of ovarian stimulation was included., Participants/materials, Setting, Methods: Only cycles using a freeze-all strategy performed during the study period and resulting in singleton live births were included. Patients were categorized into five groups according to the number of oocytes retrieved: 1-3, 4-9, 10-15, 16-20 or >20 oocytes. In univariate and multivariate logistic regression analysis of the association between ovarian response and the outcomes of PTB, early PTB, LBW and other neonatal outcomes, the 10 to 15 oocyte category was used as a reference and other four groups were analysed as dummy variables. Multiple linear regression analysis was used to evaluate possible associations of birth weight z-scores and the number of oocytes retrieved (analysed as a continuous variable) with other confounding factors., Main Results and the Role of Chance: After adjusted for confounding factors, no significant differences were observed in the risk of PTB (P = 0.837), LBW (P = 0.974), early PTB (P = 0.341), very LBW (P = 0.848), congenital malformation (P = 0.916) and other adverse neonatal outcome among patients with different number of oocytes retrieved. There was a higher risk of early PTB among women with a poor ovarian response (1-3 oocytes) compared with women with a normal response (10-15 oocytes) (1.5% vs 0.8%), crude odds ratio (OR): 2.001, 95% CI: 1.159-3.465, P = 0.013. However, the difference was not significant after adjusting for confounders, adjusted OR: 1.753, 95% CI: 0.997-3.081, P = 0.051., Limitations, Reasons for Caution: Data on some known confounders such as smoking and medical history of gestational diabetes mellitus and preeclampsia were lacking. As with any retrospective study, unknown confounders may affect outcomes., Wider Implications of the Findings: In the freeze-all cycles, there was no association between number of oocytes retrieved and adverse neonatal outcomes. This is a reassuring finding for both clinicians and patients who are planning to use freeze-all cycles for a variety of indications., Study Funding/competing Interest(s): Grants from the National Natural Science Foundation of China (NSFC) (31770989 to Y.W.) and the Shanghai Ninth People's Hospital Foundation of China (JYLJ030 to Y.W.). None of the authors have any conflicts of interest to declare., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose of Review: The objective of this review is to analyze and summarize the current anesthetic methods used to alleviate pain and discomfort during transvaginal oocyte retrieval procedures (TORP), to try to reach practical recommendations, based on the evidence, which will translate into daily practice, the knowledge on the anesthetic management of patients scheduled for TORP., Recent Findings: There is no strong evidence to recommend the avoidance of any technique or drug for TORP, including nitrous oxide or halogenated agents. Women should be offered any available technique. The evidence available up to date is not convincing enough to recommend avoiding any anesthetic technique in terms of pregnancy and birth rates., Summary: TORP is painful for women and different techniques may be used for pain relief in day case surgery. The other important outcome to consider is the pregnancy rate, and any anesthetic technique or drug which would improve this pregnancy rate should be recommended. Conscious sedation and general anesthesia proved to be well tolerated for woman and the oocytes, despite the use of propofol, opioids, benzodiacepines, nitrous oxide, or other drugs. Spinal anesthesia and paracervical block are also acceptable options, and can be combined with conscious sedation. Nevertheless, more studies are needed to find out the ideal drug or technique combination for the woman and the oocyte.

Purpose: To investigate a possible influence of repetitive micro-traumata on the ovaries in the course of oocyte retrieval during IVF/ICSI treatment on serum anti-Müllerian hormone (AMH) levels., Methods: The study included retrospectively collected data from women who underwent three or more consecutive IVF/ICSI treatments between 2007 and 2017. The primary endpoint of the study was to evaluate changes in serum AMH levels on cycle days 1-3 during the course of repetitive IVF/ICSI treatments., Results: A total of 125 patients were included in this study. Median AMH levels before the first, second and third IVF/ICSI cycles were 3.8 ng/mL (IQR 1.8-7.1), 3.3 ng/mL (IQR 1.8-6.1) and 3.0 ng/mL (IQR 1.6-5.3), respectively (p = n.s.). In patients who underwent IVF/ICSI due to polycystic ovary syndrome (PCOS), we found a significant decrease in AMH serum levels between the first [AMH 9.7 ng/mL (IQR 7.4-14.4)] and the third [AMH 5.3 ng/mL (IQR 3.3-10.4)] IVF/ICSI cycles (p = 0.026). When performing a generalized linear model, we found PCOS to be an independent predictor for serum AMH decrease during the course of three oocyte retrievals (p < 0.001)., Conclusions: When comparing the indications for IVF/ICSI, we observed a significant decrease in AMH serum levels after repetitive oocyte retrievals only in women with PCOS, while the decrease in AMH was not significant in patients with tubal factor, endometriosis, male factor and unexplained infertility. This finding leads us to hypothesize that repetitive micro-traumata on the ovarian cortex might diminish/normalize functional ovarian reserve in women with PCOS. Further prospective studies are highly warranted to allow firm conclusions.

Objective: To assess the effect of class III (body mass index [BMI] 40-49.9 kg/m 2 ) and class IV obesity (BMI ≥ 50 kg/m 2 ) on oocyte retrieval complications and outcomes., Design: Cohort study., Setting: Academic center., Patient(s): Women who underwent an oocyte retrieval from January 1, 2012 to May 31, 2017. Women with BMI ≥ 40 kg/m 2 (n = 144) were age-matched to women with BMI <25, 25-29.9, 30-34.9, and 35-39.9 kg/m 2 (n = 1,016)., Intervention(s): None., Main Outcome Measure(s): Anesthetic and procedural outcomes during oocyte retrieval., Result(s): Overall, 1,924 of 1,947 oocyte retrievals (98.8%) were performed under total intravenous anesthesia. No patients with BMI ≥ 40 kg/m 2 required intraoperative conversion to endotracheal intubation or hospital admission. Two patients (0.8%) with BMI ≥ 40 kg/m 2 required a laryngeal mask airway intraoperatively owing to oxygen desaturation. An oral/nasal airway was used to resolve oxygen desaturation in 16 patients (6.25%) with BMI ≥ 40 kg/m 2 , compared with in 17 patients (1.0%) with BMI < 40 kg/m 2 . As BMI increased, a statistically significant increase in propofol dose, fentanyl dose, and procedure time was observed. Eighteen patients (7.0%) with BMI ≥ 40 kg/m 2 underwent a transabdominal retrieval, compared with 15 (0.9%) with BMI < 40 kg/m 2 ., Conclusion(s): Serious intraoperative and postoperative complications were uncommon across all BMI groups, though minor complications were more common with class III and class IV obesity. These patients were also more likely to require higher doses of propofol and fentanyl, have longer oocyte retrievals, and require a transabdominal retrieval. Overall, oocyte retrieval can be safely performed as an outpatient procedure in women with class III and class IV obesity., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: More than one million fertilization cycles are performed every year. The incidence of serious complications associated with transvaginal oocyte pick-up is low, but the procedure is not risk-free. Risks are inherent to procedures in which thin needles and sharp instruments are introduced into the vaginal wall and ovarian capsule to access the ovaries., Case Description: A 45-year-old patient reported urinary discomfort and difficulty urinating after her second cycle, 12 hours after oocyte pick-up. She had visible hematuria with small blood clots. Transvaginal ultrasound examination performed 24 hours after pick-up showed a heterogeneous intravesical image suggestive of a clot; her bladder measured 23x19mm. She was afebrile and in good condition. The patient was managed conservatively and offered fluids. The clot was expelled within a matter of hours. This case of a bladder hematoma was the first in the 21 years of a clinic where all procedures are guided by ultrasonography with clear visualization of the tip of the needle throughout the 15-20 minutes of the procedure. Patients submitted to ultrasound-guided transvaginal oocyte pick-up procedures in IVF protocols must be informed of this rare potential complication.

The increase in demand for in vitro produced horse embryos is fostering the development of commercial laboratories for this purpose. Nevertheless, blastocyst production after intracytoplasmic sperm injection (ICSI) is still not as great as desired in most of these laboratories. In relation to horse oocyte classification, both expanded and compact cumulus-oocyte-complexes (COCs) are used for in vitro embryo production. The aim of this study was to compare in vitro embryo developmental capacity of COCs from horses including those with only the corona radiata, frequently collected after aspiration procedures. Horse oocytes were collected by follicular aspiration of abattoir-derived ovaries. After classification as expanded, compact or corona radiata COCs, these were in vitro matured, fertilized by ICSI and in vitro cultured for 7.5 days. Maturation rate, cleavage rate and morula/blastocyst rates were recorded. No significant differences (P > 0.05) were detected among groups in maturation rate. Cleavage rate was less (P < 0.05) for embryos derived from oocytes with a corona radiata as compared to compact-derived embryos, but embryo development after 7.5 days of culture was similar among groups (P > 0.05). In conclusion, even if embryos derived from oocytes with corona radiata had a lesser cleavage rate after ICSI, the developmental capacity was similar to embryos derived from oocytes with a compact and expanded cumulus morphology, indicating these can be an useful source of embryos in horses., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: Epidemiologic data suggest that in vitro fertilization (IVF) is associated with an increased risk of disorders of placentation including preeclampsia and fetal growth restriction. Specifically, studies have demonstrated that singleton pregnancies conceived following a fresh embryo transfer are at an increased risk of delivering an infant with low birth weight compared to those conceived following a frozen embryo transfer. The mechanism responsible for this association remains unclear. Procedures utilized in IVF have also been linked with epigenetic changes and gene expression changes in both fetal and maternal tissues. Data suggest that modifications in the maternal endometrium can lead to disordered trophoblast invasion and placentation. This study examines the effect of ovarian stimulation on endometrial gene expression and DNA methylation during the window of implantation to examine potential pathways playing a role in the adverse outcomes associated with IVF., Methods: Endometrial biopsies were obtained from oocyte donors and age-matched naturally cycling women 11 days following oocyte retrieval in donors or 12 days following luteinizing hormone (LH) surge in naturally cycling women. Global gene expression was analyzed via Affymetrix Human Gene 1.1 ST array and confirmed with RT-qPCR. DNA methylation was assessed with the Infinium DNA methylation 450 K BeadChip., Results: Analysis of endometrial gene expression from 23 women (11 oocyte donors and 12 controls) demonstrated 165 genes with a greater than twofold change in expression between donors and controls. While there were 785 genes with significant differential methylation in the endometrium of donors when compared with control subjects, none of the genes with altered expression showed significant changes in DNA methylation. Analysis of the differentially expressed genes showed enrichment for genes involved in endometrial remodeling including PLAT, HSPE2, MMP2, and TIMP1. Validation studies using RT-qPCR found a 73% reduction in expression of heparanase 2 (HSPE2) an enzyme associated with both angiogenesis and cell invasion, a greater than twofold increase in tissue-type plasminogen activator (PLAT), a serine protease participating in matrix degradation, and a 70% increase in MMP2, a gelatinase involved in collagen and fibronectin breakdown., Conclusions: Superovulation alters expression of genes critical to endometrial remodeling during early implantation. Such changes could lead to altered trophoblast migration and impaired endovascular invasion. These findings offer a potential mechanism for the adverse perinatal outcomes observed following embryo transfer during fresh IVF cycles.

Objective: To study opioid dispensing patterns following oocyte retrieval., Design: Retrospective cohort., Setting: Not applicable., Patient(s): Women undergoing oocyte retrieval with a maximum of 1 opioid prescription in the 12 weeks prior to the procedure, without an opioid use or other substance use disorder., Intervention(s): None., Main Outcome Measure(s): We measured the frequency of opioids dispensed within 3 days of oocyte retrieval, most common opioids dispensed; and quantity dispensed, in median (interquartile range [IQR] and 10th-90th percentile ranges) oral morphine milligram equivalents (MME). Multivariate regression analyses were used to calculate odds ratios and 95% confidence intervals (CI) to examine the association between patient characteristics and the occurrence of an opioid dispensing., Result(s): In total, 61,463 women with an oocyte retrieval met the criteria for analysis. After oocyte retrieval, 11.9% were dispensed an opioid, most commonly hydrocodone (48.5%), codeine (23.0%), and oxycodone (17.7%). The median (IQR; 10th-90th percentile) oral MME dose dispensed after retrieval was 90 (50-125; 50-207). Women with mood disorders (adjusted odds ratio [aOR] 1.17, 95% CI 1.00-1.36), tobacco use (aOR 1.67, 95% CI 1.18-2.37), or anti-depressant use (aOR 1.62, 95% CI 1.47-1.80) were more likely to fill an opioid prescription, compared to those without these diagnoses., Conclusion(s): Although only a small proportion of women fill a prescription for opioids after oocyte retrieval, there is substantial variation in the amount dispensed. Patients with a concurrent mood disorder or those taking anti-depressants were more likely to fill an opioid prescription., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Question: Is there an association between the number of oocytes retrieved for IVF, and perinatal and obstetric outcomes?, Summary Answer: No significant association was found between the number of oocytes retrieved and perinatal outcomes, while an association was found for placenta praevia and male gender., What Is Known Already: Previous studies have shown that between 6 and 15 oocytes retrieved is optimal for the live birth rate in fresh cycles. In a recent study, we showed that the cumulative live birth rate, including fresh and all cryopreservation cycles following one OPU, increases by the number of oocytes retrieved, up to approximately 20 oocytes. However, there was also an increase in serious side effects such as severe ovarian hyperstimulation syndrome (OHSS). A few studies, with contradictory results, have investigated whether the number of oocytes retrieved might also be associated with negative obstetric and perinatal outcomes., Study Design, Size, Duration: A retrospective population-based registry study including all singleton babies born after fresh IVF cycles from 2002 to 2015 (n = 27 359) in Sweden., Participants/materials, Setting, Methods: Data on treatment characteristics from the Medical Birth/IVF Registry and the Swedish National Quality Registry of Assisted Reproduction, including all fresh IVF cycles performed in public or private infertility clinics during the study period and resulting in singleton deliveries, were cross-linked to the Medical Birth Registry and the National Patient Registry for maternal and neonatal outcome. Data on educational level, ethnicity and paternal age were obtained through cross-linking to Statistics Sweden. Oocyte donation cycles were excluded. Main perinatal outcome variables were preterm birth (PTB <37 gestational weeks), very PTB (<32 gestational weeks), small for gestational age (SGA: <2 SD), peri/neonatal death and major birth defects. Main obstetric outcome variables were hypertensive disorders of pregnancy and placenta praevia. Univariable and multivariable analyses were used to explore the association between the number of oocytes retrieved and outcome variables. Adjustments were performed for maternal age, parity, smoking, BMI, cause of infertility, maternal educational level, maternal country of birth, treatment period, embryo stage, fertilization method (IVF/ICSI), number of embryos transferred, OHSS and vanishing twin., Main Results and the Role of Chance: The number of oocytes retrieved was analyzed as a continuous variable as well as categorized as <10, 10-14, 15-19 and >20 oocytes. A number of between four and nine oocytes was used as a reference. Single embryo transfer was performed in 20 910 (76.4%) of the cycles. Blastocyst transfer was performed in 3478 (12.7%) and cleavage stage embryo transfer was performed in 23 881 (87.3%) of the cycles. No significant association was observed between the number of oocytes retrieved (continuous variable) and PTB (adjusted odds ratio [AOR] 1.002, 95% CI 0.994-1.011), very PTB (AOR 1.013, 95% CI 0.994-1.032), SGA (AOR 0.998, 95% CI 0.988-1.009), peri/neonatal death (AOR 1.008, 95% CI 0.975-1.043) or major birth defects (AOR 1.009, 95% CI 0.998-1.020). Concerning obstetric outcomes, a significant association was found for placenta praevia (AOR 1.021, 95% CI 1.005-1.037) while no association was found for hypertensive disorders of pregnancy (AOR 0.991, 95% CI 0.981-1.001). Furthermore, a significant association was detected between the number of oocytes retrieved and the secondary outcome variable gender distribution, with a higher rate of males after >20 oocytes (AOR 1.126, 95% CI 1.014-1.249)., Limitations, Reasons for Caution: As in all observational studies, unknown confounders may affect outcomes., Wider Implications of the Findings: These results are reassuring, indicating that there is no association between adverse neonatal outcomes and the number of oocytes retrieved. The association between the number of oocytes and placenta praevia was significant, though weak. The finding of an association with gender should be interpreted with caution., Study Funding/competing Interest(s): Financial support was received through Sahlgrenska University Hospital (ALFGBG-70 940) and the Hjalmar Svensson Research Foundation. None of the authors declares any conflict of interest.

Objective: To highlight the risk of complications among women with sickle cell anemia (SCA) receiving fertility preservation treatment (FPT) before hematopoietic stem cell transplant (HSCT)., Design: Single-center case series., Setting: Academic fertility center., Patient(s): Women aged 15-32 years with SCA undergoing FPT before HSCT., Intervention(s): Retrospective, systematic review., Main Outcome Measure(s): FPT modality, SCA complications during FPT., Result(s): Over an 8-year period (2009-2017), seven women with SCA ages 15-32 years (mean 28.5 years) underwent FPT with embryo cryopreservation (n = 1), oocyte cryopreservation (n = 4), and ovarian tissue cryopreservation (n = 2). The five women subjects who underwent oocyte or embryo cryopreservation were treated with an antagonist controlled ovarian hyperstimulation protocol and individualized gonadotropin dosing. The trigger medications included leuprolide acetate (n = 2), and human chorionic gonadotropin (n = 3). Most patients (n = 5) received a disease-modifying therapy for SCA (hydroxyurea or chronic transfusions) before FPT. Three patients experienced periprocedural SCA complications that included life-threatening respiratory failure, painful crisis requiring interruption of a stimulation cycle, and severe postharvest painful crisis., Conclusion(s): Women with SCA may choose to undergo diverse FPT strategies before HSCT and are at risk for serious SCA-related complications. Evidence-based strategies to mitigate SCA-related morbidity and to optimize fertility preservation outcomes are needed., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to determine the incidence of oocytes with severe ovoid zona pellucida (ZP), investigate the development potential of their sibling oocytes and the clinical outcomes from affected cycles. The data were collected from our medical records. Cycles having at least one oocyte with severe ovoid ZP were defined as the 'severe ovoid group', cycles having at least one oocyte with mild ovoid ZP were defined as the 'mild ovoid group', whereas cycles without oocytes with ovoid ZPs were defined as the 'control group' (n = 150 for each group). The results showed that sibling embryos in the 'severe ovoid group' were characterized by delayed development and lower available embryo rate. The implantation, clinical pregnancy and live birth rates in this group were also significantly lower than that in the other two groups. There were five cycles in which only one embryo with severe ovoid ZP was transferred and two healthy babies were born. The mild ovoid group showed comparable embryo development and clinical outcomes compared with the control group. This study suggests that cycles containing oocytes with severe ovoid ZPs had delayed embryo development, lower available embryo rate, compromised implantation, clinical pregnancy and live birth rates.

Research Question: Does music therapy help in reducing pain and anxiety in women undergoing transvaginal ultrasound-guided oocyte retrieval (TUGOR)?, Design: In this randomized controlled open label study, 209 participants were recruited and randomized into three groups (music group, n = 70; headphone group, n = 70; control group, n = 69). Patients' psychological status was assessed using the visual analogue scale of pain (VAS-P), satisfaction of pain control, state-trait anxiety inventory (STAI), Beck depression inventory (BDI), and general health questionnaire (GHQ). Stress biomarkers, including salivary alpha amylase (sAA) and salivary cortisol (sCort), were measured before and after TUGOR., Results: No significant differences were found in psychological scoring of STAI, BDI, GHQ and the stress biomarkers. Although neither the anxiety scores nor the analgesic requirements differed among the three groups, the visual measure of vaginal pain (median, range) showed music group (20,0-70) was significantly (P = 0.005) lower than headphone group (30,0-90) and control group (30,0-100). The degree of satisfaction with pain control (median, range) in the music group (80,30-100), was significantly (P = 0.001) higher than the headphone group (80,10-100) and control group (70,0-100)., Conclusion: Music is a simple, inexpensive and effective way to reduce pain score and increase satisfaction with pain control during TUGOR procedure, which may justify its routine use., (Copyright © 2018 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess complications encountered after transvaginal oocyte retrieval procedures., Design: Retrospective analysis., Setting: University hospital, fertility center., Patient(s): A total of 23,827 consecutive transvaginal oocyte retrieval procedures in 12,615 patients., Intervention(s): Oocyte retrieval procedures performed between June 1996 and October 2016., Main Outcome Measure(s): All oocyte retrieval complications. Those requiring hospital admission for at least 24 hours were considered severe., Result(s): A total of 96 patients (0.76 %) suffered complications, with hospital admission necessary for 71 patients (0.56 %). When calculated per retrieval, the overall complication rate was 0.4%, whereas 0.29% was the admission rate, with an average duration of hospital stay of 2.77 ± 2.5 days. A surgical procedure was necessary for 24 patients (0.1% per retrieval and 0.19% per patient). Multivariate analysis showed a significant correlation between complications and women age, body mass index (BMI), the number oocyte retrieved, and the mean time to complete oocyte retrieval. The incidence of complications was significantly higher for physicians who had performed <250 retrievals compared with those who had completed >250 retrievals (odds ratio 0.63, 95% confidence interval 0.40-0.99)., Conclusion(s): Oocyte retrieval can be considered a safe procedure but is not without risks. The most important, identifiable, risk factors for the occurrence of complications are: [1] high number of oocytes retrieved, [2] a long duration of the procedure and mean time per oocyte retrieved, [3] inexperience of the surgeon, [4] younger patients with a lesser BMI, and [5] history of prior abdominal or pelvic surgery or pelvic inflammatory disease., Clinical Trial Registration Number: NCT03282279., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

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, I 2 = 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, I 2 = 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, I 2 = 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, I 2 = 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, I 2 = 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.

This study aimed to investigate whether intracytoplasmic sperm injection (ICSI) shows an advantage over in vitro fertilization (IVF) in non-male factor cycles as the number of oocytes retrieved decreases from four to one. We undertook a retrospective analysis of 1305 IVF/ICSI cycles of non-male factor in which four or fewer oocytes were retrieved. Comparisons were made between conventional IVF (CI) and ICSI when one, two, three or four oocyte(s) were retrieved. Primary outcomes including normal fertilization rate, proportion of embryos per obtained oocyte, cycle cancellation rate, implantation rate, clinical pregnancy rate (PR), live birth rate (LBR), cumulative PR and cumulative LBR were evaluated. The results showed that the normal fertilization rate (72.5% vs. 50.0%) and the proportion of embryos per obtained oocyte (72.5% vs. 55.0%) were significantly increased in one oocyte retrieved cycles in ICSI group as compared with CI group. However, the proportion of embryos per obtained oocyte was markedly decreased in ICSI group when three (52.3% vs. 61.3%) or four (56.9% vs. 64.0%) oocytes were retrieved. The implantation rates, clinical PRs, LBRs, cumulative PRs and cumulative LBRs in CI group were comparable to those in ICSI group when one, two, three or four oocyte(s) were retrieved. In conclusion, ICSI doesn't show advantages over IVF in low oocyte yield cycles of non-male factors, even when only one oocyte was retrieved.

In women undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF), a poor ovarian response, defined as three of fewer mature follicles, can lead to cancellation of the cycle. However, in women with at least one patent tube and normal semen parameters, conversion to intrauterine insemination (IUI) is considered an option, offering reasonable pregnancy rates at a lower cost and without the complications associated with oocyte retrieval. Studies have shown that in cycles with only one mature follicle, IVF should be canceled. However, in cycles with 2 or 3 mature follicles, patients have the choice between IVF and conversion to IUI. Some studies have shown that IVF is superior to IUI in such cases, whereas other reports failed to find any difference. Most of these studies are retrospective and limited by the presence of several biases and low numbers of cycles, and to this date, there is no consensus on the best approach. We have thus designed a multicenter, randomized non-inferiority study, comparing live birth rates following conversion to IUI or IVF in patients with 2 or 3 mature follicles in COH cycles. Nine hundred and forty patients will be randomized on trigger day to either IVF or conversion to IUI. Our study will also include a medico-economic analysis., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Study Question: What is the relationship between the number of oocytes collected in fresh IVF treatments and the likelihood of cumulative delivery rate (fresh and frozen) per oocyte aspiration, severe ovarian hyperstimulation syndrome (OHSS) and thromboembolic events?, Summary Answer: Cumulative delivery rate per aspiration increases up to 20 oocytes retrieved and then evens out while the incidence of severe OHSS increases more rapidly from around 18 oocytes and thromboembolic events, although rare, occurs in particular if 15 or more oocytes are retrieved., What Is Known Already?: Previous studies have shown that the number of oocytes retrieved for IVF is a positive predictor of live birth in fresh cycles. Few studies have investigated cumulative live birth rates and OHSS in relation to the number of aspirated oocytes., Study Design, Size, Duration: Retrospective population-based registry study including 39 387 women undergoing 77 956 fresh IVF cycles in the period 2007-2013 and 36 270 consecutive transfers of frozen/thawed embryos in the period 2007-2014., Participants/materials, Setting, Methods: Data from The Swedish National Quality Registry of Assisted Reproduction (Q-IVF) including all IVF cycles with oocyte retrieval performed in public or private infertility clinics during the study period, was cross-linked to the National Patient Register regarding diagnostic codes (ICD 10) for severe (OHSS) and thromboembolic events. Oocyte donation cycles were excluded., Main Results and the Role of Chance: Live birth delivery rate in fresh cycles increased up to 11 oocytes retrieved and then evened out, where the live birth rate was 30.3% for a 34-year-old woman. The cumulative delivery rate per aspiration, including fresh transfer and all subsequent transfers of frozen-thawed embryos (FET cycles) per oocyte retrieval, increased up to approximately 20 oocytes where it reached 45.8%. The adjusted odds ratio (AOR) for live birth by the number of oocytes was 1.064 (95% CI: 1.061; 1.067). The incidence of severe OHSS increased significantly by the number of oocytes, particularly if more than 18 oocytes were retrieved. The AOR for OHSS by the number of oocytes was 1.122 (95% CI: 1.08; 1.137). Thromboembolic events were rare, a total of 16 events in 14 patients were observed, and occurred in particular if 15 or more oocytes were retrieved., Limitations, Reasons for Caution: All FET cycles might not be included. Some embryos cryopreserved between 2010 and 2013 might still result in additional births until 2018. Furthermore the gonadotrophin dose was not included in the Q-IVF Registry in the study period, thus adjustment for dose was not possible., Wider Implications of the Findings: The results suggest a shift at approximately 18-20 oocytes where the cumulative delivery rate per aspiration levels off and, at the same time, the incidence of severe OHSS increases more rapidly. Thromboembolic events, although rare, should also be taken into consideration at stimulation regimes for IVF. Evaluating data taking both efficacy and the most serious safety aspects into account, is a new approach and of crucial importance both for patients undergoing IVF and their physicians., Study Funding/competing Interest: Financial support was received through an agreement relating to research and the education of doctors (ALFGBG-70 940) and grant from the Hjalmar Svensson Research Foundation. None of the authors declares any conflict of interest., (© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com)