Review of the evidence base of strategies to prevent ovarian hyperstimulation syndrome

Does cabergoline administration affect endometrial VEGFR-2 expression in a rat model of ovarian hyperstimulation syndrome?

OBJECTIVE

To assess the effect of cabergoline on endometrial vascular endothelial growth factor receptor-2 (VEGFR-2) immunoexpression in an ovarian hyperstimulation syndrome (OHSS) rat model.

MATERIAL AND METHODS

Twenty-one immature female Wistar rats were assigned into three groups: group 1, the control group; group 2, stimulated with gonadotropins to mimic OHSS; and group 3, in which an OHSS protocol was induced and thereafter treated with cabergoline (100 μg/kg/day). Body weight, ovarian volume, corpora lutea numbers, and endometrial VEGFR-2 expression were compared between the groups.

RESULTS

Weight gain and ovarian volume were highest in the OHSS-placebo group, while cabergoline administration significantly reversed those effects (p = 0.001 and p = 0.001, respectively). VEGFR-2 stained cells were significantly lower in groups 2 and 3 compared to group 1 (p = 0.002). Although VEGFR-2 expression was lowest in group 3, the difference was not statistically significant. Corpora lutea numbers were also similar (p = 0.465).

CONCLUSION

While successful implantation requires a vascularized receptive endometrium, impaired expression of VEGFR-2 and disrupted endometrial angiogenesis due to cabergoline administration may be associated with IVF failure in fresh OHSS cycles. The insignificant decrease in endometrial VEGFR-2 expression observed in this research needs to be investigated by further studies involving additional techniques such as immunoblotting and/or RT-PCR analyses.

EGR1 Promotes Ovarian Hyperstimulation Syndrome Through Upregulation of SOX9 Expression

Angiogenesis is strongly associated with ovarian hyperstimulation syndrome (OHSS) progression. Early growth response protein 1 (EGR1) plays an important role in angiogenesis. This study aimed to investigate the function and mechanism of EGR1 involved in OHSS progression. RNA-sequencing was used to identify differentially expressed genes. In vitro OHSS cell model was induced by treating KGN cells with human chorionic gonadotropin (hCG). In vivo OHSS model was established in mice. The expression levels of EGR1, SOX1, and VEGF were determined by Quantitative Real-Time polymerase chain reaction (qRT-PCR), Western blot, immunofluorescence staining, and immunochemistry assay. The content of VEGF in the culture medium of human granulosa-like tumor cell line (KGN) cells was accessed by the ELISA assay. The regulatory effect of EGR1 on SRY-box transcription factor 9 (SOX9) was addressed by luciferase reporter assay and chromatin immunoprecipitation. The ERG1 and SOX9 levels were significantly upregulated in granulosa cells from OHSS patients and there was a positive association between EGR1 and SOX9 expression. In the ovarian tissues of OHSS mice, the levels of EGR1 and SOX9 were also remarkedly increased. Treatment with hCG elevated the levels of vascular endothelial growth factor (VEGF), EGR1, and SOX9 in KGN cells. Silencing of EGR1 reversed the promoting effect of hCG on VEGF and SOX9 expression in KGN cells. EGR1 transcriptionally regulated SOX9 expression through binding to its promoter. In addition, administration of dopamine decreased hCG-induced VEGF in KGN cells and ameliorated the progression of OHSS in mice, which were companied with decreased EGR1 and SOX9 expression. EGR1 has a promoting effect on OHSS progression and dopamine protects against OHSS through suppression of EGR1/SOX9 cascade. Our findings may provide new targets for the treatment of OHSS.

Dopamine agonists for preventing ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication of ovarian stimulation in assisted reproduction technology (ART). It is characterised by enlarged ovaries and an acute fluid shift from the intravascular space to the third space, resulting in bloating, increased risk of venous thromboembolism, and decreased organ perfusion. Most cases are mild, but forms of moderate or severe OHSS appear in 3% to 8% of in vitro fertilisation (IVF) cycles. Dopamine agonists were introduced as a secondary prevention intervention for OHSS in women at high risk of OHSS undergoing ART treatment.  OBJECTIVES: To assess the effectiveness and safety of dopamine agonists in preventing OHSS in women at high risk of developing OHSS when undergoing ART treatment.

SEARCH METHODS

We searched the following databases from inception to 4 May 2020: Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO for randomised controlled trials (RCTs) assessing the effect of dopamine agonists on OHSS rates. We also handsearched reference lists and grey literature.

SELECTION CRITERIA

We considered RCTs for inclusion that compared dopamine agonists with placebo/no intervention or another intervention for preventing OHSS in ART. Primary outcome measures were incidence of moderate or severe OHSS and live birth rate. Secondary outcomes were rates of clinical pregnancy, multiple pregnancy, miscarriage, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and full texts of publications; selected studies; extracted data; and assessed risk of bias. We resolved disagreements  by consensus. We reported pooled results as odds ratios (OR) and 95% confidence interval (CI) by the Mantel-Haenszel method. We applied GRADE criteria to judge overall quality of the evidence.

MAIN RESULTS

The search identified six new RCTs, resulting in 22 included RCTs involving 3171 women at high risk of OHSS for this updated review. The dopamine agonists were cabergoline, quinagolide, and bromocriptine. Dopamine agonists versus placebo or no intervention Dopamine agonists probably lowered the risk of moderate or severe OHSS compared to placebo/no intervention (OR 0.32, 95% CI 0.23 to 0.44; 10 studies, 1202 participants; moderate-quality evidence). This suggests that if the risk of moderate or severe OHSS following placebo/no intervention is assumed to be 27%, the risk following dopamine agonists would be between 8% and 14%. We are uncertain of the effect of dopamine agonists on rates of live birth (OR 0.96, 95% CI 0.60 to 1.55; 3 studies, 362 participants; low-quality evidence). We are also uncertain of the effect of dopamine agonists on clinical pregnancy, multiple pregnancy, miscarriage  or adverse events (very low to low-quality evidence). Dopamine agonists plus co-intervention versus co-intervention Dopamine agonist plus co-intervention (hydroxyethyl starch, human albumin, or withholding ovarian stimulation 'coasting') may decrease the risk of moderate or severe OHSS compared to co-intervention (OR 0.48, 95% CI 0.28 to 0.84; 4 studies, 748 participants; low-quality evidence). Dopamine agonists may improve rates of live birth (OR 1.21, 95% CI 0.81 to 1.80; 2 studies, 400 participants; low-quality evidence). Dopamine agonists may improve rates of clinical pregnancy and miscarriage, but we are uncertain if they improve rates of multiple pregnancy  or adverse events (very low to low-quality evidence). Dopamine agonists versus other active interventions We are uncertain if cabergoline improves the risk of moderate or severe OHSS compared to human albumin (OR 0.21, 95% CI 0.12 to 0.38; 3 studies, 296 participants; very low-quality evidence), prednisolone (OR 0.27, 95% CI 0.05 to 1.33; 1 study; 150 participants; very low-quality evidence), hydroxyethyl starch (OR 2.69, 95% CI 0.48 to 15.10; 1 study, 61 participants; very low-quality evidence), coasting (OR 0.42, 95% CI 0.18 to 0.95; 3 studies, 320 participants; very low-quality evidence), calcium infusion (OR 1.83, 95% CI 0.88 to 3.81; I² = 81%; 2 studies, 400 participants; very low-quality evidence), or diosmin (OR 2.85, 95% CI 1.35 to 6.00; 1 study, 200 participants; very low-quality evidence). We are uncertain of the effect of dopamine agonists on rates of live birth (OR 1.08, 95% CI 0.73 to 1.59; 2 studies, 430 participants; low-quality evidence). We are uncertain of the effect of dopamine agonists on clinical pregnancy, multiple pregnancy or miscarriage (low to moderate-quality evidence). There were no adverse events reported.

AUTHORS' CONCLUSIONS

Dopamine agonists probably reduce the incidence of moderate or severe OHSS compared to placebo/no intervention, while we are uncertain of the effect on adverse events and pregnancy outcomes (live birth, clinical pregnancy, miscarriage). Dopamine agonists plus co-intervention may decrease moderate or severe OHSS rates compared to co-intervention only, but we are uncertain whether dopamine agonists affect pregnancy outcomes. When compared to other active interventions, we are uncertain of the effects of dopamine agonists on moderate or severe OHSS and pregnancy outcomes.

Fertility outcomes in women after controlled ovarian stimulation with gonadotropin releasing hormone agonist long protocol: fresh versus frozen embryo transfer

Background

Along with progress in embryo cryopreservation, especially the vitrification, freeze all strategy has become more acceptable than ever. Some studies have found comparable or higher live birth rate with frozen embryo transfer (FET) than with fresh embryo transfer(ET)in gonadotropin releasing hormone antagonist (GnRH-ant) protocol. However from our literature research, there have been no reports about live birth rate comparison between fresh ET and FET with gonadotropin releasing hormone agonist (GnRH-a) long protocol. The aim of this study is to retrospectively investigate whether patients benefit from freeze all strategy in GnRH-a protocol using real-world data.

Methods

This is a retrospective cohort study, in which women undergoing fresh ET or FET with GnRH-a long protocol at Chongqing Reproductive and Genetics Institute from January 2016 to December 2018 were evaluated. The primary outcome was live birth rate. The secondary outcomes were implantation rate, clinical pregnancy rate, pregnancy loss and ectopic pregnancy rate.

Results

A total of 7,814 patients met inclusion criteria, implementing 5,216 fresh ET cycles and 2,598 FET cycles, respectively. The demographic characteristics of the patients were significantly different between fresh ET and FET groups, except BMI. After controlling for a broad range of potential confounders including age, infertility duration, BMI, AMH, number of oocytes retrieved and of available embryos, multivariate logistic regression analysis demonstrated that there was no significant difference in clinical pregnancy rate, ectopic pregnancy rate and pregnancy loss rate between two groups (all P > 0.05). However, the implantation rate and live birth rate in fresh ET group were significantly higher than FET group (P < 0.001 and P = 0.012, respectively).

Conclusions

Under GnRH-a long protocol, compared to FET, fresh ET was associated with higher implantation rate and live birth rate in infertile patients that underwent in vitro fertilization (IVF). The freeze all strategy should be individualized and made with caution especially with GnRH-a long protocol.

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.

Pathophysiology, treatment and prevention of ovarian hyperstimulation syndrome

PURPOSE OF REVIEW

Severe ovarian hyperstimulation syndrome (OHSS) is an iatrogenic condition that affects 1% of women that undergo treatment with assisted reproductive technology. The review aims to summarize recent evidence on pathophysiology, treatment, and prevention of OHSS.

RECENT FINDINGS

The pathophysiology is still not completely understood; however, vascular endothelial growth factor is likely to be an important mediator. Human chorionic gonadotropin was previously thought to be necessary for OHSS to occur; however, recent case reports have proven otherwise. The contribution of an attenuated anti-Mullerian hormone signalling pathway and CD11c + HLA-DR + dendritic cells and associated interleukins has been explored recently as contributors to pathogenesis.Treatment is largely supportive and is based mainly on consensus statements rather than evidence. Therefore, it is important to prevent this condition by identifying women at risk, allowing the clinician to implement preventive strategies, including the use of GnRH antagonist cycles with agonist triggers.

SUMMARY

More research is required to elucidate the pathophysiology behind the condition. Clinicians should employ strategies to prevent OHSS.

Management of ovarian stimulation for IVF: narrative review of evidence provided for World Health Organization guidance

In this paper, a review of evidence provided to the World Health Organization (WHO) guideline development, who prepare global guidance on the management of ovarian stimulation for women undergoing IVF, is presented. The purpose of ovarian stimulation is to facilitate retrieval of multiple oocytes during a single IVF cycle. Availability of multiple oocytes compensates for inefficiencies in subsequent stages of the cycle, which include oocyte maturation, IVF, embryo culture, embryo transfer, and implantation. Multiple embryos can be transferred in most women, and spare embryos can be frozen to allow for future chances of pregnancy without the need for repeated ovarian stimulation and oocyte retrieval. Our evidence synthesis team addressed 10 clinical questions on management of ovarian stimulation for IVF, prepared a narrative review of the evidence and drafted recommendations to be considered through WHO guideline development processes. Our main outcome measures were live birth, clinical pregnancy, and ovarian hyperstimulation syndrome.

Use of Point-of-Care Ultrasound for the Diagnosis of Ovarian Hyperstimulation Syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) occurs when ovaries are overstimulated and enlarged due to fertility treatments resulting in a shift of serum from the intravascular space to the third space, mainly the abdominal cavity. It is the most serious complication of ovarian hyperstimulation for assisted reproduction.

CASE REPORT

We present the case of a 40-year-old woman who presented with abdominal bloating and nausea 2 weeks after undergoing in vitro fertilization (IVF); she was diagnosed by an outside radiology ultrasound as having a ruptured ovarian cyst. A point-of-care emergency ultrasound performed by the emergency physician made the diagnosis of ovarian hyperstimulation syndrome. This led to more expedient management and obstetrical consultation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abdominal bloating and nausea are common presenting complaints in pregnant women. OHSS is a rare but potentially fatal complication of IVF. Recognition and early diagnosis by the emergency physician can lead to appropriate intervention and consultation.

Gonadotrophin-releasing hormone antagonists for assisted reproductive technology

BACKGROUND

Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without the hypo-oestrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotrophin release within several hours through competitive binding to pituitary GnRH receptors. This property allows their use at any time during the follicular phase. Several different regimens have been described including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of an oral contraceptive pill. Further, women receiving antagonists have been shown to have a lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable clinical outcomes for the antagonist and agonist protocols, these benefits would justify a change from the standard long agonist protocol to antagonist regimens. This is an update of a Cochrane review first published in 2001, and previously updated in 2006 and 2011.

OBJECTIVES

To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists compared with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycles.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched from inception to May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to 28 April 2015), Ovid MEDLINE (1966 to 28 April 2015), EMBASE (1980 to 28 April 2015), PsycINFO (1806 to 28 April 2015), CINAHL (to 28 April 2015) and trial registers to 28 April 2015, and handsearched bibliographies of relevant publications and reviews, and abstracts of major scientific meetings, for example the European Society of Human Reproduction and Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). We contacted the authors of eligible studies for missing or unpublished data. The evidence is current to 28 April 2015.

SELECTION CRITERIA

Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different GnRH agonist versus GnRH antagonist protocols in women undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted the data. The primary review outcomes were live birth and ovarian hyperstimulation syndrome (OHSS). Other adverse effects (miscarriage and cycle cancellation) were secondary outcomes. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for each comparison using GRADE methods.

MAIN RESULTS

We included 73 RCTs, with 12,212 participants, comparing GnRH antagonist to long-course GnRH agonist protocols. The quality of the evidence was moderate: limitations were poor reporting of study methods.Live birthThere was no conclusive evidence of a difference in live birth rate between GnRH antagonist and long course GnRH agonist (OR 1.02, 95% CI 0.85 to 1.23; 12 RCTs, n = 2303, I(2)= 27%, moderate quality evidence). The evidence suggested that if the chance of live birth following GnRH agonist is assumed to be 29%, the chance following GnRH antagonist would be between 25% and 33%.OHSSGnRH antagonist was associated with lower incidence of any grade of OHSS than GnRH agonist (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, n = 7944, I(2) = 31%, moderate quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is assumed to be 11%, the risk following GnRH antagonist would be between 6% and 9%.Other adverse effectsThere was no evidence of a difference in miscarriage rate per woman randomised between GnRH antagonist group and GnRH agonist group (OR 1.04, 95% CI 0.82 to 1.30; 33 RCTs, n = 7022, I(2) = 0%, moderate quality evidence).With respect to cycle cancellation, GnRH antagonist was associated with a lower incidence of cycle cancellation due to high risk of OHSS (OR 0.47, 95% CI 0.32 to 0.69; 19 RCTs, n = 4256, I(2) = 0%). However cycle cancellation due to poor ovarian response was higher in women who received GnRH antagonist than those who were treated with GnRH agonist (OR 1.32, 95% CI 1.06 to 1.65; 25 RCTs, n = 5230, I(2) = 68%; moderate quality evidence).

AUTHORS' CONCLUSIONS

There is moderate quality evidence that the use of GnRH antagonist compared with long-course GnRH agonist protocols is associated with a substantial reduction in OHSS without reducing the likelihood of achieving live birth.

Electroacupuncture decreases the progression of ovarian hyperstimulation syndrome in a rat model

This study aimed to elucidate the effect of electroacupuncture treatment on preventing early ovarian hyperstimulation syndrome (OHSS) and the potential mechanisms involved using an induced rat model. The ovarian response was examined by measuring ovary weight, vascular permeability, levels of inflammation (interleukin-6), tumour necrosis factor alpha, chemokine ligand 2 (also known as monocyte chemoactic protein 1), vascular endothelial growth factor and hormone concentrations (oestradiol, progesterone, testosterone and prolactin). Sprague-Dawley female rats underwent ovarian stimulation to induce OHSS. Hyperstimulated rats received consecutive electroacupuncture treatment from 3 days before the beginning of pregnant mare serum gonadotrophin treatment or the time point of pregnant mare serum gonadotrophin treatment respectively, and last until 3 days after HCG administration. Electroacupuncture treatment reduced ovary weight and vascular permeability in hyperstimulated rats. Electroacupuncture treatment also reduced the levels of serum steroid hormones (progesterone and testosterone), inflammatory cytokines (interleukin-6, tumour necrosis factor alpha and monocyte chemotactic protein 1 and vascular endothelial growth factor in hyperstimulated rats. The results indicate that electroacupuncture can modulate endocrine hormone secretion and affect the secretion of inflammatory cytokines and vascular endothelial growth factor, and thus prevent the progress of OHSS. Electroacupuncture may provide a simple and effective method for the prevention and treatment of OHSS.

Multicenter, noninterventional, post-marketing surveillance study to evaluate dosing of recombinant human follicle-stimulating hormone using the redesigned follitropin alfa pen in women undergoing ovulation induction

This prospective, noninterventional, post-marketing surveillance study evaluated doses of recombinant human follicle-stimulating hormone (r-hFSH) using the redesigned follitropin alfa pen in women who were anovulatory or oligomenorrheic and undergoing ovulation induction (OI) alone or OI with intrauterine insemination. The primary endpoint was the proportion of patients who achieved monofollicular or bifollicular development (defined as one or two follicles ≥15 mm). Secondary endpoints included characteristics of ovulation stimulation treatment, such as mean total and mean daily r-hFSH doses. Data were analyzed for 3,193 patients from 30 German fertility centers. The proportion of patients with monofollicular or bifollicular development was 71.1% (n=2,270 of a total of 3,193 patients; intent-to-treat population). The mean±standard deviation total and daily doses of r-hFSH were 696.9±542.5 IU and 61.7±29.4 IU, respectively. The three doses prescribed most frequently were: 37.5 IU (n=703 from N=3,189; 22.0%), 50.0 IU (n=1,056 from N=3,189; 33.1%), and 75.0 IU (n=738 from N=3,189; 23.1%) on the first day of stimulation; and 37.5 IU (n=465 from N=3,189; 14.6%), 50.0 IU (n=922 from N=3,189; 28.9%), and 75.0 IU (n=895 from N=3,189; 28.1%) on the last day of stimulation. This noninterventional, post-marketing surveillance study found that monofollicular or bifollicular development was achieved in 71% of patients studied and the small dose increment (12.5 IU) of the redesigned follitropin alfa pen allowed individualized treatment of women undergoing OI.

The prevention of ovarian hyperstimulation syndrome

OBJECTIVE

To review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its prevention.

OPTIONS

Preventative measures, early recognition, and prompt systematic supportive care will help avoid poor outcomes.

OUTCOMES

Establish guidelines to assist in the prevention of ovarian hyperstimulation syndrome, early recognition of the condition when it occurs, and provision of appropriate supportive measures in the correct setting.

EVIDENCE

Published literature was retrieved through searches of Medline, Embase, and the Cochrane Library from 2011 to 2013 using appropriate controlled vocabulary ([OHSS] ovarian hyperstimulation syndrome and: agonist IVF, antagonist IVF, metformin, HCG, gonadotropin, coasting, freeze all, agonist trigger, progesterone) and key words (ovarian hyperstimulation syndrome, ovarian stimulation, gonadotropin, human chorionic gonadotropin, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to February 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. The particular follicle-stimulating hormone formulation used for ovarian stimulation does not affect the incidence of ovarian hyperstimulation syndrome. (I) 2. Coasting may reduce the incidence of severe ovarian hyperstimulation syndrome. (III) 3. Coasting for longer than 3 days reduces in vitro fertilization pregnancy rates. (II-2) 4. The use of either luteinizing hormone or human chorionic gonadotropin for final oocyte maturation does not influence the incidence of ovarian hyperstimulation syndrome. (I) 5. There is no clear published evidence that lowering the human chorionic gonadotropin dose will result in a decrease in the rate of ovarian hyperstimulation syndrome. (III) 6. Cabergoline starting from the day of human chorionic gonadotropin reduces the incidence of ovarian hyperstimulation syndrome in patients at higher risk and does not appear to lower in vitro fertilization pregnancy rates. (II-2) 7. Avoiding pregnancy by freezing all embryos will prevent severe prolonged ovarian hyperstimulation syndrome in patients at high risk. (II-2) 8. Pregnancy rates are not affected when using gonadotropin-releasing hormone (GnRH) agonists in GnRH antagonist protocols for final egg maturation when embryos are frozen by vitrification for later transfer. (II-2) Recommendations 1. The addition of metformin should be considered in patients with polycystic ovarian syndrome who are undergoing in vitro fertilization because it may reduce the incidence of ovarian hyperstimulation syndrome. (I-A) 2. Gonadotropin dosing should be carefully individualized, taking into account the patient's age, body mass, antral follicle count, and previous response to gonadotropins. (II-3B) 3. Cycle cancellation before administration of human chorionic gonadatropin is an effective strategy for the prevention of ovarian hyperstimulation syndrome, but the emotional and financial burden it imposes on patients should be considered before the cycle is cancelled. (III-C) 4. Gonadotropin-releasing hormone (GnRH) antagonist stimulation protocols are recommended in patients at high risk for ovarian hyperstimulation syndrome (OHSS). The risk of severe OHSS in patients on GnRH antagonist protocols who have a very robust ovarian stimulation response can be reduced by using a GnRH agonist as a substitute for human chorionic gonadotropin to trigger final oocyte maturation. (I-B) 5. A gonadotropin-releasing hormone (GnRH) antagonist protocol with a GnRH agonist trigger for final oocyte maturation is recommended for donor oocyte and fertility preservation cycles. (III-C) 6. Albumin or other plasma expanders at the time of egg retrieval are not recommended for the prevention of ovarian hyperstimulation syndrome. (I-E) 7. Elective single embryo transfer is recommended in patients at high risk for ovarian hyperstimulation syndrome. (III-C) 8. Progesterone, rather than human chorionic gonadotropin, should be used for luteal phase support. (I-A) 9. Outpatient culdocentesis should be considered for the prevention of disease progression in severe ovarian hyperstimulation syndrome. (II-2B).

Severe ovarian hyperstimulation syndrome complicated by Stenotrophomonas maltophilia peritonitis: a case report and literature review

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic disorder resulting from ovulation induction. Although the occurrence of this disorder is rare, it can be potentially life-threatening in its most severe forms. We herein present the case of a young nulliparous woman who presented with features of abdominal compartment syndrome and was subsequently diagnosed with severe OHSS. All physicians, in particular critical care doctors, must be aware of this rare, but potentially life-threatening iatrogenic disorder.

Anticoagulation and in vitro fertilization and ovarian stimulation

Assisted reproductive technology is widely used to treat couples affected by infertility. Complications associated with assisted reproduction include venous thromboembolism, ovarian hyperstimulation syndrome, and recurrent implantation failure. It has also been proposed that thrombophilia may be associated with an increased likelihood of these events. Although data are limited, antithrombotic therapy is frequently used to enhance the likelihood of successful assisted reproduction. This chapter reviews the risks of venous and arterial thromboembolism associated with assisted reproduction, as well as available data regarding the impact of thrombophilia on the risks of thromboembolism and failure of implantation. The role of antithrombotic therapy in reducing the likelihood of these events, along with recommendations from various guidelines, are also discussed.

A guide to understanding polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder affecting women of reproductive age. Some 20% of women will have polycystic ovaries on an ultrasound scan and around 7% of women have the additional clinical or biochemical features of PCOS. As a complex multisystem disorder its background can be confusing to understand. They key feature, however, is an increased production of androgen by the ovaries. This review uses ovarian biology to describe a strategy to aid understanding and explanation of PCOS. This framework can be also be used to teach about PCOS and to inform different approaches to its management.

A potential novel strategy, inhibition of vasopressin-induced VEGF secretion by relcovaptan, for decreasing the incidence of ovarian hyperstimulation syndrome in the hyperstimulated rat model

OBJECTIVE

To investigate the effects of V1A receptor antagonist through inhibition of vasopressin-induced VEGF secretion in an experimental model.

STUDY DESIGN

Thirty rats were randomly divided into five groups. Four groups were given 10IU pregnant mare serum gonadotropin/day (sc) at 8:00-8:30am on days 22-25 of life. They were administered 30IU hCG at 8:00-8:30am on day 26 of life. On days 26 and 27 of life at 8:00am and 4:00pm, (ip) per animal, 50μg/kg/day GnRH antagonist in the GnRH antagonist group, 0.3mg relcovaptan in the high dose relcovaptan group, and 0.15mg relcovaptan in the low dose relcovaptan group were administered. The control group was given the same dosage of 0.9% saline solution (ip) on days 22-26 day of life. The main outcomes were weight gain, ovarian weights, peritoneal fluid VEGF values, corpus luteum count, and atretic follicle count.

RESULTS

Weight gain was highest in the OHSS group; it was almost twice as much in the OHSS group than it was in the control group. Ovarian weights were significantly lower in all treatment groups (p=0.03). There was no statistically significant difference in ovarian weights between the GnRH antagonist and relcovaptan groups (p=0.176). The evaluation of peritoneal fluid VEGF-A levels revealed statistically significant differences between levels in the treatment groups and in the OHSS group (p=0.005). Atretic follicle count in the OHSS group was significantly lower (p=0.048). In all treatment groups, CL counts were prominently lower than they were in the OHSS group (p=0.002).

CONCLUSION

Relcovaptan may be a novel strategy for decreasing risk of OHSS by inhibition of vasopressin-induced VEGF secretion through V1A receptor antagonist.

Targeting angiogenesis in the pathological ovary

The ovary is a key tissue in the study of physiological neo-vascularisation in the adult and its study has highlighted important molecules involved in the regulation of angiogenesis in vivo. These include vascular endothelial growth factor, delta-like ligand 4, thrombospondin-1, prokineticin-1 and prostaglandin E2. Targeting these molecular pathways has therapeutic potential and their manipulation has an increasing preclinical and clinical role in the management of the pathological ovary. Targeting angiogenic pathways has utility in the promotion of ovarian angiogenesis to improve tissue and follicle survival and function as well as the prevention and management of ovarian hyperstimulation syndrome. There is a theoretical possibility that targeting angiogenesis may improve the function of the polycystic ovary and a real role for targeting angiogenesis in ovarian cancer.

Prospective analysis of ovarian reserve markers as determinant in response to controlled ovarian stimulation in women undergoing IVF cycles in low resource setting in India

INTRODUCTION

The objective of this study was to determine whether ovarian reserve markers can predict ovarian response in women undergoing their first cycle of assisted reproduction.

MATERIALS AND METHODS

This prospective observational study included 292 infertile patients undergoing their first IVF trial in the Assisted Reproductive Unit in a tertiary care hospital. Day 2 follicle stimulating hormone (FSH), Inhibin B, anti-Mullerian hormone (AMH), antral follicle count (AFC) and ovarian volume was measured before commencement of controlled ovarian hyperstimulation. The main outcome measures were oocytes retrieved and this was correlated with ovarian reserve markers.

RESULTS

The mean age was 31.8 (±4.4) years and mean duration of infertility 8.2 (±3.9) years. The correlation between oocytes retrieved and age, day 2 FSH, Inhibin B, AMH, AFC and volume of the ovary was calculated. A negative correlation was found with age (r = -0.22, p < 0.001) and day 2 FSH (r = -0.35, p < 0.001). A positive correlation was seen with AMH (r = 0.15, p = 0.022), AFC (r = 0.48, p < 0.05) and volume (r = 0.17, p = 0.009). In the bivariate analysis, 1 year increase in age was found to decrease the oocytes retrieved count by 0.37 with a significant p value. The independent significant factors found in multiple linear regression analysis were day 2 FSH and AFC.

DISCUSSION

The present study concludes that day 2 FSH and AFC are promising biomarkers for ovarian reserve in predicting ovarian response to gonadotropin stimulation in IVF patients.

Cabergoline as treatment of ovarian hyperstimulation syndrome: a review

One of the most serious complications of assisted reproduction techniques is ovarian hyperstimulation syndrome (OHSS). OHSS not only increases morbidity and mortality in IFV cycles, but also causes significant other problems, as cancelled in vitro fertilization (IVF) cycles, prolonged hospitalization, causing emotional and sociofinancial consequences. Several treatments for OHSS have been proposed and among these Cabergoline (Cb2). Despite the above-mentioned beneficial effect, Cb2 has not been widely used in everyday's clinical practice. With our study, we try to review all studies with strong evidence examining Cb2 use for OHSS prevention.

The diagnosis and management of ovarian hyperstimulation syndrome

OBJECTIVE

To review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its diagnosis and clinical management.

OUTCOMES

These guidelines will assist in the early recognition and management of ovarian hyperstimulation. Early recognition and prompt systematic supportive care will help avert poor outcomes.

EVIDENCE

Medline, Embase, and the Cochrane database were searched for relevant articles, using the key words "ovarian hyperstimulation syndrome" and "gonadotropins," and guidelines created by other professional societies were reviewed.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

RECOMMENDATIONS

1. Once the diagnosis of ovarian hyperstimulation syndrome is made, disease severity should be classified as mild, moderate, severe, or critical. (III-B) 2. The physician prescribing gonadotropins should inform each woman of her personal risk for ovarian hyperstimulation syndrome. (III-A) 3. In areas where patients do not have ready access to physicians familiar with the diagnosis and management of ovarian hyperstimulation syndrome, the physician prescribing gonadotropins should ensure that women are made aware that they should contact a physician or a member of the team within the hospital unit who has relevant experience, should the need arise. (III-B) 4. Outpatient management is recommended for women with mild and moderate ovarian hyperstimulation syndrome. If outpatient management for more severe ovarian hyperstimulation syndrome is to be undertaken, the physician should ensure that the woman is capable of adhering to clinical instructions and that there is a system in place to assess her status every 1 to 2 days. (III-A) 5. Paracentesis should be performed in admitted patients with tense ascites to alleviate their discomfort. (II-2B) 6. Outpatient culdocentesis should be considered for the prevention of disease progression in moderate or severe ovarian hyperstimulation syndrome. (II-2B) 7. Women with severe and critical ovarian hyperstimulation syndrome should be admitted to hospital for intravenous hydration and observation. (III-A) 8. Intravenous hydration should be initiated with a crystalloid solution to prevent hemoconcentration and provide adequate end-organ perfusion. If end-organ perfusion is not maintained with a crystalloid solution, an alternate colloid solution should be administered. (II-2B) 9. Pain relief in admitted patients should be managed with acetaminophen and/or opioid analgesics. (III-B) Non-steroidal anti-inflammatory drugs with antiplatelet properties should not be used. (III-B) 10. Women with severe ovarian hyperstimulation syndrome should be considered for treatment with prophylactic doses of anticoagulants. (II-2B) 11. Critical ovarian hyperstimulation syndrome should be managed by a multidisciplinary team, according to the end organ affected. (III-C).

Comparison of cabergoline and intravenous albumin in the prevention of ovarian hyperstimulation syndrome: a randomized clinical trial

PURPOSE

To compare the efficacy of cabergoline (Cb2) and intravenous human albumin (HA) in the prevention of ovarian hyperstimulation syndrome.

METHODS

In this randomized controlled trial study, 138 women who were at high risk for developing OHSS were randomly allocated into two groups. In Group one, 20 gr of HA 20% was infused over 1 h. Group two received 0.5 mg per day of Cb2 orally for 7 days, starting on oocyte pickup day. All patients were visited seven and 14 days after oocyte retrieval to determine early clinical or ultrasound evidence of OHSS.

RESULTS

Moderate OHSS was observed in 33 versus 14 cases in the HA and Cb2 groups, respectively, which was significantly different. The number of severe OHSS cases in the HA group was significantly higher than in the Cb2 group (P < 0.001).

CONCLUSIONS

Prophylactic oral low dose cabergoline was more effective and less costly than intravenous human albumin in the prevention of OHSS in high-risk patients.

Rapid determination of serological cytokine biomarkers for hepatitis B virus-related hepatocellular carcinoma using antibody microarrays

Hepatocellular carcinoma (HCC) is one of the most frequent tumors worldwide with an increasing incidence. The exploration of biomarkers for HCC is one of the main aims for improving the efficacy of diagnosis and treatment. The microarray technology provides a high-throughput platform for parallel exploration of biomarkers for clinics. In this study, we used antibody microarrays to screen the novel cytokine biomarkers of hepatitis B virus (HBV)-related HCC. Cytokine-secreting patterns in sera were determined from 109 cases including 43 HBV-related HCC patients, 33 chronic hepatitis B patients, and 33 normal controls by RayBio Biotin label-based human antibody array. The correlation analysis was performed with conventional clinical diagnostic biomarkers, including serum alanine aminotransferase, alpha-fetoprotein (AFP) and hepatitis B surface antigen. Our results showed that in HBV-related HCC group, which had the highest percentage of AFP positive (>20 ng/ml) ratio, six cytokines were found differentially expressed in HCC patients (P < 0.05), compared with either normal controls or chronic hepatitis B group. Two macrophage-related cytokines, macrophage-derived chemokine (MDC) and macrophage-stimulating protein α (MSPα), displayed significant difference in the HCC group. Furthermore, an HCC diagnostic model for prediction was constructed, by which the combination of MDC and MSPα together with AFP had improved the diagnostic sensitivity from 60% (AFP alone) to 73.2% with similar specificity. Our results suggested that MDC and MSPα screened by antibody microarrays might serve as novel cytokines biomarkers for potential auxiliary diagnosis of HBV-related HCC.

Heterosexual couples’ uses and meanings of ovarian stimulation: Relatedness, embodiment and emotions

This article is about how ovarian stimulation is understood within the context of heterosexual couples’ relationships. The empirical research involves 15 semi-structured interviews with patients in Portugal who have undergone IVF programmes performed with eggs collected in stimulated cycles. We argue that the uses and meanings of ovarian stimulation expressed in the patients’ narratives represent situated values and knowledges conveyed by existing emotional resources within multiple gendered relations and identities. We discuss how empirical reconfigurations work in a mode of conversion of physical and emotional pain so that the application of subcutaneous injections to women’s bodies makes sense within IVF couples’ daily routine and in their conjugal relationship. The different practices of men’s involvement in the injection of hormones into women’s bodies are perceived as emotional moments, and men’s cooperation and/ or protection seems to be essential in this domain. The cultural assumptions underlying women’s duties regarding maternity reinforce a moral framework in which the pain and the complications associated with the ovarian stimulation are naturalized, normalized and accepted.

Multi-marker assessment of ovarian reserve predicts oocyte yield after ovulation induction

BACKGROUND

Many hormone and ultrasound measurements have been assessed as possible markers of ovarian reserve and to identify potential poor responders to ovulation induction. The objective of this study is to determine whether multiple biomarkers measured in blood samples collected immediately before commencement of ovulation induction for IVF can predict the outcome of ovarian stimulation.

METHODS

We conducted a prospective observational study, including 356 unselected women undergoing ovulation induction/IVF at two centers. Anti-Müllerian hormone (AMH), inhibin B and FSH were measured before commencement of ovulation induction. The main outcome measures were the number of oocytes retrieved and pregnancy outcome.

RESULTS

Univariate analyses showed that age, FSH, inhibin B and AMH were significant predictors for poor oocyte yield. AMH presented the highest receiver operating characteristic area under the curve (ROC(AUC)) of 0.827 indicating a good discriminating potential for predicting poor ovarian response, followed by FSH with an ROC(AUC) of 0.721. In the multivariate analysis, the variables age, FSH and AMH remained significant and the resulting model provided a high ROC(AUC) of 0.819. Women with an ovarian reserve test of <0.3 have more than a 75% chance of having their treatment cycle canceled, but a value over 0.73 indicates a 38% chance of pregnancy. Number of oocytes and oocyte yield per unit FSH administered were correlated with log model for no pregnancy (r = -0.217, P < 0.001 and r = -0.367, P < 0.001, respectively) but had limited predictive value.

CONCLUSIONS

A derived estimate of ovarian reserve demonstrated superior ability for predicting oocyte yield after ovulation induction when compared with any single endocrine marker (AMH, inhibin B, FSH).

Proposed oocyte donation guidelines for stem cell research

To expand the availability of stem cell lines suitable for basic research and clinical application, somatic cell nuclear transfer has been proposed and will require human oocyte donation. The recommendations made by the California Institute of Regenerative Medicine advisory committee on oocyte donation are based on peer-reviewed, best practices, and best clinical judgment and are intended to assist researchers in design and Institutional Review Board (IRB) evaluation of research protocols for oocytes donated exclusively for research purposes.

A woman with polycystic ovary syndrome treated for infertility by in vitro fertilization

BACKGROUND

A 25-year-old South Asian woman presented at an infertility unit with a 2-year history of anovulatory infertility. She had experienced irregular and infrequent periods for over a decade.

INVESTIGATIONS

Endocrine profile (follicle-stimulating hormone, luteinizing hormone, thyroid-function test, prolactin, testosterone), oral glucose tolerance test and pelvic ultrasonography were performed.

DIAGNOSIS

Polycystic ovary syndrome, in accordance with the recent Rotterdam consensus (2004) criteria.

MANAGEMENT

The patient failed to conceive by conventional ovulation-induction therapies with clomifene and gonadotropins. She subsequently underwent an in vitro fertilization cycle, to which she over-responded and developed a severe form of ovarian hyperstimulation syndrome. The diagnosis of ovarian hyperstimulation syndrome was based on clinical and ultrasonographic features. She was hospitalized and needed extensive supportive care, including insertion of chest and abdominal drains.

Ovarian stimulation for ovulation induction and in vitro fertilization in patients with systemic lupus erythematosus and antiphospholipid syndrome

OBJECTIVE

To review the current evidence regarding the relationship between systemic lupus erythematosus (SLE) and antiphospholipid syndrome and female infertility, as well as the risks associated with ovarian stimulation for ovulation induction and IVF. To establish, based on this information, guidelines for safe and successful assisted reproductive technology (ART).

DESIGN

A MEDLINE computer search was performed to identify relevant articles.

RESULT(S)

Systemic lupus erythematosus and antiphospholipid syndrome are not related to infertility, except for cases of amenorrhea accompanying severe flares, renal insufficiency-related hypofertility, and ovarian failure secondary to cyclophosphamide (CTX) therapy. The most threatening conditions in affected women undergoing ovarian stimulation are lupus flares and thrombosis, with the latter being especially associated with the occurrence of an overt ovarian hyperstimulation syndrome (OHSS). Friendly ovarian stimulation, single embryo transfer, avoidance of OHSS, administration of coadjuvant therapy, and use of natural E(2) or P through a nonoral route may constitute the safest approach. Systemic lupus manifested in acute flares, badly controlled arterial hypertension, pulmonary hypertension, advanced renal disease, severe valvulopathy or heart disease, and major previous thrombotic events are situations on which to discourage ART, especially due to the high risk of complications for both mother and fetus during pregnancy and puerperium.

CONCLUSION(S)

Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well-selected women with SLE and antiphospholipid syndrome.

Approaches to improve the diagnosis and management of infertility

BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.

Can quantitative three-dimensional power Doppler angiography be used to predict ovarian hyperstimulation syndrome?

OBJECTIVE

To test the hypothesis that ovarian vascularity is increased in women developing ovarian hyperstimulation syndrome (OHSS) and to assess its value as a predictor of OHSS during in-vitro fertilization (IVF).

METHODS

118 subjects undergoing their first cycle of IVF had a three-dimensional (3D) transvaginal ultrasound scan in the early follicular phase of the menstrual cycle preceding IVF treatment. 18 of them developed moderate or severe OHSS and 100 subjects had normal ovarian response. Antral follicle count, ovarian volume, and ovarian vascularity (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were compared between OHSS and control groups. Multiple regression analysis was used to assess the predictive value of these variables against age, body mass index and basal follicle-stimulating hormone level for the development of OHSS.

RESULTS

The ovarian blood flow indices VI (11.1 +/- 11.6 vs. 8.6 +/- 7.3%; P = 0.23), FI (38.0 +/- 4.8 vs. 38.0 +/- 5.5; P = 0.95) and VFI (4.2 +/- 3.3 vs. 3.5 +/- 3.1; P = 0.40) were similar in the OHSS group and the normal responders. While antral follicle count was significantly higher in women developing OHSS (33.0 +/- 15.1) than in the control group (19.2 +/- 9.9, P < 0.001), ovarian volume did not differ between the two groups (10.6 +/- 3.8 vs. 8.9 +/- 4.8 cm(3), respectively, P = 0.11). On multiple regression analysis, antral follicle count was the only significant predictor of OHSS (P < 0.01).

CONCLUSIONS

Women developing OHSS during IVF do not demonstrate an increased ovarian blood flow as measured by 3D ultrasound but do have a significantly higher antral follicle count, which is the only significant predictor of OHSS.

Molecular mechanisms of ovarian hyperstimulation syndrome: paracrine reduction of endothelial claudin 5 by hCG in vitro is associated with increased endothelial permeability

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of ovarian stimulation associated with severe vascular hyperpermeability. Primary co-cultures of human luteinized granulosa cells (LGCs) and human umbilical vein endothelial cells (HUVECs) were used as a model of steroidgenic/endothelial cell interaction in OHSS.

METHODS

hCG and the vascular endothelial growth factor (VEGF) inhibitor, Flt-1Fc, were added to co-cultures of LGCs and HUVECs separated by a micropore membrane. Endothelial permeability to labeled bovine serum albumin was measured and the expression of the endothelial cell-specific adhesion protein claudin 5 was investigated using immunocytochemistry and western blotting.

RESULTS

The addition of hCG increased HUVEC permeability in the presence of LGCs (P < 0.05). hCG increased VEGF concentrations in both chambers of the co-culture system (P < 0.05). The increased permeability in the presence of LGCs and hCG was inhibited when VEGF was blocked by Flt-1Fc (P < 0.05). Endothelial membrane claudin 5 protein was reduced in the presence of hCG and LGCs, as measured by immunocytochemistry (P < 0.05) and western blotting (P < 0.05) and this reduction was inhibited by Flt-1Fc. hCG had no direct effects on endothelial cell claudin 5.

CONCLUSIONS

For OHSS, this novel paradigm suggests that hCG can increase endothelial permeability by up-regulating VEGF in LGCs which causes reduction in endothelial claudin 5 expression.

Doxycycline inhibits vascular leakage and prevents ovarian hyperstimulation syndrome in a murine model

OBJECTIVE

To determine whether doxycycline would inhibit the development of ovarian hyperstimulation syndrome (OHSS) in a murine model.

DESIGN

Testing the effect of oral doxycycline treatment on gonadotropin-induced peritoneal capillary leakage in mice.

SETTING

Animal research facility.

ANIMAL(S)

Four-week-old female C57Bl/6 mice.

INTERVENTION(S)

Ovarian hyperstimulation syndrome was induced in mice by administering gonadotropins for 3 days followed by human chorionic gonadotropin. Peritoneal vascular leakage was quantified using the Miles vascular permeability assay. Mice were treated with daily oral doxycycline or vehicle.

MAIN OUTCOME MEASURE(S)

The concentration of dye in abdominal fluid extracted by peritoneal lavage was measured spectrophotometrically. Ascites volume was determined using dye dilution.

RESULT(S)

Doxycycline inhibited peritoneal vascular leakage and ascites accumulation in the hormonally stimulated mice. Doxycycline treatment did not inhibit ovarian stimulation or ovulation when compared with controls, as indicated by similar ovarian morphology, ovarian weights, and corpora lutea counts. Importantly, vessel density within the corpora lutea was similar in the two groups.

CONCLUSION(S)

Doxycycline prevents OHSS in a murine model without compromising ovarian stimulation. This effect is caused by inhibition of vascular leakage. Doxycycline's potential in preventing human OHSS is promising and warrants further studies.

[The use of GnRH antagonists in ovarian stimulation for intrauterine inseminations: is there any interest?]

The use of the GnRH antagonists during ovarian stimulation for intrauterine insemination is relatively recent. The primary aim was to improve the timing of the inseminations on working days. However, according to published data, the consequences on pregnancy rate remain uncertain. Moreover, the impact of this strategy on stimulation's parameters, specifically on the size of the follicle cohort, should be better assessed.