Prevention and treatment of ovarian hyperstimulation syndrome

Multiple births from medically assisted reproduction: contribution of different types of procedures and trends over time

OBJECTIVE

To evaluate the relative impact of different strategies of medically assisted reproduction (MAR), i.e. first line treatment (ovarian stimulation with or without intrauterine insemination) and in vitro fertilization (IVF) procedures (conventional IVF or intracytoplasmic sperm injection), on the risk of multiple births.

STUDY DESIGN

We utilized the health care utilization databases of the Lombardy region to identify births resulting from MAR between 2007 and 2022. We gathered data on the total number of multiple births and calculated the prevalence rate by dividing the number of multiples by the total number of births. To examine the temporal trend in the proportion of multiple births after MAR over time, a linear regression model was employed separately for different types of techniques and in strata of maternal age.

RESULTS

A total of 30,900 births after MAR were included; 4485 (14.5 %) first line treatments and 26,415 (85.5 %) IVF techniques. Overall, 4823 (15.6 %) multiple births were identified. The frequency of multiple births over the study period decreased from 22.0 % in 2007 to 8.7 % in 2022 (p < 0.01). Multiple births from first line treatments were stable ranging from 13.5 % in 2007-2008 to 12.0 % in 2021-2022 (p = 0.29). Multiple births from IVF procedures decreased from 23.8 % in 2007-2008 to 8.4 % in 2021-2022 (p < 0.01). Stratifying for maternal age (i.e. < 35 and ≥ 35 years), the trends remained consistent.

CONCLUSIONS

The reduction in multiple births has been influenced by changes in IVF strategy and procedures. The decline has been gradual but steady since 2009, when a law restricting embryo freezing was repealed in Italy. In contrast, the proportion of multiple births resulting from first line treatments has remained constant over time. Despite declining, multiple births from MAR remained about one order of magnitude higher than those from spontaneous pregnancies.

Sp1 regulates steroidogenic genes and LHCGR expression in primary human luteinized granulosa cells

Luteinizing hormone and human chorionic gonadotropin (hCG) bind to the luteinizing hormone/chorionic gonadotropin receptor (LHCGR). LHCGR is required to maintain corpus luteum function but the mechanisms involved in the regulation of LHCGR in human luteal cells remain incompletely understood. This study aimed to characterize the expression of LHCGR mRNA in primary human luteinized granulosa cells (hLGCs) obtained from patients undergoing in vitro fertilization and to correlate LHCGR expression with the response of hLGCs to hCG by assessing the expression of genes known to be markers of hCG actions. The results show that LHCGR expression is low in freshly isolated cells but recovers rapidly in culture and that hCG maintains LHCGR expression, suggesting a positive feedback loop. The activity of a LHCGR-LUC reporter increased in cells treated with hCG but not with follicle-stimulating hormone. Treatment with hCG also stimulated the expression of genes involved in steroidogenesis in a time-dependent manner. LHCGR promoter expression was found to be regulated by SP1, which we show is highly expressed in hLGCs. Moreover, SP1 inhibition prevented the stimulation of steroidogenic genes and the increase in LHCGR-LUC reporter activity by hCG. Finally, we provide evidence that a complex formed by SP1 and GATA4 may play a role in the maintenance of LHCGR expression. This report reveals the mechanisms involved in the regulation of the LHCGR and provides experimental data demonstrating that the proximal region of the LHCGR promoter is sufficient to drive the expression of this gene in primary hLGCs.

Ovarian hyperstimulation syndrome: A review for emergency clinicians

INTRODUCTION

A great deal of literature has recently evaluated the prevention and management of ovarian hyperstimulation syndrome (OHSS) in the outpatient setting, but there remains a dearth of research evaluating OHSS in the emergency department (ED) and its management.

OBJECTIVE

This narrative review evaluates the underlying pathophysiology and clinical manifestations of OHSS and discusses approaches to patient care in the ED based on current literature.

DISCUSSION

OHSS is an iatrogenic complication caused by an excessive response to controlled ovarian stimulation during assisted reproductive cycles (ART). OHSS complicates up to 30% of ART cycles, and many of these patients seek initial care in the ED. Risk factors for the development of OHSS include age < 35, history of polycystic ovarian syndrome or previous OHSS, and pregnancy. Emergency physicians will be faced with several complications including ascites, abdominal compartment syndrome, renal dysfunction, acute respiratory distress syndrome, thromboembolic disease, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary obstetrics/gynecology team is needed, which improves patient outcomes. This review provides several guiding principles for management of OHSS and associated complications.

CONCLUSIONS

OHSS occurs in up to 30% of IVF cycles and carries a high morbidity. Effective care of the OHSS patient begins with early diagnosis while evaluating for other diseases and complications. Understanding these complications and an approach to the management of OHSS is essential to optimizing patient care.

Is thromboprophylaxis cost effective in ovarian hyperstimulation syndrome: A systematic review and cost analysis

BACKGROUND

The majority of serious thromboembolic events occurring in assisted reproductive technologies (ART) are in women with ovarian hyperstimulation syndrome (OHSS).

OBJECTIVES

The purpose of this study was to present a thorough review and cost analysis regarding the use of venous thromboembolism (VTE) prophylaxis in OHSS to inform clinical management.

DATA SOURCES

Databases used were Pubmed and Embase, in addition to checking reference lists of retrieved articles (inception to November 2017).

METHODS

The systematic search strategy identified 365 titles and abstracts. Articles included in the qualitative synthesis had identified venous thrombosis incidence rates or ratios. A separate search for the cost model was conducted recognizing all associated complications of VTE. The decision tree was modeled to best fit the patient population and a sensitivity analysis was performed over a range of variables.

RESULTS

The cost of VTE event per OHSS patient not on prophylaxis was €5940 (range €3405 to €38,727), versus €4134 (€2705 to €23,192) per event per patient on prophylaxis, amounting to a saving of (€19 to €23,192) per VTE per patient. Sensitivity analysis found VTE prophyaxis to be cost effective if the incidence of VTE in the OHSS population was greater than 2.79%. Prophylactic therapy was cost effective through 16 weeks of treatment.

LIMITATIONS

OHSS is infrequent and hence, the incidence of VTE in patients with OHSS is low; therefore, the data used to inform the incidence of VTE in OHSS in the model carry some uncertainty. Further, low molecular weight heparin (LMWH) has side effects therefore individualization of care must be considered.

CONCLUSIONS

With the increasing incidence of infertility and requirement for ART, thromboembolism in OHSS poses a major health threat for patients. VTE prophylaxis using enoxaparin was cost effective in patients with severe OHSS over a wide range of costs and incidences. Prophylaxis was also cost effective through the completion of the first trimester of pregnancy.

Relationship between human chorionic gonadotropin serum levels and the risk of ovarian hyperstimulation syndrome

The object of this retrospective cohort study was to determine if hCG levels correlate with ovarian hyperstimulation syndrome (OHSS) risk after adjustment for other risk factors during in vitro fertilization (IVF). We measured serum hCG approximately 12 h after hCG trigger in women undergoing 406 cycles of controlled ovarian hyperstimulation for IVF between June 2006 and December 2009. Serum hCG levels were measured 12 h after trigger. Bivariate logistic regression was used to assess the association between patient and cycle characteristics and OHSS. In our series, mild to moderate OHSS occurred in 9% (38/406), and severe OHSS diagnosed in 1.5% (6/406) of IVF cycles. OHSS risk was increased in younger women (<30 years old: adjusted odds ratio: aOR 2.46, 95% confidence interval: CI 1.14-5.34), increased number of oocytes (11-20: aOR 6.79, 95% CI 1.97-23.40; >20: aOR 17.55, 95% CI 4.84-63.70), and increase E2 levels (≥3,000 pg/mL: aOR 2.59, 95% CI 1.33-5.05), but was unrelated to hCG level (100-200 IU/L: aOR 1.53, 95% CI 0.60-3.91; ≥200 IU/L: aOR 1.42 95% CI 0.48-4.20). These results indicate that OHSS risk during IVF is unrelated to serum hCG level measured approximately 12 h after trigger.

Ascites ultrafiltration and concentration-reinfusion in severe ovarian hyperstimulation syndrome

Mild forms of ovarian hyperstimulation syndrome are common in women undergoing in-vitro fertilization, affecting up to 33% of in-vitro fertilization cycles; 3-8% of cycles are complicated by moderate or severe ovarian hyperstimulation syndrome (Royal College of Obstetricians and Gynaecologists, 2006). To treat severe ovarian hyperstimulation syndrome, albumin and other colloid solutions are used intravenously to increase the perfusion pressure (Manaka et al, 1995; Balasch et al, 1996), heparin to restore coagulation (Balasch et al, 1996) and dopamine to increase renal blood flow (Brinsden et al, 1995), but these all have limited effects.

Estimating the risks of ovarian hyperstimulation syndrome (OHSS): implications for egg donation for research

This study aims to provide an estimate of women's risk of ovarian hyperstimulation syndrome (OHSS) when undergoing superovulation to donate eggs for research. This is an essential prerequisite for appropriate informed consent. In the absence of sufficiently large numbers of egg donors to assess the risk, comparative data was obtained from women undergoing the same superovulation protocol for in vitro fertilization (IVF) treatment. In this prospective study 339 women, who developed >/=20 follicles after superovulation in their first treatment cycle (total number of treatment cycles during the same period - 2417), were intensively monitored on five occasions, between human chorionic gonadotrophin and pregnancy test, according to our routine clinical protocol. Hospital admission was needed for 49 (14.5%) women, 13 (3.8%) needed intravenous fluids and 9 (2.7%) needed paracentesis. The admission rates were similar in pregnant and non-pregnant women (13.5% vs. 15%); the need for intravenous fluids and paracentesis were 3.2% vs. 2.3% and 6.3% vs. 2.3%, respectively. The peak increase in haematocrit occurred on Day 4 after hCG, and the mean day of hospital admission was Day 5. If an egg donor develops <20 follicles, she can be reassured that the risk of OHSS is very small (<0.1%). If >/=20 follicles develop, her risk of hospital admission due to OHSS is <15%. The absence of pregnancy in egg donors does not eliminate the risk of OHSS. Given the timescale of development of the haematological and biochemical abnormalities, egg donors who develop >/=20 follicles should be actively monitored for the first week after egg collection.

Pathophysiology of cyclic hemorrhagic ascites and endometriosis

Massive hemorrhagic ascites (4470 mL, range 1-10 L) in women with endometriosis is a rare condition occurring predominantly in black women. Of the 43 case reports published, 42 are compatible with the hypothesis that the hemorrhagic ascites is predominantly a consequence of excessive ovarian transudation similar to a Meigs syndrome. Indeed, bilateral ovariectomy cures the condition without recurrences, whereas after unilateral ovariectomy or cystectomy recurrence rate is more than 50%; during ovarian suppression by luteinizing hormone-releasing hormone agonist ascites disappears, but reappears after treatment. Superficial pelvic endometriosis also contributes to the ascites because after superficial endometriosis destruction the recurrence rate is only 4 in 14. Based on these data, it is suggested, to scrutinize the ovaries for tumors given the analogy with Meigs syndrome. In women desiring fertility, conservative treatment with destruction of endometriosis only can be attempted given the cure rate of some 20%. It is unknown what the effect of ovulation induction would be.

Spontaneous ovarian hyperstimulation in a pregnant woman with hypothyroidism

OBJECTIVE

This report describes an unusual case in which a naturally conceived pregnancy is associated with spontaneous ovarian hyperstimulation and hypothyroidism.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

A 30-year-old pregnant woman with abdominal pain and distension caused by ovarian hyperstimulation.

INTERVENTION(S)

Medical management and laparotomy.

MAIN OUTCOME MEASURE(S)

Incomplete regression after 3 months.

RESULT(S)

Thyroid-stimulating hormone level was elevated. Hormonal studies confirmed hypothyroidism with spontaneous ovarian hyperstimulation. She was given levothyroxine 200 mug/d. Results of the hormonal tests for thyroid function were normal 3 months after treatment, but in this case the ovarian cysts did not regress completely until delivery. Laparotomy and cesarean section were done for both diagnosis and treatment. Ten weeks after delivery ovarian cysts regressed completely.

CONCLUSION(S)

Thyroid hormone replacement seems to be the best therapeutic approach in some patients, but, in some, complete resolution of the ovarian cysts does not occur after 3 months.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Incidence and prediction of ovarian hyperstimulation syndrome in women undergoing gonadotropin-releasing hormone antagonist in vitro fertilization cycles

OBJECTIVE

To determine the incidence of ovarian hyperstimulation syndrome (OHSS) in a large series of GnRH antagonist-stimulated cycles and to assess the predictive value of E2 and the number of follicles on the day of hCG administration.

DESIGN

Prospective cohort study of women undergoing IVF treatment with a GnRH antagonist protocol over a 2-year period.

SETTING

Tertiary university hospital.

PATIENT(S)

One thousand eight hundred one patients who underwent 2,524 cycles.

INTERVENTION(S)

Multifollicular ovarian stimulation with recombinant FSH and GnRH antagonist for IVF-ICSI treatment.

MAIN OUTCOME MEASURE(S)

Incidence of OHSS in GnRH antagonist cycles, predictive value of E2, and number of follicles on the day of hCG for OHSS occurrence.

RESULT(S)

Fifty-three patients were hospitalized because of OHSS (2.1%; 95% confidence interval [CI]:1.6-2.8). Early OHSS presented in 31 patients (1.2%; 95% CI: 0.9-1.8), whereas the late type was a complication in 22 patients (0.9%; 95% CI: 0.5-1.3). Late OHSS cases compared with the early OHSS cases always occurred in a pregnancy cycle (100% vs. 40%); had higher probability of being severe (72.7% vs. 42%), and more often were related to a multiple pregnancy (40% vs. 0). Receiver operating characteristic curve analysis for several E2 concentrations and number of follicles with a diameter of > or =11 mm revealed that the predictive value of the optimal threshold of > or =13 follicles (85.5% sensitivity; 69% specificity) was statistically significantly superior to the optimal threshold of 2,560 ng/L for E2 concentrations (53% sensitivity, 77% specificity) in identifying patients at risk for OHSS. Considering that severe OHSS represents the most clinically significant pattern, the combination of a threshold of > or =18 follicles and/or E2 of > or =5,000 ng/L yields a 83% sensitivity rate with a specificity as high as 84% for the severe OHSS cases.

CONCLUSION(S)

Clinically significant OHSS still remains a limitation of multifollicular ovarian stimulation for IVF even with the use of GnRH antagonist protocols. The number of follicles can discriminate the patients who are at risk for developing OHSS, whereas E2 concentrations are less reliable for the purpose of prediction. There is more than ever an urgent need for alternative final oocyte maturation-triggering medication.

Early and late ovarian hyperstimulation syndrome: early pregnancy outcome and profile

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) in IVF/ICSI cycles may occur either as an early (early onset) or a late pattern (late onset). This observational study was designed to identify whether the onset pattern of OHSS is associated with the occurrence of pregnancy and the early pregnancy outcome.

METHODS

Among 4376 consecutive IVF/ICSI cycles, 113 patients were hospitalized for OHSS after IVF/ICSI treatment and were included in the study. The setting was the Dutch-speaking Brussels Free University Hospital, between June 2000 and September 2002.

RESULTS

Early OHSS occurred in 53 patients, and late OHSS complicated 60 patients. A total of 96.7% of the late OHSS cases occurred in a pregnancy cycle and were more likely to be severe than the early cases (P < 0.05). Although in the early group there initially was a 41.5% positive HCG rate per cycle, the clinical pregnancy rate fell to 28.3% as a result of a significantly (P < 0.05) increased preclinical pregnancy loss rate compared with the non-OHSS patients (31.8 versus 88.3%, respectively). The ongoing pregnancy rate per cycle was 14.4% in the early and 26.4% in the late group. Multiple pregnancy rates were high in both groups (40 and 45.5%, respectively), but only in the late group did the incidence reach significance compared with the non-OHSS population (45.5 versus 29.1%, P = 0.02). Estradiol levels and number of follicles on the day of HCG were significantly higher in the early OHSS group. However, there was no difference in estradiol values on the day of hospital admittance between the two groups. In addition, the number of follicles on the day of HCG administration appears to be a better prognostic indicator for the occurrence of severe OHSS than the estradiol values (87% of the severe cases had > or = 14 or follicles of a diameter > or = 11 mm, whereas only 50% of them had an estradiol value > or = 3000 ng/l).

CONCLUSIONS

The early OHSS pattern is associated with exogenously administered HCG and a higher risk of preclinical miscarriage, whereas late OHSS may be closely associated with the conception cycles, especially multiple pregnancies, and is more likely to be severe. Further clarification of these two different clinical entities could have implications for research protocols as well as for preventive and management strategies for OHSS.

Adnexal mass with pelvic pain

In a pregnant woman who presents with acute pelvic pain and an adnexal mass, pregnancy-related etiologies, such as ectopic pregnancy or ovarian torsion, are typically the first diagnoses to be considered. Many other causes of pelvic pain associated with an adnexal mass can occur in pregnant patients, however. Some causes are benign and others require urgent management and treatment. Clinical presentation and physical examination can be misleading in pregnancy. The location of pain may be atypical for the pathologic entity, the pain may be muted, and in the case of infection, fever and leukocytosis can be absent. US examination is a safe and effective method for evaluating these patients. Sonographic characterization of adnexal masses may make a definitive diagnosis or focus the differential, which allows for prompt and appropriate treatment of patients.