Massive exsanguinating hematuria – a rare post-operative complication of transvaginal ultrasound-guided oocyte retrieval for invitro fertilization

Purpose: To report the occurrence of massive exsanguinating hematuria after transvaginal oocyte retrieval for invitro fertilization.

Methods: Two cases with similar presentation of massive hematuria that compromised the cardiovascular status of the patients and required the surgical intervention of the author are presented.  The relevant literature related to the incidence of complications arising from this procedure is reviewed.

Results: The rare occurrence of exsanguinating hematuria after oocyte retrieval for in vitro fertilization is highlighted.

Conclusion: This report of two cases suggests that although severe complications post oocyte retrieval rarely occur, the procedure may not be altogether innocuous.

This is a report of the occurrence of exsanguinating haematuria post oocyte retrieval for IVF leading to acute hypovolemia and requiring surgery for amelioration. Two cases highlighting this phenomenon are presented to suggest that, although severe complications post oocyte retrieval rarely occur, the procedure is not innocuous.

The in vitro fertilization procedure involves four primary stages – induction of ovulation, oocyte retrieval, insemination and fertilization, and embryo transfer.

The most common technique used for oocyte retrieval is ultrasound-guided aspiration. First described in 1985, transvaginal ultrasound guided oocyte retrieval (TVOR) remains the gold standard in vitro fertilization (IVF) procedure. Nevertheless, despite its advantages, the aspiration needle may injure pelvic organs and structures adjacent to the ovaries leading to severe complications. Life threatening complications following transvaginal ultrasound-guided oocyte aspiration have been reported as rare1, 2.There is so far in existing literature two reports of post aspiration haematuria and urinary retention3,4  both of which were managed conservatively .The two almost identical cases presented here describes massive exsanguinating haematuria necessitating emergency pelvic laparatomy and open cystostomy in both patients.

This paper therefore brings to the fore this rare complication.

KO is 35 year old. She had primary infertility for two and a half years due to male factor. Her pre-treatment assessments were essentially normal and she went on to have ovarian stimulation as protocol. On the thirteenth day of GnRH treatment, she underwent, transvaginal ultrasound-guided ovarian puncture for oocyte retrieval under general anaesthesia and prophylactic antibiotic therapy. After emptying her bladder, oocytes were aspirated through the lateral vaginal fornices with a 17G fine aspiration needle loaded on a biopsy guide affixed to a transvaginal ultrasound probe. The ovary with the follicles closest to the vaginal fornices was first punctured, followed by sequential puncture of other follicles, without reinserting the needle through the vaginal wall. The aspirates were noted not to be heavily blood-stained and post-procedure ultrasound of the pelvis did not reveal any sign of haemmorhage from the ovary or iliac vessels. No immediate peri-operative complications were observed. Five days post procedure, the patient developed sudden onset total haematuria.This was recurrent over a twelve  hour period and associated with voiding blood clots, lower abdominal discomfort, dysuria and strangury. She had no vaginal bleeding, was slightly pyrexic and had a packed cell volume (PCV) of 22%. Abdomino-pelvic sonography revealed two enlarged multicystic ovaries with imtraluminal bladder masses suggestive of haematoma from a possible intra-peritoneal bladder injury. She had initial conservative management with intravenous fluids and antibiotics. In the absence of facilities for lower urinary tract endoscopy (LUTE), which would have necessitated a referral to another centre, and on account of the patients unstable vital cardiopulmonary statistics, she was scheduled for emergency pelvic exploration. At surgery, the bilaterally enlarged multicystic ovaries were visualized but no bladder rent was seen. She subsequently had open cystostomy. About 500mls of stale blood clots were evacuated from the bladder and several pin-point haemorrhagic spots were observed in the region of the trigone and posterior wall. There was no active bleeding point. The patient recovered uneventfully and was discharged home on the 10th post-operative day.

LD is a 30year old lady with a one and half year history of primary infertility who consented to transvaginal ultrasound-guided ovarian puncture for oocyte retrieval under general anaesthesia. The bladder was emptied before the procedure, as described in Case 1 above, and no immediate peri-operative adverse events were recorded. Five days after the procedure, the patient had initial sudden onset macroscopic haematuria, which recurred over a five hour period and was associated with lower abdominal pains, dysuria and voiding of blood clots. There was no vaginal bleeding and central temperature was normal. Abdomino-pelvic sonography revealed two enlarged multicystic ovaries and bladder hematoma.She had intravenous fluids and antibiotics but continued to have massive haematuria with clots and recurring clot retention. Her clinical condition deteriorated suddenly when her blood pressure dropped to 90mmHg/45mmHg and a PCV check revealed a drop from 35% to 25%.She was transfused with two units of fresh whole blood and an emergency pelvic exploration and open cystostomy was performed. The decision for open surgery was taken because facilities for LUTE were not available and a referral at the time to another facility would have been deleterious to the patient’s already precarious clinical condition. At surgery, there were multiple perforations of the posterior bladder wall with a solitary bleeding spot within the perforated areas, ~200mls of blood clots in the bladder and multiple petecheciae haemorrhagic spots in the trigone The blood clots were evacuated  and haemostasis was secured with a figure of eight vicryl stitch over the bleeding point. Post operative course was uneventful and the patient was discharged from hospital on the 8th day post surgery.

Following fours years of experience with the technique, Feichtinger and workers5 in 1988 strongly recommended the replacement of other ultrasound guided follicle aspiration techniques with TVOR .The reasons advanced were that the transvaginal route has the shorter puncture course with an empty bladder that is outside the pathway of the follicle-aspirating needle. Moreover the elastic nature of the vagina brings the tip of the ultrasound probe to the tip of the ovary, even reaching ovaries located high up in the

pelvis.

Over the last several decades, several reports have described the complications associated with the technique, the most common being haemorrhage, trauma to adjoining pelvic structures and pelvic infection.

During a 4-year prospective study  in which complications arising from a series of 2670 consecutive TVOR procedures were monitored, Bennett et al1 identified  vaginal hemorrhage in 229 (8.6%) of the cases, with a significant loss (> 100 ml) in 22 (0.8%) and postoperative pelvic infection  in 18 (0.6%) of the cases- nine of these being severe with pelvic abscess formation. Furthermore, haemorrhage from the ovary with haemoperitoneum formation was rarely seen and necessitated emergency laparotomy in one instance, while a single case of pelvic haematoma formation from a punctured iliac vessel was recorded, settling without intervention.

Ludwig et al6 in their review of over 1000 oocyte retrievals performed over a 17month period recorded no cases of intrabdominal bleeding and pelvic infections, an isolated case each of ureteric injury and unexplained fever, with only 2.8% of procedures causing vaginal bleeding.

In all of the reviews of complications in literature, the only reported incidence of transient macroscopic haematuria as a specific complication of transvesical oocyte collection was by Ashkenazi and colleagues7.

Minimal vaginal haemorrhage is one of the most common consequence of transvaginal oocyte aspiration and is susceptible to local treatment such as application of pressure or topical haemostatic agents or both or suture of the lesion8. On the other hand, haemoperitoneum from direct damage to pelvic organs i.e. uterus, bladder,

bowels or pelvic blood vessels, with serious cases requiring laparoscopy or emergency laparatomy have been described by Bergh and Lundkvist9

It is instructive that to date, it is not known that any case of massive exsanguinating haematuria compromising the patients cardiovascular status and requiring multiple blood transfusions and further emergency pelvic laparatomy for control has been reported as a direct complication of the TVOR.

In the cases presented there were no evidence, at pelvic laparotomy, of iatrogenic damage to other pelvic structures besides the bladder. However, there were sufficient reasons to believe that the multiple perforating injuries to the posterior bladder wall during the TVOR procedures formed the nidus for the massive hematuria that was to occur in the fifth post-operative day subsequently.

When it occurs, reactionary haemorrhage is caused by post-operative infection. Furthermore, haematuria is a known complication of urinary tract infections (UTI). It is not unlikely therefore that the presence of UTI‘s in both post-operative patients acted synergistically to provoke the exsanguinating hematuria which this case reports.

Transvaginal ultrasonographically-guided procedures are simple and safe and often represent the only means of access for adequate treatment of many gynaecological and non-gynaecological pelvic pathologic conditions i.e. aspiration of cystic pelvic masses and core biopsy of solid pelvic masses. However, in the IVF setting, pelvic ultrasound is hindered by changes in ovarian volume and structure due to super ovulation and follicular puncture.

In spite of the fact that ultrasonically-guided transvesical oocyte collection has few complications, they should be reported in order to draw attention to their occurrence. These cases underscore the need for proper information on potentially serious procedure-related complications to all oocyte retrieval patients.

1. Bennett SJ, Waterstone JJ, Cheng WC, Parsons J. Complications of transvaginal    ultrasound- directed follicle aspiration: a review of 2670 consecutive procedures. J.Assist Reprod Genet 1993; 10: 72-77.

2. Dicker D, Ashkenazi J, Feldberg D, Levy T, Dekel A, Ben-Rafael Z. Severe abdominal complications after transvaginal ultrasonographically guided retrieval of oocytes for in vitro fertilization and embryo transfer. Fertil Steril. 1993 Jun; 59(6):1313-5.

3. Sauer MV. Defining the incidence of serious complications experienced

    by oocyte donors: a review of 1000 cases. Am J Obstet Gynecol 2001; 184:277– 8.

4.   Modder J, Kettel LM, Sakamoto K. Hematuria and clot retention after   transvaginal oocyte aspiration: a case report. Fertil Steril.2006 Sep; 86(3):720.e1-2.

5. Feichtinger W, Putz M, Kemeter P. Four years of experience with ultrasound-guided follicle aspiration. Ann N Y Acad Sci. 1988;541:138-42

6. Ludwig AK, Glawatz M, Griesinger G, Diedrich K, Ludwig M, Perioperative and post-operative complications of transvaginal ultrasound-guided oocyte retrieval: prospective study of > 1000 oocyte retrievals. Human Reproduction 2006; 21(12): 3235-3240

  7.    Ashkenazi J, Ben David M, Feldberg D, Shelef M, Dicker D, Goldman JA. Abdominal complications following ultrasonically guided percutaneous transvesical collection of oocytes for in vitro fertilization. J In Vitro Fert Embryo Transf. 1987 Dec; 4(6):316-8.

      8.   Tureck RW, Garcia C, Blasco L, Mastroianni L: Perioperative complications arising after transvaginal oocyte retrieval. Obstet Gynecol 1993; 81:590–593

       9.    Bergh T, Lundkvist O: Clinical complications during in vitro fertilization treatment. Hum Reprod 1992; 7:625–626