Conditions: Infertility
Keywords: fentanyl midazolam pethidine diazepam
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 170
Healthy volunteers: no

Brief summary:
The objective of the trial is to compare fentanyl and midazolam vs diazepam and pethidine in terms of the pain levels and post-operative side effects of TUGOR

Detailed description:
In-vitro fertilization / embryo transfer (IVF / ET) is a well-established method to treat various causes of infertility. It involves multiple follicular development, retrieval of oocytes and embryo transfer after fertilization. Egg retrieval at the majority of IVF units is performed through the transvaginal route under ultrasound guidance (TUGOR) \[1\]. During TUGOR, the needle has to pass through the mucosa in the vaginal vault in order to puncture the follicles in the ovary. The procedures are generally short, lasting about 20-30 minutes but are still painful without anaesthesia or analgesia.

Intravenous sedation with or without local anaesthesia is the most widely used method. Conscious sedation is a safe and cost-effective method of providing analgesia and anesthesia for TUGOR. \[2\] It is easy to administer in cooperative and motivated patients. It has a relatively low risk for adverse effects on oocyte and embryo quality and pregnancy rates. \[3\] Paracervical block (PCB) in conjunction with conscious sedation during TUGOR was shown to significantly reduce the pain during TUGOR when compared to PCB alone \[4\].

A Cochrane review on various methods of sedation and analgesia for pain relief during TUGOR has shown no single method or delivery system appeared superior for pregnancy rates and pain relief. \[5\] Most of the methods seemed to work well and the effect was usually enhanced by addition of another method such as pain relief with paracervical block. \[6\]

The investigators' reproductive centre has recently aligned with the Assisted Reproduction Centre of the University of Hong Kong (HKU). The investigators are using 0.1mg fentanyl and 5mg midazolam intravenously for pain relief in TUGOR at Kwong Wah Hospital (KWH) whereas 5mg diazepam and 25mg pethidine intravenously are being used in HKU. The investigators would like to compare fentanyl and midazolam vs diazepam and pethidine in terms of pain levels and post-operative side effects of TUGOR in this prospective non-inferiority randomized double-blinded trial. The investigators postulate there are no differences in the pain levels between two groups but the postoperative side effects may be different.

Arms:
arm 1: group A will be given intravenous 0.1mg fentanyl and 5mg midazolam prior oocyte retrieval arm 2: group B will be given intravenous 25mg pethidine, 5mg diazepam prior oocyte retrieval

Interventions: intervention 1: fentanyl intervention 2: pethidine intervention 3: Diazepam intervention 4: Midazolam
Intervention descriptions: intervention 1: arm A receiving iv fentanyl intervention 2: arm B receiving iv pethidine intervention 3: arm B receiving iv diazepam intervention 4: arm A receiving iv midazolam

Protocol document:
Prot_SAP_000.pdf: 
TUGOR pain relief study protocol (Version 2, 24th Mar 2015) 
 
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1. Title page 
Title:  A prospective, non-inferiority randomized double-blinded trial comparing fentanyl and 
midazolam vs diazepam and pethidine for pain relief during oocyte retrieval 
 
Version: 2 
Date:  24 Mar 2015 
 
 
Chief investigator: 
Name: 
 
Dr. Lai Shui Fan 
Title:   
Resident Specialist 
Address: 
 Department of Obstetrics and Gynaecology, Kwong Wah Hospital 
Tel. No.: 
 35176914 
E-mail:  
 lsf087@ha.org.hk 
 
 
Co-Investigators: 
Dr. LAM Mei Ting 
Resident Specialist, Department of Obstetrics and Gynaecology, Kwong Wah Hospital 
 
Dr. LI Hang Wun Raymond 
Associate Professor, Department of Obstetrics and Gynaecology, the University of Hong Kong 
Honorary Consultant, Department of Obstetrics and Gynaecology, Kwong Wah Hospital 
 
Professor NG Hung Yu Ernest 
Professor, Department of Obstetrics and Gynaecology, the University of Hong Kong 
Honorary Consultant, Department of Obstetrics and Gynaecology, Kwong Wah Hospital 
 
 
2. 
Background:  
In-vitro fertilization / embryo transfer (IVF / ET) is a well-established method to treat various 
causes of infertility. It involves multiple follicular development, retrieval of oocytes and embryo 
transfer after fertilization. Egg retrieval at the majority of IVF units is performed through the 
transvaginal route under ultrasound guidance (TUGOR) [1]. During TUGOR, the needle has to 
pass through the mucosa in the vaginal vault in order to puncture the follicles in the ovary. The 
procedures are generally short, lasting about 20-30 minutes but are still painful without anaesthesia 
or analgesia.  
 
Intravenous sedation with or without local anaesthesia is the most widely used method. Conscious 
sedation is a safe and cost-effective method of providing analgesia and anesthesia for TUGOR. [2] 
It is easy to administer in cooperative and motivated patients. It has a relatively low risk for adverse 
effects on oocyte and embryo quality and pregnancy rates. [3] Paracervical block (PCB) in 
conjunction with conscious sedation during TUGOR was shown to significantly reduce the pain 
during TUGOR when compared to PCB alone [4].  
 


TUGOR pain relief study protocol (Version 2, 24th Mar 2015) 
 
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A Cochrane review on various methods of sedation and analgesia for pain relief during TUGOR 
has shown no single method or delivery system appeared superior for pregnancy rates and pain 
relief. [5] Most of the methods seemed to work well and the effect was usually enhanced by 
addition of another method such as pain relief with paracervical block. [6] 
 
Our reproductive centre has recently aligned with the Assisted Reproduction Centre of the 
University of Hong Kong (HKU). We are using 0.1mg fentanyl and 5mg midazolam intravenously 
for pain relief in TUGOR at KWH whereas 5mg diazepam and 25mg pethidine intravenously are 
being used in HKU. We would like to compare fentanyl and midazolam vs diazepam and pethidine 
in terms of pain levels and post-operative side effects of TUGOR in this prospective non-inferiority 
randomized double-blinded trial. We postulate there are no differences in the pain levels between 
two groups but the postoperative side effects may be different. 
 
References: 
1. Hammarberg K, Enk L, Nilsson L, Wikland M. Oocyte retrieval under the guidance of a 
vaginal transducer: evaluation of patient acceptance. Hum Reprod 1987; 2: 487-490 
2. Trout SW, Vallerand AH, Kemmann E. Conscious sedation for in vitro fertilization. Fertil 
Steril 1998;69:799-808. 
3. Vlahos NF, Giannakikou I, Vlachos A, Vitoratos N. Analgesia and anesthesia for assisted 
reproductive technologies. Int J Gyne Obs 2009;105:201-205 
4. Ng EHY, Tang OS, Kwai DCC, Ho PC. A prospective, randomized, double-blind and 
placebo-controlled study to assess the efficacy of paracervical block in the pain relief during 
egg collection in IVF. Hum Reprod 1999;14:2783-2787 
5. Kwan I, Bhattacharya S, Knox F, McNeil A. Conscious sedation and analgesia for oocyte 
retrieval during IVF procedures: a Cochrane review. Hum Reprod 2006;21:1672-1679 
6. Kwan I, Bhattacharya S, Knox F, McNeil A. Pain relief for women undergoing oocyte 
retrieval for assisted reproduction. Cochrane Database Syst Rev 2013;1:CD004829 
 
 
3. 
Trial objectives and purpose: 
The objective of the trial is to compare fentanyl and midazolam vs diazepam and pethidine in terms 
of the pain levels and post-operative side effects of TUGOR  
 
 
4. 
Research design: 
This is a prospective non-inferiority randomized, double-blinded trial. Patients will be randomized 
into two groups receiving either  
 
A. Intravenous 0.1mg fentanyl and 5mg midazolam 
B. Intravenous 5mg diazepam and 25mg pethidine 
 
 
5. 
Selection and withdrawal of subjects: 
5.1 
Subject selection criteria: 


TUGOR pain relief study protocol (Version 2, 24th Mar 2015) 
 
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The study will be jointly conducted in the N10, Dr Chow Chun-Kay Assisted Reproduction 
Centre, Department of Obstetrics and Gynaecology, Kwong Wah Hospital and K5N, the Assisted 
Reproduction Centre, Department of Obstetrics and Gynaecology, the University of Hong Kong. 
 
Patients fulfil the following criteria will be recruited into the study: 
(a) presence of both ovaries; 
(b) body mass index  30   
(c) written informed consent and 
(d) Chinese 
 
5.2 
Subject exclusion criteria: 
(a) IVF cycle converted from ovulation induction or intrauterine insemination cycles;  
(b) patient requests general anaesthesia for TUGOR;  
(c) history of drug sensitivity to lignocaine/fentanyl/midazolam/diazepam/pethidine;  
(d) less than 3 dominant follicles present; 
(e) dominant follicles present in one ovary only and 
(f) TUGOR performed on one side only. 
 
5.3      Subject withdrawal criteria 
Participation in the study is totally voluntary. The subjects can withdraw from the study at any 
time and they will receive standard medical care. Their participation may be discontinued in case 
of severe side effects during the procedure. 
 
 
6. 
Treatment of subjects: 
Women undergoing IVF will be assessed for eligibility. They will follow the ovarian stimulation 
regimen according to the Standard Operation Procedures (SOP) of our unit. Human menopausal 
gonadotrophin (HMG, Pergonal, Serono, Switzerland) injection is started on the next day after 
ultrasound when there is no abnormality in ultrasound and serum estradiol levels are below <220 
pmol/L at a dosage according to the antral follicle count. Ovarian response will be monitored by 
both serum estradiol level and transvaginal scanning. Human chorionic gonadotrophin (HCG, 
Profasi, Serono, Switzerland) 10,000 IU will be given to trigger the final maturation when the 
leading follicle reaches 18mm in diameter and there are at least 3 follicles >15mm in diameter. 
 
Transvaginal ultrasound-guided oocyte retrieval will be performed 36 hours after the ovulatory 
dose of hCG injection. Patients will be admitted early in the morning and an intravenous cannula 
will be inserted in a convenient location in the forearm. Prophylactic antibiotic (1gram cefazolin 
or 1.5mg/kg gentamicin and 500mg flagyl if penicillin allergy) will be given intravenously 30 
minutes before the retrieval. TUGOR will be performed in the minor operation theatre. The 
patient will be positioned in a dorsal lithotomy position on an electrically operated chair with 
calf-supporting stirrups.  
 
Eligible women will be recruited for the study on the day of TUGOR. Informed written consent 
will be obtained. 
 
Randomization 


TUGOR pain relief study protocol (Version 2, 24th Mar 2015) 
 
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Before the procedure, each patient will be randomized into two groups with a predetermined 
computer-generated randomization code prepared by a research nurse to receive  
 
A. Intravenous 0.1mg fentanyl and 5mg midazolam 
B. Intravenous 5mg diazepam and 25mg pethidine 
 
Blinding 
Fentanyl, midazolam, diazepam and pethidine are all colourless. They will be each admixed with 
normal saline to make it 2.5ml in total in a 2.5ml syringe. The nurse assisting TUGOR will open 
the sealed envelopes arranged according to the computer-generated list and helps preparing and 
giving the medications. The patient and the physician will not know the group allocation. 
 
The procedure 
In addition to the study medications, a paracervical block will be given by injecting 10ml 1% 
lignocaine at 4 and 8 o’clock positions through a 21 gauge needle into the vaginal vault 2.5cm 
beneath the mucosa. The retrieval will be performed 5 minutes after the administration of 
paracervical block. Vaginal puncture sites during TUGOR would be kept at two i.e. one for each 
ovary. Each follicle will be flushed once and the follicular fluid from aspiration and flushing will 
be examined by an embryologist for an oocyte as usual. They will usually be discharged from the 
day ward 4 hours after the procedure.  
 
Assessment of pain levels 
Patients will be asked to rate their pain levels during (intraoperative) and within 4 hours after the 
procedure (postoperative) by means of 100mm linear visual analogue scale (VAS, 0 = non to 100 
= intolerable).  
 
The surgeon will also rate the levels of sedation of patients (S = sleeping, easily aroused; 1 = 
awake and alert; 2 = occasionally drowsy, easy to arouse; 3 = frequently drowsy, arousable, 
drifts off to sleep during conversation; 4 = somnolent, minimal or no response to stimuli). The 
patient will be asked by another nurse not involved in the TUGOR procedure to give the 
anticipated pain levels before TUGOR and report the vaginal and abdominal pain levels 
associated with TUGOR within 4 hours after the procedure. Side-effects such as nausea, 
vomiting, drowsiness and dizziness will be noted and graded by patients. 
 
A maximum of two normally cleaved embryos will be replaced into the uterine cavity 48-72 
hours after the retrieval. Excess embryos will be frozen for subsequent transfer if the women are 
not pregnant in that cycle. Luteal phase will be supported by endometrin vaginal pessary 100mg 
twice daily for 14 days starting 2 days after TUGOR. 
 
Data collection 
Apart from assessment of pain levels and side effects, we will also record patient characteristics 
including age, BMI, number of follicles/oocytes aspirated, the retrieval rate, the fertilization rate, 
duration of procedure, complications, clinical pregnancy rate, ongoing pregnancy rate and 
patient’s satisfaction.  
 
Follow-up 


TUGOR pain relief study protocol (Version 2, 24th Mar 2015) 
 
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Urine pregnancy test will be checked 18 days after ovulation trigger (day of HCG) and pelvic 
scan will be scheduled later to confirm intrauterine pregnancy and assess number of gestational 
sacs. 
  
 
7. 
Assessment of Efficacy: 
The primary outcomes are the pain level during and after the procedure as assessed by the visual 
analogue scale. Secondary outcome measures include sedation level, side effects of medications, 
patient’s satisfaction, clinical pregnancy rate and ongoing pregnancy rate. 
 
 
8. 
Safety assessment: 
Both the combinations of fentanyl and midazolam vs diazepam and pethidine were well-
established drugs of choice for conscious sedation and proven to be safe. Patients will be 
monitored closely with continuous oxygen saturation throughout the procedure of TUGOR to 
look for respiratory depression. Blood pressure and pulse monitoring will be carried out before 
TUGOR and then hourly up to 4 hours after TUGOR. Emergency trolley with equipment for 
airway support is readily available in both centres. Anaesthetic support for difficult airway is 
available in both centres. 
 
Lignocaine is a commonly used anaesthetic agent. Its use as paracervical block was evaluated in 
many studies and proven to be safe and effective.  
 
 
9. 
Statistics 
Sample size estimation 
The mean pain score and standard deviation of pain level during TUGOR after diazepam and 
pethidine with paracervical block is 25 and 25 respectively based on our previous trial [1]. The 
sample size needed for this trial will be determined by the pre-defined non-inferiority margin and 
a non-inferiority margin of 10 was considered appropriate. Therefore, 78 patients in each arm are 
required to achieve a power of 80% at a type I error of 0.05 in order to account for drop outs, 85 
patients will be recruited into each group and therefore 170 patients will be recruited for the 
whole study.  
 
Data analysis 
Demographic features of two groups will be compared. The primary outcome is the pain level 
during TUGOR and 4 hours after TUGOR. Secondary outcome measures include side effects of 
medications, patient’s satisfaction, clinical pregnancy rate and ongoing pregnancy rate. 
 
Chi-square test and Fisher’s exact test will be used for categorical variables. P values of <0.05 
will be considered clinically significant. Subjects may be excluded from the data analysis if 
essential data is missing. 
 
References: 


TUGOR pain relief study protocol (Version 2, 24th Mar 2015) 
 
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1. Ng EHY, Tang OS, Kwai DCC, Ho PC. A prospective, randomized, double-blind and 
placebo-controlled study to assess the efficacy of paracervical block in the pain relief during 
egg collection in IVF. Hum Reprod 1999;14:2783-2787 
 
 
10. 
Direct access to source data / documents: 
The investigators permit trial-related monitoring, audits, IRB/IEC review and regulatory 
inspections, providing direct access to source data/documents. 
 
 
11. 
Quality control and quality assurance 
Patients will be managed by the investigators who are specialists in obstetrics and gynaecology. 
 
 
12. 
Ethics: 
Ethics approval for the current study will be obtained from the Kowloon West Cluster Research 
Ethics Committee and Hong Kong West Research Ethics Committee. Written consent will be 
obtained from recruited subjects. Their participation is totally voluntary. They can withdraw 
from the study at any time. 
 
 
13. 
Data Handling and record keeping 
All data will be stored in locked computer files that are accessible only to the investigators and 
research staffs involved in the study. The principal investigator will be responsible for data 
management including data coding, monitoring and verification. 
 
 
14. 
Financing and insurance 
We are now applying for the TWGH Research Fund 2014/2015 
 
 
15. 
Publication policy 
The findings of this study will be submitted for consideration for publication in peer-reviewed 
scientific journal. 
 
 
16. 
Supplements 
The study will be conducted in compliance with the Declaration of Helsinki and Good Clinical 
Practice (ICH-GCP). 
 
 
17. 
We certify that the information given is complete and accurate to the best of our knowledge.