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.

Infertile couples? experience of family stress while women are hospitalized for Ovarian Hyperstimulation Syndrome during infertility treatment

AIMS AND OBJECTIVES

The aim of this study was to explore the essential structure of family stress among hospitalized women receiving infertility treatment with Ovarian Hyperstimulation Syndrome.

BACKGROUND

When hospitalization is necessary for infertile women with Ovarian Hyperstimulation Syndrome, they face health-illness transition stress and their families are traumatized by the pressure of hospitalization. Most literature on infertility treatment has dealt with the infertile women's physio-psychological reactions, the impact on the couples' relationships and the influence of social support on infertile couples.

DESIGN

A descriptive phenomenological design consistent with Husserl's philosophy.

METHODS

Ten married couples from a Taipei medical centre participated in the study. All the couples were receiving infertility treatment because the female partners were suffering from moderate or severe Ovarian Hyperstimulation Syndrome and this required hospitalized. An open in-depth interview technique encouraged parents to reflect on their experience, which raised their feelings to a conscious level. Data were analysed using Colaizzi's approach.

RESULTS

This study explored infertile women's experiences from the couples' perspectives and the results identify the overall stresses that the family face. Five themes emerged from the study, namely, the stress of 'carrying on the ancestral line', the psychological reactions of the couple, a disordering of family life, reorganization of family life and external family support.

CONCLUSIONS

The results demonstrate that the experience of family stress involves impacts that range across the domains of individual, marital, family and social interactions and there is a need to cope with these when the wife is hospitalized for moderate to severe Ovarian Hyperstimulation Syndrome.

RELEVANCE TO CLINICAL PRACTICE

The findings indicated that nurses should provide infertile couples with family-centred perspectives that are related to Chinese cultural family values. Nurses should supply information on infertility treatment and assist couples to cope with their personal and family stress.

Update on ovarian hyperstimulation syndrome: Part 1--Incidence and pathogenesis

Ovarian hyperstimulation syndrome (OHSS) is a rare and potentially life-threatening complication during controlled ovarian stimulation. It can be associated with severe morbidity and may even be fatal. The etiology of the condition and predisposing factors are still not fully understood. Data concerning pathophysiology in patients with OHSS were searched using PubMed and other medical data bases. The incidence of severe OHSS, as calculated by World Health Organization (WHO), is 0.2-1% of all stimulation cycles in assisted reproduction. Considerations on OHSS classifications and forms of manifestations are discussed in detail. New insights concerning genetics and altered FSH receptor are given. OHSS may involve, according to its grade of severity, elevated or decreased levels of growth factors, cytokines, mediators, changes in hormones, renin-angiotensin and kinin-kallikrein system. There are massive electrolytic imbalances and changes in hemodynamic and fluid metabolism. Furthermore, liver and pulmonary dysfunction is observed as well as increased coagulation with subsequent thromboembolism. The influence of OHSS on the pregnancy rate and outcome of pregnancy is a matter of controversy. Patients with OHSS have high pregnancy rates with a tendency to an increased incidence of abortion.

[Ovarian hypertimulation syndrome: a review]

OBJECTIVE

Discuss prevalence, risk factors, pathophysiology, symptoms, complications and therapy of OHSS.

DESIGN

A review article.

SETTING

Department of Obstetrics and Gynaecology, 1st Faculty of Medicine and General faculty Hospital, Charles University, Prague.

SUBJECT AND METHODS

A review from literature and bibliographic databases.

RESULTS

OHSS is an iatrogenic complication of ovarian stimulation. We still can not completely explain the pathophysiology of OHSS. The therapy is based on symptomatic approach. To prevent OHSS, the hCG should not be given to induct the ovulation, or we should not transfer embryos during the IVF-stimulated cycle.

Vascular endothelial cadherin regulates vascular permeability: Implications for ovarian hyperstimulation syndrome

CONTEXT

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of treatment with fertility drugs. It is characterized by increased vascular permeability and simultaneous overexpression of vascular endothelial growth factor (VEGF) in ovarian cells.

OBJECTIVE

We tested the hypothesis that the endothelium and endothelial cell-to-cell junctions are downstream targets of VEGF during OHSS pathogenesis. We investigated the potential involvement of vascular endothelial (VE)-cadherin, an interendothelial adhesion molecule, in the capillary hyperpermeability in OHSS.

DESIGN

Human endothelial cells from umbilical veins (HUVEC) were used as an in vitro model of OHSS.

INTERVENTION

Cell cultures were treated with varying doses of estradiol (E2), human chorionic gonadotropin (hCG), VEGF, and antihuman VEGF antibodies, either alone or in combination, and the effect on VE-cadherin release was evaluated at different time points. Permeability assays were performed using fluoresceinisothiocyanate-labeled albumin, and actin filaments rearrangement was evaluated by fluorescent microscopy.

RESULTS

Culturing of HUVEC with high doses of E2 produced no significant changes in VE-cadherin concentration, but hCG and VEGF produced a significant increase in VE-cadherin release. Time-course experiments showed that VE-cadherin was secreted 12 h after VEGF addition. Antihuman VEGF antibodies prevented these changes. Permeability assays demonstrated that, although E2 did not alter the arrangement of HUVEC in vitro, hCG and VEGF caused changes in the actin fibers indicative of increased capillary permeability. VEGF also induced an increase in paracellular permeability of HUVEC at the same doses used in the previous experiments.

CONCLUSIONS

Adhesion molecules like VE-cadherin may play a role in the development and progression of increased capillary permeability in severe OHSS.

[The ovarian hyperstimulation syndrome--diagnostic criteria, management procedures]

The ovarian hyperstimulation syndrome (OHSS) is still a difficult diagnostic and therapeutic problem. OHSS is associated with significant hypertrophy of the ovaries associated with the loss of the intravascular fluid to the third space which results in hypovolaemia, oliguria, electrolyte imbalance, and a rise in haematocrit. The endogenous OHSS is rare. Most often OHSS appears as a complication of induction of ovulation. The fundamental issue in pathophysiology of OHSS is an increase of capillary permeability which results in the leakage of fluid to the third space. The vascular endothelial growth factor--VEGF--is considered to be the factor directly responsible for the processes involved. The most common are the mild and moderate forms of the syndrome. The severe form of OHSS is a life-threatening condition. The following symptoms may be present: ascites, pleural and pericardial effusion, oliguria, dyspnoea with tachypnoe, tachycardia, adult respiratory distress syndrome, renal failure, venous thrombosis, ischaemic stroke, haemorrhage from a ruptured ovary. Therapy should be based on the correction of hypovolaemia, hypotension and oliguria. Antithrombotic prophylaxis is an integral part of the OHSS management. Some interesting attempts have been undertaken to re-infuse the protein-rich ascites fluid directly to the systemic circulation, so called continuous auto-transfusion system of the ascites (CATSA).

[Severe ovarian hyperstimulation syndrome treatment by decompressive paracentesis and self-transfusion of ascitis fluid]

BACKGROUND

The ovarian hyperstimulation syndrome is a serious complication in patients who undergo controlled ovarian stimulation and for that reason all clinicians who prescribe ovulation inducing agents must be prepared to recognize and manage ovarian hyperstimulation syndrome, to prevent severe and ocasionally mortal complications.

OBJECTIVE

To communicate the experience in the treatment of ovarian hyperstimulation syndrome as a complication in patients who undergo controlled ovarian stimulation.

PATIENTS AND METHODS

In the present study seven patients who developed severe ovarian hyperstimulation syndrome were included, and were treated by ultrasound guided paracentesis and self-transfusion of the ascitic fluid.

RESULTS

In all patients we observed a clinical improvement immediately after the drainage of ascitic fluid no hematological or infectious disease were observed after the self-transfusion. We observed a reduction in hemoglobin of 20.9% and 22.2% in the hematocrit after paracentesis and self-transfusion, meanwhile we observed an increase of 55.5% in the albumin level. Any patient developed hemodynamic disturbance after paracentesis after drainage of great volume in the paracentesis (mean of 4453.4 mL per patient).

CONCLUSIONS

The drainage of ascitis by paracentesis and self-transfusion of the fluid is a good therapeutic option in patients with severe ovarian hyperstimulation syndrome in combination with intravenous fluids and administration of human albumin 25%.

Successful ongoing pregnancies after vitrification of oocytes

OBJECTIVE

To demonstrate the efficiency of vitrifying mature human oocytes for different clinical indications.

DESIGN

Descriptive case series.

SETTING

Cryobiology laboratory, Centro Colombiano de Fertilidad y Esterilidad-CECOLFES LTDA. (Bogotá, Colombia).

PATIENT(S)

Oocyte vitrification was offered as an alternative management for patients undergoing infertility treatment because of ovarian hyperstimulation syndrome, premature ovarian failure, natural ovarian failure, male factor, poor response, or oocyte donation. Mature oocytes were obtained from 33 donor women and 40 patients undergoing infertility treatment.

INTERVENTION(S)

Oocytes were retrieved by ultrasound-guided transvaginal aspiration and vitrified with the Cryotops method, with 30% ethylene glycol, 30% dimethyl sulfoxide, and 0.5 mol/L sucrose. Viability was assessed 3 hours after thawing. The surviving oocytes were inseminated by intracytoplasmic sperm injection. Fertilization was evaluated after 24 hours. The zygotes were further cultured in vitro for up to 72 hours until time of embryo transfer.

MAIN OUTCOME MEASURE(S)

Recovery, viability, fertilization, and pregnancy rates.

RESULT(S)

Oocyte vitrification with the Cryotop method resulted in high rates of recovery, viability, fertilization, cleavage, and ongoing pregnancy.

CONCLUSION(S)

Vitrification with the Cryotop method is an efficient, fast, and economical method for oocyte cryopreservation that offers high rates of survival, fertilization, embryo development, and ongoing normal pregnancies, providing a new alternative for the management of female infertility.

Hyperreactio luteinalis presenting with marked hyperglycemia and bilateral multicystic adnexal masses at 21 weeks gestation

We present an unusual case in which a 23-year-old nulliparous patient was noted to have bilateral multicystic adnexal masses at 21 weeks gestation. Subsequent severe nausea, vomiting, and hyperglycemia with a serum glucose level of 450 mg/dL led to the diagnosis of gestational diabetes. Gradual development of marked maternal virilization ensued and was associated with a serum testosterone level of 4030 ng/mL (free testosterone level of 224 pg/mL), with normal serum dehydroepiandrostendione, estriol, and cortisol levels, leading to the diagnosis of hyperreactio luteinalis. Following vaginal delivery at 38 weeks gestation, gradual and complete spontaneous resolution of signs, symptoms, adnexal masses, diabetes, and testosterone levels were documented.

Ovarian hyperstimulation syndrome

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation usually occurring during the luteal phase or during the early part of pregnancy. OHSS is a potential complication of ovarian induction by almost every agent used for ovarian stimulation. Today, due to aggressive treatment protocols including the development of in vitro fertilization and cryopreservation with the goal of obtaining sufficient numbers of oocytes and embryos, an increased risk of developing OHSS is present. OHSS is now becoming increasingly more recognized due to the higher number of women undergoing assisted reproductive techniques.

DESIGN

Review of the literature regarding ovarian hyperstimulation syndrome.

METHODS

A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and treatment and prevention of OHSS.

CONCLUSION

OHSS can be thought of as the loss of control over the hyperstimulation of the ovaries. Although the prevalence of the severe form of OHSS is small, it is important to remember that OHSS is usually an iatrogenic complication of a nonvital treatment that has the potential for a fatal outcome. Therefore, critical care physicians play an integral part in the care of these patients and therefore should be familiar with and recognize the various clinical manifestations and potential outcomes of this entity.

Polycystic ovaries and ovarian hyperstimulation syndrome: a systematic review*

OBJECTIVES

To assess and quantify the relationship between polycystic ovaries (PCOs) and ovarian hyperstimulation syndrome (OHSS).

DATA SOURCES

Published studies, any language, identified through MEDLINE, EMBASE, BIOSIS, Web of Science, and bibliographies. Studies were selected if exposure (ultrasound findings of PCO before treatment) and outcome (OHSS) could be abstracted to two-by-two tables.

RESULTS

Ten studies, meeting inclusion and exclusion criteria, were analyzed. When PCO were present, the combined odds ratio for OHSS was 6.8 (95% confidence interval 4.9-9.6).

CONCLUSION

There is a significant and consistent relationship between PCO and OHSS. When PCO are present before treatment with assisted reproduction, deliberate policies to moderate treatment appear justified.

Liver dysfunction in severe ovarian hyperstimulation syndrome

We report the case of a 32-year-old woman suffering from severe liver dysfunction in the course of ovarian hyperstimulation syndrome (OHSS). Complications occurred after successful fertilization subsequent to ovarian stimulation with human menopausal gonadotropin followed by ovulation induction with human chorionic gonadotropin. Because of nausea, vomiting, abdominal distention and enlarged ovaries on an ultrasound examination, she was admitted on the diagnosis of OHSS. During the course of hospitalization severe hepatic injury developed. An increase of more than 100-fold in blood aminotransferase activity was observed. Applied treatment resulted in gradual reduction of ovarian size and resolution of ascites, as well as pleural and pericardial effusions. The patient was discharged from hospital after 46 days. Follow-up examinations at the 13th and 32nd weeks of gestation did not reveal any abnormalities. Pregnancy developed without complications and the woman went into spontaneous labor, giving birth to a viable child at 38 weeks' gestation. Taking into account the above case and previously published reports, the issue of liver dysfunction may have a great impact on the understanding both the pathology and the treatment of OHSS.

[An experience nursing a patient with ovarian hyperstimulation syndrome who has undergone artificial fertilization treatment]

With the growing incidence of infertility in the modern world, artificial fertilization techniques provide new hope for many would-be parents. However, side-effects of the treatment can have a huge impact on patients and their families. This article employs Roy's adaptation model to study a patient with ovarian hyperstimulation syndrome who had undergone artificial fertilization treatment. Under careful assessment and examination, the author discovered that the patient suffered from such problems as malnutrition, fluid overload, pain and lethargy, etc. By employing skillful communication techniques and the display of empathy, the author helped to alleviate the patient's sufferings during treatment, as well as providing professional knowledge and advice. To help the patient in resolving difficulties that might have been encountered in the family, the author also exercised the idea of the family as core. The author hopes to share the knowledge that, in the care of patients with infertility, it is vital that health care professionals look after their psychological requirements as well as their physical care, in order to provide optimum care.

Oocyte quality in patients with severe ovarian hyperstimulation syndrome: a self-controlled clinical study

OBJECTIVE

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

DESIGN

Self-controlled clinical study.

SETTING

University teaching hospital.

PATIENT(S)

Twenty-two patients from our assisted reproductive technology (ART) program who developed severe OHSS during their first controlled ovarian hyperstimulation for IVF or intracytoplasmic sperm injection (ICSI) (OHSS cycles) during a period of 10 years and had a second ART attempt performed in our center in which OHSS did not develop (control cycles).

INTERVENTION(S)

IVF and ICSI.

MAIN OUTCOME MEASURE(S)

Oocyte yield and quality, fertilization rate, embryo yield and quality, implantation rate, and pregnancy rate.

RESULT(S)

The total number of oocytes retrieved and the mean number of metaphase II oocytes were significantly higher in patients with OHSS than in control cycles. Fertilization rates were similar in both groups of ART cycles, and thus the number of viable embryos were significantly higher in OHSS cycles. Implantation and pregnancy rates were similar in OHSS and control cycles. Oocyte and embryo yield and quality were similar in early and late OHSS. Oocyte yield and quality, embryological outcome, and implantation and pregnancy rates were similar in patients with and without polycystic ovarian syndrome (PCOS) both in cycles developing OHSS and control cycles.

CONCLUSION(S)

Oocyte quality is not compromised in severe OHSS cycles irrespective of whether patients had or did not have PCOS.

[Intensive care and treatment of severe ovarian hyperstimulation syndrome]

OBJECTIVE

To investigate the clinical manifestations, pathogenesis and treatment of severe ovarian hyperstimulation syndrome (OHSS).

METHODS

The clinical data of 20 OHSS patients were analyzed retrospectively.

RESULTS

Severe OHSS occurred after controlled ovarian hyperstimulation for superovulation. The major manifestations of OHSS included abdominal distension, nausea, ascites, hydrothorax, oliguria, concentrated blood, acid-base and electrolytes, disturbance, azotemia, thrombosis etc., which could be controlled by volume expansion with albumin, low-molecular-weight dextran, 6% Haes, abdominal and thoracic drainages or even early pregnancy termination.

CONCLUSION

Preventive measure of OHSS is very important, and the patients must be treated timely and correctly once OHSS occurs.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that is associated with modern techniques for in vitro fertilization. Extensive efforts have been made to understand the pathophysiology and to improve the management of this entity. The severe and life-threatening forms of the ovarian hyperstimulation syndrome are still challenging for critical care physicians. This article reviews the pathogenesis, epidemiology, classification, clinical manifestations, and complications of these forms of OHSS. The different therapeutic options currently available are reviewed, and a stepwise approach for the management of these patients is provided.

Predicted value of renin activity in a woman who had severe ovarian hyperstimulation syndrome with internal jugular vein thrombosis

OBJECTIVE

To assess plasma renin activity in a patient with severe ovarian hyperstimulation syndrome (OHSS) and internal jugular vein thrombosis.

DESIGN

Case report.

SETTING

University-affiliated infertility center.

PATIENT(S)

A 33-year-old woman with OHSS and internal jugular vein thrombosis.

INTERVENTION(S)

Controlled ovulation hyperstimulation with recombinant FSH induction.

MAIN OUTCOME MEASURE(S)

Plasma renin activity (PRA), color Doppler ultrasound of the neck.

RESULT(S)

The patient had internal jugular vein thrombosis caused by severe OHSS. The PRA was significantly elevated during the acute stage and subsequently declined after resolution of the OHSS.

CONCLUSION(S)

In this patient elevated PRA appeared to be associated with the development of OHSS and thrombosis. The implication of the ovarian renin-angiotensin system in the development of OHSS and thrombosis is relevant.

Effects of coasting on the outcome of intracytoplasmic sperm injection-embryo transfer cycles

OBJECTIVES

To determine the effects of 'coasting' on the outcome of controlled ovarian hyperstimulation (COH) and intracytoplasmic sperm injection-embryo transfer (ICSI-ET).

DESIGN

Retrospective study.

SETTING

IVF Centre, Ozel Ege Tup Bebek Merkezi, Izmir, Turkey.

SAMPLE

Twenty-six coasted and 52 non-coasted COH and ICSI-ET patients were enrolled in this retrospective study.

METHODS

Coasted patients were enrolled consecutively during the study period, and two non-coasted controls were selected from our database for each coasted patient. Coasting was decided when serum oestradiol level was > or = 4000 pg/mL. Groups were compared using chi2 and Mann-Whitney U-tests for statistical analysis.

MAIN OUTCOME MEASURES

Number of oocytes collected, metaphase II (MII) oocytes and cleaving embryos, the fertilisation rate and clinical pregnancy rate were the main outcome measures.

RESULTS

Number of oocytes collected, number of MII oocytes, number of cleaving embryos, fertilisation rate and clinical pregnancy rate for the coasted and non-coasted groups were 15.5 +/- 5.2 and 14.0 +/- 7.1, 9.7 +/- 4.8 and 9.3 +/- 3.9, 6.8 +/- 3.9 and 5.8 +/- 3.1, 0.85 +/- 0.18 and 0.78 +/- 0.18, 13/26 and 24/52, respectively; these differences were not statistically significant. None of the patients in the coasted group were hospitalised for signs or findings of severe ovarian hyperstimulation syndrome.

CONCLUSIONS

Coasting does not adversely affect the number and the function of mature oocytes and the clinical pregnancy rate.

Continuous abdominal paracentesis for management of late type severe ovarian hyperstimulation syndrome

The ovarian hyperstimulation syndrome (OHSS) is often observed in patients undergoing assisted reproductive technology (ART). In severe form OHSS is a serious and potentially life-threatening. Here we report a 36-year-old woman with primary infertility due to endometriosis who underwent controlled ovarian hyperstimulation. Ten days later, severe late-onset ovarian hyperstimulation syndrome, severe ascites and pulmonary effusion, developed. Continuous abdominal paracentesis of 5000 mL/day was performed on the third day. With this procedure, ascitic fluid was drained efficiently and the patient's condition improved. This report suggests that early continuous abdominal paracentesis with drainage of ascitic fluid is an efficacious procedure for management of the severe ovarian hyperstimulation syndrome as soon as euvolemia is achieved clinically.

Bilateral partial oophorectomy in the management of severe ovarian hyperstimulation syndrome (OHSS): ovarian mutilating surgery is not an option in the management of severe OHSS

Ovarian mutilating surgery is not an option in the management of ovarian hyperstimulation syndrome (OHSS), except in cases with evident tissue necrosis after torsion. When severe OHSS occurs, preservation of fertility must be the target. Therefore, conservative management should be the only feasible approach, as recommended in literature worldwide. Individualization of controlled ovarian hyperstimulation, and an early active management when OHSS initiates, are the most effective measures for reducing the incidence and severity of this disease.

Clinical and laboratory evaluation of hospitalized patients with severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an important complication of ovarian stimulation and IVF that enhances patients' morbidity. To evaluate any increased incidence of hospitalization from severe OHSS during 2000, this study analysed certain clinical, ultrasound and laboratory characteristics of hospitalized patients with severe OHSS. These studies were carried out on women undergoing IVF who were hospitalized because of severe OHSS between 1996 and 2000 at the Hôpital Antoine Béclère. Patients' ages and serum hormone concentrations were collected on day 3 of ovarian stimulation for various assays, and laboratory and ultrasound measurements taken during ovarian stimulation for IVF were compared. An increase was noted during last year in the frequency of the severe form of OHSS requiring hospitalization (0.9 versus 1.8%, P < 0.05). Patients' ages and hormonal characteristics on day 3 of menstrual cycle, and laboratory and ultrasound variables were similar between the two groups. In addition, the increased incidence of OHSS during 2000 was not associated with any special laboratory or ultrasound parameter, and the policy of ovarian induction had not changed. It is essential to introduce a simple ovarian stimulation protocol providing acceptable IVF results with a minimum of risk.

Prevention and treatment of ovarian hyperstimulation syndrome

The ovarian hyperstimulation syndrome (OHSS) is a potentially fatal condition with a pathophysiology that is not clearly understood. A shift in fluid from the extravascular space occurs, thought to be induced by cytokines and/or vascular endothelial growth factor. Human chorionic gonadotrophin (hCG), exogenous or endogenous, seems to be the triggering mechanism, resulting in early and late development of the syndrome, respectively. The management of the syndrome is mainly symptomatic. Preventive strategies are being developed and constantly refined. Women at increased risk of OHSS need to be on the lowest possible dose of gonadotrophin with the aim of reducing the granulosa/luteal cell mass. Ultrasound and serum oestradiol (E2) measurements are, at present, the main methods used to identify and monitor those at risk during controlled ovarian hyperstimulation (COH). Withholding gonadotrophin stimulation (coasting), but continuing down-regulation, when a large number of follicles (greater than 20) and a rising serum oestradiol level are seen, is the most widely favoured and used preventive measure and the most cost effective. Management is symptomatic and aimed at achieving fluid balance, restoring plasma volume and improving renal function. This may be combined with an early resort to ascitic fluid aspiration, which will improve the feeling of wellbeing and may remove those agents responsible for the syndrome. Heparin, to prevent the risk of thromboembolism as a result of haemoconcentration, is important.

Review of clinical course and treatment of ovarian hyperstimulation syndrome (OHSS)

The ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy. This complication is unusual as it is not the consequence of a treatment which is vital or mandatory for the patient's health. Nevertheless, it can be accompanied by severe morbidity and may even be fatal. Data pertaining to the clinical course and consequences of OHSS in women and its treatment were searched using Medline, Current Contents and PubMed. To date, only a few studies have collected a large number of cases of OHSS. The clinical course of OHSS may involve, according to its severity and the occurrence of pregnancy, electrolytic imbalance, neurohormonal and haemodynamic changes, pulmonary manifestations, liver dysfunction, hypoglobulinaemia, febrile morbidity, thromboembolic phenomena, neurological manifestations and adnexal torsion. Treatment of the acute phase relies only on an empirical and symptomatic approach. The general approach will be adapted to the levels of severity. Specific approaches such as paracentesis, pleural puncture, surgical approach of OHSS and specific medication during OHSS were evaluated sporadically. More adequate treatment methods would require a better understanding of the underlying pathophysiological mechanisms, to promote an aetiological therapeutic approach. Properly conducted studies, including large numbers of patients are required in order to determine the best method of prevention and management.

[Some aspects of ovarian hyperstimulation syndrome]

Ovarian hyperstimulationsyndrome (OHSS) is a serious and potentially life-threatening complication of ovarian stimulation. The clinical picture of severe OHSS, includes ovarian enlargement, ascites, pleural effusion, hypercoagulation and electrolyte disorders. In this study we describe some factors which are linked with pathogenesis of OHSS. We had a case of moderate OHSS with a twin pregnancy after IVF-ET. In this case, because of abdominal pain and discomfort from the ascites, we perform abdominal paracentesis without termination of pregnancy.

Current management of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is an iatrogenic and usually self-limiting condition which can occasionally be life threatening. This article reviews methods of prevention and management of ovarian hyperstimulation syndrome.

Postparacentesis bilateral massive vulvar edema in a patient with severe ovarian hyperstimulation syndrome

OBJECTIVE

To report a case of bilateral massive vulvar edema following lower abdominal paracentesis in a patient with ovarian hyperstimulation syndrome.

DESIGN

Case report.

SETTING

University teaching hospital.

PATIENT(S)

A 32-year-old woman with primary infertility.

INTERVENTION(S)

The patient underwent ovarian stimulation with leuprolide acetate, highly purified FSH, and hCG. Because of the development of severe ovarian hyperstimulation syndrome, bilateral paracentesis through the lower abdominal quadrants was performed.

MAIN OUTCOME MEASURE(S)

Treatment of ovarian hyperstimulation syndrome.

RESULT(S)

Development of bilateral massive vulvar edema 24 hours after lower abdominal paracentesis.

CONCLUSION

This case report suggests that lower abdominal paracentesis could be the cause of vulvar edema development in ovarian hyperstimulation syndrome, probably due to a fistulous tract created between the peritoneal cavity and the subcutaneous tissues.

Aggressive outpatient treatment of ovarian hyperstimulation syndrome with ascites using transvaginal culdocentesis and intravenous albumin minimizes hospitalization

PURPOSE

To assess the effectiveness of outpatient treatment of Ovarian Hyperstimulation Syndrome associated with ascites.

METHODS

Forty-eight patients diagnosed with ovarian hyperstimulation and ascites from 2,246 consecutive in vitro fertilization cycles were retrospectively studied. Patients were treated with outpatient transvaginal culdocentesis and rehydration with intravenous crystalloids and albumin every 1-3 days until resolution of symptoms or hospitalization was required. Outcomes measured included incidences of hospitalization, pregnancy outcomes, cycle characteristics, and oocyte donors versus nondonors comparisons.

RESULTS

No complications occurred from outpatient treatments, and 91.6% of patients avoided hospitalization. The pregnancy rate in patients undergoing transfer was 84.7%, and the spontaneous loss rate was 16%. Overall, the estradiol on day of hCG was 4331 pg/mL (range 2,211-8,167), ascites removed was 1910 cm3 (122-4,000), and number of outpatient treatments was 3.4 (1-14). Nondonors averaged more outpatient treatments than donors (3.97 vs. 1.85), but similar rates of hospitalization (3/35 vs. 1/13).

CONCLUSIONS

Outpatient treatment consisting of culdocentesis, intravenous rehydration, and albumin minimized the need for hospitalization in hyperstimulated patients.

[Ascitic fluid puncture in the treatment of severe forms of ovarian hyperstimulation syndrome]

OBJECTIVE

Evaluate the contribution and complications of ascitic fluid puncture in the treatment of severe ovarian hyperstimulation syndrome.

DESIGN

Retrospective analysis of 18 patients.

SETTING

Department of Gynaecology and Obstetrics, University Hospital, Palacky University, Olomouc.

METHODS

18 patients with the diagnosis of severe ovarian hyperstimulation syndrome admitted to intensive care unit from January 1996 to June 2000 were analysed. As a part of the therapy of severe OHSS 11 punctures of ascitic fluid was performed. In 3 patients the reinfusion of the ascites into the blood circulation was performed.

RESULTS

The transabdominal paracentesis under the ultrasound control in 11 patients was performed. In 6 patients the puncture had to be repeated. The amount of removed ascitic fluid in single procedure was between 600-3750 ml. Total amount of fluid in different patients was between 1500-17,300 ml. Sterility of ascites and high contents of proteins was proved. In 3 patients with the refractory ascites the reinfusion of the ascitic fluid to the circulation was performed. No serious complications of the punctures were observed, 4 patients had a slight rise of body temperature, which fell down without antibiotics therapy.

CONCLUSION

Puncture of the ascitic fluid is a save and effective part of the therapy of severe OHSS. In the treatment of the refractory ascites the reinfusion of the ascitic fluid should be used.

Hydroxyethylstarch versus human albumin for the treatment of severe ovarian hyperstimulation syndrome: a preliminary report

OBJECTIVE

To compare the efficacy and safety of 6% hydroxyethylstarch and human albumin as colloid solutions for treatment of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled cohort study.

SETTING

Tertiary medical center.

PATIENT(S)

Sixteen patients with severe OHSS.

INTERVENTION(S)

Six percent hydroxyethylstarch (6 patients) and human albumin (10 patients).

MAIN OUTCOME MEASURE(S)

Urine output, number of abdominal and pleural drainage procedures, complications, duration of hospitalization, and perinatal outcome.

RESULT(S)

Patients who received 6% hydroxyethylstarch had higher urine output, needed fewer abdominal and pleural paracenteses, and had a shorter hospital stay than those who received human albumin. In each group, no adverse effects or congenital malformations were observed and the rates of miscarriage were similar.

CONCLUSION(S)

These results suggest that 6% hydroxyethylstarch may be superior to albumin as a colloid solution for the treatment of severe OHSS.

Severe spontaneous ovarian hyperstimulation syndrome with MR findings

We describe a case of severe spontaneous ovarian hyperstimulation syndrome (OHSS) with MR findings. MR scans showed bilateral symmetric enlargement of ovaries with multiple cystic changes, giving the classic "wheel-spoke" appearance. There was no definite abnormally thickened or enhanced wall, but there was internal hemorrhage in some chambers. To avoid unnecessary laparotomy, we emphasize the importance of careful diagnosis to differentiate spontaneous OHSS from ovarian cystic neoplasms.

10% hydroxyethyl starch for plasma expansion in the treatment of severe ovarian hyperstimulation syndrome. A case report

BACKGROUND

Severe ovarian hyperstimulation syndrome is a complication of hormonal therapy for in vitro fertilization and carries the risk of renal failure. The injection of 6% hydroxyethyl starch has been used as a preventive measure.

CASE

A 33-year-old woman was admitted with severe ovarian hyperstimulation syndrome after receiving gonadotropins as part of our in vitro fertilization protocol. Despite treatment with saline, albumin and abdominal taps, oliguria developed on the third day. The patient was transferred to the general intensive care unit and treated with 10% hydroxyethyl starch, furosemide and a further abdominal tap. Recovery was rapid.

CONCLUSION

Ten percent hydroxyethyl starch is an efficient plasma expander. It is safe, biohazard free and cost-effective. It seems to effectively control severe ovarian hyperstimulation syndrome and to overcome acute prerenal failure. Larger prospective studies are necessary to further evaluate its role in the treatment of severe ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome and its effect on renal function in a renal transplant patient undergoing IVF treatment: case report

Ovarian hyperstimulation syndrome (OHSS) in a renal transplant patient undergoing assisted conception treatment is reported. A couple with infertility secondary to tubal blockage and pelvic endometriosis received IVF treatment. Ovarian enlargement secondary to OHSS resulted in obstruction in the transplanted kidney and deterioration of renal function. No other systemic manifestations of OHSS were evident. Conservative management was successful and a twin live birth was later achieved by replacement of two frozen-thawed embryos.

The ovarian hyperstimulation syndrome

OBJECTIVE

To review the up-to-date literature concerning the pathogenesis of, risk factors for, prevention of, and therapy for the ovarian hyperstimulation syndrome, and to provide suggestions for management of this syndrome.

DESIGN

Literature review combined with on-site clinical experiences at the authors' institution of practice.

PATIENT(S)

Women who have risk factors for or manifest the ovarian hyperstimulation syndrome.

INTERVENTION(S)

Intravenous fluid management, thrombosis prevention techniques, paracentesis techniques, and critical care management protocols.

MAIN OUTCOME MEASURE(S)

Staging system of the ovarian hyperstimulation syndrome, criteria for outpatient versus hospitalization management, and indications for varying levels of interventional management.

RESULT(S)

The ovarian hyperstimulation syndrome, unique to the field of assisted reproductive technology, remains a largely elusive and unpredictable iatrogenic physiologic complication in the course of pharmacologic ovarian stimulation. Reliable information on risk factors, possible physiologic mechanisms, prevention techniques, and management is fortunately progressing, and overall advances are being made in this field. The present review is an attempt to summarize the modern literature regarding this syndrome and to use this current knowledge to provide a basis for acceptable management regimens.

CONCLUSION(S)

Ovarian hyperstimulation syndrome is a serious complication of assisted reproductive technology, with potential for critical morbidity and death. Physicians who prescribe medications known to be associated with this syndrome should be familiar with identifiable risk factors, means of prevention, and a system for staging and treating the disease and have a current knowledge base for putative models of pathogenesis.

A tale of two syndromes: ovarian hyperstimulation and abdominal compartment

Abdominal compartment syndrome complicated severe ovarian hyperstimulation in a 35 year old woman with multiple bowel resections due to Crohn's disease. Pain from ovarian enlargement necessitated hospital admission. Despite intravenous fluid administration and heparin prophylaxis, ilio-femoral deep vein thrombosis developed. Treatment by intravenous heparin was complicated by repeated intra-ovarian bleeding, anaemia and acute renal failure requiring haemodialysis. Intra-abdominal pressures were elevated. After placement of an inferior vena caval filter and discontinuation of heparin, there was slow spontaneous recovery without surgery.

Ovarian hyperstimulation syndrome (OHSS): diagnosis and management

OBJECTIVE

To present our experience and the current knowledge about pathophysiology, diagnosis, and management of the ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective study concerning clinical and laboratory findings of severe OHSS.

SETTING

General ICU at a maternity-surgical hospital.

PATIENTS

Ten patients suffering from severe OHSS.

INTERVENTIONS

Supportive and preventive therapeutic measures applied are described.

MEASUREMENTS AND RESULTS

Admission and discharge data as well as worst values during disease course were recorded. Clinical and laboratory findings showed third space fluid shift leading to weight gain, generalized tissue edema, ascites, hydrothorax, abdominal distension and pain, chest discomfort, hypovolemia, dehydration, ovaries enlargement, electrolyte disturbances, hypoalbuminemia, high hematocrit, urea, and WBC.

CONCLUSIONS

OHSS is an iatrogenic complication of assisted conception of unknown pathogenesis, with potentially life-threatening sequelae due to hemoconcentration such as circulatory shock, ARDS, hepato-renal failure, thromboembolic phenomena, and multi-organ dysfunction syndrome. Gynecologists and intensivists must be aware of the diagnosis and management of the syndrome because of the widely used reproductive techniques for assisted conception.