Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

Summary

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

Abstract

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.

When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 °C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.

In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

Introduction

With an incidence of approximately 1 in 4-10,000 women, MRKHS is the cause of 15% of primary amenorrhea cases. MRKHS is characterized by the congenital absence of the upper segment of the vagina and the uterus, whereas urinary tract and skeletal anomalies are associated variably. More specifically, a vaginal vault with a depth of 1-2 cm is usually present, and two rudimental uterine horns may be found¹.

In the past, the primary medical interest in MRKHS was to enable normal sexual intercourse, which generally requires the construction of a neovagina by either non-surgical or surgical approaches²

Protocol

The local ethical committee at the tertiary referral center for MRKHS (IRCCS San Raffaele University Hospital, Milan, Italy) was notified and approved the protocol before its implementation in July 2017. All patients or guardians gave signed informed consent for laparoscopic oocyte retrieval and cryopreservation during vaginoplasty and for the use of anonymized clinical/laboratory data for scientific purposes.

1. Team composition

1. Designate a dedicated team, composed of an experienced laparoscopic surgeon, an experienced vaginal surgeon, an infertility expert, a dedicated psychologist, and a committed nurse.
....

Results

Table 2 includes ovarian stimulation data of the patients, whereas main surgical and functional outcomes are described in Table 3. The concomitant laparoscopic procedures of oocyte retrieval and vaginoplasty were combined successfully in all patients. An average of 11.4 ± 5.4 (mean ± SD) oocytes were retrieved, and 9.6 ± 4.3 MII oocytes were cryopreserved (Table 3). In our experience with oocyte cryopreservation in patients undergoing ART, postwarming oocy.......

Discussion

This protocol reduces the invasiveness in the treatment of MRKHS by combining the procedures of vaginoplasty and oocyte retrieval. To this purpose, it is crucial that a dedicated team is designated to ensure that the timing of COS, the surgical procedure, and oocyte vitrification are scheduled efficiently.

MRKHS patients for whom this combined laparoscopic method is expected to be most beneficial are those in whom a transvaginal retrieval would be considered technically challenging or unfeasib.......

Materials

Name	Company	Catalog Number	Comments
Oocyte retrieval procedure
Equipment
CO2 O2 Incubator	Sanyo
Incubator	Thermo Scientific
Laminar Flow Hood	Cooper Surgical
Portable incubator	Cooper Surgical
Stereomicroscope	Nikon
Consumables
14 mL Polystyrene Round-Bottom Tube	Falcon	352057
4-well dish	Nunc	144444
60 mm Petri dish	Nunc	FA9150270
90 mm Petri dish	Nunc	FA9150360
Human Serum Albumin 100 mg/ml in Normal Saline (5%)	Origio	3001
Mineral oil for embryo culture	Origio	4008
One Well Dish	Oosafe	OOPW-CW05
Quinn’s Advantage Fertilization medium SAGE	Origio	1020
Quinn’s Advantage medium with HEPES	Origio	1024
Sterile glass pasteur pipettes
Oocyte denudation
Equipment
CO2 O2 Incubator	Sanyo
Flexipet adjustable handle set	Cook	G18674
Incubator	Thermo Scientific
Laminar Flow Hood	Cooper Surgical
Stereomicroscope	Nikon
Consumables
4-well dish	Nunc	144444
CSCM (Continuos single culture) medium	Fujifilm irvine Scientific	90165
Human Albumin 100 mg/mL in Normal Saline (5%)	Origio	3001
Hyaluronidase	Fujifilm Irvine Scientific	90101
IVF culture 60 mm petri dish	Nunc	FA9150270
Mineral oil for embryo culture	Origio	4008
One Well Dish	Oosafe	OOPW-CW05
Quinn’s Advantage medium with HEPES	Origio	1024
Serum Substitute Supplement	Fujifilm irvine Scientific	99193
Sterile glass pasteur pipettes
Stripping pipette tips (140 μm)	Cook	K-FPIP-1140-10BS-5
Stripping pipette tips (170 μm)	Cook	K-FPIP-1170-10BS-5
Oocyte vitrification
35 mm Petri dish	NUNC	150255
60 mm Petri dish	NUNC	150270
90 mm Petri dish	NUNC	150360
Container for Cooling rack	Kitazato
Cryodevice/cryotop	Kitazato	81111
Electronic timer
Flexipet	COOK	K- 1000
Gilson Pipetman	Gilson	F123601
Lab Printer LabXpert	Brady	XSL-86-461
Tips 20-200 µL	Thermo Scientific	2160G
Tips 2-20 µL	Thermo Scientific	2139-HR
Visotubes	Cryo Bio System	20
Vitrification Freeze Kit	Fujifilm Irvine Scientific	90133-SO
Vitrification Thaw kit	Fujifilm Irvine Scientific	90137-SO