The pathogenesis of ovarian hyperstimulation syndrome: a continuing enigma

Ovarian hyperstimulation syndrome-model rats; the manifestation and clinical implication

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of ovulation induction with the gonadotropins. Though vascular endothelial growth factor (VEGF) has been implicated as a prime causative factor of OHSS progression, other factors must also be involved in the pathogenesis of OHSS. We have established an experimental model of OHSS in immature female rats. The ovarian weights and vascular permeability of the OHSS model rats are significantly increased by the ovarian stimulation with human chorionic gonadotropin (hCG). hCG elicits VEGF production in OHSS model rat ovaries. The addition of potent synthetic progesterone antagonist RU486, which reduces the extension of OHSS, attenuates the ovarian kinin and VEGF production dose-dependently whereas the VEGF gene expression was stable. VEGF protein detected in both the lung and the liver of the OHSS model rats is not affected at 24 h after the addition of hCG and RU486 in contrast to the ovary. Our results demonstrate that progesterone is implicated in the development of OHSS, in part, to enhance the ovarian VEGF production by post-transcriptional and organ-specific control.

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

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

Ovarian hyperstimulation and oophorectomy following accidental daily clomiphene citrate use over three consecutive months

We describe the longest-known continuous use of clomiphene citrate ever reported in a human. As a result of a pharmacy error, a woman took 50 mg/day clomiphene citrate for three months. The prolonged use of this medication resulted in ovarian hyperstimulation and unilateral oophorectomy for torsion.

Evaluation and management of infertility in women: the internists' role

Interventions for infertility have greatly increased in number and sophistication. Women with multiple medical problems and women near or beyond menopause are now able to conceive. The internist will be called on to assess the risk that infertility interventions pose and to counsel patients accordingly. Knowledge of the medical illnesses associated with infertility, the types of infertility treatments available, and the medical complications of these interventions are required to properly assess this risk. Medical complications of infertility interventions can be direct effects of related drugs and technologies and indirect consequences of the induced pregnancy, multiple gestation, or associated medical conditions. This article reviews the definitions and scope of infertility, the interventions used for treatment of infertility, the medical complications of these interventions, the potential risks of fertility treatment in women unable to conceive spontaneously, and important issues for preconception counseling.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is an iatrogenic complication of assisted reproduction. In its most severe form, it is potentially fatal. The major clinical components are marked ovarian enlargement and increased capillary permeability leading to ascites, hydrothorax and pericardial effusion. Severe cases are associated with thromboembolic phenomena, respiratory distress and renal failure. The definitive pathophysiology is unknown. The available evidence would support a central role for inflammatory cytokines and angiogenic growth factors. Ultrasound examination and serum oestradiol values are currently used to predict patients at risk. The ideal treatment is prevention, but there has been only limited success. The main aims of treatment are to correct fluid imbalance, maintain renal perfusion and support the patient until the condition resolves. Drug therapy has a limited role, although anticytokine agents may prove useful.

Can we advise ovulation induction in patients with SLE?

The prognosis of systemic lupus erythematosus (SLE) has greatly improved during the last two decades, now allowing most patients to have a very long survival including a satisfactory quality of life. Initially considered contraindicated in SLE due to its overwhelming risks, pregnancy is nowadays allowed in a majority of patients, and fair results are usually obtained under appropriate management (1-3). Consequently, patients thought to have infertility ask the question of a possible therapy, i.e. ovulation induction (OI) associated or not with in vitro fertilization (IVF). Considering the importance of estrogens in the pathogenesis of the disease, the use of such procedures raise several questions in SLE. Though data remain to date extremely scarce, the theoretical and practical aspects of OI in SLE will be briefly reviewed here.