19. Complications in Oocyte Retrieval
KeywordsOocyte retrievalComplicationsHematomaInfectionPrevention methodsOvaries
The most important step for the in vitro fertilization (IVF) process is oocyte retrieval. Under ultrasound guidance, a needle is inserted through the vagina and directed to the ovary and the follicles. Subsequently, the follicular fluid together with the oocyte is aspirated. Although it is a very precise technique, complications may occur. Although these complications are rare, they could be serious and life threatening. In this chapter, we present the complications after oocyte retrieval for IVF as they are reported in case reports and studies with small series of cycles. All studies conclude that these events are associated with pelvic inflammatory disease or endometriosis that may coexist with infertility.
19.2 Incidence of IVF Complications as Reported Through the Years
In a retrospective report, Tureck et al. in 1993  included 674 patients that underwent oocyte retrieval in the same unit, covering a period of 3 years. All surgeons had extensive experience with OPU. About 1.5% (10) of patients required hospitalization, nine for intravenous antibiotics, and one for broad ligament hematoma observation. Two patients had significant vaginal arterial bleeding after the procedure. Most of the hospitalized patients had a history of extensive pelvic adhesions with or without a history of salpingitis. Authors conclude that a history of previous pelvic inflammatory disease and/or adnexal adhesions is a risk factor for perioperative morbidity. In a narrative review, El-Shawarby et al. in 2004  described the OPU complications presented at that time in literature. Eventually, he formed a table of general recommendations, to increase safety during oocyte retrieval. These include a detailed preoperative evaluation, the construction of a risk assessment list for complications during OPU, and the establishment of a clinical risk management group at each unit to evaluate and solve eventual problems. In addition, he advises to avoid multiple penetrations of the ovary and vaginal wall, in order to prevent intraperitoneal bleeding and pelvic infection. He emphasizes the need for clinical guidelines and the importance of training for junior doctors on oocyte retrieval. He suggests that clinical research is needed to optimize this procedure while the use of color Doppler might be beneficial.
Ludwig et al. in 2006  reported the perioperative and postoperative complications after 1058 OPUs. There were no complications from general anesthesia. Vaginal bleeding was evident in 2.8% of the participants (29 patients). For 28 of them, the bleeding was stopped by compression for more than 1 min and for the remaining one patient tamponade was required for more than 2 h without the need for suturing. The majority of patients (41.6%) experienced mild pain 2 h after oocyte retrieval, 16.9% presented with medium pain, 2.7% with severe pain, and 0.4% with very severe pain. Most importantly, the mean pain score was dependent on the number of oocytes retrieved. Regarding the persistence of pain, 2–3 days after oocyte retrieval, 7.6% of the patients reported medium pain, 1.5% severe pain, and 0.2% very severe pain. Only 25.6% of them suffered from mild pain on the day of embryo transfer. Overall, only 98 patients were hospitalized for ovarian hyperstimulation, complications from oocyte retrieval, pain and complications during early pregnancy. Only one patient was hospitalized for injury to the ureter. Authors conclude that oocyte retrieval is a procedure that is well tolerated with a minority of women developing severe pain.
Bodri et al. in 2008  evaluated the complications of 4052 IVF cycles, of which 1238 were downregulated with agonist and 2814 with antagonist. Fourteen patients developed intra-abdominal bleeding, two presented with severe pain, and one had an ovarian torsion. Among oocyte retrievals, almost half of them (1917) have been for egg donation. For patients who received GnRH antagonists, oocytes final maturation was triggered either by hCG or GnRH agonist, in order to prevent ovarian hyperstimulation. Nevertheless, 22 oocyte donors developed early onset moderate/severe OHSS. One patient had to undergo ascites puncture by culdocentesis. Surprisingly more patients developed ovarian hyperstimulation in the GnRH antagonist/hCG protocol that in the GnRH agonist/hCG one although this did not reach statistical significance. In the oocyte donation group, 11 patients developed intra-abdominal bleeding. Of these, six required observation only, four needed laparoscopy for cauterization, and one required laparotomy due to ovarian torsion resulting in acute abdomen. Most of them had a large number of oocytes retrieved, except for two patients hospitalized for observation that had a small amount of oocytes collected. In the IVF group, two women developed intra-abdominal bleeding, eight presented with an early onset moderate/severe ovarian hyperstimulation, and seven with late onset moderate/severe OHSS.
In a very large series of 7098 IVF cycles, Aragona et al. in 2011 , monitored the complications of transvaginal oocyte retrieval. Four patients developed severe peritoneal bleeding and required surgical intervention while two patients developed pelvic abscesses. Intraperitoneal bleeding was developed immediately, in 2 h and 12 h, respectively, for these four patients. Three patients underwent laparoscopic hemostasis and one had a laparotomy. Three patients had an embryo transfer while the laparotomy patient received no embryo. Regarding the two patients who developed pelvic abscesses, this was evident at 7 and 10 days after embryo transfer and oocyte retrieval, respectively. The first patient had a left oophorectomy while for the second patient, right ovarian abscess drainage was performed.
19.3 Complications Developed in the Uterus, Ovaries, and Fallopian Tubes
19.3.1 Tubo-Ovarian Abscess in General
In a case series of 7098 patients that underwent transvaginal oocyte retrieval, only two cases of pelvic abscess have been reported. Abscesses have been developed despite antibiotic prophylaxis. These abscesses have not been developed early and did not involve the tubo-ovarian complex entirely, but developed alone, one in the left ovary and the other at the right ovary . The authors suggest that it might be beneficial to perform vaginal culture for infections and antibiotic prophylaxis before the oocyte retrieval. Only if patient is found negative for vaginal infections, then it is allowed to proceed to the OPU.
184.108.40.206 Risks of Developing Tubo-Ovarian Abscess
19.3.2 Tubo-Ovarian Abscess from Specific Microorganisms Actinomycosis
220.127.116.11 Tubo-Ovarian Abscesses from Actinomycosis urogenitalis
Van Hoecke et al. in 2013  reported a tubo-ovarian abscess in a 40-year-old woman with Crohn’s disease and previously right hemi-colectomy. The responsible microorganism was Actinomyces urogenitalis. Patient presented 14 days after OPU with infection signs and antibiotics have been administered (amoxicillin–clavulanic acid (two doses, 2 g each) and doxycycline (two doses, 100 mg each)). She was discharged but pelvic inflammatory disease continued. Patient was admitted again after 2 days and underwent laparoscopic exploration that ended in laparotomy and right adnexal abscess drainage. Authors found a large right adnexal multiocular collection with abscess formation and bacteremia, while after the pelvic exploration, amoxicillin–clavulanic acid for four doses (1 g each one), was administered. Eventually she was discharged 8 days after surgery.
18.104.22.168 Actinomycosis israelii Pelvic Abscess
In another case report, infection with Actinomyces israelii, presented as pelvic abscess. In a 31-year-old woman, with no previous pregnancies and male factor as a cause for infertility, pelvic infection developed 6 days after oocyte retrieval. She was presented with pelvic pain, nausea, vomiting, urinary urgency, anorexia, and fever. A diagnosis of urinary tract infection was set up before 2 days and nitrofurantoin, (100 mg daily for 3 days) was administered. On pelvic ultrasound and computed tomography, large bilateral loculated pelvic abscesses have been diagnosed and (IV) vancomycin, gentamicin, and clindamycin were administered for 7 days. At that time, a CT-guided drainage was performed with a pig-tailed drain to be left in situ. This is where the diagnosis of Actinomyces israelii was set. Same antibiotic regimen continued for the next 4 days. Patient was discharged on ninth day, and continued oral amoxicillin/clavulanate potassium and metronidazole for 14 days .
22.214.171.124 Ureaplasma Parvum Peritonitis
Bébéar et al. in 2014 , reported an infection, 72 h after oocyte retrieval for male factor infertility. Patient presented with severe pelvic pain and fever, indicating an abdominal infection. She had (IV) cefoxitin 2 mg during oocyte pickup. By TVS, pelvic fluid collection reported in the pouch of Douglas and a perriapendiceal collection. An exploratory laparoscopy was performed and a retro-uterine collection of pus was found. Abscess was drained and on bacteriology, Ureaplasma parvum was reported while blood cultures at the time of admission have been negative. Neither her husband nor she has been infected from U parvum during OPU. As a treatment, she received ticarcillin, clavulanic acid, and ciprofloxacin. This regimen was changed to (o) ciprofloxacin, 2 days after she established apyrexia. This treatment continued for 21 days. No pregnancy was stated.
126.96.36.199 Pelvic Tuberculosis
Annamraju et al. in 2008 , reported pelvic tuberculosis reactivation in a 40-year-old, nulliparous woman with three previous unsuccessful IVF attempts. Last attempt was 9 months before symptoms development. She developed a biloculated cystic mass in the left iliac fossa. By ultrasound, it was found, that it was ovarian in origin, thin walled, avascular, and uniform. A laparotomy revealed a large left retroperitoneal mass, between the descending colon, sigmoid colon, and uterus while the fimbrial end, including the left ovary, was encapsulated in the mass. Operators left this ovary intact while dissected the mass and cleaned the discharge. The examination of the mass, by pathology, suggested tuberculosis. Patient had (IV) cefuroxime and metronidazole for 48 h and for the next 14 days continued on oral medications. Patient advised that before any IVF attempts, a hysteroscopic evaluation of the uterus and a laparoscopic evaluation of the peritoneal cavity (or hysterosalpingogram), is needed. In addition, an endometrial biopsy has to be performed to rule out active tuberculosis lesions.
19.4 Complication During Pregnancy
19.4.1 Early Pregnancy Complicated Tubo-ovarian Abscess
Matsunaga et al. in 2003 , reported a tubo-ovarian abscess during pregnancy after oocyte retrieval. Patient delivered at 22 weeks of pregnancy and a left salpingo oophorectomy was performed afterwards. Varras et al. in 2003 presented a case of tubo-ovarian abscess in a 38-year-old patient with primary infertility and bilateral hydrosalpinx aspiration, at the time of TVOR. The authors consider that the possible cause of this infection was PID reactivation of latent pelvic infection . Patient previously had PID. They also conclude that tubo-ovarian abscess has to be taken into diagnosis of peritonitis after OPU. Fertility preservation should be opted for with uterus and ovary preservation. Laparoscopic drainage was the choice for operating a left ovarian abscess with diffuse pus, which developed 3 weeks after oocyte retrieval. This patient was 26 years old and underwent ART for male factor infertility . She was presented with mild abdominal pain and fever that remained even after antibiotic treatment. After laparoscopic drainage and whole pelvis irrigation, three microorganisms have been found (Escherichia coli, bacteroides and peptostreptococcus species). Patient was discharged 5 days after the surgery. She was pregnant at 5 weeks of gestation, during surgery, but miscarried at 8 weeks. No recurrence took place.
19.4.2 Pregnancy at Second Trimester Complicated Tubo-ovarian Abscess
Den Boon et al. in 1999  described the rupture of a bilateral ovarian abscess, at the end of second trimester and the acute abdomen development. Patient had two IVF cycles in the past for male infertility. She had a previous pregnancy delivered at the 28 weeks of gestation with cesarean section (after IVF). From her medical history, patient had a laparotomy for an ovarian endometrioma. During the second IVF procedure, operators detected an endometrioma that was not punctured, in the left ovary. Antibiotic prophylaxis was administered the day before, during, and after the OPU. A diamniotic dichorionic pregnancy was the result of this IVF. At 25 weeks of gestation, she was admitted to the hospital with symptoms of labor. Tocolysis was performed and cervical effacement and dilatation was evident. The days of admission, she developed an infection, acute abdomen, rebound tenderness, and guarding. An emergency laparotomy was performed. Pus in the pouch of Douglas originating from the right ovary has been found. Both ovaries had small abscesses that drained with multiple incisions. A drain was placed in the pouch of Douglas. Antibiotics have been administered. Peritoneal cultures revealed Staphylococcus aureus and mixed anaerobic bacteria. At 26 weeks of gestation, she went into labor delivering two boys. Pulmonary edema and peritonitis was developed. On the fifth postpartum day, a second laparotomy was performed but no pus was found. She was discharged after 3 weeks from her delivery. One of the infants died 9 weeks postpartum.
19.4.3 Term Delivery Complicated Tubo-ovarian Abscess
Kim et al. in 2013  reported a tubo-ovarian abscess after oocyte retrieval. This infertility treatment, ended to a pregnancy. A 33-year-old patient, with 4 years of infertility, presented with a history of a left tubal pregnancy, bilateral tubal obstruction, and a 4.5-cm endometrioma on the right ovary. Tubal factor was considered the reason for infertility treatment. Before ovarian stimulation, she had a course of ciprofloxacin 250 mg for 5 days because of vaginitis due to Ureaplasma urealyticum and Mycoplasma hominis. During OPU, no puncture of endometrioma took place. After the procedure, patient became pregnant and at 7 weeks of pregnancy, presented with right lower abdominal pain and growth of an endometrioma mass. At that time, conservative management and observation was decided. At 14 weeks gestation, patient presented with lower abdominal pain mimicking appendicitis. After ultrasonography and MRI, a pelvic abscess was found, that arise from the right adnexa, adherent to the posterior wall of the uterus, right pelvic sidewall, and sigmoid colon. On laparoscopic examination, it was found that the abscess was encapsulated within the ovary and there was no pus within the pelvis. Pus drainage was performed and a drain was placed in the pouch of Douglas. Cefotiam (IV) (1 g every 12 h) and metronidazole (500 mg every 8 h) was administered for treatment. The drain was retained for 2 days, while patient was discharged after 10 days. Her pregnancy continued at 8 months while no recurrence was observed.
19.4.4 Late in Pregnancy Complicated Tubo-ovarian Abscess
Younis et al. in 1997  reported three cases of pelvic abscess that developed on ovarian endometriosis. The first one was a 34year-old woman with 12 years of primary infertility. The second one was a 36-year-old with 10 years primary infertility and the last one was 29 years old with 4.5 years of infertility. Both the first and the second had a stage IV endometriosis and the last one had diffuse pelvic endometriosis with bilateral endometrioma. These have been considered the reason for infertility. The first case received laparoscopic adhesiolysis, bilateral tubolasty, and right endometriosis cystectomy. The last two had laparoscopy with the second one to receive bilateral endometriosis cystectomy. All three patients received GnRH agonist downregulation. In the first case, a 4-cm endometrioma was aspirated while in the other two cases, aspiration was not performed. All three patients received prophylactic antibiotics (IV cefazolin). The first patient, 40 days after oocyte retrieval, admitted to the hospital with signs of abdominal infection and a left ovarian multicystic mass. Laparotomy was performed and chocolate-like material was expelled from the cyst. Patient received broad spectrum antibiotics and discharged. Eight weeks later, she developed pelvic peritonitis. In TVS, bilateral complex adnexal masses compatible with bilateral tubo-ovarian abscesses have been revealed. IV antibiotics have been administered again but sonographic findings remained the same. Three weeks later, she had bilateral salpingo-oophorectomy with spillage of pus coming from both ovaries. She recovered uneventfully. The second patient developed high temperature, 24 days after oocyte retrieval. She had no signs from the ovaries, and admitted to the internal medicine department to be treated for Q fever. She was discharged and after 4 weeks, was admitted with high temperature, low abdominal pain, and bilateral tender adnexal masses. On transvaginal ultrasound, bilateral adnexal multicystic complex masses have been observed and the diagnosis was set up for tubo-ovarian abscesses. Patient received intravenous antibiotics and a laparotomy with bilateral salpingo-oophorectomy was performed. In addition, the second patient, recovered uneventfully. The third patient, 22 days after OPU, developed low abdominal pain, bilateral tender adnexal masses, and high temperature. These masses were also complex and compatible with tubo-ovarian abscess. She received IV antibiotics and clinical improvement was evident, although fever remained up to 38 C. On the sixth day of admission, IV treatment was changed and fever and WBC fell to normal levels. Patient was discharged home, after 15 days of intravenous antibiotics, and continued on oral antibiotics. She became pregnant, with an intrauterine viable fetus and at 14 weeks pregnancy, a viable pregnancy was observed. Patient delivered at term.
19.4.5 Pyometra Development and Hysterectomy
A 43-year-old woman, with three previous IVF attempts and no pregnancy, underwent the last oocyte retrieval. Four weeks after OPU, she presented with fever and chills and left lower quadrant tenderness. Laboratory studies showed an ever-increasing infection while CT and MRI revealed a large heterogeneous myomatosus uterus with several fibroids. Patient was administered vancomycin, aztreonam, metronidazole, and ciprofloxacin but her condition did not resolve. After that diagnostic laparoscopic and hysteroscopy was performed to evaluate focal points of infection. On laparoscopy, an old pelvic inflammatory disease with bilateral hydrosalpinges and perihepatic adhesions was seen. On the contrary, hysteroscopy revealed pyometra. Endometrial cultures were taken and revealed vancomycin-resistant enterococci. Linezolid added to the treatment scheme and vancomycin was taken out. Patient discharged on linezolid and metronidazole. Two weeks later patient readmitted with signs of infection and the CT scan showed resistant pyometra. Severe infection and signs of shock have been developed while fever remained at high levels. For that reason, total abdominal hysterectomy was performed and her condition was substantially improved. Patient discharged after 5 days. No other postoperative problems have been reported .
19.5 Endometriosis-Endometrioma Associated Complications
19.5.1 Endometrioma Abscess
19.5.2 Endometrioma and Pregnancy Outcome
In another study , 24 patients with an ovarian endometrioma that aspirated at the time of OPU, completed 29 cycles. These patients have been compared retrospectively with 84 patients (147 cycles) for all main IVF parameters. No adverse outcomes have been reported following endometrioma aspiration and a similar total number of embryos have been obtained. There was no difference in clinical pregnancies, between the two groups. It appears that endometriosis does not adversely affect pregnancy rates and ovarian endometriomas after IVF, have a minimal impact on pregnancy rates.
19.5.3 Endometriosis-Pelvic Infection
Moini et al. in 2005 , answered the question, whether endometriosis raises the risk of pelvic inflammatory disease (Fig. 19.5), after OPU. In his retrospective study, out of 5958 cycles, ten patients developed pelvic inflammatory disease. Diagnosis of PID was set up on certain criteria, and usually was evident 4–7 days after oocyte retrieval. Eight out of the ten women that diagnosed with PID, had endometriosis. It was found after clinical symptoms for endometriosis and diagnostic laparoscopy. One of them had an endometrioma, and the others had stage II, III, IV endometriosis. The non-endometriosis patients had bilateral tubal obstruction and a history of PID. After the diagnosis of pelvic inflammatory disease, five of them treated conservatively with antibiotics, while the other three needed surgical intervention. Two of the patients had laparoscopic drainage of abscess; one of them had a transvaginal drainage of abscess, while the other two needed laparotomy. All patients recovered well. Authors conclude that inoculation of vaginal bacteria and anaerobe microorganisms after oocyte retrieval can cause pelvic inflammatory disease. On the contrary, no pelvic infection has been reported in the literature, after laparoscopic or abdominal oocyte retrieval.
19.5.4 Bilateral Ovarian Abscess
Kelada et al. in 2007 , reported on a 35-year-old woman, with no previous pregnancies and a bilateral ovarian abscess formation. Patient presented with left iliac fossa pain and diarrhea, 16 days after oocyte retrieval. Also she presented with vaginal bleeding. Ovarian hyperstimulation syndrome was evident and at first, clexane 20 mg/day administered. On further evaluation with transvaginal ultrasonography, bilateral ovarian masses have been seen. Although, infection was not evident, at the later stage, she developed fever (over 38 °C). Patient administered cefuroxime and metronidazole for 48 h but infection continued. Even after a replacement to clindamycin and gentamicin, there is no improvement on infection signs while abdominal guardening and generalized tenderness was developed. Consumption coagulopathy was evident while her condition has been deteriorating. Laparotomy has been performed and the abscess capsule was excised, from each ovary. Pus drained and the culture showed staphylococci. Peritoneal cavity was washed out from pus while two drains where left in the site. As a treatment, clindamycin and gentamicin were continued postoperatively while the patient was discharged on the fourth day. Authors did not mention further complications but they conclude that if antibiotics response in 72 h is minimal, then exploratory laparoscopy or laparotomy should take place.
19.5.5 Right Ovarian Abscess
In one of the earliest reports for endometrioma abscess after oocyte retrieval, it was documented the development of a right ovarian endometrioma that aspirated during OPU . Patient after OPU had an embryo transfer. Two weeks after oocyte retrieval, she developed signs of peritonitis and an immediate laparoscopy revealed a ruptured right ovarian abscess. The patient had laparoscopic drainage and IV antibiotics. Fortunately she achieved a single ongoing pregnancy, at the time of the publication.
19.5.6 Ovarian Abscess During Pregnancy
Sharpe et al. in 2006  described an ovarian abscess in a 35-year-old nulliparous woman with long-term infertility. From her medical history, she had endometriosis and a right ovarian endometrioma. During OPU, this endometrioma was aspirated while antibiotic prophylaxis was administered (IV cefazolin and metronidazole). Patient became pregnant with a dichorionic diamniotic pregnancy. Thirteen weeks after oocyte retrieval, she complained of vaginal discharge. At 17 weeks of pregnancy, she presented with an ongoing vaginal discharge and low-grade fever, nausea, vomiting, and malaise. Vaginal and blood cultures, chest X-rays and ultrasound have been performed. Except the twin pregnancy, no other findings have been found to indicate the infection origin. Patient improved transiently on azithromycin but vaginal discharge increased. On 18th week, after a repeat ultrasound, a mild enlargement in the right ovarian mass was observed. Metronidazole was administered but with no effect. After 30 weeks of pregnancy, discharge was increasing while by ultrasound and MRI, a right ovarian abscess was revealed. A vaginal fistula was evident clinically while cefotaxime and metronidazole was started. On first instance, S. viridans was recognized. Despite clinical improvement, a cesarean section was performed at 31 weeks of pregnancy and two healthy twins have been delivered. In abscess fluid, S. viridans, Escherichia Coli, Bacteroides, and Peptostreptococcus species, have been identified. At that time, it was preferred not to drain. A percutaneous drain was inserted, 23 days later. Patient discharged 10 days postpartum while parenteral antibiotic therapy was continued for 4.5 weeks. Antibiotics sustained for another 4 weeks, orally. Authors agree that delayed diagnosis and therapy was made, due to variable symptoms. The continuation of pregnancy did not allow for surgical intervention before 32 weeks.
19.5.7 Gigantic Ovarian Abscess
Hameed et al. in 2010 , reported a rare case of De Novo gigantic ovarian abscess within an endometrioma. The patient, a 47-year-old nulliparous woman, with primary infertility, had an increase in temperature (38.5 °C) and in abdominal girth. The abdominal extension was more evident in the right side and the whole abdomen was tender. On a CT scan, a large ovarian mass, ascites, and obstruction of the left ureter were evident. Patient started on antibiotics and a midline laparotomy incision, was performed. A large cystic mass in the right adnexa was identified, after aspiration of 6 L of pus. Ovarian cyst was drained and 5 L of pus aspirated. Inside the cavity wall there was necrotic tissue. Many fibroids existed on the large uterus. For this reason, a subtotal hysterectomy with right oophorectomy was performed. As a next step, a left oophorectomy with adjunct endometriotic cysts was performed. Patient remained in intensive care and transfused six units of blood. On pus cultures, Bacteroides fragilis was developed, and treated with tazocin. She remained on antibiotics for 10 days and discharged on the 14th postoperative day. On histology, marked inflammation was on the right ovarian cyst wall with glandular foci, indicating endometriosis. In addition, the left ovary had an endometriotic cyst. Authors conclude that patient’s primary infertility was due to undiagnosed endometriosis. An infection, ascending from the vaginal canal, was spread to the endometrioma. Pus leakage from the abscess created peritonitis and transformed ovarian abscess to an acute gynecological emergency.
19.6 Hydrosalpinx and Its Management
19.6.1 Starting Recommendation
19.6.2 Hydrosalpinx Aspiration
In a case report, Hinckley and Milki in 2003  reported two patients that had hydrosalpinges aspiration at the time of oocyte retrieval and rapid accumulation of hydrometra before embryo transfer. The first patient had bilateral distal tubal occlusion and prominent hydrosalpinx on the left with no visualization of hydrometra. After oocyte retrieval and aspiration, an ultrasound was performed on day three that suggested fluid accumulation inside the uterus. This fluid was aspirated and partially accumulated 1 h later. A second aspiration was performed and embryo transfer was postponed until day five. At this day, fluid accumulation in the uterus was increased, aspirated again but returned to the same size 2 h later. Embryo transfer was postponed and patient underwent laparoscopic salpingectomy and left proximal tubal ligation. No hydrometra was seen at the time of embryo transfer. The second patient had a previous salpingectomy for ectopic pregnancy and a hydrosalpinx of the remaining tube. Patient underwent controlled ovarian hyperstimulation, and at day 3 just before embryo transfer, uterine fluid accumulation was suspected. Hydrometra was 5 mm, hydrosalpinx was refilled to 1.9 cm. Embryo transfer was postponed until day five, and aspiration was performed. Fluid disappearance was evident with ultrasound. Embryo transfer was canceled and blastocyst cryopreservation was performed. Patient underwent proximal tubal ligation and after that frozen/thaw, embryo transfer was performed with no hydrometra to be seen at the time of embryo transfer.
19.6.3 Hydrosalpinx Aspiration and Pregnancy Rates
In a randomized controlled trial, Hammadieh et al. in 2008 , examined the effect of ultrasound-guided hydrosalpinx aspiration on pregnancy rates. The control group consisted of patients with hydrosalpinges, which received no intervention. Aspiration was performed on the day of the oocyte retrieval. There is significant difference in biochemical pregnancy rates favoring the aspiration group. As a next step, authors examined the time of fluid re-accumulation. They scanned 2–3 days after the aspiration and 14 days later. About 38% of the patients that had fluid accumulation at 14 days got pregnant while 39% of the patient that did not get fluid re-accumulation became pregnant. Authors conclude that fluid re-accumulation after aspiration does not impair pregnancy rates. Most importantly, after microbiological cultures only one patient found positive to Escherichia coli. Improvement in the clinical pregnancy and implantation rates, in the aspiration group, did not reach statistical significance. No ectopic pregnancy was reported in this study.
19.6.4 Hydrosalpinx Aspiration/Pregnancy Rates Trials
Sharara in 2009 , in a letter to the journal of Human Reproduction, poses certain questions that need to be taken into account in the design of clinical trials for ultrasound-guided hydrosalpinx aspiration. All patients have to have hysterosalpingography or a prior laparoscopy for diagnosis of hydrosalpinx. Endometrial fluid collection should be noted and hydrosalpinx fluid accumulation to be recorded. The time needed for fluid re-accumulation should be associated with pregnancy rates. Bilateral hydrosalpinx need to be compared to unilateral hydrosalpinx, in terms of pregnancy rates.
19.6.5 Hydrosalpinx Aspiration and Mouse Embryo Assay
Chen et al. in 2012  presented a case report of ultrasound-guided hydrosalpinx aspiration combined with the mouse embryo assay of hydrosalpinx fluid for selection of appropriate treatment. Left hydrosalpinx was recognized at the seventh day of ovarian stimulation that increased in size. On the day of hCG administration, endometrial fluid collection of 15 mm was organized. At oocyte retrieval, hydrosalpinx aspiration was performed transvaginally, until it completely collapsed. Microbiological cultures of the fluid were performed and bacterial infection was not found. After that, the mouse embryo assay was performed with hydrosalpinx fluid. Two days after oocyte retrieval, an ultrasound examination, indicated that the endometrial fluid was reduced to 5 mm. A decision was taken, to perform a day three embryo transfer. Seven days later, no endometrial fluid collection or hydrosalpinx, was noted. A singleton pregnancy was established and delivered at 39 weeks of gestation.
19.6.6 Hydrosalpinx Aspiration vs. Laparoscopic Salpingectomy
In a randomized controlled trial that compared hydrosalpinx fluid aspiration versus laparoscopic salpingectomy, no significant difference was found in clinical and ongoing pregnancy rates. Laparoscopic salpingectomy performed at least 2 months before oocyte retrieval while hydrosalpinx aspiration performed at the time of OPU. Fluid re-accumulation was examined on the day of embryo transfer and 2 weeks after, by ultrasound. In the ultrasound, aspiration group three patients had re-accumulation of hydrosalpinx fluid and uterine collection on the day of embryo transfer and did not become pregnant. At the same group, eight other patients had fluid re-accumulation. Obviously, rapid accumulation of hydrosalpinx after aspiration decreases pregnancy rates .
19.6.7 Unilateral Hydrosalpinx Fluid Aspiration
In a case report of ultrasound-guided aspiration of unilateral hydrosalpinx, at the time of oocyte retrieval, a patient became pregnant in the same cycle. She had a left hydrosalpinx with blocked right tube that was found 6 years before IVF. She received hydrosalpinx drainage, immediately after oocyte retrieval. Hydrosalpinx fluid was sterile. Patient became pregnant and she had an uneventful antenatal period .
19.6.8 Long-Term vs. Short-Term Diagnosis for Hydrosalpinx Fluid Aspiration
Zhou et al. in 2016  have retrospectively tested, whether hydrosalpinx aspiration during oocyte retrieval had a positive effect on embryo implantation and clinical pregnancy rates. In this study, unilateral or bilateral hydrosalpinges have been included, after diagnosed by hysterosalpingography and ultrasound. Four groups have been assigned and further partitioned. The first group included hydrosalpinx diagnosis before IVF while the second group had diagnosis during treatment. Both these two groups received ultrasound-guided hydrosalpinx aspiration immediately after oocyte retrieval. The third group included hydrosalpinges that received no treatment, while the fourth group included women with no hydrosalpinges and received no treatment. This group served as control. All patients received the same downregulation protocol and the same criteria for diagnosing hydrosalpinx either by hysterosalpingography or ultrasound. Study results show that embryo implantation and clinical pregnancy rates are lower in the group of hydrosalpinx diagnosed before IVF and received treatment and the group with hydrosalpinges that received no treatment when compared with the other two groups. There is no difference in these two factors between control group and the second group. Abortion rate was higher in the first and the third group. Ongoing pregnancy rates have been significantly lower in the third group compared with the fourth group. It is not clear why there was significant difference in pregnancy rates between the two groups (A and B) that received hydrosalpinx aspiration immediately after oocyte retrieval. Authors conclude that ultrasound-guided aspiration during controlled ovarian hyperstimulation improves the clinical outcome of IVF, only for hydrosalpinx diagnosed during COH.
19.7 Ureteric Injury
19.7.1 Ureteral Stricture
Fugita and Kavoussi in 2001  reported a ureteral stricture after oocyte retrieval. A 41-year-old woman with a history of laparoscopic myomectomy and five oocyte retrievals underwent IVF. After the last OPU, she experienced dysuria and left-sided flank pain. After 2 weeks, she came to the hospital. On renal ultrasound, it was revealed left ureterohydronephrosis. A nephrostomy tube was placed and retrograde pyelography revealed hydronephrosis and a left distal ureteral obstruction. A CT scan confirmed this obstruction at a level between the vagina and the left ovary. A laparoscopic approach was used to reimplant the left ureter. Laparoscopy was a choice to minimize pain and length of hospitalization. Patient was discharged 2 days after the operation. No complications arose after 6 months of observation when examined by either ultrasound, IV pyelography, or diuretic renography.
19.7.2 Ureteral Obstruction
Miller et al. in 2002  reported an acute ureteral obstruction after oocyte retrieval. A 34-year-old woman with primary unexplained infertility, and a history of diagnostic laparoscopy and hysteroscopy, underwent OPU. After 7 h, from OPU, she presented with right lower quadrant tenderness and guarding. On transvaginal ultrasound, a small amount of fluid was revealed in the pelvis. On renal ultrasound, a mild right hydronephrosis with debris on the right collection system was evident. Patient was administered (IV) amoxicillin and sulbactam. On a CT scan, the next day, a right hydronephrosis and mild hydroureter was revealed, down to the right adnexa. A ureteral stent was inserted through cystoscopy. Patient had an embryo transfer but did not become pregnant. The stent was removed 3 weeks after, in an office cystoscopy. No complications were reported 6 weeks after stent removal.
Fiori et al. in 2006  reported a different complication of ureteric injury after OPU, the development of uro-retroperitoneum. A 33-year-old woman, with two previous pregnancies that were delivered by cesarean section, presented with uro-retroperitoneum. This complication developed in the first 2 days after OPU. She has no medical history of endometriosis or renal pathology. Two hours after oocyte retrieval, patient presented with severe abdominal pain, dysuria and fluid in the pouch of Douglas. She was hospitalized with IV paracetamol but in the next day she developed fever, nausea, urinary urgency, and bladder tenesmus with abdominal guarding in the right iliac fossa. She started ofloxacin and metronidazole (IV).On the next day an MRI revealed a right lateral uterine collection in the broad ligament and dilation of the right urinary tract collection system. An abdominal CT showed a leakage of the medium through a pelvic-ureter lesion, near the right vesicoureteral junction. A right ureteral stent was inserted through cystoscopy. Patient discharged after 6 days, and the ureteral stent was removed 10 weeks later.