Human Reproduction vol.7 no.6 pp.85O-851, 1992
CASE REPORT
Perforated appendicitis following transvaginal oocyte retrieval for in-vitro fertilization and embryo transfer
Guido JJ.Van Hoorde, Arie Verhoeff1 and Gerard H.Zeilmaker2 Department of Gynaecology and Obstetrics, Zuiderziekenhuis, Groene Hilledijk 315, 3075 EA Rottenlam and 2Department of Endocrinology, Growth and Reproduction, Faculty of Medicine, Erasmus University, 3000 DR Rotterdam, The Netherlands 'To whom correspondence should be addressed
A case of appendicitis following transvaginal oocyte retrieval is presented. The time sequence and the finding of puncture holes in the appendix indicate a causal relationship between the two events. Although minor infectious complications have been reported previously, this is the first report of appendicitis caused by transvaginal oocyte retrieval. Key words: appendicitis/TVF — ET/transvaginal oocyte retrieval
Introduction In The Netherlands, in-vitro fertilization (TVF) and embryo transfer with transport of oocytes is a well established procedure (Jansen etal., 1986). As it is an out-patient procedure, it is necessary for physicians to be very alert to possible complications. We report an unusual complication of transvaginal oocyte retrieval, where an appendicitis developed after the treatment. Case report A 37 year-old patient was referred to our infertility clinic because of primary infertility of 10 years' duration. Routine diagnostic procedures including hysterosalpingography, laparoscopy, semen analysis, post-coital test and hormonal screening could not reveal any cause for this infertility. Attempts to achieve pregnancy through classical ovulation induction, including several intrauterine inseminations, were successful. The couple was assigned the classification 'long-standing unexplained infertility' and was admitted to the IVF/ET programme. The first cycle was uneventful and unsuccessful. Six oocytes were easily retrieved by a transvaginal, ultrasound-directed procedure. Five oocytes were fertilized and four embryos were transferred, but embryo transfer was not followed by a detectable pregnancy. In a second IVF/ET cycle, the same treatment scheme was used with daily subcutaneous luteinizing hormone-releasing hormone analogues (Lucrin®; Abbott, Chicago, USA) starting from day 1 and 225 IU human menopausal gonadotrophin (Humegon®; Organon, Oss, The Netherlands), daily i.m. from day 3 onwards. Human chorionic gonadotrophin (HCG, 850
Pregnyl®; Organon, Oss, The Netherlands) was given on day 12 (10 000 IU). Transvaginal oocyte retrieval took place on day 14. The patient was given 10 mg of nalbuphinechloride (Nubaine®; Du Pont de Nemours, Willington, Delaware, USA) i.m. and 5 mg oral diazepam (Valium®; Hoffman-La Roche, Basel, Switzerland) 30 min prior to the recovery procedure. She also received a paracervical block with 15 ml 1% mepivacainehydrochloride (Scandicaine®; Astra, Sodertalje, Sweden). Five oocytes were aspirated. This second retrieval was felt by the patient to be more painful than the previous operation, although the procedures were technically identical. Four of the oocytes were fertilized in vitro. Embryo transfer took place on day 17. The luteal phase was supported by 1500 IU of HCG on days 14, 17 and 20. Following the retrieval, the patient experienced gradually worsening lower abdominal pain and subsequently subfebrile temperature. She was admitted to the gynaecology department of the initially referring hospital on day 22 where i.v. amoxicillin and clavulanic acid (Augmentin, Beecham, Heppignies, Belgium) were administered. Because of a worsening general condition in spite of the antibiotic therapy, the patient was transferred to the surgery department of the same hospital with fever up to 40.3°C (104.5F). At this time, various other signs and symptoms were suggestive of peritonitis. Subsequently a laparotomy was performed. A perforated appendix was embedded in the pouch of Douglas. The appendix was removed and the peritoneal cavity was washed. On histological examination the wall of the appendix showed several puncture holes. The patient received metronidazole (Flagyl®, Rhone Poulenc, Paris, France) 500 mg three times a day and sodium cefuroxime (Zinacef®, Glaxo, Ulverston, England) 750 mg, also three times a day, both i.v. for 10 days. She recovered steadily. Menstruation occurred 12 days after embryo transfer.
Comment This case clearly demonstrates the hazards of transvaginal oocyte retrieval. Nevertheless, according to our own data, the incidence of infectious complications of this kind is very low. In our centre, which is specialized in IVF/ET with transport of oocytes (Jansen etal., 1986), in co-operation with the University hospital Dijkzigt Rotterdam, infectious complications only occurred in four cases out of a total of 623 transvaginal oocyte retrievals in the last 2 years (0.6%). The three other patients had only minor symptoms, which were attributed to bowel puncture lesions or leaking endometrial cysts and needed no surgical treatment. In these cases further investigations were not carried out since the © Oxford University Press
Appendicitis after transvaghral oocyte retrieval
symptoms subsided spontaneously, or after i.v. administration of antibiotics in one case. This complication rate compares favourably with those found by others (Baber et al., 1988). It may seem obvious to consider the use of prophylactic antibiotics, for instance in a single i.v. dose, in order to prevent possible contamination of the peritoneal cavity. However, there are norelevantdata available that support their use in transvaginal oocyte retrieval procedures. Most probably prophylactic antibiotics only delay the diagnosis and therapy of infectious complications, as happened in this case, where inappropriate administration of antibiotics initially masked the early symptoms of an overt appendicitis. As we are dealing with a healthy population undergoing optional surgical procedures, great care should be taken to inform the patients in detail of the possible, perhaps fatal, risks they are taking. Therefore, we provide a leaflet, given on admission to every couple, concerning the risks and possible complications involved in the procedure. This creates an informed consent situation and thus minimizes the risk of legal action in the event of complications. In none of the above-mentioned cases did patients react with legal action.
References Baber.R., Porter.R., Picker,R., Robertson, R., Dawson,E. and Saunders.D. (1988) Transvagina] ultrasound directed oocyte collection for in vitro fertilization: successes and complications. J. Ultrasound Med., 7, 377-379. Jansen.C.A.M., van Beek.J.J., Verhoeff.A., Alberda.A.T. and Zeilmaker.G.H. (1986) In vitro fertilization and embryo transfer with transport of oocytes. Lancet, i, 676. Received on January 22, 1992; accepted on April 3, 1992
851
CASE REPORT
Perforated appendicitis following transvaginal oocyte retrieval for in-vitro fertilization and embryo transfer
Guido JJ.Van Hoorde, Arie Verhoeff1 and Gerard H.Zeilmaker2 Department of Gynaecology and Obstetrics, Zuiderziekenhuis, Groene Hilledijk 315, 3075 EA Rottenlam and 2Department of Endocrinology, Growth and Reproduction, Faculty of Medicine, Erasmus University, 3000 DR Rotterdam, The Netherlands 'To whom correspondence should be addressed
A case of appendicitis following transvaginal oocyte retrieval is presented. The time sequence and the finding of puncture holes in the appendix indicate a causal relationship between the two events. Although minor infectious complications have been reported previously, this is the first report of appendicitis caused by transvaginal oocyte retrieval. Key words: appendicitis/TVF — ET/transvaginal oocyte retrieval
Introduction In The Netherlands, in-vitro fertilization (TVF) and embryo transfer with transport of oocytes is a well established procedure (Jansen etal., 1986). As it is an out-patient procedure, it is necessary for physicians to be very alert to possible complications. We report an unusual complication of transvaginal oocyte retrieval, where an appendicitis developed after the treatment. Case report A 37 year-old patient was referred to our infertility clinic because of primary infertility of 10 years' duration. Routine diagnostic procedures including hysterosalpingography, laparoscopy, semen analysis, post-coital test and hormonal screening could not reveal any cause for this infertility. Attempts to achieve pregnancy through classical ovulation induction, including several intrauterine inseminations, were successful. The couple was assigned the classification 'long-standing unexplained infertility' and was admitted to the IVF/ET programme. The first cycle was uneventful and unsuccessful. Six oocytes were easily retrieved by a transvaginal, ultrasound-directed procedure. Five oocytes were fertilized and four embryos were transferred, but embryo transfer was not followed by a detectable pregnancy. In a second IVF/ET cycle, the same treatment scheme was used with daily subcutaneous luteinizing hormone-releasing hormone analogues (Lucrin®; Abbott, Chicago, USA) starting from day 1 and 225 IU human menopausal gonadotrophin (Humegon®; Organon, Oss, The Netherlands), daily i.m. from day 3 onwards. Human chorionic gonadotrophin (HCG, 850
Pregnyl®; Organon, Oss, The Netherlands) was given on day 12 (10 000 IU). Transvaginal oocyte retrieval took place on day 14. The patient was given 10 mg of nalbuphinechloride (Nubaine®; Du Pont de Nemours, Willington, Delaware, USA) i.m. and 5 mg oral diazepam (Valium®; Hoffman-La Roche, Basel, Switzerland) 30 min prior to the recovery procedure. She also received a paracervical block with 15 ml 1% mepivacainehydrochloride (Scandicaine®; Astra, Sodertalje, Sweden). Five oocytes were aspirated. This second retrieval was felt by the patient to be more painful than the previous operation, although the procedures were technically identical. Four of the oocytes were fertilized in vitro. Embryo transfer took place on day 17. The luteal phase was supported by 1500 IU of HCG on days 14, 17 and 20. Following the retrieval, the patient experienced gradually worsening lower abdominal pain and subsequently subfebrile temperature. She was admitted to the gynaecology department of the initially referring hospital on day 22 where i.v. amoxicillin and clavulanic acid (Augmentin, Beecham, Heppignies, Belgium) were administered. Because of a worsening general condition in spite of the antibiotic therapy, the patient was transferred to the surgery department of the same hospital with fever up to 40.3°C (104.5F). At this time, various other signs and symptoms were suggestive of peritonitis. Subsequently a laparotomy was performed. A perforated appendix was embedded in the pouch of Douglas. The appendix was removed and the peritoneal cavity was washed. On histological examination the wall of the appendix showed several puncture holes. The patient received metronidazole (Flagyl®, Rhone Poulenc, Paris, France) 500 mg three times a day and sodium cefuroxime (Zinacef®, Glaxo, Ulverston, England) 750 mg, also three times a day, both i.v. for 10 days. She recovered steadily. Menstruation occurred 12 days after embryo transfer.
Comment This case clearly demonstrates the hazards of transvaginal oocyte retrieval. Nevertheless, according to our own data, the incidence of infectious complications of this kind is very low. In our centre, which is specialized in IVF/ET with transport of oocytes (Jansen etal., 1986), in co-operation with the University hospital Dijkzigt Rotterdam, infectious complications only occurred in four cases out of a total of 623 transvaginal oocyte retrievals in the last 2 years (0.6%). The three other patients had only minor symptoms, which were attributed to bowel puncture lesions or leaking endometrial cysts and needed no surgical treatment. In these cases further investigations were not carried out since the © Oxford University Press
Appendicitis after transvaghral oocyte retrieval
symptoms subsided spontaneously, or after i.v. administration of antibiotics in one case. This complication rate compares favourably with those found by others (Baber et al., 1988). It may seem obvious to consider the use of prophylactic antibiotics, for instance in a single i.v. dose, in order to prevent possible contamination of the peritoneal cavity. However, there are norelevantdata available that support their use in transvaginal oocyte retrieval procedures. Most probably prophylactic antibiotics only delay the diagnosis and therapy of infectious complications, as happened in this case, where inappropriate administration of antibiotics initially masked the early symptoms of an overt appendicitis. As we are dealing with a healthy population undergoing optional surgical procedures, great care should be taken to inform the patients in detail of the possible, perhaps fatal, risks they are taking. Therefore, we provide a leaflet, given on admission to every couple, concerning the risks and possible complications involved in the procedure. This creates an informed consent situation and thus minimizes the risk of legal action in the event of complications. In none of the above-mentioned cases did patients react with legal action.
References Baber.R., Porter.R., Picker,R., Robertson, R., Dawson,E. and Saunders.D. (1988) Transvagina] ultrasound directed oocyte collection for in vitro fertilization: successes and complications. J. Ultrasound Med., 7, 377-379. Jansen.C.A.M., van Beek.J.J., Verhoeff.A., Alberda.A.T. and Zeilmaker.G.H. (1986) In vitro fertilization and embryo transfer with transport of oocytes. Lancet, i, 676. Received on January 22, 1992; accepted on April 3, 1992
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