1 Reproductive Medicine Unit and 2 Department of Anaesthesia, Leeds General Infirmary, Leeds LS2 9NS, UK
3 To whom correspondence should be addressed. Email: adam.balen{at}leedsth.nhs.uk
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Abstract |
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Key words: anaesthesia/conscious sedation/oocyte retrieval
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Introduction |
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In the huge volume of literature on assisted reproduction technology, there is a paucity of studies on the evaluation of the different methods of pain relief during oocyte retrieval. The ideal method of pain relief would be one that is (i) safe, providing adequate pain relief with minimal side effects and complications; (ii) easy to administer and monitor; (iii) short acting and easily reversible; and (iv) without deleterious effects on oocytes and embryos.
The primary concern of safety is governed by the type, number and quantity of drugs, the personnel administering them and monitoring the patients, and the kind of infrastructure available at the site of oocyte collection.
In November 2001, the Academy of Royal Colleges published a report on safe sedation practices on health care in adults. Previously published guidelines were reviewed and evidence of continued poor standards in sedation was discussed. Some general recommendations and new measures were proposed. The rationale for this report was a history of deaths during and after procedures under sedation typified by one survey of 14 000 endoscopic procedures that revealed a 30-day mortality of 1 in 2000 from cardio-respiratory problems (Bell et al., 1991).
Is this topic important to workers in reproductive medicine? The patient population presenting for procedures under sedation in reproductive medicine is relatively young and healthy, and serious morbidity, let alone mortality, appears to be rare. However, just one critical incident due to sedation would be a disaster for all involved, and the consequences for the specialty far reaching. A previous survey (Elkington et al., 2003) noted a great deal of variation in personnel present during the procedure, the use of drugs, the degree of monitoring and the availability of emergency drugs. Given the renewed focus on safe sedation, we aimed to produce a basic description of current practice and facilities used for sedation in UK reproductive medicine, and to assess the deficits highlighted in the earlier surveys from which further enquiries can be targeted and recommendations considered. We also wanted to evaluate the drugs that were being used for anaesthesia/sedation. Concentrations of the drugs have been demonstrated in the follicular fluid at the time of oocyte retrieval (Christiaen et al., 1999
; Ben Shlomo et al., 2000
).
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Materials and methods |
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Results |
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Seventy-seven percent of responding units were part of a hospital with resuscitation facilities; 23% of the units responding were free-standing units without an in-house resuscitation team.
I.v. sedation was the preferred method of sedation for oocyte collection, being used in 62.4% of units. General anaesthesia was the primary method in 24.6% of units, 2.8% used either general or i.v. sedation, and another 5% combined i.v. sedation with a paracervical block. One respondent (1.6%) used spinal anaesthesia with i.v. sedation and 3.6% used i.m. analgesics with i.v. sedation.
Of those units using i.v. sedation, 39 out of the 46 (84.8%) employed a combination of two drugs, usually midazolam in combination with fentanyl, alfentanil, pethidine or propofol. More than two sedative drugs were used in 10.85% of units (Figure 1).
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Units were asked if oxygen, suction, a tilting operating table, resuscitation trolley and a defibrillator were available to them at the site of oocyte collection. All units possessed oxygen, suction and a tilting operating table, with 78.6% having all five facilities. However, 4.8% had no resuscitation trolley and 21.4% had no defibrillator (Figure 3).
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Discussion |
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When these findings are compared with the practical recommendations in many of the published guidelines, it shows some obvious deficiencies. Free-standing units and those isolated from operating theatre departments may not have the in-house skill to deal with serious cardio-respiratory complications of sedation, unless anaesthetists are present. This is not always a practical or economically viable solution for many units, so existing staff, training and facilities need to be improved in some units. Formal training in sedation and resuscitation, the availability of appropriate equipment, and on-going audit of complications and compliance with protocols are vital. Even within hospitals where resuscitation staff are available, shortfalls in basic resuscitation equipment, particularly in the recovery area, cannot be treated with complacency.
The Intercollegiate Report on Safe Sedation Practice made several new recommendations, which include the following:
The second issue governing mode of pain control is the effect of the agents used on outcome such as number of oocytes retrieved, fertilization and cleavage rates, and pregnancy outcome. Use of halothane and neuroleptic analgesia has been studied and deemed unfit for oocyte retrieval (Naito et al., 1989). Use of general anaesthesia with NO2 is also considered to have an adverse outcome leading to reduced pregnancy rates (Gonen et al., 1995
). During paracervical blocks, the concentrations of lidocaine found in follicular fluid have not revealed any detrimental effect on oocytes (Wikland et al., 1990
). A prospective randomized, placebo-controlled study by Ng et al. (1999)
has observed lower abdominal pain scores without any negative effect on pregnancy rates when paracervical block with lignocaine is combined with i.v. sedation. The effect of propofol has been a matter of debate. Concentration of propofol has been demonstrated in the follicular fluid in a number of studies (Coetsiev et al., 1992; Christiaen et al., 1999
; Ben-Shlomo et al., 2000
). Ben-Shlomo et al. (2000)
found no difference in fertilization, cleavage and embryo cell number, while Vincent et al. (1995)
demonstrated lower pregnancy rates with propofol than with isoflurane for laparoscopic embryo transfer. Ben-Shlomo et al. (1999) compared general anaesthesia with sedation and found a comparable number of oocytes retrieved and no difference in rate of embryo transfers and pregnancies. Studies of human and non-human oocytes have revealed no deleterious effects with the drugs generally used in conscious sedation such as fentanyl and midazolam (Bruce et al., 1985
; Swanson and Leavitt, 1992
; Chopineau et al., 1993
). There remains the possibility that anaesthetic during oocyte retrieval can influence the results of IVF, and more studies are required in this field.
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Conclusion |
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Appendix. The questionnaire |
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References |
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Bell GD, McCloy RF, Charlton JE, Campbell D, Dent NA, Gear MWL and Logan RFA (1991) Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. Gut 32, 823827.[Abstract]
Ben Shlomo I, Amodai I, Levran D, Dor J, Echkin A and Perl AZ (1992) Midazolamfentanyl sedation in conjunction with local anaesthesia during oocyte retrieval for in vitro fertilization. J Assist Reprod Genet 9, 8385.[ISI][Medline]
Ben Shlomo I, Moskovich R, Golan J, Eyali V, Tabak A and Shalev E (2000) The effect of propofol anaesthesia on oocyte fertilization and early embryo quality. Hum Reprod 15, 21972199.
Ben Shlomo I, Moskovich R, Katz Y and Shalev E (1999) Midazolam/ketamine sedative combination compared with fentanyl/propofol/isoflurane anaesthesia for oocyte retrieval. Hum Reprod 14, 17571759.
Bokhari A and Pollard BJ (1999) Anaesthesia for assisted conception: a survey of UK practice. Eur J Anaesthesiol 16, 225230.[CrossRef][ISI][Medline]
Bruce DL, Hinkley R and Norman PF (1985) Fentanyl does not inhibit fertilization or early development of sea urchin eggs. Anesth Analg 64, 498500.[Abstract]
Chopineau J, Bazin JE, Terrisse MP, Sautou V, Janny L, Schoeffler P et al. (1993) Assay for midazolam in liquor folliculi during in vitro fertilization under anesthesia. Clin Pharm 12, 770773.[ISI][Medline]
Christiaens F, Janssenswillen C, Verborgh C, Moerman I, Devroey P, Van Steirteghem A and Camu F (1999) Propofol concentrations in follicular fluid during general anaesthesia for transvaginal oocyte retrieval. Hum Reprod 14, 345348.
Costier T, Dhont M, De Sutter P, Merchiers E, Versichelen L and Rosseel MT (1992) Propofol anaesthesia for ultrasound guided oocyte retrieval: accumulation of the anaesthetic agent in follicular fluid. Hum Reprod 7, 14221424.[Abstract]
Ditkoff EC, Plumb J, Selick A and Sauer MV (1997) Anesthesia practices in the United States common to in vitro fertilization (IVF) centers. J Assist Reprod Genet 14, 145147.[ISI][Medline]
Elkington NM, Kehoe J and Acharya U (2003) Intravenous sedation in assisted conception units: a UK survey. Hum Fertil 6, 7476.
Gohar J, Lunenfield E, Potashik G and Glezerman M (1993) The use of sedation only during oocyte retrieval for in vitro fertilization: patient's pain self assessments versus doctor's evaluations. J Assist Reprod Genet 10, 476478.[ISI][Medline]
Gonen O, Shulman A, Ghelter Y, Shapiro A, Judeiken R, Beyth Y, Ben-Nun I (1995) The impact of different types of anaesthesia on in vitro fertilization-embryo transfer treatment outcome. J Assist Reprod Genet 12, 678682.[ISI][Medline]
Independent Expert Working Group (2000) Standards in Conscious Sedation for Dentistry.
Naito Y, Tamai S, Fukata J, Seo N, Nakai Y, Imura H, Mori K (1989) Comparison of endocrinological stress response associated with transvaginal ultrasound oocyte pick-up under halothane anaesthesia and neuroleptanaesthesia. Can J Anaesth 36, 633636.[Abstract]
Ng Yu Hung Ernest, Tang Shan Oi, Chui Chi Kwai David and Ho Chung Pak (1999) A prospective, randomized, double-blind and placebo controlled study to assess the efficacy of paracervical block in the pain relief during egg collection in IVF. Hum Reprod 14, 27832787.
Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB and Hopkins A (1995) A prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing and sedation methods. Gut 36, 462467.[Abstract]
Report of an Independent Expert Working Group, October 2000. Standards in Conscious Sedation for Dentistry. Published by Society for the Advancement of Anaesthesia in Dentistry, London.
Robinson JN, Forman RG, Lockwood GM, Hickey JB, Chapman MG and Barlow DH (1991) A comparison of the transient hyperprolactinaemic stress response obtained using two different methods of analgesia for ultrasound guided transvaginal oocyte retrieval. Hum Reprod 6, 12911293.[Abstract]
Swanson RJ and Leavitt MG (1992) Fertilization and mouse embryo development in the presence of midazolam. Anesth Analg 75, 549554.[Abstract]
Trout SW, Vallerand AH and Kemmann E (1998) Conscious sedation for in vitro fertilization. Fertil Steril 69, 799808.[CrossRef][ISI][Medline]
Vincent RD, Syrop CH, Van Voorhis BJ, Chestnut DH, Sparks AE, McGrath JM et al. (1995) An evaluation of the effect of anaesthetic technique on reproductive success after laparoscopic pronuclear stage transfer. Propofol/nitrous oxide versus isoflurane/nitrous oxide. Anaesthesiology 82, 352358.[CrossRef][ISI][Medline]
Wikland M, Evers H, Jakobsson AH, Sandqyist U, Sioblom P (1990) The concentration of lidocaine in follicular fluid when used for paracervical block in a human IVF-ET programme. Hum Reprod 5, 920923.[Abstract]
Submitted on June 3, 2004; accepted on August 20, 2004.
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