Individualized Periprocedural Management of Congenital Dysfibrinogenemia during Transvaginal Oocyte Retrieval: A Case Report

Summary

In a carefully selected, low-risk patient with congenital dysfibrinogenemia, stable laboratory findings, no bleeding phenotype, and prior uneventful surgeries, a multidisciplinary trigger-based hemostatic plan enabled safe transvaginal oocyte retrieval without routine prophylactic transfusion.

Abstract

Congenital dysfibrinogenemia is a qualitative fibrinogen disorder with phenotypes ranging from isolated laboratory abnormalities to bleeding or thrombosis. Transvaginal ultrasound-guided oocyte retrieval is minimally invasive but may cause pelvic bleeding, and peri-procedural management in patients with congenital dysfibrinogenemia is not standardized. We report a 34-year-old woman with tubal-factor infertility and persistently low functional fibrinogen who pursued in vitro fertilization. Targeted sequencing of coagulation-related genes identified a heterozygous fibrinogen gamma chain gene (FGG) variant (NM_021870.3:c.902G>A, p.Arg301His), which was considered potentially contributory to the laboratory phenotype. She had no personal history of abnormal bleeding or thrombosis and had previously tolerated laparoscopic salpingotomy without transfusion or fibrinogen supplementation. A multidisciplinary team involving reproductive medicine, anesthesia, laboratory medicine, transfusion medicine, and internal medicine implemented a conservative, trigger-based plan without routine prophylactic transfusion, with prearranged availability of fibrinogen-containing products and predefined escalation criteria based on symptoms, hemodynamics, hemoglobin trends, and ultrasound findings. Controlled ovarian stimulation was performed using a gonadotropin-releasing hormone antagonist protocol, and oocyte retrieval was completed under standard intravenous sedation by an experienced operator. Ten oocytes were retrieved with an estimated blood loss of <5 mL. Postprocedure monitoring with serial vital signs, complete blood counts, coagulation tests, and transvaginal ultrasound showed hemodynamic stability and no clinically significant hemoperitoneum. This case illustrates the feasibility of transvaginal oocyte retrieval in a carefully selected, low-risk patient with congenital dysfibrinogenemia and provides a practical framework for individualized, risk-stratified peri-procedural management.

Introduction

Transvaginal ultrasound-guided oocyte retrieval (TVOR) is the standard method for follicular aspiration in assisted reproductive technology (ART). Although it is generally considered safe, it remains an invasive transvaginal needle procedure and may be complicated by pelvic bleeding. Large retrospective series have shown that severe complications after TVOR are uncommon in routine IVF practice^1,2. Despite the overall low complication rate, clinically significant hemorrhagic events after TVOR have been well documented. Severe hemoperitoneum caused by ovarian bleeding is rare but potentially life-threatening, an....

Protocol

All procedures were performed in accordance with institutional policies. Written informed consent for publication was obtained from the patient.

1. Preprocedure confirmation and risk stratification

1. Abnormal fibrinogen function was confirmed on repeated preprocedure coagulation testing using fibrinogen activity measured by the Clauss method together with thrombin time¹⁶.
2. Fibrinogen antigen quantitation was performed in parallel, and the fibrinogen activity/antigen ratio was assessed to support evaluation of a qualitative fibrinogen disorder rather than a simple quantitative defic....

Results

TVOR was completed 36.5 h after trigger and yielded 10 mature (MII) oocytes with an estimated blood loss of <5 mL. Seven oocytes fertilized normally and all cleaved, generating seven high-quality cleavage-stage embryos; five blastocysts were cryopreserved. Serial clinical, hematologic, coagulation, and ultrasonographic findings are summarized in Table 1. Pre-trigger ultrasound findings are shown in Figure 2. At 7 h after TVOR, transvaginal ultrasound detected a small pelv.......

Discussion

The present case supports the feasibility of conservative peri-procedural management only in a carefully selected, low-risk patient. Although TVOR is usually described as minimally invasive, that designation should not obscure the fact that clinically important bleeding can occur. Large IVF series show that severe complications are uncommon overall^1,2, whereas systematic review-level evidence confirms that severe hemoperitoneum due to ovarian bleeding, although r.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Corning (Falcon)	352096	General specimen handling tubes.
Diagnostica Stago	00597 (STA-C.K. Prest 5)	Routine APTT testing on Stago-compatible coagulation analyzers.
Cook Medical	MAR5200 (Cook Vacuum Pump)	Low-flow regulated vacuum source for oocyte retrieval.
Diagnostica Stago	STA R Max 3	Representative mainstream hemostasis analyzer for PT/APTT/TT/fibrinogen assays.
Sysmex	XN-1000	Representative mainstream hematology analyzer for complete blood count.
Institutional blood bank	Leukoreduced RBC unit	Prepared in advance for rescue transfusion if clinically indicated.
Institutional blood bank	Cryoprecipitate, pooled standard component	Fibrinogen-containing blood component for rescue replacement if indicated.
Diagnostica Stago	00662 (STA-Liatest D-Di Plus)	D-dimer measurement (if performed).
Cook Medical	G38692 / K-DVLF-240	Connects aspiration needle to vacuum pump; helps prevent contamination of vacuum system.
GE HealthCare	KTZ303987 (RIC5-9-D)	Intracavitary probe compatible with Voluson systems for follicle monitoring and TVOR guidance.
Diagnostica Stago	00649 (STA-Liatest FDP)	Fibrin(ogen) degradation products measurement (if performed).
Akorn	17478-030-02	Analgesia; a real mainstream commercial presentation. Confirm local formulary before submission.
Diagnostica Stago	00673 (STA-Liquid Fib)	Quantitative fibrinogen activity assay by Clauss method on Stago-compatible analyzer.
Siemens Healthineers	10446313 (N Antiserum to Human Fibrinogen)	Fibrinogen antigen measurement on BN II/BN ProSpec-type nephelometric systems.
CSL Behring	63833-0891-51 (RiaSTAP)	Representative human fibrinogen concentrate; use only according to local indication, specialist guidance, and product labeling.
Institutional blood bank	Fresh frozen plasma, standard component	Alternative fibrinogen-containing plasma product if rescue replacement is required.
EMD Serono	44087-1225-1 (Cetrotide)	Used to prevent premature LH surge in antagonist stimulation protocols.
Cook Medical	G34175 / K-DOPU-1735-T-A-60	Single-lumen OPU needle commonly used for TVOR; adjust gauge/length per institutional practice.
BD (Becton Dickinson)	320119	Representative pen-needle size for gonadotropin cartridge systems.
Fresenius Kabi	63323-269-10 (Diprivan)	Sedation/anesthesia agent; a real mainstream commercial presentation. Confirm local formulary before submission.
Diagnostica Stago	01163 (STA-NeoPTimal 5)	Routine PT/INR testing on Stago-compatible coagulation analyzers.
Organon	0052-0316-01 (Follistim AQ Cartridge 600 IU/0.72 mL)	Representative recombinant FSH cartridge for antagonist stimulation protocols.
EMD Serono	44087-1150-1 (Ovidrel prefilled syringe)	Final oocyte maturation trigger; use per protocol.
Baxter Healthcare	0338-9151-30	Use locally available equivalent; preservative-free preferred for IV use.
BD (Becton Dickinson)	363080	For coagulation assays (PT/INR, APTT, TT, fibrinogen activity, D-dimer, FDP).
CIVCO Medical Solutions	610-214-5	Barrier cover for TVUS-guided needle procedures.
Parker Laboratories	911409 (Aquasonic 100 sterile gel)	Sterile coupling gel for intracavity ultrasound procedures.
Diagnostica Stago	00611 (STA-Thrombin 2)	Routine thrombin time testing on Stago-compatible coagulation analyzers.
GE HealthCare	Voluson E10	Representative mainstream ultrasound platform used for follicle monitoring and TVOR guidance.
Organon	78206-150-01 (Pregnyl 10,000 IU)	Alternative hCG source; dose (e.g., 2,000 IU) can be drawn from vial according to protocol.