A Systematic Review Comparing Perioperative Pain Regimens on Pain Outcomes Following Transvaginal Oocyte Retrievals

OBJECTIVE: To evaluate the utilization of different perioperative pain regimens on pain outcomes following transvaginal oocyte retrieval (TVOR). DESIGN: Systematic Review. MATERIALS AND METHODS: After registering in PROSPERO (CRD420251179763), we performed a systematic review in accordance with PRISMA guidelines of individuals undergoing TVOR who received standardized perioperative pain medications compared to those who received different or no standardized perioperative pain medications. Primary outcomes were post-operative opioid requirement and post-operative pain scores. Secondary outcomes were oocyte retrieval outcomes, pregnancy outcomes, and patient satisfaction scores. We included paracervical blocks and the following as perioperative pain medications given as standardized dosing: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentin, pregabalin, ketamine, and dexmedetomidine. We reviewed randomized controlled trials and cohort studies with appropriate sensitivity analyses. We only included studies published in English with full text available. Screening, analysis, data extraction for all studies were completed by three independent reviewers (C.J.B, D.H.B, and K.F.H.), and discrepancies were resolved with consensus review. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). RESULTS: A total of 338 studies were screened, with 33 meeting inclusion criteria for analysis. Most studies analyzed had less than 50 participants per comparison arm and only two were published in the last five years. Despite no consistent defined pain scoring system, most studies used the Visual Analogue Scale (VAS). Studies that compared paracervical blocks overall found that paracervical blocks afforded benefit compared to placebo injection or no injection. Opioid studies were heterogenous, comparing multiple types and doses with varying levels of sedation, with no consensus reached on optimal perioperative use of opioids. NSAIDs were associated with lower pain scores compared to placebo. Studies examining dexmedetomidine were mixed, with some finding an association with improved patient satisfaction. There were no included studies directly comparing acetaminophen, gabapentin, pregabalin, and ketamine. No significant differences in laboratory or pregnancy outcomes between groups regardless of standard perioperative pain intervention. Nearly half of the studies (n=15, 45.5%) had a low risk of bias. Consistent with a priori criteria, no meta-analysis was performed due to heterogeneity of the study design. CONCLUSIONS: The inconsistency of defined patient reported pain scoring systems, variety in standardized pain medications, and small comparison groups preclude recommending a standardized perioperative pain regimen in TVORs. Nevertheless, most studies found no clinically significant differences in pain scores or need for additional medications. Laboratory and clinical outcomes were similar regardless of intervention.