An acute psychiatric episode following transvaginal oocyte retrieval: Case report

Jiann-Loung Hwang1, Min-Che Kuo1,6, Bih-Chwen Hsieh1, Chien-Hui Chang2, Lih-Chih Jou3, Wei-Hung Chen4 and Gong-Jhe Wu5

1 Department of Obstetrics and Gynaecology, Shin Kong Wu Ho-Su Memorial Hospital, 2 Department of Obstetrics and Gynaecology, Taipei Shan-Chung Hospital, Shan-Chung City, 3 Department of Psychiatry, Shin Kong Wu Ho-Su Memorial Hospital, 4 Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital 5 Department of Anaesthesia, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 Acknowledgements
 References
 
Psychological disorders of infertile patients are traditionally thought to be chronic, to advance gradually, and to be long-term problems. We describe a patient in whom an acute psychiatric episode developed immediately after transvaginal ultrasound-guided oocyte retrieval. A 34 year old women without history of psychiatric disturbance or adverse reaction to drugs suffered an acute psychiatric episode immediately after oocyte retrieval. She exhibited tachycardia, tachypnoea, transient hypertension and limb rigidity, as well as alterations to stupor and posture. Her vital signs stabilized and she opened her eyes 6 h later, but she persistently raised her head to the left and stared blankly without response to external stimuli. Nine hours later, she was able to look around but remained unresponsive to stimuli. Aphasia was noted in the next morning and a wishful thinking of having delivered a baby was noted in the afternoon. Memory loss was noted on the third day. The patient was diagnosed as having dissociative amnesia and was discharged after three courses of supportive psychotherapy. Assisted reproductive technology-related acute psychiatric episodes, which may initially mimic brainstem stroke, are rare; however, attention should be paid to high-risk patients, and they should be offered elective psychological counselling.

Key words: dissociative amnesia/infertility/psychological disorder/stroke/transvaginal ultrasound-guided oocyte retrieval


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 Acknowledgements
 References
 
Over the past few decades, gonadotrophin ovulation induction has become a major infertility treatment. In addition to pregnancy rates, the gynaecologist is also concerned with iatrogenic complications, which include ovarian hyperstimulation syndrome (OHSS). The severe form of OHSS is characterized by marked ovarian enlargement, haemoconcentration, ascites, pleural effusions, hypovolaemia, oliguria, electrolyte imbalances, and thromboembolic phenomena (Mozes et al., 1965Go; Forman et al., 1990Go; Aurousseau et al., 1995Go; Germond et al., 1996Go; Stewart et al., 1997Go), and can sometime develop into a life-threatening complication.

The impact of infertility on patient psychology has been explored for decades, but remains something that may be overlooked by the gynaecologist, since it is much less likely to be acute and life threatening. To date, investigations have focused on partner satisfaction, sexual function, self-esteem, mood disorders, anxiety, psychosomatic symptoms, differences between husbands and wives, and the distribution of distress during the treatment course of infertility (e.g. Downey et al., 1989Go; Klock and Maier, 1991Go; Sabourin et al., 1991Go; Wright et al., 1991Go; Tarlatzis et al., 1993Go; Bringhenti et al., 1997Go; Boivin et al., 1998Go). Here we present a case of an acute psychiatric episode that developed immediately after oocyte retrieval.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 Acknowledgements
 References
 
A 34 year old woman had no previous history of psychiatric disturbance or allergy to food and medication. Her husband had a 9 year history of obstructive azoospermia and she had been unable to achieve pregnancy during this time. The woman had undergone two courses of IVF and embryo transfer 6 years previously at another medical centre, but both attempts had failed. The couple had now presented for an ICSI programme. The husband underwent percutaneous epididymal sperm aspiration and the sperm were preserved in seven cryovials.

Human menopausal gonadotrophin (HMG) 150 IU/day (Humegon; Organon, Oss, The Netherlands) was administered for 7 days as part of the controlled ovarian hyperstimulation (COH) regimen after pituitary down-regulation with intramuscular (i.m.) injection, 0.5 mg/day (long protocol) of the gonadotrophin releasing hormone (GnRH) agonist buserelin acetate (Supremon; Hoechst, Frankfurt, Germany). Follicular growth was monitored using serial vaginal ultrasonography and serum estradiol measurements. Human chorionic gonadotrophin (HCG) 10 000 IU (Pregnyl; Organon) was administered i.m. 36 h before oocyte retrieval.

Transvaginal ultrasound-guided oocyte retrieval was performed under general anaesthesia using fentanyl citrate (DBL; F H Faulding, Victoria, Australia) and induction with propofol (Diprivan; Fresenius Kabi AB, Stockholm, Sweden) and resulted in the retrieval of 25 oocytes. Whilst the patient was in recovery, tachycardia of over 160 beats per minute, an increase in blood pressure (BP) up to 190/125 mmHg and limb spasm suddenly developed. The staff anaesthesiologist and neurologist were consulted and emergency treatment with antihypertensive agents and sedatives was commenced and an intensive care unit (ICU) stay arranged. Serum electrolytes (Na, K, Cl, Ca, P), glucose, body temperature and blood gas were checked and results were normal. Over the next 3 h, the patient's BP and heart rate fell to within normal range, but excessive sweating and tachypnoea were noted. Lower limb rigidity and spontaneous flexion of the upper limbs persisted. The patient remained stuporous and agitated in response to external stimuli. Brain tomography identified nothing abnormal. At this point, psychological rather than physiologically based causes were suspected and the staff psychiatrist was consulted. Six hours later, the patient's vital signs had stabilized. The tachypnoea and sweating ceased, and the patient was able to open her eyes spontaneously, but she persistently raised her head to the left and stared blankly, and was unresponsive to external stimuli, such as the presence of family members. After another 3 h had passed, the patient's limbs became freely movable. She opened her eyes and looked around, but was still unresponsive to external stimuli.

The next morning, the patient responded to her name, but did not verbalize. She sobbed and cried when her husband visited. By the afternoon, the patient had been transferred from ICU to an ordinary ward. According to her husband's reports, the patient called her nephew's name and attempted to eat, but failed to produce any verbal responses in front of doctors and nurses. During the psychiatric clinical diagnostic interview, a wishful thinking was noted that she thought she had delivered a baby. Her face showed expressions of suffering when mention was made of the oocyte retrieval. The patient's head was facing away from the psychiatrist, and no verbal responses to questions were given. An electroencephalogram (EEG) found nothing abnormal.

The patient started talking 3 days after oocyte retrieval, but some gaps in her recollection persisted. The patient knew why she had come to the hospital but could not remember what had happened in the 2 h before the anaesthesia. Over the next few days, the patient's generalized weakness and soreness improved and the gap in her memory resolved on day 8 following oocyte retrieval. The patient could remember events up to the time of the anaesthesia but professed to have no recollection of her ICU admission. The patient was discharged 8 days after oocyte retrieval, following three courses of supportive psychotherapy, and was then followed up in the Obstetric and Psychiatric outpatient departments. The embryos were cryopreserved with a view to transfer at an appropriate juncture.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 Acknowledgements
 References
 
Infertility is stressful for both female patients and their partners. Both male and female patients suffering infertility have been found to be significantly more distressed than same-sex population samples and infertile women exhibit higher levels of distress than their partners (Sabourin et al., 1991Go; Wright et al., 1991Go; Tarlatzis et al., 1993Go; Boivin et al., 1998Go). The most distressing stages of treatment for both men and women are the active stages of oocyte retrieval, embryo transfer and the day of the pregnancy test (Boivin et al., 1998Go). Generally speaking, the psychological aspects of infertility that have been investigated in these studies are not acute problems; instead they include things such as partner satisfaction, sexual function, self-esteem, mood disorders, anxiety, and psychosomatic symptoms (Downey et al., 1989Go; Klock and Maier, 1991Go; Bringhenti et al, 1997Go). To the best of our knowledge, this is the first reported case of an acute psychiatric episode developing after transvaginal ultrasound-guided oocyte retrieval, presenting with rigidity, posturing, aphasia and amnesia.

Ovarian hyperstimulation syndrome is a potential problem encountered by patients undergoing COH. It sometimes results in life-threatening complications such as pulmonary oedema or even stroke (El Sadek et al., 1998; Hwang et al., 1998Go). A case of ischaemic stroke that occurred 1 week after HCG (10 000 IU) administration without evidence of OHSS has also been described (Inbar et al., 1994Go). These cases highlight the risk of stroke in patients receiving COH, even though there have been no large scale studies performed to quantify this risk. In our case, at the commencement of the acute psychiatric episode, unstable vital signs and limbs rigidity made brain stem stroke seems a possibility. This was later ruled out owing to the normal tomographic findings and the subsequent remission in symptoms over several hours.

In this case, several aetiological factors should be considered to rule out physiological or drug effects, including electrolyte and glucose abnormality, acid–base imbalance, hypothermia, hypoxia, carbon dioxide narcosis, residual effects of anaesthetic agents or other adverse reaction to drugs, and organic cerebral insult. Serum electrolyte, glucose and body temperature were checked and results were normal. Blood gas analysis carried out immediately after the acute episode ruled out the possibility of hypoxia and acid-base imbalance. Ventilatory alkalosis was noted several hours later; however, the patient could already move her limbs freely and there was no specific neurological sign. Propofol is a rapidly metabolized drug, and any adverse reactions should therefore be short-lived. Neuromuscular excitation associated with propofol has been reported (Figueira et al., 1993Go), but the presentation of generalized tonic and clonic convulsions and opisthotonos in the observed effects was not compatible with our patient. Reviews of the literature revealed no such adverse reaction to the medication we administered to our patient (e.g. HMG, ß-HCG, GnRHa, fentanyl citrate, etc.). At the beginning of the episode, the increased sympathetic tone made an anaphylactic response to drugs seem less likely. Subsequently, the unusual presentation, including the persistent raising of the head to the left, the blank staring, spontaneous movement of the upper limbs in flexion posture, and the fact that she looked around but was unresponsive to external stimuli, all made psychologically, rather than physiologically, based causes more likely.

In the ward, the patient failed to recall the 2 h from when she arrived in hospital to anaesthesia. The memory gap contained a purposive element, the oocyte retrieval. The psychiatric diagnosis is dissociative amnesia. According to the American Psychiatric Association, the dissociative amnesia should be one or more episodes of inability to recall important personal information, usually of a stressful nature, that is too extensive to be explained by ordinary forgetfulness (American Psychiatric Association, 1994Go). The wishful thinking that she thought she had delivered a baby indicated that she was seeking to shorten the suffering, both mentally and physically (including the IVF and embryo transfer procedure).

Male infertility has been related to increased emotional and marital difficulties for the couple concerned (Edelmann and Connolly, 1986Go; Connolly et al, 1992). Male patients were found to have a tendency towards repressed anxiety and thus have a greater risk of psychosomatic illness (Tarlatzis et al., 1993Go). In the traditional Chinese culture, females always take the stress. The young patient we described had a low educational level, having completed elementary school only. She longed for a baby very much but had two failed attempts at IVF and embryo transfer, thus leaving her in a very emotional state. As we recalled, she was more withdrawn and tense than the other patients during the infertility interview in the outpatient department. She was therefore at high risk of psychological disturbance.

A higher transient hyperprolactinaemic stress response in the procedure of oocyte retrieval under general anaesthesia with propofol was investigated (Robinson et al., 1991Go). A similar psychiatric incident involving failure to recover properly from general anaesthesia has been reported; however, it was a case of factitious disorder (Albrecht et al., 1995Go). In the presently describe patient, it is possible that underlying resentment was aroused under general anaesthesia.

In conclusion, given that psychiatric morbidity in infertile patients is significantly associated with female gender and the number of treatment cycles undergone, and given that physicians are insufficiently trained to diagnose certain psychiatric disorders (Guerra et al., 1998Go), it seems reasonable to offer elective psychological counselling to the wives of infertile couples who are thought to be at high risk of psychiatric disturbance.


    Acknowledgements
 Top
 Abstract
 Introduction
 Case report
 Discussion
 Acknowledgements
 References
 
We are indebted to Jesse Chuang MD for his support, and the nursing staff who cared for this patient.


    Notes
 
6 To whom correspondence should be addressed. E-mail: m004376{at}ms.skh.org.tw Back


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 Acknowledgements
 References
 
Albrecht, R.F., Wagner, S.R., Leicht, C.H. and Lanier, W.L. (1995) Factitious disorder as a cause of failure to awaken after general anesthesia. Anesthesiology, 83, 201–204.[ISI][Medline]

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association, Washington DC, 477pp.

Aurousseau, M.H., Samama, M.M., Belhassen, A. et al. (1995) Risk of thromboembolism in relation to an in-vitro fertilization programme: three case reports. Hum. Reprod., 10, 94–97.[Abstract]

Boivin, J., Andersson, L., Skoog-Svanberg, A. et al. (1998) Psychological reactions during in-vitro fertilization: similar response in husbands and wives. Hum. Reprod., 13, 3262–3267.[Abstract]

Bringhenti, F., Martinelli, F., Ardenti, R. and La Sala, G.B. (1997) Psychological adjustment of infertile women entering IVF treatment: differentiating aspects and influencing factors. Acta Obstet Gynecol Scand., 76, 431–437.[ISI][Medline]

Connolly. K.J., Edelmann, R.J., Cooke, I.D. and Robson, J. (1992) The impact of infertility on psychological functioning. J. Psychosom. Res., 36, 459–468.[ISI][Medline]

Downey, J., Husami, N., Yingling, S. et al. (1989) Mood disorder, psychiatric symptoms, and distress in women presenting for infertility evaluation. Fertil. Steril., 52, 425–432.[ISI][Medline]

Edelmann, R.J. and Connolly, K.J. (1986) Psychological aspects of infertility. Br. J. Med. Psychol., 59, 209–219.[ISI][Medline]

El Sadek, M.M., Amer, M.K. and Fahmy, M. (1998) Acute cerebrovascular accidents with severe ovarian hyperstimulation syndrome. Hum. Reprod., 13, 1793–1795.[Abstract]

Forman, R., Frydman, R. and Egan, D. (1990) Severe ovarian hyperstimulation syndrome using agonist of gonadotrophin releasing hormone for in vitro fertilization: a European series and a proposal for prevention. Fertil. Steril., 53, 502–509.[ISI][Medline]

Figueira, A., Duro, J., Comez, M. and Baldomir, E. (1993) Presentation of 2 cases of neuromuscular excitation associated with propofol. Rev. Esp. Anestesiol. Reanim., 40, 32–33.[Medline]

Germond, M., Wirthner, D., Thorin, D. et al. (1996) Aorto-subclavian thromboembolism: a rare complication associated with moderate ovarian hyperstimulation syndrome. Hum. Reprod., 11, 1173–1176.[Abstract]

Guerra, D., Llobera, A., Veiga, A. and Barri, P.N. (1998) Psychiatric morbidity in couples attending a fertility service. Hum. Reprod., 13, 1733–1736.[Abstract]

Hwang, W.J., Lai, M.L., Hsu, C.C. and Hou, N.T. (1998) Ischemic stroke in a young woman with ovarian hyperstimulation syndrome. J. Formos. Med. Assoc., 97, 503–506.[ISI][Medline]

Inbar, O.J., Levran, D., Mashiach, S. and Dor, J. (1994) Ischemic stroke due to induction of ovulation with clomiphene citrate and menotropins without evidence of ovarian hyperstimulation syndrome. Fertil. Steril., 62, 1075–1076.[ISI][Medline]

Klock, S.C., Maier, D. (1991) Guidelines for the provision of psychological evaluations for infertile patients at the University of Connecticut Health Center. Fertil. Steril., 56, 680–685.[ISI][Medline]

Mozes, M., Bogowsky, H., Antebi, E. et al. (1965) Thromboembolic phenomena after ovarian stimulation with human menopausal gonadotrophins. Lancet, ii, 1213–1215.

Robinson, J.N., Forman, R.G., Lockwood, G.M. et al. (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, 1291–1293.[Abstract]

Sabourin, S., Wright, J., Duchesne, C. and Belisle, S. (1991) Are consumers of modern fertility treatments satisfied? Fertil. Steril., 56, 1084–1090.[ISI][Medline]

Stewart, J.A., Hamilton, P.J. and Murdoch, A.P. (1997) Upper limb thrombosis associated with assisted conception treatment. Hum. Reprod., 12, 2174–2175.[Abstract]

Tarlatzis, I., Tarlatzis, B.C., Diakogiannis, I. et al. (1993) Psychosocial impacts of infertility on Greek couples. Hum. Reprod., 8, 396–401.[Abstract]

Wright, J., Bissonnette, F., Duchesne, C. et al. (1991) Psychosocial distress and infertility: men and women respond differently. Fertil. Steril., 55, 100–108.[ISI][Medline]

Submitted on July 23, 2001; accepted on November 16, 2001.





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