Pain relief for women undergoing oocyte retrieval for assisted reproduction

Transvaginal Ovum Pick-Up in sows: Impacts on welfare and reproduction

There are few existing publications that describe transvaginal ultrasound-guided Ovum Pick-Up (OPU) in sows, and the impacts of the procedure for the welfare of the animals are unknown. In this study, we evaluated the effects of OPU, performed following restraint in a claw-trimming chute, on the animal welfare and reproductive health of second parity hybrid sows. The study utilized a generalized randomized block design at a commercial sow pool. We assessed salivary cortisol levels before, during, and after the procedure to compare the physiological stress response between OPU and restraint chute procedures (control group). We found a significant increase in salivary cortisol caused by the physical restraint procedure, and that the salivary cortisol level at the end of the procedure did not differ between OPU and control groups (p = 0.51). Furthermore, we conducted a novel approach-aversion test for sows, designed to assess if a feed reward would motivate the animals to willingly participate in the OPU-procedure. The animals were trained daily to enter the chute to access a feed reward. Ten animals in each group failed to complete the training period and did not voluntarily enter the restraint chute on the experimental day. This indicates that even the short daily restraint procedure during the four-day long training period was aversive to some animals. There was no difference in aversion towards the restraint chute between OPU and control groups one day after the procedure. The reproductive performance of the animals was subsequently evaluated through oestrus synchronization and insemination of the sows after the experiment. There was no observed difference in the farrowing rate (p = 0.72) and total number of born piglets (p = 0.84) between OPU and control sows. On average, we retrieved 9.0 ± 5.9 oocytes during the OPU-sessions (N = 26). Our results show that a majority of the sows prioritize the motivation for feed over their aversion to the OPU procedure. However, the physical restraint procedure is unpleasant for the animals and elicits a temporary stress response. We suggest that transvaginal OPU may be used for the recovery of oocytes from live sows, but refinements are needed to avoid stress during the lifting procedure. Such modifications could also potentially reduce the observed inter-individual variations in oocyte recovery outcomes.

Genome-wide analyses identify 21 infertility loci and over 400 reproductive hormone loci across the allele frequency spectrum

Genome-wide association studies (GWASs) may help inform treatments for infertility, whose causes remain unknown in many cases. Here we present GWAS meta-analyses across six cohorts for male and female infertility in up to 41,200 cases and 687,005 controls. We identified 21 genetic risk loci for infertility (P≤5E-08), of which 12 have not been reported for any reproductive condition. We found positive genetic correlations between endometriosis and all-cause female infertility (rg=0.585, P=8.98E-14), and between polycystic ovary syndrome and anovulatory infertility (rg=0.403, P=2.16E-03). The evolutionary persistence of female infertility-risk alleles in EBAG9 may be explained by recent directional selection. We additionally identified up to 269 genetic loci associated with follicle-stimulating hormone (FSH), luteinising hormone, oestradiol, and testosterone through sex-specific GWAS meta-analyses (N=6,095-246,862). While hormone-associated variants near FSHB and ARL14EP colocalised with signals for anovulatory infertility, we found no rg between female infertility and reproductive hormones (P>0.05). Exome sequencing analyses in the UK Biobank (N=197,340) revealed that women carrying testosterone-lowering rare variants in GPC2 were at higher risk of infertility (OR=2.63, P=1.25E-03). Taken together, our results suggest that while individual genes associated with hormone regulation may be relevant for fertility, there is limited genetic evidence for correlation between reproductive hormones and infertility at the population level. We provide the first comprehensive view of the genetic architecture of infertility across multiple diagnostic criteria in men and women, and characterise its relationship to other health conditions.

Analgesic effects of LI4 acupuncture during intrauterine device insertion: a randomized controlled clinical trial

PURPOSE

Intrauterine device (IUD) is one the most effective contraceptive methods with reversible long-term effects. However, the major drawback of IUD use is pain perception during the insertion of the device. The aim of this study is to investigate the effects of bilateral LI4 acupuncture, administered before IUD insertion, on pain perception.

METHODS

This is a prospective randomized controlled study. It was held in Community Health Center in Niğde, Turkiye. Individuals enrolled in the study were randomized into the acupuncture group and non-intervention group. Acupuncture group received bilateral LI4 acupuncture prior to IUD insertion while others received no interventions. After IUD insertion, 10 cm visual analog scale (VAS) score was evaluated at 3rd minute and at 10th minute. Health care provider performing the IUD insertion and VAS evaluation was blind to randomization.

RESULTS

In total 72 participants were included in the study. The VAS scores were significantly lower in the acupuncture group both at 3rd minute and at 10th minute (1.93 ± 1.68; 3.81 ± 1.95; p < 0.001 and 0.53 ± 0.84; 1.64 ± 1.10; p < 0.001 respectively). Linear regression analysis showed that acupuncture was a significant predictor for lowering VAS both at 3rd minutes and 10th minutes following IUD insertion (p < 0.001).

CONCLUSION

This is the first randomized controlled clinical study investigating the effects of acupuncture on pain control during IUD insertion. The results demonstrated that bilateral LI4 acupuncture provides significant pain relief at both cervical and fundal components. Acupuncture prior to IUD insertion is a significant predictor of lowering overall VAS scores of individuals.

TRIAL REGISTRATION

NCT04963582.

General anesthesia with propofol during oocyte retrieval and in vitro fertilization outcomes: retrospective cohort study

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.

The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study

BACKGROUND

There are debates in acupuncture related systematic reviews and meta-analyses on whether searching Chinese databases to get more Chinese-language studies may increase the risk of bias and overestimate the effect size, and whether the treatment effects of acupuncture differ between Chinese and non-Chinese populations.

METHODS

In this meta-epidemiological study, we searched the Cochrane library from its inception until December 2021, and identified systematic reviews and meta-analyses with acupuncture as one of the interventions. Paired reviewers independently screened the reviews and extracted the information. We repeated the meta-analysis of the selected outcomes to separately pool the results of Chinese- and non-Chinese-language acupuncture studies and presented the pooled estimates as odds ratios (OR) with 95% confidence interval (CI). We calculated the Ratio of ORs (ROR) by dividing the OR of the Chinese-language trials by the OR of the non-Chinese-language trials, and the ROR by dividing the OR of trials addressing Chinese population by the OR of trials addressing non-Chinese population. We explored whether the impact of a high risk of bias on the effect size differed between studies published in Chinese- and in non-Chinese-language, and whether the treatment effects of acupuncture differed between Chinese and non-Chinese population.

RESULTS

We identified 84 Cochrane acupuncture reviews involving 33 Cochrane groups, of which 31 reviews (37%) searched Chinese databases. Searching versus not searching Chinese databases significantly increased the contribution of Chinese-language literature both to the total number of included trials (54% vs. 15%) and the sample size (40% vs. 15%). When compared with non-Chinese-language trials, Chinese-language trials were associated with a larger effect size (pooled ROR 0.51, 95% CI 0.29 to 0.91). We also observed a higher risk of bias in Chinese-language trials in blinding of participants and personnel (97% vs. 51%) and blinding of outcome assessment (93% vs. 47%). The higher risk of bias was associated with a larger effect estimate in both Chinese-language (allocation concealment: high/unclear risk vs. low risk, ROR 0.43, 95% CI 0.21 to 0.87) and non-Chinese-language studies (blinding of participants and personnel: high/unclear risk vs. low risk, ROR 0.41, 95% CI 0.23 to 0.74). However, we found no evidence that the higher risk of bias would increase the effect size of acupuncture in Chinese-language studies more often than in non-Chinese-language studies (the confidence intervals of all ROR in the high-risk group included 1, Table 3). We further found acupuncture appeared to be more effective in Chinese than in non-Chinese population (Table 4).

CONCLUSIONS

The findings of this study suggest the higher risk of bias may lead to an overestimation of the treatment effects of acupuncture but would not increase the treatment effects in Chinese-language studies more often than in other language studies. The difference in treatment effects of acupuncture was probably associated with differences in population characteristics.

TRIAL REGISTRATION

We registered our protocol on the Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/PZ6XR ).

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

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

Optimizing embryological aspects of oocyte retrieval, oocyte denudation, and embryo loading for transfer: a state of the art review

Oocyte retrieval, oocyte denudation, and embryo transfer are crucial processes during assisted reproduction (ART). Air quality in the ART laboratory, temperature, pH of the media used and the time interval between oocyte retrieval and insemination are all critical factors. Anesthesia is required for oocyte retrieval, however evidence regarding the potential impact of different methods (general anesthesia, conscious sedation, and local anesthesia) on the clinical outcomes is unclear. The optimal timing of oocyte denudation following retrieval has not been established. Regarding the mechanical denudation process, there is a lack of evidence to demonstrate the safest minimum inner diameter of denuding pipettes used to complete the removal of granulosa cells surrounding the oocytes. During embryo transfer, many clinics worldwide flush the catheter before embryo loading, in an attempt to potentially rinse off any toxic agents; however, there is insufficient evidence to show that flushing the embryo transfer catheter before loading increases the success of ART outcome. Considering the serious gaps in knowledge in ART practice, the aim of this review is to provide an updated overview of the current knowledge regarding the various steps and techniques involved in oocyte retrieval, oocyte denudation, and embryo loading for transfer.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Lay summary

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

The effect of Propofol versus Dexmedetomidine as anesthetic agents for oocyte pick-up on in vitro fertilization (IVF) outcomes

This study aimed to evaluate the effects of propofol and dexmedetomidine over different timescales on the IVF outcomes for transvaginal oocyte retrieval (TVOR). Twenty-four rats included in the study were divided into two main groups and three subgroups were subjected to the ovulation induction process. Group 1 was administered propofol (100 mg/kg i.v.) and group 2 were administered dexmedetomidine (25 µg/kg i.p.) The oviduct collection procedure was completed within 15 min for subgroup Pro15min, Dex15min (n = 4), within 16 to 30 min for subgroup Pro30min, Dex30min (n = 4) and within 31 to 60 min for subgroup Pro60min, Dex60min (n = 4) after euthanasia. The total number of oocytes was counted. After in vitro fertilization, the number and quality of embryos were evaluated. The number of pups born were evaluated after embryo transfer. The embryo number, quality and pup count decreased as the administration time for propofol increased (p < 0.05). No statistically significant difference was found between the dexmedetomidine subgroups for embryo number, quality and pup count(p > 0.05). As the exposure time to propofol increased, the number and quality of embryos obtained, and the pup count, decreased. The use of dexmedetomidine had no negative impacts on the number of embryos, their quality or the number of pups.

Severe Hemoperitoneum After Oocyte Retrieval Due to Ovarian Hemorrhage Possibly Caused by Violent Cough Under General Anesthesia With Propofol and Pentazocine: A Case Report and Literature Review

Oocyte retrieval is an invasive procedure for patients undergoing assisted reproductive technology (ART). Complications regarding oocyte retrieval are rare; however, once they occur, patients often require hospitalization and, could in some cases, lead to life-threatening situations.

We report a case of severe hemoperitoneum due to ovarian hemorrhage after oocyte retrieval. A 39-year-old patient wanted to have a second child and received ART treatment because of severe male infertility. Oocyte aspiration was performed under intravenous anesthesia with propofol and pentazocine. She suddenly coughed and violently moved her body while the puncture needle was inside the ovary. After increasing the propofol dose, the coughing subsided and oocyte retrieval continued. Five hours following oocyte retrieval, she revisited the clinic with severe abdominal pain. Transvaginal ultrasonography revealed echogenic findings in the Douglas’ pouch; 300 mL of blood was aspirated by puncture of the Douglas pouch. She was transferred to our hospital because of suspected severe hemoperitoneum. Contrast-enhanced computed tomography revealed hematoma formation in the right ovary with a small amount of extravasation. Laparoscopic surgery revealed extensive hemoperitoneum due to right ovarian hemorrhage. The right ovary was enlarged to the size of a fist and contained a clot; the bleeding was due to a tear in the cortex of the ovary. The partially torn ovarian tissue was excised; hemostasis was performed using a bipolar device. The body movement caused by violent coughing during oocyte retrieval may have led to increased laceration at the ovarian puncture site.

Although cough during general anesthesia using propofol and pentazocine is very rare, physicians and staff should be aware of the high risk of intra-abdominal hemorrhage when such complications occur.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Assessing efficacy of intravenous acetaminophen for perioperative pain control for oocyte retrieval: a randomized, double-blind, placebo-controlled trial

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.

Systematic Review and Meta-Analysis of Acupuncture for Pain Management in Women Undergoing Transvaginal Oocyte Retrieval

Objective

To obtain evidence-based conclusions about the effect of acupuncture on pain relief in women undergoing oocyte retrieval, the results of randomized controlled trials (RCTs) that met the criteria were assessed on the Pain Assessment Scale and pregnancy indicators.

Search Methods

References were retrieved in MEDLINE, EMBASE, CNKI database, CBM database, VIP database, and Wanfang database from inception to June 26, 2021. Unpublished ongoing trials were searched in the Clinical Trials Registries. This review included RCTs that investigated the acupuncture analgesic effects during oocyte retrieval in women undergoing in vitro fertilization.

Results

Fourteen RCTs (2503 women in total) with six types of comparisons were finally included. The quality of concluding evidence was generally low or very low. Performance bias and outcome assessment bias was the main risk of bias of the included studies. Acupuncture combined with conscious sedation and analgesia (CSA) was associated with less intraoperative (SMD=−1.03; 95% CI: −1.71 to −0.36) and postoperative (SMD = −1.11; 95% CI: −1.51 to −0.71) pain compared to receive CSA alone in oocyte retrieval. Acupuncture with non-steroidal anti-inflammatory drugs (NSAIDs) was more effective than using NSAIDs alone for postoperative analgesia (MD = −1.76; 95% CI: −2.08 to −1.44).

Conclusion

Acupuncture complex analgesic therapy is more effective than utilizing CSA or NSAIDs alone. Furthermore, there is no significant consensus on whether there is an analgesic effect of applying acupuncture alone during oocyte retrievals, which needs further research. The overall results should be interpreted with caution due to the high risk of bias/low-GRADE scores among these studies.

Protocol and Registration

PROSPERO registration number: CRD42020170095.

Comparison of Two Different Sedation Protocols during Transvaginal Oocyte Retrieval: Effects on Propofol Consumption and IVF Outcome: A Prospective Cohort Study

(1) Background: There has been various reports on the potential impact of anesthetic agents used during oocyte retrieval (OR) on the impairment of the capacity of the oocyte for fertilization and subsequent embryo quality; results have been conflicting; (2) Methods: The effects of two different sedation protocols during OR in two groups of patients undergoing In Vitro Fertilization/Intra-Cytoplasmic Sperm Injection IVF/ICSI, were compared on propofol consumption and on in vitro fertilization (IVF)/ICSI success. The study group received dexmedetomidine and fentanyl, while the control remifentanil and midazolam. In a prospective cohort study, we encompassed 72 cycles/patients. The administered dose of propofol per patient and fertilization rates were the primary outcomes, while anesthesiological parameters and IVF/ICSI outcomes were the secondary endpoints; (3) Results: We found a significant increase in propofol consumption in the study compared to the control group (77.0 ± 10.6 mg vs. 12.1 ± 6.1; p < 0.001), but fertilization rates were similar (p = 0.469). From the secondary anesthesiological outcomes, the post anesthesia discharge scores were better in the control group (15.0 (13.5 min) vs. 5.0 (10.0 min), p = 0.028). From the IVF/ICSI secondary outcome parameters, we found a higher quality of embryos on day three in the study compared to the control group (p = 0.040). The comparison of the other secondary outcomes yielded non-significant differences; (4) Conclusions: The use of dexmedetomidine, as an alternative agent during OR, was associated with higher propofol consumption as a rescue dose compared to remifentanil but was linked with similar fertilization rates and higher quality of embryos produced.

Effect of needle diameter on pain during oocyte retrieval-a randomized controlled trial

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).

Resuming Assisted Reproduction Services during COVID-19 Pandemic: An Initial Indian Experience

BACKGROUND

The pandemic of COVID-19 has affected many countries and medical services including assisted reproductive treatment (ART) have been hampered.

AIM

The study was conducted to assess the preparedness of ART clinics and staff to resume services; patients' reasons to initiate treatment; and key performance indicators (KPIs) of ART laboratories during the pandemic.

SETTING AND DESIGN

This was a semidescriptive, prospective study in two private in vitro fertilization (IVF) clinics in Maharashtra, India, when COVID-19 testing for asymptomatic people was unavailable.

MATERIALS AND METHODS

Time required for replenishing consumables and clinic preparedness to function under "new norms" of pandemic was documented. Infection mitigation measures and triaging strategy were evaluated. KPIs following resumption were analyzed. The Student's t-test was performed for comparing parameters.

RESULTS

Thirty percent of the patients consulted through telemedicine accepted or were eligible to initiate treatment on clinic resumption. Lack of safe transport and financial constraints prevented majority from undergoing IVF, and 9% delayed treatment due to fear of pandemic. With adequate training, staff compliance to meet new demands was achieved within a week, but procuring consumables and injections was time-consuming. Fifty-two cycles of IVF were performed including fresh and frozen embryo transfers with satisfactory KPIs even during pandemic. Conscious sedation and analgesia during oocyte retrieval were associated with reduced procedure time and no intervention for airway maintenance compared to general anesthesia. Self-reported pain scores by patients ranged from nil to mild on a graphic rating scale.

CONCLUSIONS

This study provides practical insight for the resumption of IVF services during the COVID-19 pandemic.

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

RESEARCH QUESTION

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Local and Systemic Analgesic Effects of Nerve-Specific Acupuncture in Healthy Adults, Measured by Quantitative Sensory Testing

OBJECTIVE

This study aims to assess whether acupuncture analgesia's effects are local or systemic and whether there is a dose response for these effects.

METHODS

Twenty-eight healthy volunteers aged 18-45 were randomized to two doses of acupuncture using points closely associated with peripheral nerves in the legs. The lower-dose group involved acupoints overlying the deep peroneal nerve (DP), and the higher-dose involved acupoints overlying the deep peroneal and posterior tibial nerves (DPTN). Baseline and acupuncture quantitative sensory testing (QST) assessments were obtained locally in the calf and great toe and systemically in the hand. Results were analyzed using factorial repeated-measures analysis of variance for each of the QST variables-cold detection threshold (CDT), vibration detection threshold (VDT), heat pain threshold (HP0.5), and heat pain perception of 5/10 (HP5.0). Location (leg/hand) and time (baseline/acupuncture) were within-subject factors. Intervention (DP/DPTN) was a between-subject factor.

RESULTS

CDT was increased in the calf (P < 0.001) and in the hand (P < 0.001). VDT was increased in the toe (P < 0.001) but not in the hand. HP0.5 was increased in the calf (P < 0.001) and in the hand (P < 0.001). HP5.0 was increased in the calf (P = 0.002) and in the hand (P < 0.001), with the local effect being significantly greater than the systemic (P = 0.004). In all of the above QST modalities, there was no difference between the low-dose (DP) and high-dose (DPTN) acupuncture groups.

CONCLUSIONS

Acupuncture caused comparable local and systemic analgesic effects in cold detection and heat pain perception and only local effects in vibration perception. There was no clear acupuncture dose response to these effects.

The Experience of Dutch Women Using a Coping Intervention for Oocyte Retrieval: A Qualitative Study

BACKGROUND

Many women experience oocyte retrieval during an IVF treatment as a stressful and emotionally difficult situation. Women fear the pain as associated with oocyte retrieval. Based on the existing literature, a coping intervention for oocyte retrieval (CIFOR) was developed to deal with the stress and pain during oocyte retrieval. The objective of this study was to explore the experiences of women using coping intervention for oocyte retrieval (CIFOR) while undergoing oocyte retrieval.

METHODS

For this generic qualitative study, a purposeful sample of fifteen women was gathered from a university clinic in the Netherlands and each participant was interviewed. Background information about the IVF treatment was collected from medical files. Semi-structured interviews were performed approximately 15 min after the OR procedure. Data were analyzed using the Qualitative Analysis Guide of Leuven and processed using MAXQDA.

RESULTS

Twenty-five women were approached for this study between January and May 2018. This study identified five themes that were important in the experiences of women using CIFOR: highly valuing the CIFOR, feasible in daily practice, need for information, sense of control and partner's involvement.

CONCLUSION

Women highly valued the tool. They found CIFOR feasible in daily practice and it fulfilled their needs for information. In addition, women had a sense of control using the intervention. Future research will involve performing a pilot study according to the Medical Research Council framework with outcomes based on the patient's sense of control, ability to cope, coping strategies, anxiety and pain.

Recommendations for good practice in ultrasound: oocyte pick up†

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN SIZE DURATION

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

PARTICIPANTS/MATERIALS SETTING METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTERESTS

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

TRIAL REGISTRATION NUMBER

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

Cochrane reviews on acupuncture therapy for pain: A snapshot of the current evidence

Cochrane is an international non-profit organization established in 1993 to produce and disseminate high quality and unbiased systematic reviews of evidence on health care interventions. At the forefront of systematic review methodology, Cochrane is generally accepted to be among the most carefully prepared and rigorous sources of systematic review evidence. There are numerous Cochrane reviews on nonpharmacologic interventions for pain and multiple Cochrane reviews evaluating acupuncture therapy in pain conditions. But how complete and up to date are those reviews relative to other rigorous systematic reviews with meta-analyses of acupuncture therapy for pain published in the literature? In this 'snapshot' overview, we found 22 relevant Cochrane reviews, some concluding that acupuncture therapy is probably useful for treating specific pain conditions. However, many of the conditions for which acupuncture is most commonly used are either not represented in Cochrane reviews or the existing Cochrane reviews are seriously outdated and do not reflect current evidence. This creates confusion with the risks of adverse effects and addiction liability associated with pain medications, the prevalence of chronic pain, the ongoing opioid epidemic and the need for evidence-based options for pain as part of comprehensive pain care. Clinicians and patients want clarification on safe and effective options to treat pain. Issues involving reviewed trials' inadequate use of sham comparators, of acupuncture as a complex intervention with interactive components and a shift in research focus from efficacy trials to real-world pragmatic trials are discussed in relation to updating Cochrane reviews of acupuncture therapy for pain.

Risk Factors and Prevention Strategies for Postoperative Opioid Abuse

Worldwide, 80% of patients who undergo surgery receive opioid analgesics as the fundamental agent for pain relief. However, the irrational use of opioids leads to excessive drug dependence and drug abuse, resulting in an increased mortality rate and huge economic loss. The crisis of opioid overuse remains a great challenge. In this review, we summarize several key factors in opioid abuse, including race, region, income, genetic factors, age and gender, smoking and alcohol abuse, history of chronic pain and analgesic drug abuse, surgery, neuropsychiatric illness, depression and antidepressant use, human factors, national policies, hospital regulations, and health insurance under treatment of pain. Furthermore, we present several prevention strategies, such as perioperative measures, opioid substitutes, treatment of the primary illness, emotional regulation, use of opioid antagonists, efforts of the state, hospitals, doctors and pharmacy benefit managers, gene therapy, and vaccines. Greater understanding and better assessment are required of the risks associated with opioid abuse to ensure the safety and analgesic effects of pain treatment after surgery.

Assisted reproductive technology: an overview of Cochrane Reviews

BACKGROUND

As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of these steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies.

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART) procedures.

METHODS

Published Cochrane systematic reviews of couples undergoing ART procedures (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The primary outcome of the overview was live birth or the composite outcome live birth or ongoing pregnancy, as reported by the included reviews. Our secondary outcomes were clinical pregnancy, multiple pregnancy, miscarriage, and ovarian hyperstimulation syndrome. We excluded studies of intrauterine insemination and ovulation induction.We undertook selection of systematic reviews, data extraction, and quality assessment in duplicate. We assessed review quality by using the AMSTAR tool. We organised reviews by their relevance to specific stages in the ART cycle. We summarised their findings in the text and reported data for each outcome in 'Additional tables'.

MAIN RESULTS

We included 68 systematic reviews published in the Cochrane Library up to May 2018. All were of high quality. These reviews identified 38 interventions that were effective (n = 23) or promising (n = 15), and they identified 19 interventions that were ineffective (n = 2) or possibly ineffective (n = 17). For 15 interventions, review authors were unable to draw conclusions owing to lack of evidence.We identified an additional 11 protocols and four titles for future inclusion in this overview.

AUTHORS' CONCLUSIONS

This overview provides the most up-to-date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly, and the stakes are high. Using the best available evidence to optimise outcomes is best practice. Evidence from this overview could be used to develop clinical practice guidelines and protocols that can be applied in daily clinical practice to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.