The role of endothelial cells in the pathogenesis of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of treatment with fertility drugs. Using human lung microvascular endothelial cells (HUMEC-L) as an in-vitro model of OHSS, we have tested the hypothesis that the endothelium is a target of HCG in the pathogenesis of OHSS. Since OHSS is characterized by increased capillary permeability, we have investigated the production and action of vasoactive agents. When HUMEC-L were cultured with high doses of estradiol (E(2)), no significant changes were observed in the secretion of vascular endothelial growth factor (VEGF), interleukin (IL)-6 or IL-1 beta. However, the addition of HCG resulted in a significant increase in the secretion of VEGF and IL-6. Time-course experiments showed that VEGF was secreted within minutes of HCG addition, whereas IL-6 was significantly increased only after 48 h in culture. The secretion of IL-1 beta was unchanged by these hormonal conditions. The presence of HCG receptors was demonstrated in HUMEC-L in basal conditions as well as after the addition of E(2). The expression of VEGF receptors was also investigated. High doses of E(2) were unable to increase the expression of KDR, flt-1 and sfl-t, but the addition of HCG significantly upregulated the KDR concentration in endothelial cells, while no change was observed for flt. Permeability assays demonstrated that while E(2) alone did not change the arrangement of HUMEC-L in vitro, the presence of HCG caused changes in the actin fibres corresponding to increased capillary permeability. Anti-human VEGF antibodies were able to overcome these changes. In conclusion, these experiments show that the endothelium may be a primary target of HCG, causing an acute release of VEGF and a significant increase in IL-6 and resulting in an autocrine-paracrine action that may increase vascular permeability.

[Preliminary study on the role of vascular endothelial growth factor in pathogenesis of ovarian hyperstimulation syndrome]

OBJECTIVE

To explore the role of vascular endothelial growth factor (VEGF) in the pathogenesis of ovarian hyperstimulation syndrome (OHSS).

METHODS

Fourteen moderate or severe OHSS patients and 13 non-OHSS cases were enrolled prospectively from in vitro fertilization and embryo transfer (IVF-ET) or intracytoplasmic sperm injection program. The VEGF levels of follicular fluid (FF) on the day of oocytes pick up (DOPU) and of sera on the day of human chorionic gonadotrophin (hCG) injection (DhCGI) and embryo transfer (DET) were measured by enzyme-labeled immunosorbent assay. Expression of VEGF protein and mRNA of luteinized granulosa cells obtained during OPU were detected by immunohistochemical and reverse transcription polymerase chain reaction respectively.

RESULTS

The VEGF levels of FF on the DOPU and of sera on DhCGI were not significantly different between the OHSS and control groups [1257.2 +/- 648.0) ng/L Vs (1745.1 +/- 802.4) ng/L and (250.1 +/- 109.5) ng/L Vs (196.7 +/- 81.7) ng/L, respectively, P > 0.05]. However, both serum VEGF levels on DET and its increments from DhCGI to DET are significantly greater in the OHSS group as compared with the controls, so was the expression of VEGF mRNA levels of luteinized granulosa cells on DOPU.

CONCLUSION

VEGF may play a role in pathogenesis of OHSS.

Correctly timed coasting reduces the risk of ovarian hyperstimulation syndrome and gives good cycle outcome in an in vitro fertilization program

One hundred and twelve severely overstimulated in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) patients were treated with coasting when estradiol concentration was > 3000 pg/ml and the leading follicles had attained > or = 18 mm in diameter. Gonadotropin withholding was offered to them as a promising method for the prevention of both cycle cancellation and complications associated with severe ovarian hyperstimulation syndrome (OHSS). The duration of prolonged coasting prior to human chorionic gonadotropin (hCG) administration ranged from 2 to 9 days (mean 3.5). hCG was administered when the serum estradiol dropped to < 3000 pg/ml and at least three growing follicles > or = 20 mm in diameter were present. Fertilization failure was noted in six couples and in another 10 cases freezing of all embryos was decided, therefore embryo transfer was performed on 96 patients. There were 31 clinical pregnancies (five twins) giving a pregnancy rate per patient and per embryo transfer of 30.4% and 32.3%, respectively, with an implantation rate of 18.1%. With regard to all 112 coasted patients, six developed moderate and two severe OHSS. This study shows that withholding gonadotropin administration in high-risk IVF patients results in a good cycle outcome and a very low risk of severe OHSS, and also demonstrates the importance of both the timing of coasting initiation and the timing of hCG administration.

Regression of ovarian enlargement in pharmacological ovulation induction

The aim of the present study was to determine a possible relationship between ovarian functionality and regression of ovarian enlargement according to the different categories and degree of severity of ovarian hyperstimulation syndrome (OHSS). Among a group of sterile woman (n = 111), two subgroups were studied: group A (n = 15), patients affected by severe syndrome; and group B (n = 96), patients with massive ovarian enlargement only. The protocol of ovarian stimulation was conducted in various in vitro fertilization (IVF) centers; ultrasonographic examination and hematological checks were carried out daily; patients with severe OHSS were hospitalized. In women of group A, severe symptoms disappeared in 7-11 days; in nine patients with regular cycles ovary size returned to normal in about 30-40 days, whereas in six subjects with anovulatory cycles, the resolution was recorded in about 50-60 days; serum estradiol returned to physiological levels within 20-30 days. Women of group B showed a spontaneous regression at different times: in 43 subjects that presented regular ovulatory cycles, the resolution was recorded in about 30-40 days, whereas in 36 women with anovulatory cycles before pharmacological induction, resolution occurred in 50-60 days, and in 17 cases with polycystic ovary syndrome before pharmacological ovulation, an incomplete resolution was obtained; serum estradiol levels returned to a physiological range within 20-30 days. Our results show that in patients with regular ovulatory cycles, resolution of symptoms is obtained in a shorter time than in patients with anovulatory cycles before pharmacological induction.

Laparoscopic treatment of a twisted hyperstimulated ovary after IVF

Ovarian Hyperstimulation Syndrome (OHSS) is a common problem associated with modern In-Vitro Fertilisation techniques (IVF). However, torsion of a hyperstimulated ovary occurring after IVF is a much rarer event. In this case report, we will describe the laparoscopic management of a pregnant patient with a twisted hyperstimulated ovary after an IVF programme.

Ovarian hyperstimulation syndrome complicating a spontaneous singleton pregnancy: a case report

It has been known that most cases of ovarian hyperstimulation syndrome (OHSS) are associated with the use of exogenous gonadotropins to induce multiple ovulation. However, OHSS is infrequently associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism, or polycystic ovarian syndrome. We report a case of severe OHSS in a spontaneously pregnant woman with no underlying disease.

A rise of the serum level of von Willebrand factor occurs before clinical manifestation of the severe form of ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) appears to be caused by increased capillary permeability in the vascular endothelial cells. Such cells secrete excess amounts of von Willebrand factor (vWF), a large adhesive glycoprotein.

METHODS

We retrospectively evaluated the circulating levels of vWF and of vascular endothelial growth factor (VEGF) twice, on the days of oocyte retrieval and embryo transfer, in 46 women who developed early-onset OHSS.

RESULTS

Nineteen, 14, and 13 women developed mild, moderate, and severe OHSS, respectively. Inconsistent changes were observed in the VEGF during oocyte retrieval and embryo transfer. However, the net increase in serum vWF during that period showed an increase in absolute value at the time of embryo transfer that paralleled an increase in the severity of OHSS. That is, in mild OHSS, the serum vWF increased from 140 +/- 44 to 164 +/- 28%; in moderate OHSS, it increased from 113 +/- 47 to 186 +/- 22%; and in severe OHSS, it increased from 120 +/- 35 to 274 +/- 63%. All 9 women with a vWF level > 230% at embryo transfer developed severe OHSS, while 9 of 13 women with severe OHSS exhibited a vWF > 230% at embryo transfer.

CONCLUSION

The results suggest that a rise of the serum level of vWF occurs prior to clinical manifestation of OHSS in patients with severe OHSS but not in patients with mild OHSS.

Dynamics of immunoreactive endothelin plasma levels during ovarian stimulation for in vitro fertilization with and without dietary sodium restriction

OBJECTIVE

To investigate the correlation between immunoreactive endothelin plasma levels and both the number and size of follicles and its relationship with the development of ovarian hyperstimulation syndrome, in in vitro fertilization cycles, with and without dietary sodium restriction.

STUDY DESIGN

Randomized study in an assisted reproduction unit of a large teaching hospital. Data of 88 women form the basis of this report (45 ad libitum sodium intake and 43 dietary sodium restriction). Non-parametric tests were used for statistical analysis.

RESULTS

Immunoreactive endothelin plasma levels neither correlate with the number of follicles, independent of their size, nor with the grade of ovarian hyperstimulation syndrome. Immunoreactive endothelin plasma levels decrease significantly in the luteal phase. These results are the same in both sodium diet groups.

CONCLUSIONS

Immunoreactive endothelin plasma levels do not correlate with the number and size of follicles and they are not related to the development of ovarian hyperstimulation syndrome. These findings are independent of sodium intake.

Ovarian hyperstimulation and oophorectomy following accidental daily clomiphene citrate use over three consecutive months

We describe the longest-known continuous use of clomiphene citrate ever reported in a human. As a result of a pharmacy error, a woman took 50 mg/day clomiphene citrate for three months. The prolonged use of this medication resulted in ovarian hyperstimulation and unilateral oophorectomy for torsion.

An autopsy case of ovarian hyperstimulation syndrome with massive pulmonary edema and pleural effusion

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of ovulation induction with exogenous gonadotropins, such as human menopausal gonadotropin and follicle-stimulating hormone. These hormones are considered to increase capillary permeability and cause third space fluid shift. We report an autopsy case of severe OHSS in a 28-year-old Japanese female. The patient developed bilateral chest pain and progressive dyspnea during the course of administration of human gonadotropins. Pleural effusion and hypouresis clinically disappeared 4 days after the onset of the symptoms, but the patient died suddenly of rapid respiratory insufficiency. Autopsy examination revealed massive pulmonary edema, intra-alveolar hemorrhage and pleural effusion without any evidence of pulmonary thromboembolism. Histopathological examination of the ovary demonstrated multiple well-developed follicle formations, consistent with OHSS. It is very important to recognize that massive pulmonary edema can occur in a patient with OHSS. To the best of our knowledge, this is the first autopsy report of a patient with severe OHSS.

Distinction between early and late ovarian hyperstimulation syndrome

OBJECTIVE

To compare patient and cycle characteristics among three study groups: early ovarian hyperstimulation syndrome (OHSS), late OHSS, and non-OHSS.

DESIGN

Prospective observational study.

SETTING

University assisted conception service.

PATIENT(S)

Women undergoing in vitro fertilization, intracytoplasmic sperm injection or gamete intrafallopian transfer treatment at Bristol University In Vitro Fertilization Service between January 1, 1995, and December 31, 1998.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Patient age, prevalence of polycystic ovaries, gonadotropin requirement, peak serum estradiol (E(2)) concentration, number of oocytes retrieved, clinical pregnancy rate, number of gestation sacs, and severity of OHSS.

RESULT(S)

Women with early OHSS had significantly higher serum E(2) levels and lower gonadotropin requirements than did the other groups. Cycles with either early or late OHSS had significantly more oocytes collected than those without OHSS. Serum E(2) and oocyte numbers did not accurately predict the risk of developing late OHSS. Clinical pregnancies occurred in all cycles with late OHSS, and multiple pregnancies were significantly more frequent in the late OHSS group than in the other groups. Late OHSS was more likely than early OHSS to be severe.

CONCLUSION(S)

Early OHSS relates to "excessive" preovulatory response to stimulation, whereas late OHSS depends on the occurrence of pregnancy, is likelier to be severe, and is only poorly related to preovulatory events.

Human albumin enhances expression of vascular endothelial growth factor in cultured human luteinizing granulosa cells: importance in ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a severe complication of ovarian stimulation for assisted reproductive techniques. Clinical manifestations are massive extravascular fluid accumulation and haemoconcentration. Vascular endothelial growth factor (VEGF) has been demonstrated to mediate the development of OHSS. Intravenous albumin at the time of oocyte aspiration has been suggested as an effective prophylactic treatment against the occurrence of severe OHSS. Here it is reported that in cultured human luteinizing granulosa cells, VEGF mRNA expression was enhanced by human albumin and maximum expression was observed in cultured granulosa cells obtained from patients with serum oestradiol concentrations >2000 pg/ml on the day of human chorionic gonadotrophin injection (P < 0. 05).

Does ovarian hyperstimulation syndrome affect the quality of oocytes?

Two wives of a Muslim with severe male factor infertility had simultaneous intracytoplasmic sperm injection (ICSI) treatments. One wife developed ovarian hyperstimulation syndrome (OHSS), and 19 of 27 oocytes retrieved were subjected to ICSI but only one fertilized; the other wife had a normal response to ovarian stimulation, normal fertilization following ICSI, successful treatment and has recently delivered a live-born infant. The wife who suffered from OHSS has since had another ICSI cycle with a normal response to ovarian stimulation, a normal fertilization rate but no pregnancy. The only variable that determined the different rate of fertilization in the simultaneous ICSI cycles appears to be oocyte quality. While the results of frozen embryo replacement cycles following the decision to freeze all embryos following OHSS is generally satisfactory, it is important to counsel couples about the possible detrimental effects of OHSS on oocyte quality.

Haematocrit, leukocyte and platelet counts and the severity of the ovarian hyperstimulation syndrome

Previous studies have shown that severe ovarian hyperstimulation syndrome (OHSS) is secondary to circulatory dysfunction due to the simultaneous occurrence of increased vascular permeability and marked arteriolar vasodilation which lead to an intense homeostatic stimulation of the renin-aldosterone and sympathetic nervous systems and antidiuretic hormone (ADH). In the present report, we have investigated the correlation between changes in haematocrit concentration, and white blood cell (WBC) and platelet counts and the severity of OHSS, as assessed by these markers of effective intra-arterial blood volume, in a series of 50 patients. In comparison with recovery values (4-5 weeks after hospital discharge), OHSS patients showed arterial hypotension, tachycardia, oliguria, very high plasma concentrations of renin, aldosterone, norepinephrine and ADH, and increased mean haematocrit values and WBC and platelet counts. The haematocrit concentration values were directly related to the plasma concentrations of vasoactive substances (plasma renin activity, aldosterone, norepinephrine and ADH) during OHSS (P < 0.001). In contrast, no correlation was evident between WBC or platelet counts and neurohormonal measurements during the syndrome. It is concluded that haematocrit, but not WBC or platelet counts, can act as a biological marker of the severity of OHSS as indicated by plasma measurement of volume-dependent endogenous vasoactive substances.

Recovery and maturation of immature oocytes in patients at risk for ovarian hyperstimulation syndrome

PURPOSE

Our purpose was to examine the rate of immature oocyte recovery and their potential for in vitro maturation from canceled human menopausal gonadotropin cycles due to the risk of having ovarian hyperstimulation syndrome develop.

METHODS

Patients underwent ultrasound-guided immature oocyte pickup. The number of oocytes recovered from these patients was recorded, and then cultured in vitro. Cumulus expansion and the stage of nuclear maturation were observed after 24 and 48 hr, respectively.

RESULTS

Seventeen patients underwent 20 immature oocyte recoveries. A total of 162 oocytes (8.1 oocytes/patient) was obtained. All of the oocytes were enclosed in dense layers of cumulus cells. Among them, 78.4% showed cumulus expansion after 24 hr and 66% completed meiotic maturation to metaphase II after 48 hr in culture. There was only one immature oocyte pickup in which no oocytes were recovered (95% recovery rate). None of the patients had ovarian hyperstimulation syndrome develop.

CONCLUSIONS

Immature oocytes can be recovered from canceled human menopausal gonadotropin cycles in patients who are at potential risk for severe hyperstimulation syndrome. These oocytes can be matured in vitro and can be used for clinical and research purposes as well.

Oocyte quality in patients with severe ovarian hyperstimulation syndrome

OBJECTIVE

To study the oocyte quality in patients with ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective study.

SETTING

The Egyptian IVF-ET Center.

PATIENT(S)

Forty-two patients who developed severe OHSS (group A) were studied for the mean number of oocytes retrieved, percentage of high-quality oocytes, embryo quality, and fertilization, implantation, and pregnancy rates; these patients were compared with an age-matched control group who did not develop OHSS (group B; n = 183) after superstimulation for IVF or intracytoplasmic sperm injection.

INTERVENTION(S)

In vitro fertilization and ICSI.

MAIN OUTCOME MEASURE(S)

Fertilization and pregnancy rates.

RESULT(S)

In group A, the mean number of oocytes retrieved was significantly higher, whereas the percentage of high-quality oocytes and the fertilization rate were significantly lower than that in group B. There were no statistically significant differences in the quality of embryos transferred or the implantation or pregnancy rate between the groups. The percentage of high-quality oocytes and the fertilization rate were significantly lower in patients with polycystic ovaries (PCO) in both groups.

CONCLUSION(S)

The inferior quality and maturity of oocytes in OHSS reduced the fertilization rate but did not affect the quality or the number of embryos transferred or the pregnancy rate. The effect on oocyte quality could be due to the prevalence of PCO in this group of patients.

Spontaneous ovarian hyperstimulation syndrome with pregnancy

Only two cases of severe spontaneous ovarian hyperstimulation syndrome with pregnancy have been reported. We report the third one and the only one that was successfully managed conservatively throughout pregnancy.

Hyperreactio luteinalis differentiated from severe ovarian hyperstimulation syndrome in a spontaneously conceived pregnancy

The clinical presentation of hyperreactio luteinalis can mimic ovarian hyperstimulation. Historically, though, the former most often leads to unnecessary surgery whereas the latter is treated supportively. We present a case of a 32-year-old woman who was initially seen with markedly enlarged multicystic ovaries, ascites, and pleural effusions in the tenth week of a spontaneously conceived gestation. Despite a noniatrogenic cause, the patient received supportive management, as would be given with ovarian hyperstimulation syndrome. Making the distinction between hyperreactio luteinalis and ovarian hyperstimulation syndrome has important consequences for diagnosis and management.

Severe ovarian hyperstimulation syndrome (OHSS) and icterus

Severe ovarian hyperstimulation syndrome (OHSS) leads to changes in laboratory analyte concentrations. Whereas elevated aminotransferase activity is often observed, a cholestatic course with hyperbilirubinaemia and icterus seldom occurs. In this report, the case of a 33 year old patient with polycystic ovary syndrome (PCOS) is described who, after stimulation with human menopausal gonadotrophin (HMG), developed severe OHSS with haemoconcentration, ascites, hydrothorax, elevated aminotransferases, hyperbilirubinaemia and icterus. The patient did not become pregnant and the OHSS regressed, together with the normalization of laboratory and clinical parameters and disappearance of the icterus. During the course of an OHSS cholestasis with icterus may occur, which could be explained by a reactive cholestatic hepatosis as a reaction to the hormonal changes induced by the stimulation therapy.

Treatment of severe ovarian hyperstimulation syndrome by a conservative medical approach

OBJECTIVE

To assess the value of a conservative medical therapeutic approach in the management of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective longitudinal study.

SETTING

Assisted Reproduction Unit of the Hospital Clínic i Provincial de Barcelona, a tertiary care setting.

PATIENTS

Twenty-five women with ascites because of OHSS.

INTERVENTIONS

Patients were treated by strict bed rest, low-sodium diet (60 mEq/day), plasma volume expansion with albumin (50 g/day of salt-poor albumin) and diuretics (20 mg of furosemide given intravenously every 8-12 hours).

MAIN OUTCOME MEASURES

Measurement at admission and 48 hours after commencement of treatment of the following: body weight, mean arterial pressure, heart rate, hematocrit, hemoglobin concentration, leukocyte and platelet counts, urine volume, sodium excretion, serum sodium, serum creatinine, plasma renin activity, and plasma aldosterone, norepinephrine, antidiuretic hormone, and atrial natriuretic peptide concentrations.

RESULTS

After 2 days of therapy there was marked improvement in clinical symptoms, standard laboratory parameters, diuresis and urinary sodium excretion in all patients. There was also a significant decrease in the plasma levels of volume-dependent endogenous vasoactive substances in the five patients in whom these measurements were repeated during treatment. The length of treatment with albumin plus furosemide ranged between 2 and 6 days with an average of 3.3 and it correlated directly with the severity of the syndrome. The hospital stay ranged from 4 to 10 days (mean 6.5 days). All patients recovered without any complication.

CONCLUSIONS

Severe ovarian hyperstimulation syndrome can be managed using the proposed conservative medical approach.

Total ovarian volume before human chorionic gonadotrophin administration for ovulation induction may predict the hyperstimulation syndrome

Total ovarian volumes were measured before the administration of HCG in 42 women undergoing treatment for infertility by in-vitro fertilization (IVF) and embryo transfer and considered to have an exaggerated response to stimulation ( > 20 follicles). Seven women who subsequently developed moderate or severe ovarian hyperstimulation syndrome (OHSS) (n = 7; group 1) were compared with 35 matched controls (five matched controls per case; n = 35; group 2) of similar age, number of follicles and duration of infertility who underwent follicular stimulation, oocyte recovery, in-vitro fertilization and embryo transfer during the same period but did not develop moderate or severe OHSS. The mean age, duration of infertility and total number of follicles were similar but the mean total ovarian volume was significantly higher in the group of women who developed moderate or severe OHSS compared with controls (271.00 +/- 87.00 versus 157.30 +/- 54.20 ml; P < 0.01). We conclude that total ovarian volume measured before HCG administration is higher in women who develop moderate or severe OHSS compared with controls and may therefore be used as an additional parameter in the preventative strategy for the ovarian hyperstimulation syndrome.

A fatal case of ovarian hyperstimulation syndrome with cerebral infarction

The ovarian hyperstimulation syndrome (OHSS) as a cause of death in infertile patients involved in in vitro fertilization is an extremely rare phenomenon. Reported here are the clinical and pathological feature of just such a case together with a discussion of the pathophysiology thought to be involved.

Predictive value of serum oestradiol concentrations and oocyte number in severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of gonadotrophin usage but it is difficult to accurately predict its occurrence. Previous investigators have identified the combination of high oestradiol concentrations and oocyte number as being predictive in 80% of cases. In this study we sought to identify the incidence of severe OHSS in patients with high oestradiol concentrations and large numbers of oocytes and to evaluate the importance of pregnancy in the development of OHSS. Between 1990 and 1993, we studied 139 cycles using two assisted reproductive techniques [oocyte donor, n = 72; in-vitro fertilization (IVF), n = 67] in which either oestradiol (> 4000 pg/ml), oocyte number (> 25), or both were elevated. OHSS was diagnosed by standard criteria. There were no cases of severe OHSS in the oocyte donor group and six in the IVF group. Among 10 patients with oestradiol concentration > 6000 pg/ml and > 30 oocytes, only one had OHSS (10%). The relative risk of OHSS with pregnancy was 12 (confidence interval 2.18-66.14). We conclude that the risk of OHSS even at high levels of stimulation is lower than previously believed. Secondly, donors have a very low risk of OHSS, probably because of the absence of pregnancy. As such, cryopreservation of all oocytes in IVF cycles is a reasonable alternative to cycle cancellation or use of adjunctive medication.

[Ovarian hyperstimulation syndrome (OHS): borderlines between physiology and pathology]

The use of gonadotropins in therapy has led to the appearance of a complication due to hyperstimulation, referred to as "syndrome due to ovarian hypertension" (SOH). There are three clinical stages of SOH: slight, moderate and severe, caused by a pathogenetic mechanism which is thought to involve the action of prostaglandins and the renin-angiotensin system leading to an alteration in capillary permeability with increased ovarian diameter. SOH can be prevented using a protocol to evaluate clinical conditions during therapy mainly based on hormone assays and echographic monitoring. SOH can be predicted but not prevented, thus making it important to commence immediate treatment for in-patients so as to restore the volume of blood and the blood protein load in the most severe cases.

[Hyperreactio luteinalis in pregnancy]

We report on the extremely rare case of ovarian overstimulation in a single pregnancy without prior hormonal stimulation therapy. During the 26th week of gestation ultrasound examination showed a 103 x 57 x 78 mm polycystic tumour with echogenic structures inside the cysts, located behind the uterus. Further management consisted of laparotomy with partial resection of a cystic part of the left ovary. Frozen section examination confirmed the diagnosis of hyperreactio luteinalis and excluded malignancy. To avoid torsion of the ovaries, cysts from both sides were aspirated. On day 8 and 18 after surgery, sonography revealed no pathological finding. In the 40th week of gestation, a healthy baby was delivered. The possibility of a hyperreactio luteinalis has to be kept in mind, when cystic solid tumours of the ovaries are diagnosed during pregnancy. A conservative management is appropriate, because a normal spontaneous remission occurs after delivery.

Relationship between serum CA 125 levels, endometrial thickness and corpus luteum function in different stages of ovarian activity

CA 125 is a cell surface antigen expressed in some derivatives of celomic epithelium, predominantly in ovarian cancer cells. However, it has also been detected in serum of healthy women and in patients with benign gynecologic diseases. The exact source or sources of the circulating levels of CA 125 and their elevations are not known. In the present study, the relationship between serum CA 125 levels, ovarian steroidogenesis and endometrial thickness is investigated at different periods: 1) mid-follicular, 2) midcycle, and 3) midluteal phases in normal cycles of fertile women, in patients stimulated for intrauterine insemination (IUI) and in patients stimulated for in vitro fertilization (IVF). Only in patients with mild and moderate ovarian hyperstimulation (OHSS) of the IVF group were luteal phase CA 125 levels (149.7 +/- 24.4 U/ml) significantly higher than midfollicular (21.2 +/- 1.9 U/ml) and midcycle phase levels (24.4 +/- 2.5 U/ml) (p < 0.001). The mean midcycle estradiol and midluteal progesterone concentrations in patients stimulated for IUI and IVF were significantly higher than those of normally cycling women (p < 0.001). Mean endometrial thickness in patients stimulated for IVF was significantly higher than in patients stimulated for IUI and normally cycling women (p < 0.001). Midluteal CA 125 levels correlated with midcycle endometrial thickness (r = 0.585, p < 0.05) and midluteal P levels (r = 0.497, p < 0.05) in patients with OHSS of IVF group. This correlation was not observed in patients who had no signs and symptoms of OHSS during stimulation for IVF and in patient stimulated for IUI and the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ovarian hyperstimulation syndrome with bilateral hydrothorax and ascites]

Ovarian hyperstimulation syndrome (OHSS) is an unusual complication of ovarian stimulation with exogenous gonadotrophins. We describe a case of severe OHSS with bilateral hydrothorax and ascites. We discuss the different pathogenetic hypothesis and the differential diagnostic possibility.