Egg retrieval is a potentially painful procedure. I say potentially, because it does not have to be painful - it does not have to hurt. We recently listened to the NY Times Podcast “The Retrievals“ which reviews the case at the Yale Fertility Clinic when patients had egg retrievals with no pain control as a nurse in the clinic was replacing fentanyl with salt water (saline). Oh my, oh my, oh my.
At Olive we do about 2200 egg retrievals per year. Patients are typically given Tylenol and Ativan orally before the procedure and then during the procedure they receive IV fentanyl and IV midazolam. At some clinics (largely outside of Canada) patients having an egg retrieval maybe given full general anaesthesia or spinal anaesthetic in an operating room. This is not common. It is not common as this level of anaesthetic is not necessary most of the time. For 99% of patients IV fentanyl and midazolam, when properly dosed, is good pain and anxiety control during an egg retrieval. Further, to provide a full general anaesthetic the procedure must be done in a hospital or hospital-like setting with an anaesthetist. This would add thousands of dollars and longer waits for IVF.
Having done thousands of egg retrievals I am witness to the pain experience of an egg retrieval. I have also done thousands of other painful in-office gynecologic procedures, like endometrial biopsy and hysteroscopy.
I have also had some of these procedures done to me. I have not had an egg retrieval myself though.
What strikes me as I pause and think about the pain of these procedures, is that we do not always manage pain well.
I think the pain of egg retrieval is well managed 99% of the time. Those 1% of people who have an egg retrieval and are in pain despite the IV fentanyl and midazolam are upsetting… heartbreaking really. Those people likely need a full general anaesthetic - unfortunately not available at Olive. How do we predict that 1%? If we realize during the procedure that they are the 1%, do we persist and retrieve the eggs despite the person’s pain? Most of these 1% of patients do ask us to continue when they are in pain as they do not want to leave any eggs un-retrieved.
What about procedures we do without IV sedation at all? What about hysteroscopy and endometrial biopsy? Pain management during these procedures is also important. I think this raises a larger question about women’s health care and how we respect their pain experience.
Hysteroscopy, endometrial biopsy, IUD insertion, cervical biopsy are all painful and generally no pain management beyond oral medications is offered. If a patient needs more than oral therapies, they need to have the procedure done at a hospital. This means month long waits, layers of bureaucracy, longer time off work/life - all for procedures that take less than 5 minutes. What is the right thing to do? It is not the same for everyone.
In an ideal world we would have an oral pain and anxiety reliever that is short acting, potent with no side effects. This does not exist today.
Listening to the podcast “The Retrievals” is disturbing. I had so many different emotions: sadness and anger for the women who experienced an egg retrieval with no IV fentanyl, wonder how they could do tens if not hundreds of procedures without wondering why the fentanyl wasn’t working, frustration at the poor drug control systems that made the drug swapping/diversion possible, anger and empathy for the drug addicted nurse who caused all of this pain.
What can come of this podcast is a reflection on pain management in fertility care. From that perhaps we can do better. The podcast has generated discussion among our team at Olive. We can all do better and modernize pain management.
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