An ounce of prevention: outpatient management of the ovarian hyperstimulation syndrome

OBJECTIVE

To evaluate a protocol of active outpatient management, including outpatient paracentesis and albumin administration, in women at risk for severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective cohort.

SETTING

Freestanding IVF program.

PATIENT(S)

Thirteen women progressing from moderate to severe OHSS.

INTERVENTION(S)

Bed rest and home monitoring with intermittent outpatient paracentesis and albumin administration.

MAIN OUTCOME MEASURE(S)

Procedural outcomes and time to resolution of OHSS symptoms.

RESULT(S)

The initial paracentesis occurred 14.1 +/- 3.3 days after oocyte retrieval, removing 1,735 +/- 506 mL of ascitic fluid. Eleven women required a second paracentesis and five women required a third paracentesis over the next 8 days. Six women received albumin on seven occasions because of hypoalbuminemia. The onset of diuresis occurred 2.8 +/- 1.9 days and recovery occurred 7. 4 +/- 3.0 days after the first paracentesis. There were no hospitalizations for OHSS symptoms and no complications. All 13 women had viable intrauterine pregnancies.

CONCLUSION

Active outpatient intervention in the early stages of OHSS, including paracentesis and albumin administration, can avoid hospitalization while minimizing the progression and complications of OHSS.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is an iatrogenic complication of assisted reproduction. In its most severe form, it is potentially fatal. The major clinical components are marked ovarian enlargement and increased capillary permeability leading to ascites, hydrothorax and pericardial effusion. Severe cases are associated with thromboembolic phenomena, respiratory distress and renal failure. The definitive pathophysiology is unknown. The available evidence would support a central role for inflammatory cytokines and angiogenic growth factors. Ultrasound examination and serum oestradiol values are currently used to predict patients at risk. The ideal treatment is prevention, but there has been only limited success. The main aims of treatment are to correct fluid imbalance, maintain renal perfusion and support the patient until the condition resolves. Drug therapy has a limited role, although anticytokine agents may prove useful.

Cytokine levels in a patient with severe ovarian hyperstimulation syndrome before and after the ultrafiltration and reinfusion of ascitic fluid

PURPOSE

To report serum concentrations of several cytokines (interleukin-6, interleukin-8, tumor necrosis factor-alpha, and vascular endothelial growth factor) before and after the reinfusion of ultrafiltrated ascitic fluid.

METHODS

A case report of a woman hospitalized for the treatment of severe OHSS at the Department of Obstetrics and Gynecology, Tottori University Hospital. The serum concentrations of cytokines were analyzed by ELISA.

RESULTS

Cytokine concentrations declined in parallel with the improvement of clinical conditions and resolution of OHSS.

CONCLUSION

Measurement of serum cytokine concentrations may be useful in evaluating the severity of OHSS.

[The lung and benign diseases of the ovary]

Two main benign diseases of the ovary which can simulate advanced stage cancer of the ovary are described. The first is Meigs' syndrome, a triad of benign ovarian tumor, usually an ovarian fibroma, ascitis, and pleural effusion with complete disappearance of serous exsudative effusions with surgical resection of the ovarian tumor. The second is ovarian hyperstimulation syndrome following ovulation induction with exogenous gonotropins for the treatment of infertility. This syndrome associates significant ovarian enlargement, hyperestrogenism and latent or clinically patent serous exsudative effusions; it usually resolves with suggestive measures and rest.

Recurrent cholestasis following ovarian hyperstimulation syndrome: case report

This is a case report illustrating a patient who developed recurrent cholestasis during a twin pregnancy following in-vitro fertilization (IVF) treatment. On the first occasion cholestasis developed unusually in the first trimester, and on the second occasion, it presented in the way that obstetric cholestasis (OC) is commonly seen in the third trimester.

Ovarian hyperstimulation syndrome: imperatives for the emergency physician

Ovarian Hyperstimulation Syndrome (OHSS) is a serious disorder complicating the use of ovary-stimulating drugs in assisted reproduction programs. While its pathogenesis is not fully understood, it is believed that human chorionic gonadotropin (hCG) stimulation is vital to the development of OHSS. Further evidence suggests that the renin-angiotensin pathway, vascular endothelial growth factor, endothelin-1, and cytokines all play a role in altering ovarian capillary permeability, leading to increased interstitial fluid. OHSS can produce a myriad of symptoms and signs involving numerous body systems, up to and including hypovolemic shock and acute renal failure. As growing numbers of women opt for assisted reproduction, it becomes increasingly important for emergency physicians to be able to recognize this condition. Clinical classification into mild, moderate, severe, and critical forms of OHSS can help the physician plan appropriate investigations, admission requirements, and acute management. Two cases of OHSS, representing the spectrum of this problem, are presented along with a review of the literature.

Clinical aspects of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is characterized by massive transudation of protein-rich fluid (mainly albumin) from the vascular space into the peritoneal pleural and to a lesser extent to the pericardial cavities. The intensity of the syndrome is related to the degree of the follicular response in the ovaries to the ovulation inducing agents. OHSS is still a threat to every patient undergoing ovulation induction. The pathophysiology of OHSS is of extreme importance in the face of the increased use of ovulation induction agents as well as the development of sophisticated assisted reproductive techniques. The correlation found between plasma cytokine activities and the severity of OHSS suggests that plasma cytokines may be involved in the pathogenesis of OHSS and may serve as a means of monitoring the syndrome during the acute phase and throughout convalescence. The interactions between cytokine and non-cytokine mediators of the syndrome, such as the renin-angiotensin system and vascular endothelial growth factor were recently clarified. Awareness of possible mechanisms and factors in the pathophysiology of OHSS will hopefully provide opportunities to design specific treatment regimens effective for both prevention and treatment of this potentially fatal iatrogenic condition. Among IVF patients with severe and critical OHSS, pregnancy rates, multiple gestations, miscarriage, preterm premature rupture of the membranes, prematurity, and low birth weight rates are significantly higher than those reported previously for pregnancies after assisted conception. The incidence of other obstetrical complications, as well as congenital malformations and Cesarean section rates are not significantly different.

Ascites and liver test abnormalities during severe ovarian hyperstimulation syndrome

OBJECTIVE

Severe ovarian hyperstimulation syndrome is an uncommon cause of ascites that is being increasingly recognized because of the high number of women undergoing assisted reproductive techniques, mainly in vitro fertilization. This prospective study investigates the clinical and biochemical characteristics of a large series of patients with this syndrome and ascites, including renal and electrolyte abnormalities, activity of neurohormonal systems participating in the regulation of extracellular fluid volume, and liver function tests.

METHODS

This was a prospective longitudinal study including 50 consecutive patients with ascites due to severe ovarian hyperstimulation syndrome. Renal function, serum electrolytes, body weight, mean arterial pressure, pulse rate, plasma renin activity, plasma concentration of aldosterone, norepinephrine, antidiuretic hormone and atrial natriuretic peptide, and standard liver function tests were measured during the syndrome and 4-5 wk after recovery. A sample of ascitic fluid was obtained from eight patients for protein measurement and cell count.

RESULTS

At diagnosis, patients had ascites associated with low urinary sodium excretion, oliguria, and hyponatremia. They had also markedly low arterial pressure and increased pulse rate in association with marked activation of vasoconstrictor and antinatriuretic factors. The ascitic fluid was characterized by a high protein concentration, low leukocyte count, and relatively high number of red blood cells. Fifteen (30%) patients had abnormal liver tests characterized by mild to moderate increases in AST (mean 103 +/- 17.1 IU/L) and ALT (76 +/- 8.3 IU/L), which were associated in some cases with increases in gamma-glutamyl transpeptidase or alkaline phosphatase. All abnormalities reverted to normal after the resolution of the syndrome.

CONCLUSIONS

With the increasing use of assisted reproductive techniques, physicians should be aware of severe ovarian hyperstimulation syndrome as a cause of ascites. The syndrome is associated with sodium retention, hyponatremia, arterial hypotension, and marked activation of vasoconstrictor and antinatriuretic systems. In one third of patients, liver tests abnormalities are present.

[Efficacy of simultaneous use of cryopreserved semen, controlled ovarian hyperstimulation and intrauterine insemination in the treatment of sterility caused by hypergonadotropic azoospermia]

The purpose of the present study is to determine the efficacy of an artificial intrauterine insemination program with frozen donor sperm and controlled ovarian hyperstimulation as an alternative therapy for infertility cause by hypergonadotropic azoospermia. Two hundred forty three insemination cycles with frozen donor sperm were analyzed. Clomiphene citrate, pure FSH, recombinant FSH or human menopausal gonadotropins were utilized for ovulation induction; human corionic gonadotropin (hCG), 10,000 IU, was administered when one or more dominant follicles with diameter > or = 16 mm were present; intrauterine insemination was performed 36 hours after the hCG injection. The pregnancy rate per cycle was 19.9%, and the cumulative pregnancy rate was 59.3%. It is concluded that intrauterine insemination with frozen donor sperm and ovulation induction is a good alternative for male factor infertility with no available treatment.

Critical ovarian hyperstimulation syndrome in a coasted in-vitro fertilization patient

We report an instance of critical ovarian hyperstimulation syndrome in a highly responsive in-vitro fertilization patient despite the preventive measure of a 4 day 'coast' interval during which no gonadotrophins were administered while gonadotrophin-releasing hormone agonist therapy continued until serum oestradiol concentrations fell below 3000 pg/ml.

Peripheral arterial vasodilation hypothesis: a new insight into the pathogenesis of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovulation induction which, at present, is being studied increasingly because of its frequent occurrence as a result of the growing number of in-vitro fertilization (IVF) programmes. The anatomical changes involving enlargement of the ovaries and increased capillary permeability leading to acute fluid shift have been traditionally proposed to explain the different clinical features observed in OHSS. Recent work from our group, however, has shown that the pathogenesis of severe OHSS is more complex than currently understood and that marked peripheral arteriolar vasodilation is a major event in the development of the syndrome. Peripheral vasodilation may, in its turn, alter microvascular haemodynamics and permeability. This leads to a circulatory dysfunction with marked homeostatic activation of endogenous vasoactive systems having vasoconstrictor and sodium- and water-retaining activities. In this way, sodium and water retention would be a cause rather than a consequence of ascites formation in severe OHSS. This report analyses current concepts on body fluid regulation as well as neurohormonal and haemodynamic studies both in patients with severe OHSS and asymptomatic IVF women, integrating their findings into the present knowledge of the pathogenesis of the syndrome. Therapeutic implications are discussed.

Laparoscopic surgery for heterotopic pregnancies: a case report and a brief review

A heterotopic pregnancy is in effect a multiple pregnancy with one or more intrauterine pregnancies coexisting with an ectopic pregnancy and is rarely spontaneous. With the increasing popularity of ovulation induction performed during assisted reproductive techniques, it will not be surprising to observe that this phenomenon has increased significantly. However, diagnosis is often delayed because of its rarity and difficulty. We report a case of a woman with a viable intrauterine pregnancy who had a complication of ovarian hyper-stimulation syndrome secondary to ovulation induction following in vitro fertilization and embryo transfer, but who, during hospitalization, presented with clinically progressive abdominal pain. An unruptured ectopic pregnancy of the right fallopian tube was diagnosed accidentally by laparoscopy and laparoscopic salpingectomy was immediately performed. Post-operative follow-up revealed that the intrauterine pregnancy continued normally. She delivered a normal female baby at 38 weeks of gestation. The promising neonatal outcome might suggest that laparoscopy might be safely performed to aid differential diagnosis in an uncertain condition during pregnancy: therefore, laparoscopic surgery might be an appropriate method to manage some carefully selected patients with HP. A brief review of the published literature on the role of laparoscopy in the diagnosis and management of heterotopic pregnancy is given.

[Severe ovarian hyperstimulation syndrome: an intensive care disease]

Ovarian hyperstimulation syndrome is a severe and potentially fatal iatrogenic disease that affects 2% of women subjected to pharmacological induction of ovulation. The newest data on the clinical picture, risk factors, pathophysiology and management of this disease, are reviewed.

Effects of repeated abdominal paracentesis on uterine and intraovarian haemodynamics and pregnancy outcome in severe ovarian hyperstimulation syndrome

The aims of this study were to investigate the effects of paracentesis on uterine and intraovarian haemodynamics by colour Doppler ultrasound and the influences of repeated paracentesis on pregnancy outcome in severe ovarian hyperstimulation syndrome (OHSS). Forty-one abdominal paracenteses were performed on seven pregnant women with tense ascites and eight thoracocenteses were performed on three pregnant women with pleural effusion. Pulsatility index (PI) and maximum peak systolic velocity (MPSV) of uterine and intraovarian arteries were measured before and after each intervention. The mean PI of uterine arteries was decreased significantly after paracentesis, but not after thoracocentesis. Furthermore, uterine PI was decreased in 13 out of 14 (92.9%) paracenteses with <2500 ml ascites removed, compared with eight out of 13 (61.5%) with >2500 ml ascites removed. After paracentesis, there were no significant changes in the intraovarian PI and MPSV in either group. The 24-hour urine output increased significantly in the paracentesis group, but not in the thoracocentesis group. There were no significant changes in haematocrit and electrolytes as a result of paracentesis. However, gradual falls in serum total proteins and albumin concentrations were observed in all patients after repeated paracentesis, necessitating post-paracentesis albumin infusion. There was no significant difference in miscarriage rates between the two groups. We conclude that repeated abdominal paracentesis increases uterine perfusion and has no adverse effects on pregnancy outcome in severe OHSS. Extraction of 2500 ml of ascitic fluid did not impair uterine perfusion.

[Integral treatment of severe ovarian hyperstimulation syndrome by means of autotransfusion of ascitic fluid and intravenous infusion of albumin]

Severe ovarian hyperstimulation syndrome (OHSS) is a potential life-threatening condition relationated with ovulation induction. It affects multiple systems. Little is known about it's pathophysiology. The treatment available consists in the correction of fluid, electrolyte and hematologic imbalances. In other hand, is mandatory the prevention of embolic phenomena. Ascitic fluid aspiration result in dramatic improvement of symptoms. The purpose of this study was to assess the effect of autotransfusion of ascitic fluid obtained by paracentesis and the intravenous infusion of albumin for the treatment of severe from of the OHSS.

Ischemic stroke in a young woman with ovarian hyperstimulation syndrome

We present a case of right middle cerebral artery occlusion after a controlled ovarian hyperstimulation regimen and cryopreserved embryo transfer (ET) in a previously healthy 22-year-old woman. The patient suffered from nausea and progressive abdominal distension 8 days after ET. Under the diagnosis of ovarian hyperstimulation syndrome, she was treated with hypertonic solution, albumin infusion, and paracentesis, with some improvement. Left hemiparesis and dysarthria occurred suddenly on the fourth day of hospitalization, 11 days after ET. The neurologic deficits progressed to complete hemiplegia within a few hours. Computed tomography of the head showed infarction in the territory of the right middle cerebral artery. Magnetic resonance angiography revealed occlusion of the main trunk of the right middle cerebral artery. Laboratory studies showed leukocytosis with neutrophil predominance and a hypercoagulable state. The pregnancy was terminated because of progressive tachycardia, dyspnea, and increased abdominal girth despite supportive treatment. The neurologic deficits remained stationary at the time of discharge. This case emphasizes that the recent advent of ovulation induction and assisted reproductive techniques is a newly recognized cause of devastating cerebral infarction in otherwise healthy women.

Ovarian hyperstimulation syndrome: facts and fallacies

Severe or critical ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian hyperstimulation for assisted reproduction techniques (ART). The syndrome is characterized by cystic enlargement of the ovaries and fluid shifts from the intravascular to the third space. The morbidity in OHSS is mainly determined by the hemodynamic changes caused by increased capillary permeability. The incidence of OHSS depends on definitions, risk factors, ovarian stimulation protocols, luteal support and conception. Currently, research on the pathogenesis of OHSS is focused on increased capillary permeability. Several theories are reviewed. Until the pathogenesis of OHSS becomes clear, treatment is restricted to supportive therapy. The various proposals for management of OHSS are discussed and, based on the available data, directions for the management of various grades of OHSS are summarized. However, prevention and early recognition are still the most important tools to handle OHSS. A flowchart with preventive measures for OHSS is presented derived from the available literature.

Rare manifestations of the ovarian hyperstimulation syndrome: a report of two cases

The increasing practice of ovulation induction has made ovarian hyperstimulation syndrome (OHSS) a frequent clinical problem which can also become life-threatening. Two unusual cases of OHSS are described. The first patient presented with a unilateral pleural effusion. The second patient developed severe OHSS after a low-dose protocol with highly purified follicle stimulating hormone (FSH HP) and in the absence of risk factors.

[An overview of ovarian hyperstimulation syndrome: a reproductive medicine-iatrogenic disease picture with internal medicine consequences]

The ovarian hyperstimulation syndrome is a complication of the controlled ovarian hyperstimulation in assisted reproduction procedures. It has become more widespread, since the techniques of ovarian hyperstimulation has become more frequent. The potentially life-threatening complication of this condition is a hemoconcentration with subsequent thrombo-embolic complications and death. In this article the pathophysiology, prevention strategies, treatment guidelines and more theoretical approaches for the therapy are reviewed and discussed.

Symptomatic unilateral pleural effusion as a presentation of ovarian hyperstimulation syndrome

Isolated acute unilateral pleural effusion has twice been reported as the only symptom of ovarian hyperstimulation syndrome (Kingsland et al, 1989; Jewelewicz and Vande Wiele, 1975). The pathogenesis of this disorder is not fully understood and the presence of an isolated pleural effusion lends support to the role of systemic factors rather than purely the transudation of fluid from grossly enlarged ovaries in the progression of this disease. This article describes a second case of an isolated pleural effusion following in-vitro fertilization and embryo transfer.

A rare case of hepatic injury associated with ovarian hyperstimulation syndrome

A 26-year-old married woman was admitted to our hospital because of massive ascites and hepatic injury. The patient had been treated with human menopausal gonadotropin and clomiphene citrate to prevent recurrence of spontaneous abortions. About 1 month later, she developed upper abdominal pain and noticed dark urine. On admission, she had elevated concentrations of serum transaminases with an asparate aminotransferase of 127 IU/L and alanine aminotransferase of 194 IU/L. An abdominal ultrasound showed massive ascites. Her serum concentration of estradiol was high at 12,100 pg/mL, which was much greater than the value of early stage of pregnancy (2,279-7,353 pg/mL). She was thus diagnosed as having ovarian hyperstimulation syndrome. Following a period of bed rest, her liver function normalized and the ascites disappeared. Based on the above findings, the patient was considered to have suffered from ovarian hyperstimulation syndrome, complicated by hepatic injury.

The possible role of the immune system in the aetiopathogenesis of ovarian hyperstimulation syndrome

This review examines recent evidence suggesting a role for the immune system, in particular cytokines, in the pathogenesis of ovarian hyperstimulation syndrome (OHSS). Ovarian tissue is known to contain cells capable of producing a range of immunological mediators and the concentrations of these have been shown to be elevated in serum and ascitic fluid from women with established OHSS. Available evidence points to a role for vascular endothelial growth factor and interleukin-2, possibly acting through other intermediary cytokines, in the pathogenesis of OHSS. However, each individual has a unique cytokine profile and several cytokines may share biological actions, making it difficult to interpret data on isolated cytokine concentrations from relatively small numbers of patients. Improved understanding of the role of the immune system in the development of OHSS may have implications for the prediction, prevention and management of this iatrogenic condition.

High renin and prorenin in plasma and pleural exudate of a patient with the ovarian hyperstimulation syndrome

We present the case of a 35-year-old woman with a severe ovarian hyperstimulation syndrome (OHSS) as a complication of ovulation induction for primary infertility. The clinical picture showed massively enlarged ovaries, pleural effusion and haemoconcentration. She needed a thoracentesis for evacuation of the large pleural effusion. High levels of renin and prorenin were observed in plasma and pleural exudate.

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.

Increased concentrations of renin, aldosterone and Ca125 in a case of spontaneous, recurrent, familial, severe ovarian hyperstimulation syndrome

We report for the first time increased concentrations of aldosterone and renin in a case of spontaneous, recurrent, familial, severe ovarian hyperstimulation syndrome (OHSS). High concentrations of Ca125 were also found. Our patient was a 26 year old woman, gravida 2, para 1, affected by severe OHSS, who denied having ever consumed any ovulation drug. Both the patient and her only sister had suffered from a similar condition in their previous pregnancies. The patient was treated with i.v. fluid therapy. Paracentesis was performed on one occasion. The patient was dismissed after 25 days in good condition. Blood count and blood chemistry confirmed the severity of the clinical picture. We conclude that spontaneous OHSS, although very rare, may have been underestimated so far. It can be recurrent and may also be familial. The intra-ovarian prorenin-renin-angiotensin system may play a role in its aetiopathogenesis.

Bilateral internal jugular venous thrombosis complicating severe ovarian hyperstimulation syndrome after prophylactic albumin administration

OBJECTIVE

To report a case of bilateral thrombosis of the internal jugular veins in a patient after controlled ovarian hyperstimulation and IVF.

DESIGN

Case report.

SETTING

University-based IVF program.

INTERVENTION(S)

Ovulation induction with gonadotropins, IVF-ET, albumin administration, and therapeutic heparinization.

MAIN OUTCOME MEASURE(S)

Doppler ultrasound of neck veins.

RESULT(S)

Severe ovarian hyperstimulation syndrome and bilateral thrombosis of the internal jugular veins occurred despite prophylactic administration of albumin. This was treated successfully with therapeutic heparinization.

CONCLUSION(S)

Internal jugular venous thrombosis, a rare complication of ovulation induction with gonadotropins, should be considered in patients with neck pain and swelling.

[Ovarian hyperstimulation syndrome--prevention and treatment]

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, potentially life-threatening condition associated with ovulation induction. With increasing numbers of women receiving various ovarian stimulation protocols as part of different infertility treatments, the number of cases is likely to increase. The syndrome has a wide spectrum of clinical and laboratory findings, and is classified into mild, moderate and severe OHSS. The pathophysiology of this syndrome is unclear, and medical management has traditionally been conservative and supportive consisting of bedrest, volume expanders and replacement of fluid. When ascites is present, paracentesis under ultrasound guidance has been found to improve the condition of the patient by reducing the hydrostatic pressure. Prevention is very important, but at present it is doubtful if OHSS can be completely avoided due to the existence of a relatively small margin of safety between successful induction of ovulation and the development of OHSS.

[Successful twin delivery following reduction of quadruplet pregnancy]

The authors report first time in the Hungarian literature on multifetal pregnancy reduction: a quadruplet pregnancy was reduced to twins on transabdominal way in the 16th week of gestation on request of the parents. The quadruplets resulted from a forcefully induced ovulation. First weeks of gestation were complicated by a severe but effectively treated ovarian hyperstimulation syndrome. Following the successful and uncomplicated intervention the course of pregnancy was undisturbed, two living healthy babies were delivered in the 35th gestation week. Placentae of the liveborn as well as of the stillborn fetuses were pathologically examined. On occasion of the case report theoretical and practical questions of multifetal pregnancy reduction are discussed in details from indications through technical implementation to a review of legal, ethical and also psychological relations of that intervention. A standpoint for the national practice is also framed by the authors.

Prevention and treatment of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of ovarian stimulation. Although the milder form is more common, particularly among patients undergoing gonadotropin stimulation for assisted reproductive technology, the severe form is rare. Classification schemes are clinically directed and useful in diagnosis and management of moderate and severe cases. The ovarian renin-angiotensin system, as well as vascular endothelial growth factor (VEGF)/vascular permeability factor (VPF) offers attractive theories as to the pathogenesis of this disorder. Unfortunately, clinical applications of these findings are not yet available. Possible prevention measures would include identification of patients at high risk, withholding human chorionic gonadotropin (hCG), using a gonadotropin-releasing hormone agonist to trigger ovulation, using a smaller dose of hCG, controlled gonadotropin drift, or avoidance of fresh embryo transfer by cryopreservation and frozen embryo transfer at a later date. Management of moderate to severe OHSS rests upon the principles of expanding intravascular volume and maintaining adequate urine output.

Unilateral vulvar edema associated with paracentesis in patients with severe ovarian hyperstimulation syndrome. A report of nine cases

BACKGROUND

Severe ovarian hyperstimulation syndrome is a life-threatening complication of ovulation induction. The clinical picture includes ovarian enlargement, accumulation of ascites and pleural effusion, increased coagulability and electrolyte disorders. Accumulation of ascites increases the intraabdominal pressure so that breathing difficulties ensue. Paracentesis is the only treatment that can immediately prevent respiratory deterioration.

CASES

Nine women with severe ovarian hyperstimulation syndrome were treated by paracentesis for the drainage of massive ascites. Unilateral vulvar edema developed in all cases in which the lower abdomen was the puncturing site. This phenomenon was not observed when paracentesis was carried out through the upper abdomen. The edema resolved spontaneously over the subsequent 10 days.

CONCLUSION

Apparently the puncturing needle created a fistulous tract through which the ascitic fluid was forced, by the increased intraabdominal pressure, into the subcutaneous tissues, presenting as unilateral vulvar edema. This can be prevented by using one of the abdominal hypochondriac regions as the puncturing site. This phenomenon is self-limited and causes only mild discomfort without late sequelae.

[Ovarian hyperstimulation in medically assisted reproduction: which practical approach?]

Ovarian hyperstimulation syndrome (OHS) with serious grade could be a live threatening disease, that occurs in 0.5% to 1% of in vitro fertilization program. The prevention of OHS is based on the recognition of risk factors and on ultrasonic and hormonal monitoring, with well adapted treatment in order to reduce the number of follicles. The level of oestradiol will determine the injection of human chorionic gonadotropins: between 2500 and 3000 pg/ml, the injection of HCG is reduced to 5000 U for the induction of ovulation, and the injections of HCG 1500 during the luteal period are avoided: between 3000 and 5000 pg/ml, the injection of HCG is reduced to 5000 U and the replacement of fresh embryos is deferred to an other cycle: after 5000 pg/ml, the injection of HCG must be abandoned. The treatment of the confirmed OHS is based on the rest, with hospitalization, correction of fluid, electrolyte and protein imbalance, prevention of thrombo embolism and aspiration of ascite fluid.

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.

[The ovarian hyperstimulation syndrome]

The use of controlled ovarian hyperstimulation has increased the efficacy of ovulation induction and enhanced the ability to recruit multiple mature oocytes for use in the assisted reproductive technologies. However, the administration of medications is not without risk. Ovarian hyperstimulation syndrome is a serious complication with various manifestations. Two fundamental pathologic changes are characteristic: ovarian enlargement with underlying stromal oedema and multiple haemorrhages of luteinized cysts coupled with a dramatic shift of fluid from the intravascular spaces into the peritoneal, pleural, and pericardial cavities. The most efficacious treatment of hyperstimulation syndrome is its prevention. The correction of hypovolaemia and electrolyte abnormalities is one of the most important procedures in the treatment of this syndrome.

[Indications of albumin for vascular loading during pregnancy]

Albumin infusion is used during pregnancy for volume loading in preeclampsia and/or intra-uterine growth retardation, before regional anaesthesia for Caesarean section, compensation of blood loss during haemorrhages of parturition, as well as prevention and treatment of ovarian hyperstimulation syndrome after in vitro fertilization. In preeclampsia, albumin is used for volume loading before initiating antihypertensive therapy. However it neither decreases blood pressure, nor increases uterine blood flow. Before regional anaesthesia for Caesarean section, an infusion of albumin 5% at a rate of 15 mL.kg-1 prevents hypotension in mothers (P < 0.05 versus Ringer lactate) and provides better Apgar scores in neonates (P < 0.05). Albumin is used to treat hypovolaemia in severe ovarian hyperstimulation syndrome. Recent studies have shown that in patients at high risk of ovarian hyperstimulation syndrome, 500 mL albumin 5% administered after ovocytes retrieval diminished the incidence of this syndrome (P < 0.05 versus normal saline).

Recurrent spontaneous ovarian hyperstimulation syndrome associated with polycystic ovary syndrome

Ovarian hyperstimulation syndrome (OHSS) is the most serious potentially life-threatening iatrogenic complication of ovulation induction. Presented here is the first reported case of recurrent severe OHSS which developed spontaneously in a women with polycystic ovary syndrome, diagnosed early in her second pregnancy, and necessitated intensive fluid and colloid therapy.