A case of cerebral infarct in combined antiphospholipid antibody and ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is a serious complication of ovulation induction and has a diverse clinical spectrum from edema to thromboembolism. Antiphospholipid antibody syndrome, one of the well known hypercoagulable states, can be also manifested as an arterial or venous thrombosis and recurrent spontaneous abortion. Sometimes a patient with antiphospholipid antibodies might not notice a miscarriage and seek for assisted reproduction treatment, which harbors a chance of developing ovarian hyperstimulation syndrome. If this happens, the ovarian hyperstimulation syndrome can exacerbate the thrombotic complication of underlying antiphospholipid antibody syndrome, resulting in a catastrophic vascular event. The authors experienced a case of middle cerebral artery infarct, which developed during ovarian hyperstimulation syndrome in a 33-yr-old woman with a previous history of fetal loss. An elevated titer of anticardiolipin antibodies was noticed and persisted thereafter. The authors suggest screening tests for the presence of antiphospholipid antibodies before controlled ovarian hyperstimulation.

A severe case of ovarian hyperstimulation syndrome with liver dysfunction and malnutrition

Ovarian hyperstimulation syndrome (OHSS) is a potentially fatal condition associated with the use of ovulation-inducing drugs. We describe a 28-year-old woman who presented with ascites, oliguria and vomiting. Over 2 weeks, the combination of intractable vomiting, intravenous rehydration, paracentesis, hypercatabolism and proteinuria led to severe hypoalbuminaemia with gross oedema and progressively worsening liver function. The patient's albumin dropped to 9 g/l with liver function abnormalities peaking at: alanine aminotransferase, 462 IU/l; alkaline phosphatase, 706 IU/l; bilirubin, 26 micromol/l; and prothrombin time, 19 s. The judicious use of paracentesis and commencement of total parenteral nutrition coincided with a rapid clinical improvement. One month after discharge, the patient was asymptomatic with normal liver function. This case demonstrates the severity of malnutrition and liver dysfunction that can occur with severe OHSS. Increasing use of in-vitro fertilization techniques makes it mandatory for clinicians to be aware of the clinical features, complications and treatment of this condition, and we would suggest that patients with severe OHSS should be jointly managed by physicians and obstetricians.

[Isolated pleurisy revealing ovarian hyperstimulation syndrome]

Ovarian hyperstimulation is a rare but serious iatrogenic complication following induction of ovulation cycles. Release of vasoactive substances by the stimulated ovaries leads to leakage of intravascular fluid into the extracellular and serous spaces due to enhanced capillary permeability. Pleural effusion is a classical finding in the most severe forms, often associated with ascitis and signs of hemoconcentration. We report the case of a women who presented pleural effusion as the sole inaugural sign of ovarian hyperstimulation.

[Acquired hemophilia A after an early abortion]

HISTORY

A 30-year-old woman was referred to our clinic because she had developed recurrent spontaneous hematomas of both calves within the last 2 months. 6 months earlier the patient had developed an ovarian hyperstimulation syndrome after ovarian stimulation treatment and intrauterine insemination. Shortly afterwards a missed abortion (8 (th) week) had been diagnosed. A curettage was carried out.

INVESTIGATIONS

Routine coagulation tests confirmed a prolongation of aPTT to 90 s and a lupus anticoagulant. A high-titre factor VIII inhibitor (56 Bethesda units) was identified.

TREATMENT AND COURSE

Given these facts an acquired post-partum hemophilia was diagnosed. The patient was treated with prednisolone and immunoglobulins. The aPTT shortened to normal values. The factor VIII inhibitor and lupus anticoagulant disappeared. There were no further hematomas.

CONCLUSIONS

The simultaneous occurrence of antibodies in an altered immune state such as pregnancy is well known. In our case, acquired factor VIII inhibitor was found after an early abortion. Treatment with steroids and immunoglobulines led to the disappearance of factor VIII inhibitor and lupus anticoagulant.

Acute myocardial infarction secondary thrombosis associated with ovarial hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is one of the most serious complication of controlled ovarian stimulation. Cerebral infarction, myocardial infarction, death and vascular thrombotic events associated with OHSS had been reported. We report a case of a patient with myocardial infarction associated with OHSS.

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.

Increased prevalence of thrombophilia among women with severe ovarian hyperstimulation syndrome

OBJECTIVE

To determine the prevalence of markers of thrombophilia in women hospitalized for severe OHSS.

DESIGN

Prospective study.

SETTING

Academic research center.

PATIENT(S)

Women undergoing induction of ovulation complicated by severe OHSS (n = 20) and women undergoing induction of ovulation without development of severe OHSS (n = 41).

INTERVENTION(S)

Blood samples to test for markers of thrombophilia were obtained during the luteal phase of the treatment cycle.

MAIN OUTCOME MEASURE(S)

Blood samples were analyzed for markers of thrombophilia, such as plasma levels of antithrombin, protein S and protein C, antiphospholipid antibodies, the factor V Leiden mutation, and 677T polymorphism in the 5,10 methyltetrahydrofolate reductase (MTHFR 677T) gene.

RESULT(S)

Seventeen of 20 patients with severe OHSS (85%) and 11 of 41 controls (26.8%) had one or more positive markers of thrombophilia. Of the women with severe OHSS, 6 had a decreased antithrombin level, 8 had decreased levels of protein S, 7 were homozygous for the MTHFR 677T mutation, 1 was heterozygous for the factor V Leiden mutation, and 5 had antiphospholipid antibodies. Eight women with OHSS and no controls had more than one positive marker of thrombophilia.

CONCLUSION(S)

The prevalence of thrombophilia is increased in women with severe OHSS. These findings suggest that prophylactic screening for this disorder and possible use of heparin prophylaxis for thromboembolic phenomena should be considered in these patients.

Inadvertent superovulation and intrauterine insemination during pregnancy: a lesson from an ectopic gestation

It is believed that follicular development and ovulation is suppressed during the early period of gestation in humans. In this report, we describe a patient who underwent ovarian hyperstimulation following a "presumed" menstrual bleeding. The case illustrates that the ovaries during early pregnancy seem to respond normally to exogenous gonadotrophin stimulation. Despite ongoing pregnancy, the high plasma concentrations of gonadotrophins have rescued pituitary and ovarian insensitivity. Normal follicular development and even ovulation are allowed to occur. Moreover, it is mandatory to preclude pregnancy before commencing superovulation and assisted reproductive technology.

Increased early pregnancy loss in IVF patients with severe ovarian hyperstimulation syndrome

BACKGROUND

Since severe ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of assisted reproduction, the focus of attention in such cases is placed firmly upon the health of the patient, with the endeavour to achieve a pregnancy being considered of secondary importance. The aim of this study was to focus on the pregnancy rate and pregnancy outcome in IVF patients hospitalized for severe or critical OHSS, in one centre, during a period of 6 years.

METHODS

We compared the characteristics of patients with severe OHSS: those who conceived with the ones who did not conceive, and among pregnant IVF patients, those with ongoing pregnancies with those that miscarried.

RESULTS

Pregnancy was achieved in 60 of 104 (58%) patients with severe OHSS. Pregnancy continued until delivery in 37 of these 60 patients (62%), whereas the remaining 23 (38%) aborted. The pregnancy and abortion rates in patients with severe OHSS were significantly higher than those of IVF patients without OHSS, during the same time period [23% (1138/4922) and 15% (169/1138) respectively, P < 0.001]. The mean duration of hospitalization for OHSS was significantly shorter in those who delivered compared with those who aborted (5.9 +/- 3.2 versus 10.5 +/- 9.6 days, P < 0.01) and in the non-pregnant patients compared with the pregnant patients (5.2 +/- 3.2 versus 7.6 +/- 6.6 days, P < 0.02).

CONCLUSIONS

The clinical pregnancy rate of IVF patients with severe OHSS was significantly higher than that of patients without the syndrome. A longer stay in hospital-reflecting a more severe form of OHSS-was correlated with a higher frequency of abortions. OHSS, necessitating hospitalization, is a detrimental clinical situation not only for the mother but also for the developing pregnancy.

The detrimental role of colloidal volume substitutes in severe ovarian hyperstimulation syndrome: a case report

Although, the mechanisms for the development of ovarian hyperstimulation syndrome (OHSS) are still not clear, the symptoms usually correlate with the levels of serum estradiol and ovarian enlargement. We report a case, where the clinical course was unusually prolonged. When menstrual bleeding had already occurred, serum estradiol was less than 10 pg/ml and the ovaries were almost normal in size, the patient developed pleural effusion and a significant alteration in blood-coagulation. This was most likely caused by an over-infusion of hydroxyethyl starch (HES) over 10 days. The pleural effusion contained high levels of HES, reaching 74% of the plasma concentration as measured by a novel method after acidic hydrolysis of HES. Carbohydrates as dextran and HES are well known to interact with the blood-coagulation system. Increase capillary permeability, typical of OHSS, leads to loss of colloidal substances into the third space, where HES is slowly degraded and osmotic pressure is high. This might prolong and aggravate the urine of OHSS.

Primary abdominal pregnancy associated with severe ovarian hyperstimulation syndrome

An uncommon case of primary abdominal pregnancy that was detected after rapid resolution of OHSS is reported. A 27-years-old nulligravida woman underwent ovarian hyperstimulation with human menoposal gonadotrophin (hMG) at another clinic and was admitted to our hospital with severe OHSS. Intravenous fluid therapy, albumin supplementation, and abodminal paracentesis was performed. The patient's massive ascites rapidly resolved, and she was discharged from our hospital. However, 4 weeks later, at about the 8th gestational week, she was readmitted to our hospital because of strong suspicion of abdominal pregnancy. Ultrasonography revealed a gestational sac (GS) and fetus with heartbeat in Douglas' pouch and an emergency laparotomy was performed. Both fallopian tubes, both ovaries and the uterus were completely intact and the GS was found on the anterior surface of the rectum. After removing GS, the muscle layer and serosal layer of the rectum were repaired. No bowel complications developed, and the post operative course was uneventful. To our knowledge, this is the first report of this very rare variant of ectopic pregnancy complicated by OHSS.

Internal jugular vein thrombosis after assisted conception therapy

Superovulation therapy during assisted conception may result in a hypercoagulable state. Five cases of upper extremity venous thrombosis were identified in women who conceived after ovarian stimulation for in vitro fertilization (IVF). They presented between 7 and 10 weeks' gestation with neck pain and swelling. Three had been treated for ovarian hyperstimulation syndrome and two had evidence of inherited thrombophilia. Four patients received thromboprophylaxis before presentation. Although thrombosis is an uncommon complication of IVF, patients should be counselled before treatment. Thrombophilia screening may be considered for 'high-risk' patients, although current regimes for thromboprophylaxis remain suboptimal.

[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.

Bilateral jugular venous thromboembolism and pulmonary emboli in a patient with severe ovarian hyperstimulation syndrome

We report here a case of severe ovarian hyperstimulation syndrome with massive ascites in a 25-year-old woman with a history of primary infertility after an IVF-ET cycle. At the 9th gestational week she presented with neck pain and dyspnea and duplex Doppler sonographic examination of the neck veins revealed bilateral jugular venous thrombosis. Despite prompt administration of low-molecular weight heparin, pulmonary emboli developed a few days later.

Hepatic dysfunction associated with moderate ovarian hyperstimulation syndrome. A case report

BACKGROUND

Liver dysfunction is a rare complication of severe ovarian hyperstimulation syndrome (OHSS). Based on a MEDLINE search from 1966 to September 2000, we report the second case of liver dysfunction associated with moderate OHSS. In addition, this is the first report of moderate OHSS with serum progesterone levels during the first trimester of pregnancy higher than the upper limit of normal for a third-trimester gestation.

CASE

A 33-year-old nulligravida with a history of infertility had previously undergone three failed cycles of assisted reproduction. During her fourth attempt at in vitro fertilization and intracytoplasmic sperm injection, she developed moderate OHSS 11 days after embryo transfer. She was managed on an outpatient basis. Her serum progesterone and liver enzyme levels were significantly elevated, as is unusual for the moderate picture of OHSS in this patient.

CONCLUSION

Hepatic dysfunction is not limited to the severe forms of OHSS. Liver function should be analyzed even in moderate cases. Further study is needed to understand the role of elevated liver function tests and serum progesterone in the pathogenesis of OHSS.

A case of forearm amputation after ovarian stimulation for in vitro fertilization-embryo transfer

OBJECTIVE

To report a case of forearm amputation after ovarian stimulation for IVF-ET.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 41-year-old woman, who had coagulation disorder as a result of an ovarian hyperstimulation syndrome (OHSS) for IVF-ET.

INTERVENTION(S)

Retrospective evaluation of angiographic studies and surgical treatment.

MAIN OUTCOME MEASURE(S)

Medical follow-up after forearm amputation due to OHSS.

RESULT(S)

The patient underwent many cycles of IVF-ET with administration of purified FSH (75 IU 10 times per day, for 12 days) and chorionic gonadotropin (5,000 IU). The patient had a coagulation disorder as a result of OHSS, with thrombosis of the axillary vein, recurring after thromboarterectomy and leading to the paradoxical result of the amputation of an arm.

CONCLUSION(S)

An ethical evaluation of this case is mandatory, since the desire for pregnancy, the role of medical science, health, and human life itself are all factors involved.

Central retinal artery occlusion associated with severe ovarian hyperstimulation syndrome

PURPOSE

Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic complication of ovulation induction. It is a potentially lethal condition, with severe complications which include ovarian enlargement, and massive fluid redistribution from the vascular system into free spaces resulting in ascites, pleural effusion, electrolyte imbalance, hemoconcentration, hypovolemia, oliguria, and adult respiratory distress syndrome. Thromboembolism is a rare but extremely serious complication.

CASE REPORT

We report a case of severe OHSS, presenting with central retinal artery occlusion (CRAO).

DISCUSSION

This combination has not been reported previously.

Occlusion of the ulnar artery in a patient with severe ovarian hyperstimulation syndrome

A patient with ovarian hyperstimulation syndrome, without additional predisposing risk factors for thrombosis suffered thrombotic occlusion of the distal left ulnar artery. Treatment with therapeutic heparinization was successful.

Internal jugular vein thrombosis after ovarian stimulation

Thromboembolic events are serious, but fortunately rare, complications following ovarian stimulation for IVF. Here, we report a case of internal jugular vein thrombosis after ovarian stimulation with gonadotrophins. Most of the cases of thrombosis are late complications of ovarian hyperstimulation syndrome (OHSS) or hereditary hypercoagulability. Screening for these risk factors in our patient was negative. The patient was successfully treated with low molecular weight heparin and a twin pregnancy is ongoing.

Perforated duodenal ulcer associated with ovarian hyperstimulation syndrome: Case Report

Ovarian hyperstimulation syndrome (OHSS) remains the most serious medical complication of controlled ovarian stimulation. An unusual case of perforated duodenal ulcer following critical OHSS is presented. A 29 year old nulligravid woman with polycystic ovarian syndrome underwent her first attempt at in-vitro fertilization. She was admitted to the hospital with critical OHSS and subsequently found to have a perforated posterior duodenal ulcer. She underwent exploratory laparotomy, antrectomy and gastrojejunostomy. Pathological analysis of her gastric antrum confirmed chronic gastritis and Helicobacter pylori. She required prolonged assisted ventilation, vasopressor support, multiple i.v. antibiotics, blood product replacement and nutritional support. The patient was hospitalized for a total of 47 days and then transferred to a rehabilitation facility for an additional 30 days before being discharged to home. In this critically ill patient with OHSS, severe stress associated with invasive monitoring and multiple medical therapies in the intensive care unit as well as H. pylori infection appear to be the most probable causative factors of her perforated viscus. Prompt recognition of potential complications and proper medical intervention are essential in the management of patients with OHSS. Avoidance strategies are still needed.

Cortical vein thrombosis misinterpreted as intracranial haemorrhage in severe ovarian hyperstimulation syndrome: case report

A case of cortical vein thrombosis presenting as intracranial haemorrhage is described in a patient with ovarian hyperstimulation syndrome (OHSS) after IVF and embryo transfer. Veno-occlusive disease of the brain could appear as a haemorrhagic lesion on magnetic resonance imaging (MRI) and this made the initial diagnosis of cortical vein thrombosis difficult. The patient developed deep vein thrombosis 2 weeks after the intracranial event and the diagnosis of cortical vein thrombosis was made at that time on MRI study after the resolution of the haemorrhage. This patient actually developed generalized thrombosis as a complication to OHSS. Although the initial MRI picture may be misleading, the diagnosis of thrombosis should always be kept in mind, as it is the commonest cause of intracranial lesions after OHSS.

Laparoscopic therapy of an intact primary ovarian pregnancy with ovarian hyperstimulation syndrome: case report

A case of an intact primary ovarian pregnancy with ultrasonographic demonstration of heart motion following ovarian stimulation is presented. After preoperative ultrasonographic confirmation of an extrauterine pregnancy, proof of the ovarian localization was achieved by intra-operative ultrasonographic visualization during a diagnostic laparoscopy on post-menstrual day 48. A moderate ovarian hyperstimulation syndrome with a concomitant increase in size, vulnerability and vascularity of the ovaries presented an additional challenge for the surgical approach. However, thanks to the early diagnosis of the ectopic pregnancy localization, a laparoscopic organ-preserving removal of the intact ovarian pregnancy was successfully performed. In this way, the fertility of the patient, who had previously undergone contralateral ovariectomy, was preserved. To our knowledge, this represents the first such treatment to be reported in the medical literature. Improvements in diagnosis and therapy of ovarian pregnancy are reviewed.

Severe unilateral hydrothorax as the only manifestation of the ovarian hyperstimulation syndrome

BACKGROUND

Unilateral hydrothorax is rarely the sole manifestation of the ovarian hyperstimulation syndrome (OHSS) and is suggestive of the severity of the disease.

CASE

A 35-year-old woman presented with mild dyspnea 2 weeks after ovarian stimulation with hMG and hCG and IVF-ET. Chest X-ray revealed a large pleural effusion on the right side. Three consecutive thoracocenteses were needed to drain a total of 6,800 cm(3) of fluid. Following drainage, the respiratory symptoms disappeared. An uneventful pregnancy is in progress.

CONCLUSIONS

Thoracocentesis is safe and efficient for the treatment of hydrothorax and may be repeated as often as necessary. Clinicians should be aware of the possibility of unilateral hydrothorax as the sole symptom of OHSS.

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.

An uncommon etiology of isolated pleural effusion. The ovarian hyperstimulation syndrome

We report three cases of pleural effusion in the context of ovarian stimulation for in vitro fertilization. The ovarian hyperstimulation syndrome usually causes pleural effusion and ascites. When the latter is lacking, an isolated pleural effusion in a pregnant patient can be mistaken for pulmonary embolism. Early recognition of the condition should allow for an appropriate diagnostic and therapeutic management. Except for some rare but life-threatening complications, such as major hypovolemia or respiratory distress syndrome, the spontaneous outcome is usually favorable. The pathogenesis of this condition may involve an increase of capillary permeability due to the release of vasoactive mediators.

Subclavian deep vein thrombosis associated with the use of recombinant follicle-stimulating hormone (Gonal-F) complicating mild ovarian hyperstimulation syndrome

OBJECTIVE

To describe two cases of subclavian deep vein thrombosis (DVT) associated with the use of recombinant gonadotropins and mild ovarian hyperstimulation syndrome (OHSS) and review the literature associated with this condition.

DESIGN

Retrospective study (case report).

SETTING

Tertiary academic IVF program.

PATIENT(S)

Two women undergoing IVF with intracytoplasmic sperm injection due to male factor infertility.

INTERVENTION(S)

Ovaluation induction with recombinant FSH, IVF, and therapeutic heparinization.

MAIN OUTCOME MEASURE(S)

Coagulation studies, resolution of DVT, delivery at term.

RESULT(S)

Mild OHSS with left subclavian thrombosis occurred in two patients. Laboratory evaluation revealed normal protein C, protein S, antinuclear antibodies (ANA), and absence of antiphospholipid (APA) and anticardiolipin antibodies (ACA). Antithrombin III levels and coagulation studies were also within normal limits. Both patients tested negative for a factor V Leiden mutation and delivered healthy infants at term.

CONCLUSION(S)

Arm swelling associated with the use of gonadotropins during controlled ovarian hyperstimulation should be promptly evaluated and treated. Subclavian vein thrombosis is a rare complication of ovulation induction, and the possibility that recombinant gonadotropins increase the risk for this complication should be further studied.

Superior vena cava thrombosis after in vitro fertilization: case report and review of the literature

Ovarian hyperstimulation syndrome (OHSS) is a rare complication of fertility medication. A 33 year old female with OHSS with thrombosis of the right internal jugular vein, subclavian vein, and superior vein cava underwent in vitro fertilization following stimulation with a GnRH analog with successful implantation. The patient developed abdominal distention and dyspnea, with persistent symptoms that resulted in a 20 lb weight loss. As pregnancy progressed, edema, pain, and tingling sensations developed by the ninth week at which time a CT scan confirmed thrombus with the right internal jugular and subclavian vein and a free floating tip in the superior vena cava. Following treatment with intravenous heparin therapy and subcutaneous low-molecular weight heparin until delivery her symptoms improved. While optimal treatment remains unclear, treatment strategies remain conservative. Identifying the risk factors that lead to the development of OHSS including the identification of those patients at risk for developing OHSS, more extensive investigation of potential underlying coagulopathy in severe or recurrent cases, and consideration of prophylactic subcutaneous heparin or IV albumin supplementation, will facilitate prevention in the high risk population.

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.

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.

Thromboembolic complications associated with reproductive endocrinologic procedures

Thromboembolism as a complication of hormonal ovarian stimulation in the context of artificial reproductive techniques is rare and seems to occur when OHS is present. Although accompanied by high serum estrogen concentrations, hCG seems to play a central role in the development of OHS, which has been observed in women with 17,18-desmolase deficiency who have low estrogen levels after induction of ovulation with hGC. Although there is some evidence that hormonal ovarian stimulation with HMG, leading to elevated estrogen levels, and ovulation induction with hCG in preparation for in vitro fertilization are associated with a state of hypercoagulability, the exact role of estrogens, hCG and the physicochemical changes (fluid shift into third spaces) involved in OHS remain to be elucidated.

Internal jugular vein thrombosis in association with the ovarian hyperstimulation syndrome

Thrombosis of the internal jugular vein is a rare entity with the potential for serious consequences. Most of the reported cases of jugular venous thrombosis have occurred in the presence of an indwelling venous catheter, an established hypercoagulable state, or in association with head and neck sepsis. This report presents a case of a patient in whom jugular venous thrombosis developed during the first trimester of pregnancy after in vitro fertilization. Thromboembolism in these circumstances can be related to a condition known as the ovarian hyperstimulation syndrome. The presentation of severe neck pain in pregnant women, especially in those who have undergone assisted reproduction procedures, should prompt evaluation by duplex scan to evaluate the jugular veins for thrombosis. Anticoagulation is the treatment of choice.

[The ovarian hyperstimulation syndrome with pericardial and pleural effusions complicated by supraventricular arrhythmia]

Problems which arise in conjunction with the use of assisted reproduction methods are no longer resolved only by the gynaecologist. The authors demonstrate on the case of a female patient the necessity of interdisciplinary collaboration in the diagnosis and therapy of developed ovarian hyperstimulation syndrome (OHSS)--the most serious complication of assisted reproduction.

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.

Multiple cerebral infarctions associated with ovarian hyperstimulation syndrome

A 26-year-old woman on human menopausal gonadotrophin-human chorionic gonadotrophin therapy for sterility showed multiple cerebral infarctions associated with ovarian hyperstimulation syndrome. A hypercoagulable state (hemoconcentration, increased plasma levels of D-dimer and thrombin-antithrombin III complex, and decreased protein S activity) was associated with her thromboembolic events. Cerebral infarction associated with mild neurologic deficits may be overlooked in patients with ovarian hyperstimulation syndrome.

Attenuation of ovarian response by low-dose ketoconazole during superovulation in patients with polycystic ovary syndrome

OBJECTIVE

To investigate the clinical efficacy of mild inhibition of ovarian steroidogenesis by very low-dose ketoconazole during induction of ovulation in patients with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized, cross-controlled study in consecutive cycles.

SETTING

Large tertiary care center.

PATIENT(S)

Eighteen patients with PCOS undergoing hMG superovulation with or without ketoconazole.

INTERVENTION(S)

A fixed hMG dosage was initiated on cycle days 5-9 in both of the study cycles. Further hMG adjustment was done according to serum E2 levels and follicular measurements. Ketoconazole was administered in one of the cycles by two protocols.

MAIN OUTCOME MEASURE(S)

Serum E2 and P levels, lead follicles, pregnancy rate, and development of ovarian hyperstimulation syndrome.

RESULT(S)

Although higher daily hMG doses were needed in cycles with ketoconazole compared with cycles without the drug, the peak E2 levels were substantially lower in the ketoconazole cycles. Although the number of lead follicles did not differ between treatments, the addition of ketoconazole significantly reduced the number of hyperstimulated cycles. Consequently, the cancellation rate dropped dramatically, thus yielding a higher pregnancy rate per patient in the ketoconazole protocols.

CONCLUSION(S)

Use of a very low dose of ketoconazole during ovulation induction effectively attenuates ovarian steroidogenesis in patients with PCOS. This effect may serve as an adjunct to better control the ovarian response in women who are prone to hyperstimulated cycles.