General Anaesthesia or Sedation in Egg Collection?

In the past, in vitro fertilization treatment, egg collection was performed by laparoscopy under general anaesthesia. However, the egg retrieval method with vaginal ultrasound, used for the first time in the mid-80s, has become the preferred method today because it is minimally invasive, can be performed under sedation, and is also accepted by patients.

Different anaesthesia and sedation techniques can be used in egg retrieval with vaginal ultrasound, depending on the doctor’s and patient’s preferences, available personnel and equipment. Which technique to choose also depends on whether the centre where the procedure will be performed is located in a hospital.

In a study on IVF centres in England in 2004, an evaluation was made about the anaesthesia and sedation techniques used during egg collection. Sixty-seven responded to the survey sent to 100 centres. It was revealed that 62.4% of the centres preferred sedation. General anaesthesia was the preferred method in 24.6% of the centres, 2.8% sometimes used general anaesthesia and sometimes sedation, and 5% used the paracervical block method with sedation. One centre (1.6%) was administering spinal anaesthesia with sedation. Also, 3.6% of the centres used intramuscular pain relief and intravenous sedation methods together.

Of the centres that responded to the survey, 77% were within a hospital, and the remainder were centres outside the hospital that had their own anaesthesia team.

Solution Alternatives

Since egg retrieval is a painful procedure, anaesthesia, analgesia and/or sedation techniques should be applied by choosing the method(s) that does not adversely affect the embryo and has the safest and least side effects.

General Anaesthesia

Although previous studies have suggested that the use of general anaesthesia has negative effects on success, recent studies have shown that there is no difference between the results obtained with general anaesthesia and the results obtained with sedation. A study comparing the effect of general anaesthesia on egg collection and IVF success with the effect of semi-awake sedation revealed that more eggs could be collected in the general anaesthesia group than in the sedation group. Still, the two groups had no difference in embryo division and pregnancy rates.

In a randomized controlled trial, the mean pain score under general anaesthesia (using fentanyl and propofol) was considerably lower than the pain score under half-awake sedation (using midazolam and ketamine). However, the high pain score under sedation was not to the point that the patient could not bear it.

In order to perform general anaesthesia, anaesthesia drugs and monitoring equipment should be available in the centre apart from the anaesthesiologist.

Paracervical Block

Sedation with a paracervical block is an effective method for egg collection. It can be performed by the IVF specialist who performed the egg collection. However, the block method also has a risk of complications. The rapid absorption of local anaesthesia from parametrial tissue may cause toxic effects. The proximity of the uterine arteries and veins to the region also means the risk of intravascular injection.

Regional Anaesthesia

Spinal and extradural (epidural) anaesthesia also requires the presence of an anaesthesiologist. Regional anaesthesia may take a long time to reach an adequate level. The most common side effects are low blood pressure, postural headache, insufficient numbness, short-term inability to move, and urinary incontinence in the postoperative period. However, as long as sedatives are not used together, almost no drowsiness is felt after the procedure.

Sedation

Many agents and techniques have been tried for effective sedation: benzodiazepines (usually midazolam), a mixture of propofol and ketamine used for intravenous anaesthesia, or analgesic drugs such as remifentanil, alfentanil, and pethidine. Deaths have been reported after using midazolam, usually in combination with opioids, and cases of hypoxemia and apnea are also common. Therefore, extreme caution should be exercised when using these two together. Likewise, care should be taken in the use of propofol, and this drug should only be administered by anaesthesiologists or people trained in the use of this drug. Since ovarian retrieval requires a pain reliever such as local anaesthesia (such as a paracervical block) or systemic analgesia (such as opioids), using sedatives without pain relief is also inappropriate.

In clinical applications, semi-awake sedation is defined as the technique of suppressing the central nervous system by using various drugs to perform the procedure while talking to the patient throughout the procedure. The drugs and techniques used for semi-awake sedation should be safe to prevent unconsciousness.

Deep sedation is defined as a situation in which the patient does not respond to verbal and physical stimuli, and the airway may not be open. Although this situation is not equivalent to general anaesthesia, its application requires equal expertise and skill. Particular attention should be paid to the combined use of sedatives and opioids.

For these reasons, in selecting the sedation technique, whether the method is in the category of semi-awake sedation should be evaluated very well.

Apart from this, it is necessary to have a specialist with sufficient training who is responsible for monitoring and recording the patient’s condition throughout the procedure. This person may not be an anaesthesiologist.

Analgesia

One of the most important aspects of post-egg retrieval care is pain management. After egg retrieval, 3% of the patients have severe pain, and 2% of them have the same intensity for two days. Therefore, it is important to use pain relievers during and after the procedure.

Summary

Problem

Which anaesthesia/analgesia method will be used during egg collection?

Basic Knowledge

• The procedure of collecting eggs from the vagina is a painful procedure, and 3% of the patients reported severe pain after the procedure.
• In a study conducted in England in 2004, 62.4% of the IVF centres participated in the sedation, 24.6% in general anaesthesia, 2.8% in both methods and the remaining 5% paracervical with sedation. It was determined that they preferred the block method.

Solutions Alternatives

• General anaesthesia is a safe method with a low pain score, and more eggs can be collected compared to sedation. Still, there is no difference between the pregnancy rates of the two methods.
• Although the paracervical block is an effective method that the IVF team can apply, toxic systemic effects can be seen when it is accidentally administered intravenously.
• Regional anaesthesia may take time to be effective, and there may be a temporary inability to move and urinary incontinence after the procedure.
• Sedation is an effective and safe method when applied by trained people. Anaesthesiologists, IVF teams or nurses can apply it.
• No matter which technique is chosen, it is very important to follow the method’s rules, have trained personnel during the procedure, carefully monitor the patient and have the necessary equipment for awakening.

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REFERENCES

https://pubmed.ncbi.nlm.nih.gov/25769434/ https://pubmed.ncbi.nlm.nih.gov/23768623/ https://pubmed.ncbi.nlm.nih.gov/26986742/