Oocyte retrieval using the lateral recumbent position

A 33-year-old nulliparous woman who had been trying to conceive for 3 years attended our center for in-vitro fertilization (IVF). She had a regular menstrual cycle, but with severe dysmenorrhea on the first day. Her body mass index was 17.9 kg/m2 and her antral follicle count was nine. She had been diagnosed with Camurati–Engelmann disease at 17 years old, a genetic disease characterized by hyperostosis of the long bones and skull, proximal muscle weakness, severe limb pain and joint contractures1. She had undergone previously diagnostic laparoscopy, which revealed endometriosis Grade I, with patency of both Fallopian tubes. Besides endometriosis as a potential cause for infertility, we also identified mild male factor infertility in her partner (total sperm motility of 25%). Controlled ovarian stimulation using menotropin 225 IU/day (Menopur, Ferring GmbH, Kiel, Germany) combined with ganirelix 0.25 mg/day (Vetter Pharma-Fertigung GmbH & Co, Ravensburg, Germany) was started on day 2 of the menstrual cycle, when a follicle of ≥ 14 mm was identified. Although somewhat difficult, and requiring some effort from the patient because of her condition, we were able to perform a transvaginal ultrasound examination in the standard gynecological position to monitor the controlled ovarian stimulation. Final oocyte maturation was triggered by a 0.25-mg dose of recombinant human chorionic gonadotropin (Ovidrel, Merck, Kenilworth, NJ, USA) on the day on which three follicles of ≥ 17 mm were observed. Oocyte retrieval was scheduled for 36 h later. On the day of oocyte retrieval, just after sedation of the patient with propofol and fentanyl, she presented intense muscle contracture at any attempt of thigh abduction and we feared she would not be able to undergo oocyte retrieval in the standard lithotomy position using stirrups. Therefore, we decided to place the patient in the lateral recumbent (or Sims') position2 (Figure 1). This is considered a good position for performing gynecological examinations, as it provides similar access to the pelvic organs, while reducing embarrassment and discomfort of the patient, possibly by avoiding the use of stirrups3, 4. However, to the best of our knowledge, there is no previous report on the use of this position for oocyte retrieval. The procedure was accomplished successfully with no complication or difficulty. We aspirated 19 follicles, retrieving 10 oocytes, eight of which were in metaphase II. Following IVF, we identified seven zygotes that were kept in culture medium for 5 days, resulting in the development of three blastocysts. Single fresh embryo transfer was performed on day 5, and the other two embryos were cryopreserved. Vaginal progesterone capsules 600 mg/day (Utrogestan, Besins Healthcare, Drogenbos, Belgium) were administered for luteal-phase support. A subsequent pregnancy test was positive and an intrauterine clinical pregnancy was confirmed by transvaginal ultrasound, showing one embryo with crown–rump length of 6 mm and a heart beat. At the time of writing, the patient was 32 weeks' gestation without complications. We thank Marcelo Di Chiara for his valuable help with the drawing. W. P. Martins*, C. A. M. Soares, M. W. P. Barbosa, E. M. M. Yamaguti and R. A. Ferriani Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900 – 8 andar - HCRP - Campus Universitário, Ribeirao Preto, Sao Paulo, 14048–900, Brazil *Correspondence. (e-mail: [email protected])