Ovarian hyperstimulation syndrome

LAPS-FSH: a new and effective long-acting follicle-stimulating hormone analogue for the treatment of infertility

Although several long-acting follicle-stimulating hormone (FSH) therapies have been developed to enhance the ovarian response, a disadvantage of FSH therapy is its relatively short half-life, which requires women to receive one to two injections per day for almost 2 weeks. In the present study, we developed a novel FSH analogue by conjugating recombinant human FSH (rhFSH) and the constant region of the human immunoglobulin G4 fragment via non-peptidyl linkers. The efficacy of the FSH analogue was evaluated in vitro by cAMP level assessments, pharmacokinetic studies and a determination of ovarian weight and by comparing these findings with the results from other FSH analogues. In addition, the total number of antral and Graafian follicles was determined after 7 days of treatment with control, 6µgkg(-1) follitropin β, 6, 12 or 42µgkg(-1) corifollitropin α or 3, 6 or 12µgkg(-1) long acting protein/peptide discovery-follicle-stimulating hormone (LAPS-FSH). As a result, the animals treated with 12µgkg(-1) LAPS-FSH produced additional and larger healthy follicles. These data demonstrate that LAPS-FSH promotes growth and inhibits atresia of the ovarian follicle compared with other available drugs, suggesting that our new drug enhances the efficacy and duration of treatment. It is expected that our new FSH analogue will result in a higher chance of pregnancy in patients who are unresponsive to other drugs.

Gonadotropin stimulation in mice leads to ovarian accumulation of immature myeloid cells and altered expression of proangiogenic genes

OBJECTIVE

Ovarian hyperstimulation syndrome is associated with increased angiogenesis and vascular leakage. Immature myeloid cells (IMCs) and dendritic cells have been shown to be actively involved in angiogenesis in several disease models in mice and humans. Nevertheless, little is known about the role of these cells in the ovary. As such, this study sought to determine whether alterations in these ovarian myeloid cell populations are associated with gonadotropin stimulation in a mouse model.

STUDY DESIGN

Four-week-old pre-pubertal C57Bl/6 female mice were allocated into three groups: high-dose stimulation (n=4; pregnant mare serum gonadotropins (PMSG) 20U for 2 days), low-dose stimulation (n=5; PMSG 5U for 1 day) and sham-treated controls (n=4). Human chorionic gonadotropin 5U was injected on Day 3, and the mice were killed on Day 5. Ovaries were analysed by flow cytometry, confocal microscopy and quantitative polymerase chain reaction.

RESULTS

Gonadotropin stimulation increased the proportion of CD11b(+)Gr1(+) IMCs among the ovarian myeloid cells: 22.6±8.1% (high dose), 7.2±1.6% (low dose) and 4.1±0.3% (control) (p=0.02). Conversely, gonadotropin stimulation decreased the proportion of ovarian CD11c(+)MHCII(+) dendritic cells: 15.1±1.9% (high dose), 20.7±4.8% (low dose) and 27.3±8.2% (control) (p=0.02). IMCs, unlike dendritic cells, were localized adjacent to PECAM1(+) endothelial cells. Finally, gonadotropin stimulation was associated with increased expression of S100A8, S100A9, Vcan and Dmbt1, and decreased expression of MMP12.

CONCLUSIONS

Gonadotropin stimulation is associated with proangiogenic myeloid cell alterations, reflected by a dose-dependent increase in ovarian IMCs and a parallel decrease in dendritic cells. Recruited IMCs localize strategically at sites of angiogenesis. These changes are associated with differential expression of key proangiogenic genes.

[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]

The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.

Severe ovarian hyperstimulation syndrome leading to ICU admission

Severe ovarian hyperstimulation is a rare complication of ovulation induction therapy. In this report, we are presenting a case of 33-year female, who required intensive care unit admission due to respiratory failure secondary to massive pleural effusion and ascites. With the positive history of in vitro fertilization, the patient was diagnosed to have severe ovarian hyperstimulation syndrome. Besides the medical treatment, abdominal paracentesis for the drainage of massive ascites and tube thoracostomy were performed, resulting in gradual improvement.

Ovarian hyperstimulation syndrome: a potentially fatal complication of early pregnancy

We present the case of a patient who presented to the Emergency Department (ED) 48 h after successful in vitro fertilization with abdominal pain, hypotension, and free fluid on an ED-focused abdominal sonogram for trauma study. This presentation is typical of Ovarian Hyperstimulation Syndrome (OHSS), a diagnosis that may be unfamiliar to many Emergency Physicians. With the increasing frequency of in vitro fertilization procedures, this disease process is becoming more common. Numerous complications can occur with OHSS, including third-space fluid accumulation, hemoconcentration, renal failure, and thromboembolic phenomena. Vigilance is required as these patients are at increased risk of ovarian torsion, ovarian rupture with internal hemorrhage, ectopic pregnancy, and infection. This case report provides an overview of clinical features and emergent management of OHSS.

Autoimmune targeted disruption of the pituitary-ovarian axis causes premature ovarian failure

Premature ovarian failure (POF) is characterized by amenorrhea and high serum levels of follicle-stimulating hormone (FSH). POF causes female infertility and represents a substantial women's health risk affecting 1% of women by age 40. Although ovarian autoimmunity has been associated with POF, the identity of ovarian Ags recognized is unknown. In this study, we show that autoimmune-targeted disruption of the pituitary-ovarian axis leads to POF. Immunization of SWXJ female mice with the p215-234 peptide derived from mouse inhibin-alpha activates CD4(+) T cells and induces experimental autoimmune oophoritis with a unique biphasic phenotype characterized by an early stage of enhanced fertility followed by a delayed stage of POF. Affected mice show high serum levels of inhibin-alpha-neutralizing Abs that prevent inhibin-mediated down-regulation of activin-induced pituitary FSH release. The loss of activin/FSH down-regulation leads to prolonged metestrus-diestrus, superovulation, increased numbers of mature follicles, increased offspring, accelerated depletion of primordial follicles, and ultimately premature infertility. Thus, inhibin-alpha-targeted experimental autoimmune oophoritis is initiated by CD4(+) Th1 T cells that stimulate B cells to produce inhibin-alpha-neutralizing Abs directly capable of mediating POF and transferring disease into naive recipients. Our inhibin-alpha autoimmune model of POF shows how premature infertility may develop in the context of elevated FSH levels thereby closely mimicking the hallmark features of human POF.

Ovarian hyperstimulation syndrome

OBJECTIVE

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

DESIGN

Review of the literature regarding ovarian hyperstimulation syndrome.

METHODS

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

CONCLUSION

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

Exacerbation of underlying pulmonary disease in pregnancy

OBJECTIVE

The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis.

DESIGN

Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants.

METHODS

A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases.

CONCLUSIONS

Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.

The Evolution of in Vitro Fertilization: Integration of Pharmacology, Technology, and Clinical Care

For the couple having trouble achieving pregnancy, the options and opportunities for assistance have never been brighter. Options such as controlled ovarian hyperstimulation, in vitro fertilization, and intracytoplasmic sperm injection have been developed over the past five decades and provide hope for couples that previously would have been considered infertile. In vitro fertilization and intracytoplasmic sperm injection represent a coalescence of advances in physiology, endocrinology, pharmacology, technology, and clinical care. In vitro fertilization has assisted well over one million couples in their efforts to start or build a family, and the demand for such services continues to increase. The purpose of this manuscript is to review the pharmacological advances that made controlled ovarian hyperstimulation, and therefore in vitro fertilization and intracytoplasmic sperm injection, possible. We will discuss the early stages of gonadotropin use to stimulate ovarian production of multiple mature eggs, the advances in recombinant technology that allowed purified hormone for therapy, and the use of other hormones to regulate the menstrual cycle such that the likelihood of successful oocyte retrieval and embryo implantation is optimized. Finally, we will review current areas that require particular attention if we are to provide more opportunity for infertile couples.