Hypothesis: Persistently elevated hCG causes gestational ovarian overstimulation associated with prolonged postpartum hyperandrogenism in mothers of aromatase-deficient babies

CONTEXT

Aromatase deficiency due to a CYP19A1 defect leads to fetoplacental inability to convert androgens into estrogens. Pregnant mothers experience virilization caused by excess nonaromatized fetal androgens entering the maternal circulation. Biochemical normalization is believed to take place shortly after delivery.

OBJECTIVE

We report prolonged postnatal hyperandrogenism and enlarged multicystic ovaries in the mother of an affected 46,XX infant and hypothesize a possible pathogenetic mechanism.

PATIENTS AND METHODS

We investigated the mother on days 12 and 20 after delivery. FSH, LH, T, estradiol (E2), androstenedione (A), dehydroepiandrosterone-sulfate (DHEA-S), and human chorionic gonadotropin (hCG) plasma levels were obtained, and ovarian ultrasonography and magnetic resonance imaging were performed.

RESULTS

T (1040 ng/dL), A (6940 ng/dL), and E2 (2787 pg/mL) levels were markedly elevated on day 12 after delivery, whereas LH and FSH were suppressed (<0.1 IU/L). On day 20, all hormones had decreased significantly; however, T, A, and E2 still remained 3.5-, 2.2-, and 1.4-fold elevated, respectively, as compared to upper reference values. hCG (18.9 U/L) was still increased. DHEA-S was normal on both occasions. Sonography and magnetic resonance imaging revealed enlarged ovaries, with several cysts up to 4 cm. There was no history of polycystic ovary syndrome.

CONCLUSIONS

We hypothesize that persistent ovarian overstimulation by hCG had occurred in the mother during pregnancy, leading to prolonged autonomous excess production of androgens during the first weeks after delivery. As a causative mechanism, we propose that gestational hyperandrogenism and hypoestrogenism reduced inhibition of placental GnRH and hCG secretion by progesterone, resulting in persistently elevated hCG.

The mechanism of thromboembolism in the course of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an uncommon complication of controlled ovarian hyperstimulation. Although principal risk factors for OHSS have been determined, unfortunately, to date we are unable to precisely predict the appearance of OHSS. Still more infrequent are thromboembolic complications of OHSS. The background for the increased blood clotting in such cases includes, but is not limited to, increased permeability of blood vessels in response to excessive vasoactive substances of ovarian origin, vasoconstrictive effects of some other agents of ovarian origin, hemoconcentration and hypovolemia with resultant arterial hypotension, gonadotropin administration, supraphysiological concentrations of 17β-estradiol following ovulation induction, and inherited thrombophilias. Arterial events are predominantly cerebrovascular accidents, usually occurring concurrently with the onset of OHSS. Venous thromboses occur several weeks later and are mostly reported in unusual yet specific sites such as large veins of the upper extremities and neck. There is some evidence that arterial events may be rather embolic by their nature. Thus, the mechanisms standing behind arterial and venous events are likely to be different. Laboratory studies on hypercoagulability in OHSS indicate a broad array of possible changes, from the disturbed balance between tissue factor and tissue factor pathway inhibitor to elevated levels of D-dimer, thrombin-antithrombin complexes, prothrombin fragment 1 + 2, plasmin-antiplasmin complexes, and von Willebrand factor antigen. Increased levels of factors I, V, and VIII, thrombocytes, and decreased levels of tissue plasminogen activator and plasminogen activator inhibitor type I have also been reported. The quite unique localization of venous thrombi requires further careful attention for understanding. Although thromboembolic events are not frequently encountered in the course of OHSS, they are strikingly serious in a proportion of affected patients, and we agree with the recommendation by Grygoruk et al. from the current issue of the Journal that anticoagulant therapy should be prophylactically administered in all OHSS patients. As we discuss it, a precautionary good practice point could be the combined administration of low-dose aspirin and low-dose heparin in all controlled ovarian hyperstimulation patients.

[Course of mole pregnancy complicated by ovarian hyperstimulation syndrome]

Ovarian hyperstimulation syndrome (OHSS) is usually an iatrogenic condition caused by ovulation induction. Spontaneous OHSS is rare. We present a case of OHSS after dilatation and curettage of a triploid partial mole. In the case symptoms of OHSS developed after the abortion when serum human chorionic gonadotropin values were declining. Noticeable was also an affected androgen metabolism and a high level of cancer antigen-125. It is important to be aware of the OHSS diagnosis in order to avoid unnecessary surgery due to suspected ovarian malignancy. The treatment of OHSS is supportive with intravenous fluid and thrombosis prophylaxis.

A functioning FSH-secreting pituitary macroadenoma causing an ovarian hyperstimulation syndrome with multiple cysts resected and relapsed after leuprolide in a reproductive-aged woman

Bioactive gonadotropin-secreting pituitary adenomas are very rare in fertile women and can cause an ovarian hyperstimulation syndrome (OHSS). A 31-year-old woman with oligo-amenorrhea, severe ovarian cystic swelling and high serum estradiol was submitted to the resection of ovarian cysts and then treated with long-acting leuprolide 11.25 mg. Two months later, the ovarian multicystic hyperplasia relapsed, thus a pituitary MRI was performed and a pituitary macroadenoma was detected. In January 2010, she was referred to our Endocrinology Department where her hormonal evaluation showed high serum estradiol, FSH, α-subunit and inhibin with low LH. In April 2010, she underwent a trans-sphenoidal pituitary adenomectomy, which rapidly regularized the hormonal profile, the ovary and pituitary morphology and the menses. The case presented confirms that gonadotrophinomas occurring in reproductive-aged women frequently produce symptoms of ovarian hyperstimulation and proves that the use of GnRH analogs is not indicated in this condition.

Quadruplet pregnancy complicated by ovarian hyperstimulation syndrome with spontaneous ovulation

Ovarian hyperstimulation syndrome (OHSS) commonly occurs as a complication of ovarian stimulation with gonadotrophins. Spontaneous OHSS is an extremely rare event, but can occur as a result of stimulation with pregnancy-derived hCG. We herein report a case of quadruplet pregnancy complicated by OHSS with spontaneous ovulation. The patient had previously undergone ovarian stimulation with clomiphene citrate plus FSH. After that, she conceived spontaneously and developed OHSS after three weeks of amenorrhea. The OHSS was managed by conservative treatment and improved at six weeks of gestation. However, a quadruplet pregnancy became apparent on ultrasound examination. The patient therefore elected to have an induced abortion. Besides the conception in the cycle without administration of exogenous gonadotrophins, the symptoms in this case had the same kinetics as iatrogenic OHSS caused by ovarian stimulation.

[Upper extremity deep vein thrombosis following ovarian stimulation]

Upper extremity deep venous thrombosis (UEDVT) is uncommon as a spontaneous event in the general population and is associated with well-defined risk factors. Thromboembotic events are serious, but fortunately rare, complications following ovarian stimulation for IVF. A review of the Literature indicates that thromboembolic events after ovarian stimulation are usually associated with ovarian hyperstimulation syndrome (OHSS). The incidence of UEDVT is higher in women undergoing assisted reproductive technology (ART) compared to the general population. The incidence of this condition is estimated to be 0.08%-0.11% of treatment cycles. While lower extremity DVT may be considered a natural consequence of OHSS, given the diminished venous return secondary to enlarged ovaries and ascites, it is unclear why there appears to be a predilection for thrombi in the upper extremities in women undergoing ART. Early diagnosis and treatment is crucial for both maternal and fetal well-being. Since infertility treatment is becoming commonplace in today's society, women undergoing treatment and their clinicians should be better informed of the presentation and clinical course of UEDVT to enable early diagnosis and start treatment. Consideration must be given to screening patients at risk for OHSS for thrombophilias, as well as administrating prophylactic anticoagulation therapy to patients who develop OHSS.

Thrombophilia and ovarian hyperstimulation syndrome: a case report

BACKGROUND

Ovarian Hyperstimulation syndrome (OHSS) is one of the most serious complications of controlled ovarian hyperstimulation. Recent prospective data revealed possible increased prevalence of thrombophilia markers in women who develop severe ovarian hyperstimulation syndrome (OHSS).

CASE

A 26-year-old nulliparous woman underwent ovarian stimulation for in vitro fertilization with recombinant follicle stimulating hormone and developed severe OHSS. She was screened for hereditary and inherited thrombophilia markers and was found to be homozygous for MTHFR mutation and had decreased antithrombin levels.

CONCLUSION

This case adds to the limited information that there may be an association between women who develop severe ovarian hyperstimulation syndrome and an increased prevalence of underlying thrombophilia markers. If further research demonstrates a cost effective strategy, screening for those markers may identify women who are at a higher risk for development of severe ovarian hyperstimulation syndrome.

Cerebral venous thrombosis secondary to ovarian hyperstimulation syndrome

We report a case of a woman who underwent in-vitro fertilisation embryo transfer treatment for infertility and developed an acute stroke (left hemiparesis and headache). The stroke was caused by cerebral venous thrombosis due to ovarian hyperstimulation syndrome. We review the current background about this uncommon disorder.

[Arterial thrombosis in ovarian hyperstimulation syndrome]

Ovarian hyperstimulation syndrome is an iatrogenic complication of controlled ovarian hyperstimulation. Its features are excessive growth of the ovaries and leakage of fluid from the intravascular space with ascites, hypovolemia and electrolyte imbalance, inducing a state of hypercoagulability, which can cause arterial or venous thrombosis. Thromboembolic events are the less common complications but they are the most serious. We communicate the case of a 30 years old woman with history of primary infertility; she was in treatment with controlled ovarian hyperstimulation. The patient developed ovarian hyperstimulation syndrome and arterial thrombosis in the right femoral artery.

[Thrombotic risk in assisted reproductive technology]

Use of assisted reproductive technology (ART) is increasing in many developed countries. Arterial and venous thromboembolic complications are reported during ART with an incidence of 0.1%. The development of these events has been mainly ascribed to the presence of ovarian hyperstimulation syndrome (OHSS). Precise mechanisms by which OHSS and exogenous hormonal stimulation used in ART induce thromboembolic events remain unclear. However, vascular endothelial growth factor secreted during OHSS, high estradiol concentrations, and blood hyperviscosity play a major role in inducing a prothrombotic state. Therefore, before planning an ART, individual thromboembolic risk should be assessed and thromboprophylaxis offered to high risk patients. Prophylaxis should be initiated in women who develop moderate-to-severe OHSS.

[Ovarial hyperstimulation syndrome in the differential diagnostics of acute abdomen]

INTRODUCTION

The massive world-wide development of assisted reproduction (AR) technology and marked increase of females with infertility treatment lead to different medical complications. One of them is ovarian hyperstimulatory syndrome (OHSS), potential fatal complication in AR. It demonstrates with abdominal discomfort, nauzea, vomitus, ascites, and general alteration. It can imitate an acute abdomen syndrome, and it can lead to the primary surgical assessment.

AIM

The description of OHSS as a cause of an acute abdomen syndrome.

METHODS

Authors present a case of OHSS with the symptomatology of acute abdomen, which was handled by surgeon, primarily.

CONCLUSION

Consistent patient history, including gynecological history, and careful physical and laboratory examinations with relevant imaging methods lead to the elimination of invasive procedures. OHSS is the most actual in differential diagnosis of acute abdomen in fertile females for that reasons.

Ovarian hyper-stimulation syndrome after spontaneous conception

Ovarian hyperstimulation syndrome (OHSS) is rather frequent (1-5%) in women submitted to superovulation with gonadotropins for in vitro fertilisation (IVF), whereas it is very rare in case of spontaneous ovulation. Spontaneous OHSS (sOHSS) was previously described to be associated to hydatiform mole, multiple conception, hypothyroidism in pregnancy. It may also depend on activating mutations of the FSH receptor (FSHR) gene that cause ovarian hyper-responsiveness to circulating FSH or even cross-responsiveness of FSHR to hormones having a structure similar to FSH, such as hCG or TSH. We report, herein, a case of sOHSS in a woman who conceived spontaneously. We checked the presence of all possible factors that could explain the onset of the syndrome, and we evidenced hypothyroidism and abnormally elevated hCG levels in the second trimester of pregnancy. The thorough molecular biology study of FSHR gene did not detect exonic mutations, but revealed the presence of intronic mutations whose role in the onset of sOHSS is still uncertain.

[Clomiphene, ovarian hyperstimulation syndrome and pregnancy]

In case of an ovarian hyperstimulation syndrome surgical treatment causes the regress of symptoms much faster than pharmacotherapy--during the resection of an ovary the concentration of estrogenes in blood is effectively reduced. Frequent use of ovulation inductors (Clomiphene Gonadotrop(h)in) is accompanied by ovarian hyperstimulation syndrome. It is characterized by the increase of sizes of ovaries; the formation of ascites and hydrothorax, by the thromboemboly of main blood vessels and etc. Clomiphene accelerates the maturation process of follicles, but contributes to the increase of concentration of oncomarker CA-125 in blood. This makes it difficult to verify the diagnosis of ovary cancer, particularly among pregnants. The case report of infertility treatment with Clomiphene is depicted. Woman became pregnant after three courses of infertility treatment, but pregnancy was complicated with cardiac and lung insufficiency; the suspicion of stage III ovarian cancer aroused. Serious threat to health of a woman resulted in prevention of pregnancy. Right side adnexectomy was conducted. Surgical treatment led to improvement and after four years the patient delivered a healthy child.

[Ovarian hyperstimulation syndrome]

Experience with ovulation induction treatment and understanding of the physiopathology of ovarian hyperstimulation syndrome (OHS), the risk factors and the clinical characteristics are of key importance for preventing and managing OHS. Light manifestations ofOHS are fairly common, occurring in up to a third of the cycles with superovulation induced by exogenous gonadotropins. A worsening of the symptoms of OHS can still normally be managed in out-patient form, but frequent monitoring and evaluation are essential. Serious disease resulting from OHS is much less common, but can involve risk to life. Hospitalisation might be necessary in some cases.

Removal of ascites up to 7.5 liters on one occasion and 45 liters in total may be safe in patients with severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a serious and potentially lethal complication of ovulation induction. We report herein a case with OHSS treated by serial vaginal paracentesis. A 31-year-old patient was hospitalized due to severe OHSS after in vitro fertilization (IVF)-embryo transfer. Transvaginal drainage was performed with a standard 17-gauge IVF needle connected to a vacuum pump through a drainage set in nine courses. We removed 45 liters of ascitic fluid in total and 7.5 liters of ascitic fluid in one course, leading to improvement of the patient's condition and laboratory parameters. In conclusion, removal of ascites up to 7.5 liters on one occasion and 45 liters in total by serial vaginal paracentesis may be performed in patients with severe OHSS.

Spontaneous and severe ovarian hyperstimulation syndrome after delivery: a case report

Ovarian hyperstimulation syndrome (OHSS) is almost exclusively associated with ovulation induction with gonadotropins or, occasionally, clomiphene citrate. Severe ovarian hyperstimulation after delivery has never been reported previously. Herein, a case of OHSS after Cesarean operation is presented. The left ovary was subjected to wedge section and three-quarters of the tissue was removed. Cysts on the right ovary were enucleated and fluid within the cysts was sucked away. The patient was treated by intravenous albumin infusion.

Ischaemic stroke with ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a rare and serious complication of hormonal treatment for induction of ovulation. Haemoconcentration owing to the large fluid shift from the intravascular to the peritoneal cavity resulting in increased blood viscosity that can lead to arterial and venous occlusion. Thromboembolic stroke, cerebral venous thrombosis and systemic arteriovenous thrombosis have been reported in OHSS. We report a case of a 30-year-old female who had undergone a successful in vitro fertilization and presented in the emergency department with sudden onset of left hemiplegia. Her CT scan showed a full thickness right- MCA territory infarct. The patient was treated with oral aspirin, intra venous plasma expanders and Mannitol. Her repeat MRI showed haemorrhagic conversion of infarct. She made a good recovery and was independent in activities of daily living when seen for follow up after six months.

[Unilateral pleural effusion in ovarian hyperstimulation syndrome]

Ovarian hyperstimulation syndrome is the most severe iatrogenic complication of fertilization modern methods. This syndrome is characterized by a massive cystic ovarian enlargement associated with an acute body fluid shift. Ascite is the most frequent manifestation of this syndrome. In some rare cases ovarian hyperstimulation syndrome is complicated by massive unilateral pleural effusion without ascite. We describe the case of a 36 year old woman who developed a massive unilateral pleural effusion without ascite. An ovarian hyperstimulation syndrome was diagnosed. Chest tube drainage improved patient parameters and symptoms. We discuss the diagnostic approach of pleural effusions.

Compressive pleural effusion after ovarian hyperstimulation syndrome—a case report and review

OBJECTIVE

To report a case of early onset ovarian hyperstimulation with massive pleural effusion and respiratory failure before IVF.

DESIGN

Case report.

SETTING

University teaching intensive care unit.

PATIENT(S)

A 26-year-old healthy woman with an unexplained infertility transferred to the intensive care unit on day 4 after hCG injection for early severe presentation of ovarian hyperstimulation syndrome with massive compressive pleural effusion before she underwent embryo transfer.

INTERVENTION(S)

Mechanical ventilation, thoracocentesis.

MAIN OUTCOME MEASURE(S)

Resolution of symptoms/stopping of embryos transfer.

RESULT(S)

Drainage of 5,300 mL of sterile exudative pleural fluid for a period of 48 hours, which permitted resolution of symptoms and allowed mechanical weaning. The IVF procedure was stopped.

CONCLUSION(S)

This case described is unusual in that the patient presented with early massive pleural effusion on day 4 after hCG injection and before embryo transfer. This is much earlier than in any case report elsewhere.

[Retinal and brain infarctions secondary to acute carotid thrombosis in ovarian hyperstimulation syndrome]

INTRODUCTION

Ovarian hyperstimulation syndrome (OHSS) is an uncommon but potentially life-threatening iatrogenic condition that may appear following ovulation induction in the course of some fertility treatments. This may lead to further complications, some of which may be severe, such as thromboembolic events. Though rarely, it can therefore be a potential cause of stroke.

CLINICAL CASE

We report the case of a 34-year old woman under ovulation induction treatment who developed retinal and brain infarctions secondary to internal carotid occlusion. Oral anticoagulation was administered and recovery was good in spite of the persistence of carotid occlusion in follow-up magnetic ressonance imaging- angiographies.

CONCLUSIONS

This is the first case of carotid occlusion following an OHSS reported in Spain and the eighth one published in the literature. Current literature on cerebrovascular complications in OHSS is also briefly reviewed.

Conservative management of adnexal torsion via transvaginal ultrasound guided ovarian cyst aspiration in patients with ovarian hyperstimulation

OBJECTIVE

To report the successful conservative management of two patients with acute adnexal torsion by ultrasound-guided transvaginal ovarian cystic aspiration.

DESIGN

Case report.

SETTING

A reproductive medical center.

PATIENTS

Two women with OHSS who had acute lower abdominal pain, nausea, and vomiting, and were found to have acute adnexal torsion.

INTERVENTION(S)

An ultrasound-guided transvaginal ovarian cystic aspiration was performed promptly.

MAIN OUTCOME MEASURE(S)

The clinical symptoms of acute adnexal torsion after the procedure.

RESULT(S)

After the cystic aspiration, acute lower abdominal pain, nausea, and vomiting were relieved immediately. The postoperative course was normal. Neither of the patients had clinical signs of pelvic or systemic thromboembolism.

CONCLUSION(S)

Ultrasound-guided transvaginal ovarian cystic aspiration is a simple, safe, and effective method for the conservative management of adnexal torsion.

Application of GnRH antagonist in combination with clomiphene citrate and hMG for patients with exaggerated ovarian response in previous IVF/ICSI cycles

PURPOSE

To investigate if the combination of clomiphene citrate, hMG, and cetrorelix (CC/hMG/cetrorelix protocol) can be applied to patients who had excessive response to GnRHa long protocol.

METHODS

Fifty patients who coasted and failed to conceive in their first cycles stimulated with GnRHa long protocol were stimulated with CC/hMG/cetrorelix protocol. The peak serum estradiol levels, the need of coasting and prolonged coasting (>/=4 days), and the incidences of OHSS were compared.

RESULTS

The peak estradiol level was significantly lower with CC/hMG/cetrorelix protocol compared to GnRHa long protocol. With CC/hMG/cetrorelix protocol, only four patients (8%) needed coasting and no one coasted >/=4 days. In contrast, in the first cycles, 11 patients (22%) needed coasting >/=4 days. The incidence of moderate OHSS was significantly lower with CC/hMG/cetrorelix protocol.

CONCLUSIONS

The CC/hMG/cetrorelix protocol is an acceptable alternative protocol for patients who had excessive response to GnRHa long protocol.

Obstructive uropathy as the etiology of renal failure in ovarian hyperstimulation syndrome

OBJECTIVE

To make people aware that there is potential for obstructive uropathy to complicate ovarian hyperstimulation syndrome (OHSS) and cause renal impairment.

DESIGN

Case report.

SETTING

Hospital.

PATIENT(S)

A 28-year-old Caucasian female presenting with acute severe OHSS.

INTERVENTION(S)

Bilateral JJ stenting.

MAIN OUTCOME MEASURE(S)

Resolution of renal impairment.

RESULT(S)

Successful treatment of renal failure.

CONCLUSION(S)

Patients with severe OHSS and renal impairment should be evaluated with renal ultrasound to rule out hydronephrosis and therefore an obstructive uropathy. Patients potentially at risk for such a complication from OHSS may include those with prior abdominal or pelvic surgery.

Isolated severe hydrothorax with respiratory distress as a main manifestation of ovarian hyperstimulation syndrome preceded by respiratory tract infection caused by Haemophilus influenzae

INTRODUCTION

An isolated unilateral pleural effusion as the only presentation of ovarian hyperstimulation syndrome (OHSS) is very rare. This case is an unusual presentation of OHSS after a confirmed respiratory tract infection, with no other coexisting risk factors identified for this syndrome. We also imply that the presence of Haemophilus influenzae in bronchial fluid can increase local reaction to vasoactive cytokines.

CASE REPORT

A 32-year-old woman presented at the Department of Reproductive Medicine and Gynaecology of the Pomeranian Medical University after 10 years of infertility with diagnosed hyperprolactinemia followed by bromocriptine treatment. The patient had three IUIs but no pregnancy was achieved. Therefore, ICSI was proposed. After an ovarian hyperstimulation, oocyte aspiration gave 8 oocytes. Although ICSI was performed in all of the oocytes there were 3 fertilizations. The ET of 3 embryos was carried out following 3 days of culture. Three weeks before the gonadotropin administration and a week before GnRH administration the patient had a respiratory tract infection with the most typical syndromes. The infection was treated successfully with over-the-counter medications and antibiotic. Three days after ET the patient was admitted to the ICU with signs of severe dyspnoea. The chest X-ray showed a large pleural effusion over the right lung. Upon admission, thoracocentesis was preformed and 1600 ml of clear fluid was aspirated. The bronchial aspirate showed evidence of Haemophilus influenzae and leukocytes. After three days of standard treatment the chest X-ray revealed no pathology. The patient was discharged asymptomatic on the 4th day of treatment. Serum beta-hCG level was negative on day 12 after ET.

CONCLUSIONS

This case suggest that respiratory tract infection prior to stimulation may constitute a new independent risk factor for OHSS. However, the true relation between the respiratory tract infection and susceptibility to OHSS still awaits explanation. Recent or existing respiratory tract infection may be a relative contraindication for starting COH.

Hydrothorax as the sole manifestation of ovarian hyperstimulation syndrome: unusual case and literature review

An unusual case of a unilateral massive hydrothorax after IVF treatment is reported in a 41-year-old patient, which developed as the only manifestation of ovarian hyperstimulation syndrome. The literature on such rare presentation is also reviewed to highlight its diagnostic features and prognosis.

Evaluating the roles of follicle-stimulating hormone receptor polymorphisms in gonadal hyperstimulation associated with severe juvenile primary hypothyroidism

CONTEXT

Rare activating mutations of the human (h)FSHR have been reported in some women with spontaneous ovarian hyperstimulation in pregnancy, where follicular growth is inappropriately stimulated by elevated concentrations of human chorionic gonadotropin acting through the hFSHR. It is not known whether ovarian hyperstimulation in peripubertal girls with untreated primary hypothyroidism is caused by hFSHR mutations and/or influenced by hFSHR allelic variants, rendering the hFSHR more sensitive to circulating TSH.

OBJECTIVE

The aim of the study was to determine whether mutations of the hFSHR and/or hFSHR allelic variants are associated with greater sensitivity of the hFSHR to TSH.

DESIGN

The hFSHR gene was sequenced from eight pediatric patients displaying gonadal hyperstimulation due to primary hypothyroidism. HEK293 cells expressing different hFSHR allelic combinations were studied for their responsiveness to recombinant (r)hTSH.

SETTING

The study was conducted at university research centers.

PATIENTS

Eight unrelated patients (seven girls and one boy) who exhibited primary hypothyroidism and gonadal hyperstimulation were included in the study.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURE

DNA sequencing of the hFSHR gene was the main outcome measure. Basal, rhFSHR- and rhTSH receptor-stimulated cAMP levels were assayed in HEK293 cells transfected with the hTSH receptor or different hFSHR allelic combinations. Cell surface receptor numbers were also determined.

RESULTS

No hFSHR mutations were identified in the patient population, but we did identify two known polymorphisms. In vitro experiments demonstrated a dose-dependent and specific rhTSH-dependent increase in cAMP production in HEK293 cells expressing the wild-type hFSHR, regardless of hFSHR isoform.

CONCLUSIONS

Pediatric gonadal hyperstimulation associated with severe primary hypothyroidism is likely due to the actions of the elevated concentrations of TSH on the wild-type hFSHR, and this response is not dependent upon the hFSHR isoform.

Update on ovarian hyperstimulation syndrome: part 2--clinical signs and treatment

Patients with polycystic ovary syndrome (PCOS), hyperandrogenemia and hypothalamic ovarian dysfunction have a predisposition for developing ovarian hyperstimulation syndrome (OHSS). Choosing treatment protocols carefully, cautious stimulation, minimizing hCG dosages for ovulation induction, and refraining from embryo transfer in case of doubt, can markedly reduce the risk. In the treatment of moderate and severe hyperstimulation syndrome, adequate hydration with fluid balance, prophylaxis against thrombosis, ascites drainage when appropriate, and close monitoring and intensive-care monitoring if necessary, must be ensured. The aim of procedures in reproductive-medicine should be to achieve pregnancy rates that are as high as possible with as few side effects of the treatment as possible.

Hydrothorax following ovarian hyperstimulation for assisted reproduction. Case report and review of the literature

In case of ovarian hyperstimulation syndrome, the high incidence of dyspnea in relation with ascites and enlarged ovaries should not justify omission of thoracic evaluation. This manuscript reviews the pathogenesis and clinical presentation of hydrothorax following controlled ovarian hyperstimulation. In addition, we describe the case of a 33-year-old woman with a right massive hydrothorax resulting from controlled ovarian hyperstimulation for intracytoplasmic sperm injection.

Diagnosing and management of iatrogenic moderate and severe ovarian hyperstymulation syndrome (OHSS) in clinical material

Severe ovarian hyperstymulation syndrome is a rare but potentially life-threatening complication in patients undergoing assisted reproductive techniques (ART). The pathogenesis of this condition is likely to be multifactorial. The aim of the retrospective study was to present management in moderate and severe iatrogenic ovarian hyperstymulation syndrome (OHSS) in clinical material. The study group was 19 women, admitted to the Department of Obstetrics and Gynecology in Central Clinical Hospital of Ministry of Interior and Administration in Warsaw from large outpatient infertility center "Novum" in Warsaw with moderate and severe OHSS between 14.07.2004 and 8.11.2005. Laboratory tests and ultrasound examination of the ovarian size and ascites were performed, abdominal circumference was measured. Patients were treated with rehydration with intravenous crystalloids and colloids, diuretics, antibiotics, anticoagulants and ultrasound-guided paracentesis if symptoms of ascites become severe (ascites causes pain and compromised pulmonary function). Oral intake of water was restricted, monitoring of fluid intake and output, and daily monitoring of body weight was performed. During treatment controlled laboratory tests were done. In one patient occurred intra-abdominal hemorrhage from ovarian rupture and laparotomy with oophorectomy was performed. The ovarian hyperstimulation syndrome is still a difficult diagnostic and therapeutic problem and more studies are required to elucidate pathophysiology of OHSS. Because of still unknown etiology treatment is empirical and in most of cases bases on experience of medical team. Thus, the management in individual patients varies according to the severity of ovarian hyperstymulation syndrome and its complications.

Course of ovarian hyperstimulation syndrome in 19 intact twin pregnancies after assisted reproduction techniques, with a case report of severe thromboembolism

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of assisted reproduction techniques using in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI). Its etiology has still not yet been fully resolved. Human chorionic gonadotrophin, administered exogenously as well as produced endogenously during pregnancy, is responsible for the onset of OHSS, and high levels of estradiol appear to worsen the condition. In this case series, the course of mild to severe OHSS was evaluated in 19 intact twin pregnancies after IVF/ICSI. Another serious complication associated with OHSS is thromboembolic events. In these cases, the pregnancy can be protected through anticoagulation treatment, but there may be exceptions to this. This series includes a case of bilateral thrombosis of the internal and external jugular veins in the 7th gestational week in a twin pregnancy after OHSS and ICSI, with termination of the pregnancy in the 9th gestational week due to progressive thrombosis during anticoagulation therapy.

Incidence of Pericardial Effusion in Females Stimulated in "in Vitro Fertilization" Program

AIMS

To evaluate the incidence of pericardial irritation in females after hormonal stimulation in in vitro fertilization program, and to set its clinical significance as a symptom of ovarian hyperstimulation syndrome (OHSS).

PATIENTS

Thirty-nine females, aged 30 +/- 5 years (20-46), with a normal echo finding prior to hormonal stimulation.

METHODS

Serial echocardiography: baseline A, in hCG application B, embryo-transfer C.

RESULTS

Thirty-nine, 39, and 35 echocardiography examinations were done on A, B, and C respectively. On B, in 7 (17.9%) of 39 patients either new pericardial effusion "1," increased pericardial echogenicity "2," or both "3" were detected (4 patients, 2 patients, and 1 patient, i.e., 10.3%, 5.1%, and 2.6% respectively.). On C, in 8 of 35 patients (22.8 %) abnormalities were detected: "1" in 2 patients (5.7 %), "2" in 1 patient (2.9 %), and "3" in 5 patients (14.2 %). No clinical symptoms related to these findings were present. No OHSS occurred in these patients. On the contrary, clinical OHSS developed later in 2 patients, classified as medium degree (1 patient) and severe degree (1 patient)-both patients had negative echo during follow-up.

CONCLUSION

Echocardiographic signs of mild pericardial irritation may appear also in patients with no clinical signs of OHSS. The incidence of these changes increases during stimulation procedure. Development of OHSS may not be preceded by the incidence of these warning signs. Consequently, routine echocardiographic examination during stimulation is not indicated, since significant pericardial effusion is rather a late sign of OHSS.

Internal Jugular Vein Thrombosis following Mild Ovarian Hyperstimulation Syndrome in Women with Factor V Leiden Mutation

OBJECTIVE

To study two women who presented with internal jugular vein thrombosis that developed shortly after in vitro fertilization (IVF) therapy complicated by mild ovarian hyperstimulation syndrome (OHSS).

METHODS

Evaluation of the past medical history, treatment, laboratory studies, and clinical outcome of both patients.

RESULTS

The two patients were found to be carriers for factor V Leiden mutation (FVLM). One was homozygote and the other heterozygote for that mutation. The genetic predisposition probably contributed to the development of an early thrombosis in these patients despite the mildness of their OHSS. In the homozygote patient, the dose of low molecular weight heparin was reduced due to vaginal bleeding. Afterwards, fetal loss due to an extensive placental infarction occurred. Infarction was confined to maternal side while the fetal side vessels were spared.

CONCLUSION

We suggest that women of European descent, especially those with personal or familial history of thromboembolic events, should be screened for FVLM before IVF treatment. In those found to be carriers of FVLM, preventive anticoagulation should be considered.

Effectiveness of treating ovarian hyperstimulation syndrome with cabergoline in two patients with gonadotropin-producing pituitary adenomas

OBJECTIVE

To report the effect of cabergoline on ovarian hyperstimulation syndrome associated with gonadotropin-secreting pituitary adenomas.

DESIGN

Case report.

SETTING

Outpatient practice.

PATIENT(S)

Two women with menstrual irregularity, enlarged ovaries, high E(2), and normal gonadotropin levels.

INTERVENTION(S)

Cabergoline treatment and transsphenoidal surgery.

MAIN OUTCOME MEASURE(S)

Estradiol levels, transvaginal ultrasonography, and pituitary magnetic resonance imaging. Transsphenoidal surgery showed pituitary adenoma staining for LH in both patients.

RESULT(S)

Cabergoline was effective in reducing E(2) levels and decreasing ovarian size but ineffective in shrinking the pituitary adenomas.

CONCLUSION(S)

This is the first description of the effectiveness of cabergoline as the primary treatment of spontaneous ovarian hyperstimulation syndrome in patients with gonadotropin-producing pituitary adenomas.

A review of upper extremity deep vein thrombosis in pregnancy: unmasking the 'ART' behind the clot

BACKGROUND

Upper extremity deep vein thrombosis (UEDVT) is uncommon and is associated with well-defined risk factors in the general population. Increasingly, UEDVTs are being reported during pregnancy, particularly those achieved with the use of assisted reproductive techniques (ART), and in conjunction with ovarian hyperstimulation syndrome (OHSS).

AIM

We performed this review was to estimate the incidence of UEDVT associated with ART, to examine the risk factors and presentation of UEDVT in pregnancy, and to determine if differences exist between this cohort and the general population.

RESULTS

There were 35 published case reports of UEDVT in pregnant women. The incidence of this condition is estimated to be 0.08-0.11% of treatment cycles in women undergoing ART. The development of UEDVT is not always be preceded by OHSS. In addition, commonly associated risk factors for UEDVT were not often reported for UEDVT that developed during pregnancy. Instead the association of UEDVT and ART was common. UEDVT in pregnancy also appears to involve the internal jugular vein more often than the subclavian vein. The reported risk of thrombus extension in this cohort, despite anticoagulation therapy, is also disconcerting.

CONCLUSION

Because UEDVT may not be a rare entity during pregnancy in association with the use of ART, clinicians should be better informed of its presentation and clinical course in these women. Once UEDVT develops, appropriate therapeutic anticoagulation should be instituted and patient carefully monitored. The long-term implications and recurrence rate of this condition in pregnancy warrants further prospective studies.

An immunohistochemical study in a fatality due to ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a complication occurring in the luteal phase of a menstrual cycle in which ovulation induction or ovarian hyperstimulation for assisted reproduction techniques has been performed. Our report concerns the death of a 31-year-old woman with primary infertility on recombinant follicle stimulating hormone therapy (Gonal-F) who developed a fatal adult respiratory distress syndrome. Immunohistochemical investigation of lung and uterine samples was performed utilizing monoclonal antibodies for antisurfactant apoprotein (PE-10) and polyclonal antibodies anti-IL-6, IL-8, IL-10, TNFalpha for lungs, and polyclonal antibodies anti-beta-HCG (human chorionic gonadotropin) for uterus. The knowledge of macroscopic and histologic findings should be of special interest for all those who perform autopsies in these victims. The exact pathogenesis of OHSS remains a mystery; so for the diagnosis of suspected OHSS, the forensic pathologist must use all the modern laboratory armament to validate the diagnosis in the extremely rare fatal cases due to this syndrome.