1 Department of Obstetrics and Gynecology, 2 Department of Anesthesiology, HaEmek Medical Centre, Afula, and 3 Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
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Abstract |
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Key words: assisted reproduction/general anaesthesia/oocyte retrieval/sedation
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Introduction |
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Several forms of pain control have been reported as useful for transvaginal oocyte retrieval. Among these were: (i) general anaesthesia, induced with intravenous agents and maintained with inhalation agents (van der Ven et al., 1988); (ii) epidural anaesthesia (Botta et al., 1995
); (iii) local anaesthesia (Wikland et al., 1990
; Batzer et al., 1994
; Christiaens et al., 1998
); and (iv) sedation, either by intramuscular or intravenous administration (Ben-Shlomo et al., 1992
; Trout et al., 1998
).
Throughout the years, attention has been devoted to possible detrimental effects of anaesthetic and analgesic agents on the results of assisted reproductive treatment. In this regard, concentrations of the specific agents have been measured in the aspirated follicular fluid (Wikland et al., 1990; Coetsier et al., 1992
; Soussis et al., 1995
) and more direct observations tested possible toxicity in animal models (Janssenswillen et al., 1997
). Propofol is chemically unrelated to earlier anaesthetic drugs. This highly lipophilic agent has a fast onset and short, predictable duration of action due to its rapid penetration of the bloodbrain barrier and distribution to the central nervous system (Kanto and Gepts, 1989
). It is very popular for a host of ambulatory procedures including oocyte retrieval (Coetsier et al., 1992
). Although some reports have not found any detrimental effect of propofol on assisted reproductive treatment outcome, a recent report challenged its safety (Tatone et al., 1998
). Our standard regimen for anaesthesia in women undergoing oocyte retrieval has been a combination of fentanyl with propofol and maintenance by isoflurane inhalation.
Sedation with a combination of midazolam and ketamine was found useful for pain control in several operative procedures (Rosenberg et al., 1995; Moscona et al., 1995
). Therefore, we decided to compare prospectively the applicability of sedation with midazolam/ketamine combination in oocyte retrieval procedures with that of our standard protocol. We evaluated objective outcome measures as well as patients' satisfaction.
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Materials and methods |
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Outcome parameters, recorded for assisted reproductive treatment, were: number of oocytes retrieved, fertilization rate, cleavage rate and clinical pregnancy.
Statistical analysis involved Student's t-test as applicable.
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Results |
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Discussion |
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Although significant, the differences that we observed in oxygen saturation and heart rate alterations between the sedation and anaesthesia protocol are not of much clinical importance, due to their short duration. In itself, pain-induced slight tachycardia could be considered a disadvantage in older patients, but assisted reproduction patients are uniformly young. At the same time, tachycardia has been attributed to ketamine's effect, and does not necessarily reflect a response to pain (Morgan and Mikhail, 1996). What is clinically significant is the avoidance of anaesthesia with its inherent risk of occasional aspiration, which is significantly increased when oestrogen concentrations are high such as during ovarian stimulation. Since some degree of nausea and vomiting is inevitable, the regimen for sedation imposes less risk for aspiration owing to partial consciousness. In this regard, a combination with propofol has an inherent advantage due to its anti-emetic property. Such an advantage is admittedly of considerable value in simplifying postoperative care.
An additional aspect of sedation is the patients' perception that they are not undergoing general anaesthesia. It is also significant that patients reported much less abdominal pain after the use of sedation as compared to general anaesthesia. It is possible that the short-acting analgesic fentanyl used in the anaesthetic combination lacks enough residual analgesic effect to provide postoperative pain relief, whereas the combination of midazolam and ketamine does.
The number of patients allocated to each group in this study was designed to compare two methods for pain control and not to evaluate possible detrimental effect on in-vitro outcome parameters. Nevertheless, our results in both groups compare to a previously reported outcome with anaesthesia using propofol (Tontisirin et al., 1996). The degree of toxicity of propofol to human oocytes is still debated (Palot et al., 1988
; Tontisirin et al., 1996
; Alsalili et al, 1997
; Janssenswillen et al., 1997
). It may be of some advantage to use alternative anaesthetic/analgesic forms, even if not yet proven safe, until future studies clarify this issue. In conclusion, the sedative combination of midazolam with ketamine for oocyte retrieval in assisted reproduction is at least comparable to general anaesthesia with fentanyl, propofol and isoflurane.
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Notes |
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References |
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Submitted on October 19, 1999; accepted on March 30, 1999.