Isolated pleural effusion in severe ovarian hyperstimulation: A case report

Assisted reproductive technology programs use controlled ovarian hyperstimulation to maximize pregnancy rates. Severe ovarian hyperstimulation syndrome is a well-known risk. Pleural effusion often accompanies severe ovarian hyperstimulation syndrome. We describe 2 cases of isolated hydrothorax without concomitant ascites and review the literature of this rare finding.

The therapeutic dilemma of an ectopic pregnancy in the setting of the severe ovarian hyperstimulation syndrome

Severe ovarian hyperstimulation syndrome as a result of assisted reproductive therapy occurs rarely. However, this iatrogenic condition can result in a life threatening illness with difficult management dilemmas for the attending physicians. A patient with severe adult respiratory distress syndrome and septicaemia after in vitro fertilization required prolonged intensive care treatment and subsequently had a probable ectopic pregnancy treated with systemic methotrexate as an alternative to surgical management. A satisfactory outcome was obtained, followed by a spontaneous successful pregnancy some months after these events.

[Ovarian hyperstimulation syndrome as a cause of pleural effusion]

In recent years many assisted reproduction units are using the ovaric induction technique as fertilization procedure. The ovarian hyperstimulation syndrome is scarcely frequent, but a potentially serious complication of this technique. Is characterized by a situation of not clearly explained hypovolemia, and increased liquid amount in serosae. Development and diffusion of assisted reproduction procedures makes the consideration of ovarian hyperstimulation syndrome as a possible cause for pleural effusion.

Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE

To assess the pulmonary manifestations of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective nationwide 10-year multicenter study.

SETTING

Sixteen of 19 tertiary medical centers in Israel.

PATIENT(S)

All patients hospitalized at these centers for severe OHSS between January 1987 and December 1996.

MAIN OUTCOME MEASURE(S)

Clinical presentation, arterial blood gases on room air, and chest roentgenogram results.

RESULT(S)

Of 209 patients, 4% had lobar pneumonia, 2% had adult respiratory distress syndrome (ARDS), and 2% had pulmonary thromboembolism. Most patients had dyspnea, tachypnea, moderate hypoxemia, increased alveolar-arterial oxygen difference, hypocarbia, respiratory alkalosis, and metabolic compensation. The most common findings on chest roentgenogram were bilateral elevation of the diaphragm, pleural effusion, and pulmonary atelectasis. Patients with pulmonary thromboembolism, ARDS, and pneumonia presented with severe hypoxemia and alveolar-arterial oxygen difference and distinct radiographic findings.

CONCLUSION(S)

Severe OHSS is characterized by an extraparenchymal restrictive type of pulmonary dysfunction, attributed to intraabdominal or pleural fluid accumulation, which limits descent of the diaphragm and expansion of the thoracic cage. This may induce uncoordinated lung ventilation and atelectasis with subsequent ventilation-perfusion mismatch and hypoxemia. The clinical picture may deteriorate further because of pulmonary infection, pulmonary thromboembolism, or ARDS, all of which have distinct clinical, radiographic, and blood gas characteristics.

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.

Increased angiotensin-converting enzyme activity in a patient with severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess plasma angiotensin-converting enzyme (ACE) activity in a patient with severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Case report.

SETTING

Private, university-affiliated infertility practice.

PATIENT(S)

A 35-year-old woman with OHSS.

INTERVENTION(S)

Clomiphene citrate induction of ovulation.

MAIN OUTCOME MEASURE(S)

Plasma ACE activity.

RESULT(S)

The patient had a brain stem infarction as a result of thrombosis caused by severe OHSS. Plasma ACE activity was significantly elevated and persisted long after resolution of the OHSS.

CONCLUSION(S)

Elevated ACE activity appears to have been associated with the development of OHSS in this patient. Further study of the ovarian renin-angiotensin system in the development of OHSS is warranted.

New technology and new challenges for assisted reproduction

As assisted reproduction technology advances, more types of procedures are becoming available, bringing more success at solving many types of infertility. In vitro fertilization has become simpler and less invasive, with success rates as high as 30% per cycle. Intracytoplasmic sperm injection has solved many types of male infertility. This article explains in vitro fertilization technology and discusses such ethical issues as embryo ownership, multiple births, and embryo genetic testing.

Febrile morbidity in severe and critical ovarian hyperstimulation syndrome: a multicentre study

The objective of this study was to define the incidence of febrile morbidity and its causes in severe and critical ovarian hyperstimulation syndrome (OHSS). For this purpose, we reviewed the medical records of all OHSS patients hospitalized in 16 out of 19 tertiary medical centres in Israel between January 1987 and December 1996. Febrile morbidity was defined as at least one episode of temperature rise above 38 degrees C lasting > or =24 h. A total of 2902 patients (3305 hospitalizations) with OHSS was identified, of whom 196 had severe, and 13 critical, OHSS. Among the 209 patients investigated the incidence of febrile morbidity was 82.3%, of which 20.5% was attributed to urinary tract infection, 3.8% to pneumonia, 3.3% to upper respiratory tract infection, 2.0% to intravenous line phlebitis, 1.0% to cellulitis at an abdominal puncture site, 1.0% to postoperative wound infections and 0.5 % to gluteal abscess at the site of progesterone injection. Non-typical organisms were frequently isolated, such as Pseudomonas, Proteus, Klebsiella and Enterobacter species. No infectious aetiology was found in 105 patients (50.2%). Hypoglobulinaemia was recorded in most patients, while ascitic and pleural fluids aspirated from these patients contained high globulin concentrations. We conclude that infection-related febrile morbidity in severe and critical OHSS is high, and may be attributed to some degree of immunodeficiency associated with loss of plasma globulins to the third space. However, non-infection-related febrile morbidity is even higher and may be attributed to endogenous pyrogenic mechanisms.

Moderate ovarian hyperstimulation syndrome complicated by deep cerebrovascular thrombosis

This report describes two cases that developed moderate ovarian hyperstimulation syndrome (OHSS) without evidence of haemoconcentration. Both patients developed serious cerebrovascular thrombosis resulting in hemiparesis, and recovered after treatment with anticoagulants. This report emphasizes that other factors may contribute to vascular thrombosis, and illustrates that cerebrovascular accidents may complicate even moderate OHSS.

Ovarian hyperstimulation syndrome (OHSS) in a spontaneous pregnancy with fetal and placental triploidy: information about the general pathophysiology of OHSS

An ovarian hyperstimulation syndrome (OHSS) in spontaneous pregnancies is a very rare event. Hence, clinicians might make wrong decisions, such as laparotomy, because of suspicion of an ovarian carcinoma, or severe complications such as renal insufficiency may develop because the diagnosis and treatment of OHSS are delayed. Here we report a case of a woman in the 15th week of gestation, presenting with a partial hydatidiform mole and a triploidy of fetus and placenta, with an ongoing and severe OHSS even after legal induced abortion. A low vascular endothelium growth factor (VEGF) concentration (50 ng/ml) was measured when human chorionic gonadotrophin (HCG) exceeded 1000 IU/l and was followed by VEGF concentrations >900 ng/ml, when the OHSS developed. The literature on spontaneous pregnancies associated with OHSS is reviewed, and possible reasons for the clinical course presented in this study and the reviewed reports are discussed. The findings in this case contribute to our theory that VEGF is a causative factor of OHSS, but has no impact on the course of this disease.

Acute cerebrovascular accidents with severe ovarian hyperstimulation syndrome

Cerebrovascular complications are by far the most serious side-effects of ovarian hyperstimulation syndrome. We report a case in which the patient developed cerebral infarction with right sided hemiplegia as a result of severe hyperstimulation syndrome after using a gonadotrophin-releasing hormone agonist for intracytoplasmic sperm injection.

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 as a rare cause of pericardial effusion. 2 case reports]

Assisted reproduction techniques (ART) are modern medical methods which should help infertile couples to resolve their problems. With the introduction of ART new ethical and technical problems arise. The authors wish to demonstrate on the submitted two case-histories the need of interdisciplinary collaboration of the specialist in internal medicine and gynaecologist when dealing with a serious complication of ART--ovarian hyperstimulation syndrome (OHSS).

Unilateral hydrothorax as a sole and recurrent manifestation of ovarian hyperstimulation syndrome following in-vitro fertilization

Acute unilateral hydrothorax may appear as the sole extra-ovarian expression of severe ovarian hyperstimulation syndrome (OHSS). This case report describes two such cases, in one of which the patient developed this rare complication in two consecutive ovarian stimulation cycles. Awareness is needed for the timely and appropriate diagnosis of this rare complication that occurs 9-14 days following human chorionic gonadotrophin (HCG) administration and may recur in consecutive stimulation cycles. Thoracocentesis and fluid balance maintenance are efficient modes of therapy resulting in good outcome.

Transvaginal drainage of ascites as an alternative to abdominal paracentesis in patients with severe ovarian hyperstimulation syndrome, obesity, and generalized edema

OBJECTIVE

To describe an alternative technique for transvaginal drainage of ascites in a case of severe ovarian hyperstimulation syndrome (OHSS), generalized edema, and obesity.

DESIGN

Case report.

SETTING

A university-based hospital IVF and Reproductive Medicine Unit.

PATIENT(S)

A patient hospitalized with severe OHSS after IVF-ET in whom drainage of large amounts of ascitic fluid was necessary.

INTERVENTION(S)

Ultrasonographic transvaginal insertion of a wire guide through a standard IVF needle into the Douglas pouch. Placement of a "peel-away" set on the wire, which was replaced with a "pigtail" indwelling catheter.

MAIN OUTCOME MEASURE(S)

Amount of drained ascitic fluid.

RESULT(S)

Ascitic fluid was drained efficiently, leading to improvement of the patient's condition.

CONCLUSION(S)

Transvaginal ultrasonography-guided insertion of a pigtail catheter through the Douglas pouch is an efficacious procedure when the abdominal approach for decompression of ascites is difficult.

Bilateral simultaneous tubal sextuplets: pregnancy after in-vitro fertilization--embryo transfer following salpingectomy

The presence of a damaged tube has been suggested in recent studies to have a negative effect on in-vitro fertilization (IVF) outcome. Performing bilateral salpingectomy prior to IVF to maximize pregnancy rates may also result in unnecessary surgery. This case is also an example of the occurrence of interstitial pregnancy after salpingectomy. This unusual type of ectopic pregnancy must be kept in mind when evaluating a patient suspected of a possible early abnormal gestation after assisted reproductive technolologies.

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.

Internal jugular vein thrombosis in patients with ovarian hyperstimulation syndrome

OBJECTIVE

To describe a case of bilateral internal jugular vein thrombosis complicating ovarian hyperstimulation syndrome (OHSS).

DESIGN

Case report.

SETTING

Internal medicine ward in a teaching hospital.

PATIENT

A 28-year-old nulliparous woman undergoing IVF.

INTERVENTION(S)

Ultrasonographic Doppler of the neck veins was performed because of pain and swelling in the neck, and bilateral jugular vein thromboses were detected. Laboratory evaluation revealed activated protein C resistance caused by factor V Leiden mutation. Low-molecular-weight heparin (enoxaparin) was administered for the remainder of the pregnancy and for 6 weeks after delivery.

MAIN OUTCOME MEASURE

Resolution of jugular venous thromboses documented by ultrasonographic Doppler and normal progression of pregnancy.

RESULT(S)

The patient delivered healthy twins at term. There were no complications arising from the jugular vein thromboses or the low-molecular-weight heparin treatment.

CONCLUSION(S)

Unusually located venous thrombosis should prompt an evaluation for a hypercoagulable state. The high prevalence (4%-7%) of factor V Leiden mutation in most Western populations and the mutation's potential contribution to thrombotic complications in OHSS suggest that screening for this abnormality in women undergoing IVF may be indicated.

A novel approach to the treatment of ascites associated with ovarian hyperstimulation syndrome

Ascites is a clinical manifestation of severe ovarian hyperstimulation syndrome (OHSS) which may complicate the induction of ovulation using exogenous gonadotrophins. In severe OHSS severe ascites may occur and can lead to dyspnoea, abdominal discomfort and oliguria. To relieve ascites paracentesis is performed two to three times weekly as needed. We report three cases where an indwelling peritoneal catheter was used to decrease the need for repeated paracentesis. Under ultrasound guidance a closed system Dawson-Mueller catheter with 'simp-loc' locking design was inserted to allow continuous drainage of the ascitic fluid. A total of 23 l of the ascitic fluid were drained from the first, 20 l from the second and 28 l from the third patient with significant decrease in abdominal discomfort and improvement in the urine output. No complications or adverse reactions were noted. Continuous drainage of the ascitic fluid is efficient. It quickly decreases the abdominal discomfort, improves the urine output and prevents the need for multiple abdominal paracenteses which some patients may require.

Upper limb thrombosis associated with assisted conception treatment

Three cases of upper limb deep venous thrombosis occurring in association with assisted conception treatment are presented. The accepted argument that lower limb thrombosis occurring in cases of complicated or severe hyperstimulation syndrome represents the likeliest thrombo-embolic disorder in this situation is questioned.

Thromboembolic disease associated with ovarian stimulation and assisted conception techniques

Thromboembolic disease, as a complication of ovarian stimulation and assisted conception techniques, is generally considered to be a rare complication of ovarian hyperstimulation syndrome and, by implication, lower limb in origin. Sporadic cases of unusually sited thromboses, both venous and arterial, have been reported. This paper aims to draw attention to the relatively large number of such thromboses reported in the world literature compared with those cited in previous commentaries, and to emphasize how little is known about their pathogenesis. It is believed that this is an issue which requires to be addressed in order to understand the background pathology to such incidents and if possible to identify women at greatest risk from such potentially debilitating or fatal complications, such that appropriate prophylactic measures can be taken.

Pleural effusion as a presenting symptom of ovarian hyperstimulation syndrome

Pharmacological ovarian stimulation is an accepted technique for amplifying the normal process of follicular development and maturation. It has been in use for the past decade, especially in cases of infertility. Pleural effusion associated with ovarian hyperstimulation syndrome (OHSS), a complication of this therapy, may be more prevalent than is commonly accepted. Four young women presented to our department with dyspnoea caused by pleural effusion as a result of ovarian hyperstimulation syndrome (OHSS). The diagnosis of OHSS was based on a history of pharmacological ovarian stimulation, clinical and laboratory evidence of ovarian enlargement and exclusion of other potential causes of pleural effusion in young women, such as infections, malignancy, pulmonary embolism and collagen vascular diseases. The fluid characteristics in all cases were exudative, with low to normal LDH. All of these patients required fluid evacuation for symptomatic relief. Resolution was achieved with supportive measures and rest. Ovarian hyperstimulation syndrome may be common enough to warrant routine consideration in the differential diagnosis of pleural effusion in young women.

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.

Superovulation combined with insemination or timed intercourse in the treatment of couples with unexplained infertility and minimal endometriosis

BACKGROUND

To compare intrauterine insemination (IUI), direct intraperitoneal insemination (DIPI), and timed-intercourse (TI), each combined with superovulation, in the treatment of couples with unexplained infertility, including couples with minimal endometriosis.

METHODS

A retrospective analysis of 233 superovulation cycles in 70 couples with unexplained infertility or minimal endometriosis. Stimulation protocol, pregnancy rate, pregnancy outcome, and complications of treatment were analyzed.

RESULTS

The pregnancy rare was 8.6% per cycle and 28.5% per couple. A majority of all treatment pregnancies (85%) occurred during the first four cycles of treatment. The duration of infertility did not influence the pregnancy rate. The pregnancy rate in patients with unexplained infertility was higher, but not significantly, than in patients with minimal endometriosis (27.7% versus 18.4%). No predictive marker for successful stimulation was found, except for the higher luteal progesterone level in cycles resulting in pregnancy. The multiple pregnancy rate was high: 30% of all pregnancies and 40% of all deliveries were multiple.

CONCLUSIONS

Superovulation in combination with insemination or intercourse is effective and is still recommended in the treatment of couples with unexplained infertility.

Markedly elevated cytokines in pleural effusion during the ovarian hyperstimulation syndrome: transudate or ascites?

OBJECTIVE

To study levels of proinflammatory cytokines in pleural fluid during the severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Case report.

SETTING

Tertiary academic medical center.

PATIENT(S)

A 35-year-old female with a 6-year history of unexplained infertility on menotropin therapy and 28 healthy normal controls.

INTERVENTION(S)

Thoracentesis for severe pleural effusion and venipunctures.

MAIN OUTCOME MEASURE(S)

Interleukin-1 beta (IL-beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) levels were measured by ELISA and compared between pleural effusion and serum from normal controls.

RESULT(S)

Pleural effusion IL-1 beta and IL-6 levels were higher than serum. Interleukin-6 levels were elevated particularly in pleural effusion (1,961.89 pg/mL) compared with serum (3.9 +/- 0.41 pg/mL).

CONCLUSION(S)

Our results confirm the high cytokine levels observed in OHSS. Cytokines have been implicated in capillary permeability, extravasation of fluid, oliguria, and shock. We have postulated that these mediators are released from the corpora lutea into the peritoneum and systemic circulation. Alternatively, the presence of high cytokine levels in pleural fluid maybe the result of diaphragmatic defects, which allow for the migration of ascites into the pleural space.

The impact of insulin secretion on the ovarian response to exogenous gonadotropins in polycystic ovary syndrome

The aim of the study was to evaluate the influence of insulin level on the ovarian response to FSH when inducing ovulation in patients affected by polycystic ovarian syndrome (PCOS). To evaluate the presence of hyperinsulinemia, 34 patients affected by PCOS were studied by an oral glucose tolerance test, then patients were stimulated for 52 cycles using FSH to induce ovulation. The ovarian response to therapy was evaluated by ultrasounds and as estradiol (E2) and androstenedione (A) plasma level determinations. On the basis of the insulinemic response to the glucose challenge, 20 patients were considered to be hyperinsulinemic and 14 normoinsulinemic. The hormonal features of each group were similar. The ovulation rate was similar in hyperinsulinemic and normoinsulinemic subjects, whereas the incidence of ovarian hyperstimulation was significantly higher in the hyperinsulinemic group. The increase in ovarian dimensions observed in hyperinsulinemic subjects after gonadotropin stimulation was more marked than that observed in normoinsulinemic ones. This was caused by the development of a larger number of immature follicles. E2 levels gradually increased after gonadotropin stimulation in both groups of subjects; however, higher levels were observed in hyperinsulinemic patients. During stimulation, the higher E2/A ratio suggests the presence of a greater aromatization activity in hyper-insulinemic patients. In conclusion, the present study suggests that, in PCOS, the insulinemic pattern may influence the ovarian response to gonadotropin administration; thus, hyperinsulinemic subjects may be at greater risk of ovarian hyperstimulation syndrome than normoinsulinemic subjects.

A unilateral hydrothorax as the only manifestation of ovarian hyperstimulation syndrome: a case report

OBJECTIVE

To describe a rare case of unilateral hydrothorax occurrence after ovarian stimulation for IVF.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 39-year-old female suffering from primary infertility due to a severe male factor.

INTERVENTION(S)

Thoracocentesis with IV albumin administration for correction of a concomitant hypoalbuminemia.

MAIN OUTCOME MEASURE(S)

Laboratory values of hematologic measures and electrolytes, screening of the thoracic fluid aspirated for viral and bacterial infections, resolution of pleural effusion after the second thoracocentesis as determined by chest roentgenogram.

RESULT(S)

Treatment of this manifestation of the ovarian hyperstimulation syndrome (OHSS) by thoracocentesis with albumin perfusion.

CONCLUSION(S)

This report describes a very rare case of thoracic complication after ovarian stimulation. It demonstrates that pleural effusion may be the only manifestation of the OHSS and implies a careful management of patients with pulmonary complaints after treatment with exogenous gonadotropins.

Simultaneous intra- and extra-uterine pregnancy with ovarian hyperstimulation syndrome after induction of ovulation: a case report

We present a case of polycystic ovary syndrome (PCOS) that developed simultaneous intra- and extra-uterine pregnancy with ovarian hyperstimulation syndrome (OHSS) after induction of ovulation with pure FSH-HCG. At 9 weeks of pregnancy, the bilateral tubal pregnancy caused an imminent spontaneous abortion, and both Fallopian tubes were resected. After the laparotomy, the pregnancy progressed without problems until 31 weeks and 5 days of pregnancy, when signs of spontaneous abortion appeared, and healthy twin female babies were delivered by cesarean section. The incidence of heterotopic pregnancy is increasing in cases in which inducers of ovulation or ART, such as IVF-ET and GIFT, have been employed. One must be well aware that the danger of heterotopic pregnancy following induction of ovulation is imminent, particularly in cases with risk factors of multiple and/or extra-uterine pregnancy, such as PCOS, a history of tubal restoration, and sexually transmitted disease(s).

Aorto-subclavian thromboembolism: a rare complication associated with moderate ovarian hyperstimulation syndrome

The case of an arterial aorto-subclavian thromboembolism associated with a moderate ovarian hyperstimulation syndrome (OHSS) and following ovulation induction for in-vitro fertilization in a young woman is reported. Because of the lack of response to systemic thrombolysis, a left postero-lateral thoracotomy was performed on day 8 after embryo transfer. A fibrinocruoric embolus situated at the junction of the left subclavian artery from the aorta was removed through a left subclavian arteriotomy. The distal axillary embolus was removed by a retrograde balloon catheter embolectomy. A moderate OHSS was observed. The ovarian stimulation and OHSS-related risks of thromboembolism are discussed. We conclude that, in the absence of risk factors, counselling about possible complications resulting from stimulation must be emphasized.

Severe ovarian hyperstimulation syndrome despite low plasma oestrogen concentrations in a hypogonadotrophic, hypogonadal patient

Ovarian hyperstimulation syndrome (OHSS) is the most serious, life-threatening, iatrogenic complication of ovulation induction. The importance of excessive oestradiol concentrations on the day of human chorionic gonadotrophin (HCG) administration as a predictor and factor in the pathophysiology of OHSS has been extensively studied and discussed. We present the case report of a woman with hypogonadotrophic hypogonadism who developed severe OHSS during ovulation induction with urinary human follicle stimulating hormone (FSH) and HCG in the presence of low circulating oestradiol concentrations. The implication of FSH treatment and complications in hypogonadotrophic hypogonadal patients, and the role of preovulatory oestradiol concentrations in the prediction of OHSS, are discussed.

Spontaneous ovarian hyperstimulation mimicking an ovarian tumour

Ovarian hyperstimulation syndrome in a spontaneous singleton pregnancy is exceedingly rare. We report a case of ovarian hyperstimulation presenting as bilateral ovarian masses in association with spontaneous pregnancy, occurring in a woman with disturbed liver function. A possible mechanism is discussed.

Elevated liver function tests in a case of moderate ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is a recognized complication of ovulation induction. Abnormalities in liver function have been considered to be a rare manifestation of the severe form of ovarian hyperstimulation syndrome (OHSS). A 28 year old woman with primary infertility underwent ovulation induction and intrauterine insemination. She was diagnosed with moderate OHSS and was followed as an outpatient. Early in her course of treatment she complained of upper right quadrant pain. Her work-up included an upper right quadrant ultrasound which showed only moderate ascites. Liver function tests at that time were elevated in a hepatocellular damage pattern. Liver function test elevations, as well as the ovarian hyperstimulation, resolved spontaneously in 10 days. Transient abnormalities in liver function do not appear to be limited to the most sever forms of OHSS.

Internal jugular vein thrombosis caused by resistance to activated protein C as a complication of ovarian hyperstimulation after in-vitro fertilization

We present a case of a 24 year old woman who became pregnant (twins) after human menopausal gonadotrophin (HMG)-induced ovarian stimulation, in-vitro fertilization (IVF) and subsequent embryo transfer. She developed a right internal jugular vein thrombosis as a complication of severe ovarian hyperstimulation syndrome (OHSS) 28 days after embryo transfer. The thrombosis developed in spite of anticoagulation with low-dose heparin. Later a resistance to activated protein C (APC) or Dahlbäck disease was diagnosed. Due to a new test procedure (accelerin inactivation test), the diagnosis was possible even under anticoagulation treatment. The coincidence of hyperstimulation and internal jugular vein thrombosis with the concurrent diagnosis of resistance to APC has not been published previously. The benefit of general screening for resistance to APC before admission to the IVF programme should be weighed. Targeted selection of a group of high-risk women would therefore be made possible.

[Adnexial torsion caused by ovarian hyperstimulation syndrome]

A case of adnexal torsion of an enlarged ovary during early pregnancy after gonadotropin therapy is presented. Adnexal torsion is a rare but serious complication to ovarian hyperstimulation. The diagnosis is difficult, but the combination of ovarian enlargement, abdominal pain, nausea, progressive leukocytosis and anaemia may indicate torsion of the adnex. Prompt diagnosis is important. Simple unwinding of the twisted adnex by a laparoscopic technique has been successful in most cases.

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.

Internal jugular vein thrombosis: a late complication of ovarian hyperstimulation syndrome despite mini-dose heparin prophylaxis

Thromboembolic events are serious but rare complications following ovarian stimulation for in-vitro fertilization (IVF). We report a case of severe ovarian hyperstimulation syndrome (OHSS), presenting in a second IVF cycle with a late complication of right internal jugular vein thrombosis despite mini-dose heparin prophylaxis. Thrombosis and thromboembolism as late complications of OHSS have been reported by others but not after prophylactic heparinization. The patient was successfully treated with heparin and the twin pregnancy is ongoing. In pregnant patients with severe OHSS consideration should be given to treatment with low dose heparin throughout the first trimester to prevent the serious complications of thrombosis and thromboembolism.