[Syndrome of ovarian hyperstimulation. Report of a severe iatrogenic complication]

Severe ovarian hyperstimulation syndrome is a rare complication of ovulation induction with exogenous gonadotrophins. Severe forms involve acute renal failure, coagulation disorders, massive ascites, pleural effusion and may require pleural and peritoneal puncture. We report a case of severe ovarian hyperstimulation syndrome effectively treated by simple procedures in an intensive care unit.

A case of severe ovarian hyperstimulation in a healthy oocyte donor

OBJECTIVE

To report an unexpected case of severe ovarian hyperstimulation syndrome (OHSS) and to compare E2 levels and number of follicles to other oocyte donors.

SETTING

Private assisted reproduction technology center.

PATIENTS

Healthy oocyte donors with normal menstrual cyclicity.

INTERVENTIONS

Prophylactic and therapeutic use of human serum albumin infusions.

MAIN OUTCOME MEASURE

The clinical development of signs and symptoms of severe OHSS.

RESULTS

More than 60% of other oocyte donors had higher E2 levels and 12% had higher number of follicles without associated OHSS.

CONCLUSION

The risk of developing severe OHSS cannot be predicted accurately to be low even in the absence of "risk factors."

Diagnosis, prevention and management of ovarian hyperstimulation syndrome

The overall incidence of clinically important (moderate to severe) OHSS ranges from 1% to 10% of IVF cycles, but only a small proportion (0.5% to 2%) of the cases are severe. In extreme but rare cases, secondary complications such as deep vein thrombosis, respiratory distress and acute hepato-renal failure may occur. The main risk factors are the presence of polycystic ovaries, high ovarian response to superovulation therapy, the use of hCG to trigger the ovulatory process or for luteal phase support, and the endogenous production of hCG by an early pregnancy. The pathogenesis of OHSS is unknown, although the predominant biochemical mediator is thought to be the renin-angiotensin system. Ovarian stimulation should always be carefully monitored to identify those women at risk. In IVF cycles, the hCG injection should be withheld if the risk is judged to be too great. Some women will benefit from a policy of proceeding to collect oocytes, but electively cryopreserving any resulting embryos, thus allowing the ovarian stimulation cycle not to be wasted. The administration of albumin at the time of oocyte collection will reduce the chance of severe OHSS occurring. If a decision is made to proceed with oocyte recovery and embryo transfer, it may be advisable to give 5000 IU of hCG, rather than 10,000 IU, as the ovulatory trigger. Progesterone, and not hCG, should be given in the luteal phase. Women developing mild or moderate OHSS should be kept under outpatient surveillance to detect the minority that may progress to severe OHSS. Those with severe OHSS should be hospitalised for fluid and electrolyte management. Paracentesis under ultrasound guidance is recommended where there are tense ascites, but further surgical intervention should rarely be undertaken and only when there is good clinical evidence of ovarian torsion or haemorrhage.

Ovarian hyperstimulation syndrome and heterotopic pregnancy after IVF

We report a case of Severe OHSS combined with Heterotopic pregnancy. During the treatment of OHSS the patient underwent transvaginal paracentesis for the ascites but no sign of blood was noticed into the fluid. The ultrasound control in the 8th week had shown a normal intrauterine pregnancy without any suspicion for heterotopic pregnancy. The diagnosis for heterotopic pregnancy became possible at 10 Weeks of gestation by Ultrasound. Laparotomy with partial tubal resection was performed. The intrauterine pregnancy is still ongoing without complications.

Angiotensin II immunoreactivity is elevated in ascites during severe ovarian hyperstimulation syndrome: implications for pathophysiology and clinical management

OBJECTIVE

To investigate the ovarian renin-angiotensin system (RAS) during severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Simultaneous sampling of blood and ascitic or peritoneal fluid (PF) during therapeutic paracentesis or laparoscopy.

SETTING

University Hospital.

PATIENTS

Twelve patients were investigated: three patients presenting severe OHSS, three patients with a spontaneous first trimester pregnancy, three normally cycling women during the early luteal phase, and three patients with ascites of nonovarian origin.

MAIN OUTCOME MEASURE

Renin-like activity and angiotensin II (ANG II) immunoreactivity were measured simultaneously in the plasma and the ascites or PF.

RESULTS

Angiotensin II immunoreactivity was much higher in the ascites or PF than in corresponding plasma during severe OHSS, first trimester pregnancy, and in the early luteal phase, while it was lower in ascites of nonovarian origin. Renin-like activity and ANG II immunoreactivity were the highest in the ascites of severe OHSS and in the PF from part of the patients with a spontaneous first trimester pregnancy.

CONCLUSIONS

The present findings argue for the ovarian origin of the elevated renin-like activity and ANG II immunoreactivity in the ascites of severe OHSS and suggest a stimulatory role of hCG on the ovarian RAS whether during severe OHSS or first trimester spontaneous pregnancy. The vasoactive peptide ANG II may contribute to the maintenance of the ascites in severe OHSS but is probably not responsible for the formation of the ascites. The efficiency of paracentesis during severe OHSS could be explained at least partially by the removing of great amounts of ANG II from the peritoneal cavity.

[The ovarian hyperstimulation syndrome. Institutional experience]

Thirty patients with OHS were analyzed; all of them had to be hospitalized. There was no difference as to sterility time and syndrome appearance. The use of menotropines caused more frequently the syndrome. There was multiple pregnancy in 33%. Abortion incidence was 16%. As the etiology is unknown there is not an adequate treatment, and care is for maintenance. Prevention is the best option.

[Ovarian hyperstimulation syndrome in medically assisted reproduction]

Ovarian hyperstimulation syndrome (OHS) is the most serious complication of ovulation induction, particularly in in vitro fertilization. It is a potentially life-threatening situation. Its pathophysiology is poorly understood. This syndrome is explained by a sudden increase in capillary permeability which results in a rapid fluid shift from the intravascular space into a third space leading to haemodynamic changes. In its most severe forms. OHS is characterized by multicystic ovarian enlargement, hemoconcentration, hypovolemia, oliguria, third space accumulation of fluid in the form of ascites and pleural effusion, renal failure, thrombotic disorders. Mild and the most of moderate forms of OHS usually do not require any active form of therapy. Severe OHS requires hospitalization, correction of fluid and electrolyte imbalance, prevention of thromboembolism, aspiration of the ascites and pleural effusion causing respiratory discomfort and dyspnea. Surgical interventions are exceptionally indicated and reserved for ovarian or rupture of ovarian cyst. Although severe OHS may not be completely avoided, early recognition of high-risk factors, judicious monitoring of ovulation induction (plasma estradiol levels and ultrasonography), and, perhaps in future, substitution of hCG for triggering ovulation should reduce the incidence of this iatrogenic syndrome.

Autologous protein reinfusion in severe ovary hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is one of the most serious complications of ovulation induction by exogenous gonadotropins. The pathophysiologic factors of this syndrome are not well known. Increased capillary permeability causes third space fluid shift, which is responsible for ascites, pleural fluid, and edemas. Severe OHSS may result in renal failure, hypovolemic shock, thromboembolic disease, respiratory distress, and may cause death. It has been observed that paracentesis is efficacious, provided that care is taken to reinfuse protein lost in the peritoneal exudate. For this reason, in three patients with severe OHSS we have used a dialytic technique of reinfusion of concentrated ascitic fluid.

STUDY DESIGN

We treated three patients with severe OHSS (grade 6). Through sonography-guided paracentesis, the ascitic fluid was concentrated by ultrafiltration and reinfused. This treatment was instituted and performed once only. Ultrafiltration was obtained with a common high-flow dialyzer (polyacrylonitryle membrane). The concentrated fluid was returned to the patient in a peripheral vein. We have limited further treatment to restoration of fluid and electrolyte balance, avoiding in particular potentially teratogenic drugs.

RESULTS

In all three patients, a progressive increase of diuresis was evident during treatment and subjective improvement was almost immediate. Fifteen days after treatment, hematologic and biochemical parameters had returned within normal limits.

CONCLUSIONS

In treating severe OHSS, we have used the technique of reinfusion of concentrated ascitic fluid to avoid protein depletion induced by paracentesis. We have been able to successfully restore to normal the hematologic and biochemical imbalance with one treatment. Use of the technique described herein should be limited to carefully selected instances and treatment should be performed in an intensive care unit.

Ovarian hyperstimulation syndrome in the emergency department: a case report

The Ovarian Hyperstimulation Syndrome (OHSS) is a complication of ovulation enhancing technologies that is becoming more prevalent with increasing use of these techniques in infertile women. In this report, we describe a 36-year-old woman who presented to the Emergency Department with hemodynamic compromise secondary to OHSS. The OHSS is characterized by ovarian enlargement, ascites, electrolyte disturbances, hypotension, and thromboembolic events. This case illustrates a serious complication of techniques used to enhance fertility.

Day care management of severe ovarian hyperstimulation syndrome avoids hospitalization and morbidity

Severe ovarian hyperstimulation syndrome (OHSS) is a dreaded complication of ovulation induction for assisted reproduction treatment. In the past, conservative management has been recommended and this leads to prolonged hospitalization. A total of 18 patients who developed severe OHSS were managed according to two protocols. The first group (n = 8) was managed conservatively with hospitalization, i.v. hydration and supportive therapy. The average duration of hospitalization was 11 days and the patients were uncomfortable throughout. A second group (n = 10) was managed on an out-patient basis with early, ultrasound-guided trans-abdominal paracentesis. While the patient was hydrated intravenously, 1-3 1 of fluid were removed over 2-3 h. The duration of hospitalization was between 6 and 7 h and no in-patient stay was required. Prompt relief of symptoms was reported and none of the patients required re-tapping. Pregnancy was achieved in 68% of all patients. Day care management with easy abdominal paracentesis was found to be simple, safe and effective; patients found it more acceptable as it avoided in-patient hospitalization.

[Ovarian hyperstimulation syndrome. Current concepts]

The ovarian hyperstimulation syndrome is the most severe iatrogenic complication of ovarian stimulation. Currently, the number of women receiving drugs for ovulation induction has markedly increased with the advent of different medically assisted reproduction programs. Consequently, this potentially life-threatening situation has become a frequent clinical problem. Since its pathophysiology is poorly understood, it is the clinician's responsibility to ensure its accurate prevention, prediction and active management. Although severe and critical ovarian hyperstimulation syndrome may be not completely avoided, it is the responsibility of the clinician to be aware of an early recognition of high-risk factors and make a judicious prevention to reduce the complication and sequelae of this iatrogenic syndrome. The present work offers an overview of the current world literature on ovarian hyperstimulation syndrome.

[The ovarian hyperstimulation syndrome]

The ovarian hyperstimulation syndrome is the most important iatrogenic complication of ovarian stimulation. Every drug used in the treatment of infertility such as FSH, HMG, CC, GnRHa, can lead to the syndrome. The authors of the article report the incidence of OHSS in their patients treated for an assisted conception program; the role of oestrogens, HCG and renin-angiotensin system; the classification, the therapy and how to prevent the syndrome.

Treatment of severe ovarian hyperstimulation syndrome by ultrafiltration and reinfusion of ascitic fluid

Two severe OHSS patients were treated by ultrafiltration and reinfusion of their ascitic fluid. Improvement of symptoms was marked after this treatment with no complications, and termination of pregnancy was avoided. Treatment of OHSS with this ultrafiltration and reinfusion method may help to resolve serious cases of OHSS and become a useful treatment for severe OHSS.

Complications of ovulation induction

Induction of ovulation has its own risks. Since this treatment is elective the physician should be convinced that it is really indicated for the specific patient. Multiple pregnancies still occur in 4 to 15% in in vivo treatment and in 15 to 20% in assisted reproduction. Abortions occur in 20% of the pregnancies achieved. These numbers demonstrate the complexity of induction of ovulation. In recent years the average age of the treated patient has increased, but it is too early to see whether this influences the frequency of complications. The physician should be aware of the possible complications and should remain in contact with the patients at risk after completion of the treatment. The patient should be well informed about the possible complications before starting treatment. At the end of the treatment she should be able to recognize any clinical warning signs of OHSS and inform her physician, in order to be treated appropriately. Further studies of the pathogenesis of OHSS in the future will hopefully lead to more specific treatments or even prevention of this phenomenon. The increasing experience in selective fetal reduction seems to be a practical solution to high rank multifetal gestation, preventing extreme prematurity and its sequelae.

Management of severe ovarian hyperstimulation syndrome by ascitic fluid aspiration and intensive intravenous fluid therapy

OBJECTIVE

To assess the value of intensive intravenous (IV) fluid therapy and ascitic fluid aspiration in the management of severe ovarian hyperstimulation syndrome.

METHODS

Forty-two women with severe ovarian hyperstimulation syndrome were treated by ultrasonically guided transvaginal aspiration of ascitic fluid and IV fluid infusion. Ten women with the same condition treated conservatively constituted a comparison group. The main outcome measures included percentage change in hematocrit, creatinine clearance, and urine output before and after aspiration. The duration of hospital stay was compared between the groups.

RESULTS

Marked improvement of symptoms and general condition followed soon after aspiration. Hematocrit readings decreased by 22%, creatinine clearance increased by 79.3%, and urine output increased by 220.7%. The average volume of aspirated fluid was 3900 mL. The average duration of hospital stay was 3.8 days in the treated women. In the comparison group, severe symptoms and electrolyte imbalance continued for an average of 9 days, and the average hospital stay was 11 days.

CONCLUSION

Intensive IV fluid therapy and transvaginal aspiration of ascitic fluid are safe and effective in improving symptoms, preventing complications, and shortening the hospital stay in severe ovarian hyperstimulation syndrome.

Autotransfusion of the ascitic fluid in the treatment of severe ovarian hyperstimulation syndrome

Three cases of severe OHSS were treated by transvaginal aspiration of the ascitic fluid and autotransfusion of the aspirated fluid. Marked improvement of the symptoms, general condition, and urine output followed the aspiration shortly. No reactions were noticed during or after the autotransfusion. The blood parameters were corrected, and the general condition and urine output continued to improve. The procedure is simple, safe, and straightforward that showed a striking physiological success in correcting the maldistribution of fluid and proteins without the use of heterogeneous biological material.

Ovarian cyst aspiration: a therapeutic approach to ovarian hyperstimulation syndrome

Ultrasonographically guided transvaginal aspiration of ovarian cysts in women with severe OHSS after GIFT or IVF was safe and has resulted in immediate relief of symptoms, a shorter disease process, and outpatient treatment. The patients were allowed to go back to normal activity after the procedure. The progression of the disease was interrupted and six of seven patients carried beyond 20 weeks' gestation.

Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment

OBJECTIVE

To overview the world literature on ovarian hyperstimulation syndrome (OHSS) and modes of prevention and treatment of OHSS.

STUDY SELECTION

All the pertinent literature on OHSS, its prevention, and strategies for treatment were reviewed.

PREVENTION

Key to prevention is proper identification of the population at risk, which includes women with either the hormonal or the morphological signs of polycystic ovarian disease, high serum estradiol (E2) before human chorionic gonadotropin (hCG) administration (E2 greater than 4,000 pg/mL), multiple follicular response (greater than 35), younger age, and lean habitus. When a high risk situation is recognized, ovulatory dose of hCG may be reduced, avoided (with cycle cancellation), or substituted by gonadotropin-releasing hormone or its agonist. Luteal support with hCG is to be bypassed. To minimize risk of OHSS, endogenous pregnancy-drived hCG may be eluded by judicious cryopreservation of all embryos. Last, follicular aspiration will allow higher levels of E2 and larger number of follicles to be matured with lesser risk of OHSS than conventional ovulation induction without follicular aspiration.

TREATMENT

In-house for the severe and intensive care for the critical form. Meticulous fluid and electrolyte balance using both crystalloids and colloids (albumin) until hemoconcentration abates. Paracentesis is indicated for tight ascites, deteriorating kidney functions, and symptomatic relief. Diuretics may be prudently used once hemodilution is achieved. Dopamine drip may be used as a renal rescue, whereas heparin is indicated for thromboembolic phenomena and surgery reserved for abdominal catastrophies. Therapeutic interruption of an early gestation may be lifesaving when all other measures have failed.

CONCLUSIONS

Although severe and critical OHSS may not be completely avoided, early recognition of high-risk factors, judicious prevention schemes, and treatment strategies should reduce the complication and long-term sequelae of this iatrogenic syndrome.

Outcome of treatment subsequent to the elective cryopreservation of all embryos from women at risk of the ovarian hyperstimulation syndrome

From 1st June 1989 to 31st May 1991, 78 women with a serum oestradiol level greater than 3500 pg/ml on the day of the ovulatory trigger, following pituitary suppression with buserelin and ovarian stimulation with human menopausal gonadotrophins (HMG), had all their embryos electively cryopreserved at the pronucleate stage to minimize the risk of developing ovarian hyperstimulation syndrome (OHS). Treatment with buserelin was continued in the luteal phase. A median of 19 oocytes (range 7-43) was obtained and 12 embryos (range 1-37) frozen per cycle. Twenty-one (27%) women developed OHS (six severe). Women developing OHS had higher (P less than 0.05) serum oestradiol concentrations on the 7th day after oocyte retrieval, compared to those who did not. No differences were found for any of the following criteria: aetiology of infertility, age, total dose of HMG, number of oocytes, fertilization rate or freeze-thaw survival of embryos. Subsequently, 125 frozen-thawed embryo replacements have been undertaken, using buserelin and hormone replacement therapy (HRT) (n = 93) or natural cycles (n = 32). The overall freeze-thaw survival and implantation rates per embryo were 71.8 and 11.7%, respectively. The pregnancy rates in natural cycles (19%) and buserelin/HRT cycles (29%) were not significantly different.

Severe ovarian hyperstimulation: a case report and essentials of prevention and management

A case of ovarian hyperstimulation syndrome is presented occurring in a young woman with polycystic ovary-like disease after induction of ovulation with the combined treatment of a luteinizing hormone releasing hormone analog and human menopausal gonadotrophins. Prevention and management based on pathophysiological considerations are reviewed.

The use of luteinising hormone releasing hormone agonists for ovarian stimulation in assisted reproductive technology

Although the use of luteinising hormone releasing hormone (LHRH) agonists and human menopausal gonadotrophin (hMG) for ovarian stimulation in assisted reproductive technology has gained wide-spread popularity, a number of major issues regarding their use remain unresolved. In this paper, we examine some of these issues in the light of the results of our own studies. We have found that although the use of LHRH agonists may be advantageous for some patients, its routine use for all patients produces no significant medical advantage compared with conventional stimulation regimens. In a number of prospective randomised studies, we have found that the long protocol of LHRH agonist administration is superior to the short and ultrashort protocols and the administration of glucocorticoids to patients at high risk of developing ovarian hyperstimulation syndrome does not reduce the incidence of this complication. Finally, we have found that when the long protocol of LHRH agonist administration is used, precise timing of human chorionic gonadotrophin administration (hCG) is not important. There are no significant differences in oocyte recovery, fertilisation and cleavage rates, or in pregnancy rates when the results of standard timing of hCG administration are compared with delayed administration. It would, therefore, appear that the major advantage of the routine use of LHRH agonists is for practical, rather than medical reasons.

Management of overstimulated gonadotrophin cycles with a controlled drift period

In an attempt to avoid cancellation, 40 cycles which were biochemically overstimulated with exogenous gonadotrophins (oestradiol level inadvertently exceeding 5400 pmol/l) in 32 patients with polycystic ovarian syndrome, classified as Group II according to the World Health Organization, were managed by a controlled drift period. This involved a schedule where further human menopausal gonadotrophin (HMG) injections were withheld but monitoring continued with daily assays of serum oestradiol and frequent follicular ultrasound examinations. The mean oestradiol level at the start of the drift period was 9249 +/- 3465 (SD) pmol/l and dropped by 64.3 +/- 25.3% to 2945 +/- 1817 pmol/l at the end of 2.8 +/- 1.5 days of drift interval (range 1-8 days) at which time human chorionic gonadotrophin was administered. There was a significant increase in the size of the lead follicle and number of follicles greater than 14 mm in diameter during the drift period. The clinical pregnancy rate per cycle was 25% (10/40). The multiple pregnancy rate was 50% (5/10), and 2.5% (1/40) of the cycles were complicated by severe ovarian hyperstimulation syndrome (OHSS). These data indicate that cycles inadvertently overstimulated with gonadotrophin can be managed with a controlled drift period as an alternative to cancellation, yielding favourable pregnancy rates. The multiple pregnancy rate was 50%, twins in all instances and the rate of severe OHSS was 2.5%, which were within the range reported in the literature for HMG-stimulated cycles.

[Treatment and prevention of the ovarian hyperstimulation syndrome]

Frequency and features of ovarian hyperstimulation syndrome (OHS) were reviewed in 41 women stimulated with human menopausal gonadotropin (HMG) during 130 cycles. There were 7 cases of OHS, since 17% of patients and 5.3% of cycles were affected; 3 cases were mild, 2 moderate and 2 severe. Of these 41 women, 21 pregnancies occurred (51%) and 19 newborns were healthy. The patients with OHS received 1060 +/- 235 (X +/- DE) UI of HMG and there was not a significative difference with the amount of HMG units in remaining subjects. Symptoms began 3-6 days after human chorionic gonadotropin (HCG) administration. Women with mild OHS were treated as out patients with bed rest and 100 mg indomethacin in suppositories two times a day. Moderate and severe OHS were hospitalized with bed rest; careful monitoring of fluid intake and output, weight and abdominal perimeter daily, as well as vital signs were withdrawn. Patients with severe OHS were treated in the intensive care unit for detection and management of complications. One patient was submitted to laparotomy because of a probably ovarian rupture, but it was discarded in the surgery. OHS remained between 6 and 8 days. Patients with OHS presented 3 pregnancies, 2 were twins and the other was ectopic. Emphasis was made in the prophylactic measures to avoid the OHS.

Modern management of ovarian hyperstimulation syndrome

The number of women receiving ovulation induction has markedly increased with the advent of medically assisted reproduction. Consequently, ovarian hyperstimulation syndrome (OHSS) has become a frequent clinical problem. It is a potentially life-threatening situation. In its severe forms it is complicated by haemoconcentration, hypovolaemia, hypotension, acute renal insufficiency and thromboembolism. The pathophysiology of OHSS is poorly understood. The occurrence of OHSS correlates well with the level of oestradiol, the number of follicles, and administration of human chorionic gonadotrophin (HCG). The risk is increased in polycystic ovarian disease. The aim of this paper is to review critically the published literature on prediction, prevention and modern management of OHSS. Complete prevention of OHSS is not possible although several methods are used to predict and reduce its occurrence. Endocrine profile and ultrasonic follicular monitoring are the mainstays of prediction. The presence of a large number of small and intermediate size follicles at sonography is a risk factor. Withholding HCG, continuation of gonadotrophin-releasing hormone analogues and cryopreservation of embryos are optional courses of action for prevention. Mild OHSS is usually self-limiting and requires no active therapy. Moderate and severe cases are treated by correction of fluid and electrolyte imbalance, and by prevention of thromboembolism. The use of surgery is limited to cases of torsion or rupture of ovarian cysts, or the presence of concomitant ectopic pregnancy. Aspiration of the ascitic fluid, preferably by the transvaginal route, is recommended in cases with severe ascites.

Ovulatory dysfunction

Ovulation is the result of a perfectly balanced and coordinated function of endocrine, paracrine, and autocrine systems. Any disruption in the delicately coordinated interaction between the integrated components of the hypothalamic-pituitary-ovarian axis may lead to ovulatory dysfunction, a multifactorial entity. The widening scope of knowledge regarding physiology of the reproductive processes as well as rapid development of new diagnostic methods and therapeutic procedures necessitates the continued reassessment and identification of factors leading to ovulatory dysfunction and the design of safe therapy for this condition. The combined use of serial ultrasonography and estradiol measurements should be the standard method of ovulation induction monitoring. The identification of high-risk groups prior to the initiation of ovulation induction regimens must also be taken into consideration if we want to improve pregnancy rate and reduce the incidence of hyperstimulation to a minimal level.