New insights into the pathophysiology of ovarian hyperstimulation syndrome. What makes the difference between spontaneous and iatrogenic syndrome?

Ovarian Hyperstimulation syndrome combined with hypothyroidism: a comprehensive review

Ovarian Hyperstimulation Syndrome (OHSS) is a systemic condition marked by the enlargement of the ovaries and heightened vascular permeability. And hypothyroidism (HT) emerges as a potential risk factor for OHSS occurrence. This review presented a comprehensive summary of pertinent case reports involving patients diagnosed with both HT and OHSS. Detailed exploration was conducted into their clinical presentations, diagnostic methodologies, and treatment modalities. Additionally, the review delved into potential interaction mechanisms between HT and OHSS, encompassing various aspects including hormone levels. Moreover, management strategies for mitigating the risk of OHSS in HT patients were thoroughly reviewed and the importance of monitoring thyroid function in those experiencing OHSS was emphasized. This review indicated that the association between HT and OHSS, underscoring its multifaceted complexity. It could accentuate the ongoing necessity for rigorous research and clinical refinement to deepen our comprehension of this association and to bolster diagnostic and therapeutic methodologies for optimal patient care. In conclusion, this review offered valuable insights for future research directions and clinical practices for patients afflicted with OHSS and HT.

Clinical characteristics of functioning gonadotroph adenoma in women presenting with ovarian hyperstimulation: Audit of UK pituitary centres

OBJECTIVE

Functioning gonadotroph adenomas (FGAs) are rare pituitary tumours stimulating ovarian function with potential life-threatening consequences in women. However, a lack of aggregated clinical experience of FGAs impairs management in affected women. The aim of this study is to present the clinical course of FGA-induced ovarian hyperstimulation syndrome (OHSS) cases as identified by some of the largest UK pituitary endocrine tertiary centres with a view to increasing awareness and improving diagnosis and management of women with FGA.

DESIGN

A retrospective observational study; audit of eight UK regional pituitary centres for cases of FGAs.

SETTING

Specialist neuroendocrine centres in the United Kingdom.

PATIENTS AND MEASUREMENTS

Women diagnosed with FGA-induced OHSS. Description of their clinical course.

RESULTS

Seven cases of FGA were identified in women, all causing OHSS. Mean age was 33.4 years at diagnosis. Abdominal pain, irregular periods, headache, and visual disturbances were reported at presentation by 100%, 71%, 57% and 43% of women, respectively. Three of seven women underwent ovarian surgery before FGA diagnosis. Six women underwent transsphenoidal surgery (TSS) with incomplete tumour resection in five of those, but all showed improvement or resolution in symptoms and biochemistry postoperatively.

CONCLUSION

FGA is a rare cause of spontaneous OHSS. TSS improves clinical and biochemical features of ovarian hyperstimulation in FGAs. Improved awareness of FGA will prevent inappropriate emergency ovarian surgery.

Spontaneous and iatrogenic ovarian hyperstimulation syndrome in the absence of FSHR mutations: a case report of two unexpected cases

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a complication of controlled ovarian hyperstimulation (COH). It is a potentially life-threatening condition that usually occurs either after human chorionic gonadotropins (hCG) administration in susceptible patients or as a result of an implanting pregnancy, regardless of whether it was achieved by natural conception or infertility treatments. Despite many years of clinical experience regarding the adoption of preventive measures and the identification of patients at high risk, the pathophysiology of OHSS is poorly understood and no reliable predictive risk factors have been identified.

CASES PRESENTATION

We report about two unexpected cases of OHSS following infertility treatments, occurring after freeze-all strategy with embryo cryopreservation approaches. The first case developed spontaneous OHSS (sOHSS), despite efforts to prevent its manifestation by a segmentation approach, including frozen embryo replacement cycle. The second case developed a late form of iatrogenic OHSS (iOHSS), even though the absence of any risk factors. No mutations in the follicle-stimulating hormone (FSH) receptor (FSHR)-encoding gene were detected, suggesting that the high levels of hCG due to the twin implanting pregnancies could be the only triggering factor of OHSS outbreak.

CONCLUSION

Freeze-all strategy with embryo cryopreservation cannot entirely prevent the development of OHSS, which may occur in its spontaneous form independently from the FSHR genotype. Although OHSS remains a rare event, all infertile patients requiring ovulation induction or controlled ovarian stimulation (COS) may be at potential risk of OHSS, either in the presence or in the absence of risk factors. We suggest closely monitoring cases of pregnancy following infertility treatments in order to provide early diagnosis and adopt the conservative management.

Tie1 contributes to the development of ovarian hyperstimulation syndrome under the regulation of EGR1 in granulosa cells

The expression of tyrosine kinase with immunoglobulin-like and epidermal growth factor-like domains 1 (Tie1), a transmembrane protein expressed almost exclusively by endothelial cells, has been reported in granulosa cells. However, its significance in ovarian hyperstimulation syndrome (OHSS), which can occur after the injection of gonadotropins in infertile women undergoing controlled ovarian stimulation, is unknown. Here, we report significantly increased Tie1 and vascular endothelial growth factor (VEGF) expression in cultured granulosa cells from OHSS patients, as well as ovaries from rats with experimentally established OHSS, compared to controls, with the levels of both proteins also increasing in granulosa and SVOG cells (a nontumorigenic human granulosa-lutein cell line) treated with an acute dose of human chorionic gonadotropin (hCG). Tie1 silencing abolished the hCG-induced VEGF level in SVOG cells and attenuated the progression of OHSS in rats, as determined by histological analysis. Further studies in SVOG cells revealed that the hCG-induced upregulation of Tie1 expression involved the phosphoinositide 3-kinase/protein kinase B signaling pathway. We also report that early growth response protein 1 (EGR1), whose expression was also upregulated by hCG, bound directly to the Tie1 promoter and activated its transcription. Taken together, our results indicate that Tie1 may be a therapeutic target in cases of moderate-to-severe OHSS. Further studies are needed to address its clinical relevance.

Onset of Spontaneous Ovarian Hyperstimulation Syndrome in the Third Trimester: Case Report

Ovarian hyperstimulation syndrome (OHSS) is a rare and occasionally fatal complication of ovulation induction. However, OHSS has occurred without interventional ovulation induction and in spontaneous ovulatory cycles. In most reported cases, physiological production of human chorionic gonadotropin was high, as in cases of multiple gestation, molar pregnancy, polycystic ovarian syndrome, and hypothyroidism. We report a very rare case of spontaneous OHSS in a healthy 36-year-old woman, gravida 5 para 2 + 2, 35 weeks pregnant, who had become pregnant naturally. According to our research, this is the first report of a case that occurred in the third trimester.

Ovarian Hyperstimulation Syndrome Complicating Spontaneous Molar Pregnancy: A Case Report and Review of the Literature

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is traditionally associated with fertility treatments and results in elevated human chorionic gonadotropin (βhCG) levels and fluid shifts to extravascular compartments. Rarely, spontaneous pregnancies with significant βhCG elevations, such as molar pregnancies, can give rise to OHSS.

CASE

A 24-year-old woman was diagnosed as having a molar pregnancy at approximately 12 weeks gestation following spontaneous conception. Her initial βhCG was over 1 million IU/L. There was no evidence of metastatic disease. She underwent an uncomplicated dilation and curettage. Three days later, she presented with chest pain, shortness of breath, and abdominal discomfort. Massively enlarged ovaries were identified with bilateral pleural effusions requiring repeated thoracentesis.

CONCLUSION

This case demonstrates rare sequelae of molar pregnancy. Treatment is mainly supportive, and close observation is required to manage complications. In patients with extremely elevated βhCG levels, clinicians must remain vigilant for signs suggesting OHSS, even following evacuation of the uterus.

Spontaneous Ovarian Hyperstimulation Syndrome: A Report of Two Cases from Different Pathogenesis

Spontaneous ovarian hyperstimulation syndrome (s-OHSS) is a rare finding that occurs in early pregnancy. There is a rapidly increasing ovarian size secreting vasoactive substances that lead to fluid shift into third spaces. This occurs in the absence of exogenous hormonal therapy. We present two cases of s-OHSS. A 35-year-old gravida 4 para 3 presented with complaints of progressive abdominal pain, distension, nausea, vomiting, and difficulty in breathing at 10 weeks gestation. On imaging, a singleton intrauterine gestation, enlarged ovaries containing multiple cysts, and moderate ascites were seen. Second, a 17-year-old primigravida presented with abdominal distension and pain and bleeding per vaginam following 4 months amenorrhea. A bulky uterus containing a large hyperechoic structure with multiple cystic spaces in keeping complete molar gestation and enlarged ovaries containing multiple cysts were seen on ultrasound imaging. The singleton gestation was managed successfully to term with conservative therapy tailored to clinical symptoms.

Spontaneous Ovarian Hyperstimulation Syndrome in a Partial Molar Pregnancy With Early Onset Severe Pre-eclampsia at 15 Weeks Gestation

Ovarian hyperstimulation syndrome is a well-known entity in assisted reproductive technology. However, it is unusual for this entity to occur without any medications that stimulate follicle stimulating hormone. Herein, we describe a case where a partial molar pregnancy with high human chorionic gonadotropin promiscuously activated follicle stimulating hormone receptors has resulted in spontaneous ovarian hyperstimulation syndrome. There are only eight other cases documented per our literature search of ovarian hyperstimulation syndrome in molar gestations, and this is the third report in partial molar gestation. In our case, it is an unique development of severe early onset pre-eclampsia in the second trimester. Our goal is to discuss the nuances in management of this entity as well as to add the available body of research on this subject.

The N680S variant in the follicle-stimulating hormone receptor gene identifies hyperresponders to controlled ovarian stimulation

OBJECTIVE

To study if the follicle-stimulating hormone receptor (FSHR) variant asparagine/serine in amino acid 680 (N680S) can predict hypersensitivity to gonadotropins in women undergoing assisted reproduction.

PATIENTS AND METHODS

In this retrospective study, 586 women undergoing their first in-vitro fertilisation treatment were enroled, and their FSHR N680S genetic variant was analysed. The main outcome measures were number of retrieved oocytes and any grade of ovarian hyperstimulation syndrome (OHSS). Experimental studies were performed on FSHR variants transfected into eukaryotic cells treated with 1-90 IU recombinant follicle-stimulating hormone. The receptors' ability to induce a second messenger 3',5'-cyclic AMP was measured.

RESULTS

The proportion of women who developed OHSS was 6% (n=36). None of the women who developed this condition had the homozygous serine variant. The N680S polymorphism in the FSHR was associated with the condition, Ptrend (genotype)=0.004 and Pallelic (alleles)=0.04. Mean oocyte number was 11±6 in women without OHSS and 16±8 in women who developed OHSS (P=0.001), despite exposure to lower total hormonal dose in the latter group. The odds ratio for developing OHSS in carriers of the asparagine allele was 1.7 (95% confidence interval: 1.025-2.839, P=0.04). A higher receptor activity in cells expressing asparagine compared with the serine was also evident at all concentrations of recombinant follicle-stimulating hormone used (P<0.05 for all).

CONCLUSION

This study confirms previous findings regarding higher hormonal sensitivity in carriers of asparagine in the N680S position. These women are at higher risk for OHSS during in-vitro fertilisation. Genetic testing could identify those at highest risk to develop this adverse effect.

What is the best predictor of severe ovarian hyperstimulation syndrome in IVF? A cohort study

PURPOSE

The purpose of the present study is to study what is the best predictor of severe ovarian hyperstimulation syndrome (OHSS) in IVF.

METHODS

This is a retrospective analysis of all consecutive IVF/intracytoplasmic injection cycles performed during a 5-year period (2009-2014) in a single university fertility centre. All fresh IVF cycles where ovarian stimulation was performed with gonadotrophins and GnRH agonists or antagonists and triggering of final oocyte maturation was induced with the administration of urinary or recombinant hCG were analyzed (2982 patients undergoing 5493 cycles). Because some patients contributed more than one cycle, the analysis of the data was performed with the use of generalized estimating equation (GEE).

RESULTS

Severe OHSS was diagnosed in 20 cycles (0.36%, 95% CI 0.20-0.52). The number of follicles ≥10 mm on the day of triggering final oocyte maturation represents the best predictor of severe OHSS in IVF cycles. The cutoff in the number of follicles ≥10 mm with the best capacity to discriminate between women that will and will not develop severe OHSS was ≥15.

CONCLUSION

The presence of more than 15 follicles ≥10 mm on the day of triggering final oocyte maturation represents the best predictor of severe OHSS in IVF cycles.

Interventions for the prevention of OHSS in ART cycles: an overview of Cochrane reviews

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) in assisted reproductive technology (ART) cycles is a treatment-induced disease that has an estimated prevalence of 20% to 33% in its mild form and 3% to 8% in its moderate or severe form. These numbers might even be higher for high-risk women such as those with polycystic ovaries or a high oocyte yield from ovum pickup.

OBJECTIVES

The objective of this overview is to identify and summarise all evidence from Cochrane systematic reviews on interventions for prevention or treatment of moderate, severe and overall OHSS in couples with subfertility who are undergoing ART cycles.

METHODS

Published Cochrane systematic reviews reporting on moderate, severe or overall OHSS as an outcome in ART cycles were eligible for inclusion in this overview. We also identified Cochrane submitted protocols and title registrations for future inclusion in the overview. The evidence is current to 12 December 2016. We identified reviews, protocols and titles by searching the Cochrane Gynaecology and Fertility Group Database of Systematic Reviews and Archie (the Cochrane information management system) in July 2016 on the effectiveness of interventions for outcomes of moderate, severe and overall OHSS. We undertook in duplicate selection of systematic reviews, data extraction and quality assessment. We used the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the quality of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables.

MAIN RESULTS

We included a total of 27 reviews in this overview. The reviews were generally of high quality according to AMSTAR ratings, and included studies provided evidence that ranged from very low to high in quality. Ten reviews had not been updated in the past three years. Seven reviews described interventions that provided a beneficial effect in reducing OHSS rates, and we categorised one additional review as 'promising'. Of the effective interventions, all except one had no detrimental effect on pregnancy outcomes. Evidence of at least moderate quality indicates that clinicians should consider the following interventions in ART cycles to reduce OHSS rates.• Metformin treatment before and during an ART cycle for women with PCOS (moderate-quality evidence).• Gonadotrophin-releasing hormone (GnRH) antagonist protocol in ART cycles (moderate-quality evidence).• GnRH agonist (GnRHa) trigger in donor oocyte or 'freeze-all' programmes (moderate-quality evidence). Evidence of low or very low quality suggests that clinicians should consider the following interventions in ART cycles to reduce OHSS rates.• Clomiphene citrate for controlled ovarian stimulation in ART cycles (low-quality evidence).• Cabergoline around the time of human chorionic gonadotrophin (hCG) administration or oocyte pickup in ART cycles (low-quality evidence).• Intravenous fluids (plasma expanders) around the time of hCG administration or oocyte pickup in ART cycles (very low-quality evidence).• Progesterone for luteal phase support in ART cycles (low-quality evidence).• Coasting (withholding gonadotrophins) - a promising intervention that needs to be researched further for reduction of OHSS.On the basis of this overview, we must conclude that evidence is currently insufficient to support the widespread practice of embryo cryopreservation.

AUTHORS' CONCLUSIONS

Currently, 27 reviews in the Cochrane Library were conducted to report on or to try to report on OHSS in ART cycles. We identified four review protocols but no new registered titles that can potentially be included in this overview in the future. This overview provides the most up-to-date evidence on prevention of OHSS in ART cycles from all currently published Cochrane reviews on ART. Clinicians can use the evidence summarised in this overview to choose the best treatment regimen for individual patients - a regimen that not only reduces the chance of developing OHSS but does not compromise other outcomes such as pregnancy or live birth rate. Review results, however, are limited by the lack of recent primary studies or updated reviews. Furthermore, this overview can be used by policymakers in developing local and regional protocols or guidelines and can reveal knowledge gaps for future research.

Cost effectiveness of letrozole and purified urinary FSH in treating women with clomiphene citrate-resistant polycystic ovarian syndrome: a randomized controlled trial

We aimed to compare the cost effectiveness of letrozole versus purified urinary follicle stimulating hormone (FSH) in treating patients with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). This was a randomized trial conducted in Cairo University and Beni-Suef University Hospitals, Egypt. A cohort of 140 eligible women was randomized to receive either letrozole 2.5 mg twice daily for five days, or FSH using a graduated regimen starting with a dose of 75 IU. Treatment was repeated for three months if pregnancy did not occur. There were no significant differences between the two treatments in the cumulative clinical pregnancy rate (30% vs. 34%; p = 0.578), cumulative ovulation rate (47% vs. 57%; p = 0.236), miscarriage rate (9% vs. 4%, p > 0.999) or multiple pregnancy rate (0% and 8%, p = 0.491) but the FSH cycles were 4.8 times more expensive. Letrozole and FSH were both effective in treating women with CC-resistant PCOS but letrozole was more cost effective.Study registration number: NCT02304107.

Placental mesenchymal dysplasia associated with spontaneous ovarian hyperstimulation syndrome

Placental mesenchymal dysplasia (PMD) is a rare disorder of unknown aetiology characterised by placentomegaly, serpiginous surface blood vessels and large cystic villi. Although a mimic of molar pregnancies and other entities, it can be distinguished from them by its association with intrauterine growth restriction or death of a relatively normal fetus and its characteristic histopathology. We report the case of a 20-year-old primigravida who presented at 16 weeks with heavy clotty vaginal bleeding and subsequent miscarriage. The placenta was grossly abnormal and resembled a partial molar pregnancy. PMD was confirmed by microscopic examination. Postmiscarriage, ultrasound revealed enlarged and multicystic ovaries similar to those seen in ovarian hyperstimulation syndrome (OHSS), which returned to normal a few weeks after miscarriage. This is the first report of PMD associated with OHSS, and we hypothesise that the most likely pathogenesis is ovarian stimulation from PMD-derived vascular endothelial growth factor.

Radiological illustration of spontaneous ovarian hyperstimulation syndrome

BACKGROUND

The role of radiology is of utmost importance not only in diagnosing s-OHSS but also in ruling out other cystic ovarian diseases and to determine the underlying etiology and course of the disease. We presented a radiological algorithm for diagnosing the various causes of s-OHSS.

CASE REPORT

A 26-year-old female, gravida one was referred to radiology department with history of lower abdominal pain, nausea and vomiting since 2 days which was gradual in onset and progression. The patient had no significant medical and surgical history.

CONCLUSIONS

This article illustrates and emphasizes that diagnosis of s-OHSS and its etiology can be completely evaluated radiologically. Biochemical markers will confirm the radiological diagnosis.

Role of the Extracellular and Intracellular Loops of Follicle-Stimulating Hormone Receptor in Its Function

Follicle-stimulating hormone receptor (FSHR) is a leucine-rich repeat containing class A G-protein coupled receptor belonging to the subfamily of glycoprotein hormone receptors (GPHRs), which includes luteinizing hormone/choriogonadotropin receptor (LH/CGR) and thyroid-stimulating hormone receptor. Its cognate ligand, follicle-stimulating hormone binds to, and activates FSHR expressed on the surface of granulosa cells of the ovary, in females, and Sertoli cells of the testis, in males, to bring about folliculogenesis and spermatogenesis, respectively. FSHR contains a large extracellular domain (ECD) consisting of leucine-rich repeats at the N-terminal end and a hinge region at the C-terminus that connects the ECD to the membrane spanning transmembrane domain (TMD). The TMD consists of seven α-helices that are connected to each other by means of three extracellular loops (ELs) and three intracellular loops (ILs) and ends in a short-cytoplasmic tail. It is well established that the ECD is the primary hormone binding domain, whereas the TMD is the signal transducing domain. However, several studies on the ELs and ILs employing site directed mutagenesis, generation of chimeric receptors and in vitro characterization of naturally occurring mutations have proven their indispensable role in FSHR function. Their role in every phase of the life cycle of the receptor like post translational modifications, cell surface trafficking, hormone binding, activation of downstream signaling, receptor phosphorylation, hormone-receptor internalization, and recycling of hormone-receptor complex have been documented. Mutations in the loops causing dysregulation of these processes lead to pathophysiological conditions. In other GPHRs as well, the loops have been convincingly shown to contribute to various aspects of receptor function. This review article attempts to summarize the extensive contributions of FSHR loops and C-terminal tail to its function.

Immunological and hemostasiological disorders in women with ovarian hyperstimulation syndrome

To assess the markers of destabilization of homeostasis in women with ovarian hyperstimulation syndrome (OHSS), the investigation of the levels of cortisol, markers of renin-angiotensin-aldosterone system, endothelin, proinflammatory cytokines, acute phase proteins, and parameters of hemostasis was performed. Our survey involved 105 women who became pregnant after IVF: 21 women with symptoms of the early moderate and severe OHSS, 28 women with the late moderate and severe OHSS, and 56 pregnant women undergoing IVF without symptoms of OHSS. It was found significant increase of levels of cortisol, interleukins, the number of leucocytes, concentration of fibrinogen and D-dimers in patients with early and late OHSS. The development of late OHSS is associated with the lower level of IL-8 and ceruloplasmin. The OHSS is characterized by leukocytosis, higher level of IL-6, TNF-α, fibrinogen, D-dimers, thus reflecting the homeostasis imbalance. The determination of the level of fibrinogen, D-dimers, leukocytes can be an important screening test of the intensity of the inflammatory process in patients with OHSS.

Ovary hyperstimulation syndrome accompanying molar pregnancy: case report and review of the literature

PURPOSE

To describe a naturally conceived woman with ovary hyperstimulation syndrome (OHSS) accompanying molar pregnancy and review the literature on this condition.

METHODS

We report a 31-year-old 2 parous naturally conceived woman with OHSS accompanying partial molar pregnancy. Dilatation and evacuation (D&E) were performed at 10 weeks of gestation. The signs and symptoms of OHSS were the severest on day 8 after D&E, when hCG had already decreased. This case is reported in detail. We also review the literature.

RESULTS

A literature search yielded seven cases of this condition. Any type of molar pregnancy, i.e., complete, partial, or invasive, can accompany OHSS. The initial manifestation of OHSS occurred at a median of the 12th week of gestation (range 7-16), which may be later compared with OHSS caused by ovulation induction. In all cases, OHSS aggravated after D&E.

CONCLUSIONS

We must be aware that OHSS can occur during molar pregnancy, and can be exacerbated after D&E.

Laparoscopic detorsion for bilateral ovarian torsion in a singleton pregnancy with spontaneous ovarian hyperstimulation syndrome

A 26-year-old primigravida with a singleton pregnancy of 9 weeks gestation presented with severe lower abdominal pain, following spontaneous hyperstimulation of the ovaries in a natural conception. Emergency laparoscopy was done and bilateral ovarian torsion with retained vascularity was noted. Bilateral detorsion with ovarian puncture and ovariopexy was performed. A review of international literature suggests that this is the first case reported with bilateral ovarian torsion following spontaneous ovarian hyperstimulation syndrome in a singleton pregnancy.

Spontaneous ovarian hyperstimulation syndrome in a triplet pregnancy

Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication, usually iatrogenic after ovulation induction. OHSS is a very rare event in spontaneously conceived pregnancies. Only few cases have been reported in literature to the best of our knowledge. We report a very rare case of spontaneous critical OHSS (according to classification of severity of OHSS as mentioned in Greentop guidelines no. 5, 2006) associated with triplet pregnancy in a 26-year-old woman suffering from severe abdominal pain, distension, and dyspnea. Our case highlights the importance of a strong suspicion for OHSS when a clinical presentation could not be explained by common medical conditions.

Ovarian hyperstimulation syndrome in a spontaneous pregnancy with invasive mole: report of a case

It is known that most cases of Ovarian Hyperstimulation Syndrome (OHSS) are associated with the therapies for ovulation induction. However, OHSS may rarely be associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism or polycystic ovary syndrome. We report a case of severe OHSS in spontaneous pregnancy with invasive mole in a 34 years old woman. The clinical picture showed abdominal pain, massive ascites, nausea, dyspnea and amenorrhea. After imaging examinations and laboratory tests, the diagnosis was established. The patient was managed expectantly with no complications. Although spontaneous ovarian hyperstimulation is a rare entity, it is important that the physician recognizes this condition. Prompt diagnosis and successful management is likely to avoid serious complications, which may develop rapidly.

Treatment options for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women. The clinical manifestation of PCOS varies from a mild menstrual disorder to severe disturbance of reproductive and metabolic functions. Management of women with PCOS depends on the symptoms. These could be ovulatory dysfunction-related infertility, menstrual disorders, or androgen-related symptoms. Weight loss improves the endocrine profile and increases the likelihood of ovulation and pregnancy. Normalization of menstrual cycles and ovulation could occur with modest weight loss as little as 5% of the initial weight. The treatment of obesity includes modifications in lifestyle (diet and exercise) and medical and surgical treatment. In PCOS, anovulation relates to low follicle-stimulating hormone concentrations and the arrest of antral follicle growth in the final stages of maturation. This can be treated with medications such as clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins or surgically by laparoscopic ovarian drilling. In vitro fertilization will remain the last option to achieve pregnancy when others fail. Chronic anovulation over a long period of time is also associated with an increased risk of endometrial hyperplasia and carcinoma, which should be seriously investigated and treated. There are androgenic symptoms that will vary from patient to patient, such as hirsutism, acne, and/or alopecia. These are troublesome presentations to the patients and require adequate treatment. Alternative medicine has been emerging as one of the commonly practiced medicines for different health problems, including PCOS. This review underlines the contribution to the treatment of different symptoms.

Thyroid function and human reproductive health

Via its interaction in several pathways, normal thyroid function is important to maintain normal reproduction. In both genders, changes in SHBG and sex steroids are a consistent feature associated with hyper- and hypothyroidism and were already reported many years ago. Male reproduction is adversely affected by both thyrotoxicosis and hypothyroidism. Erectile abnormalities have been reported. Thyrotoxicosis induces abnormalities in sperm motility, whereas hypothyroidism is associated with abnormalities in sperm morphology; the latter normalize when euthyroidism is reached. In females, thyrotoxicosis and hypothyroidism can cause menstrual disturbances. Thyrotoxicosis is associated mainly with hypomenorrhea and polymenorrhea, whereas hypothyroidism is associated mainly with oligomenorrhea. Thyroid dysfunction has also been linked to reduced fertility. Controlled ovarian hyperstimulation leads to important increases in estradiol, which in turn may have an adverse effect on thyroid hormones and TSH. When autoimmune thyroid disease is present, the impact of controlled ovarian hyperstimulation may become more severe, depending on preexisting thyroid abnormalities. Autoimmune thyroid disease is present in 5-20% of unselected pregnant women. Isolated hypothyroxinemia has been described in approximately 2% of pregnancies, without serum TSH elevation and in the absence of thyroid autoantibodies. Overt hypothyroidism has been associated with increased rates of spontaneous abortion, premature delivery and/or low birth weight, fetal distress in labor, and perhaps gestation-induced hypertension and placental abruption. The links between such obstetrical complications and subclinical hypothyroidism are less evident. Thyrotoxicosis during pregnancy is due to Graves' disease and gestational transient thyrotoxicosis. All antithyroid drugs cross the placenta and may potentially affect fetal thyroid function.

C-reactive protein as the indicator of severity in ovarian hyperstimulation syndrome

BACKGROUND

To establish correlations between laboratory findings and clinical symptoms of moderate and severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective study.

SETTING

Department of obstetrics and gynecology, public clinical hospital.

PATIENTS

Nineteen women admitted to the public hospital with a diagnosis of OHSS. The procedure of controlled ovarian stimulation (COH) was performed in the private assisted reproductive technology centre.

METHODS

Blood samples were collected, ultrasound examination of ovaries, abdominal circumference measurement were performed, intravenous crystalloids, plasma expanders such colloids and albumin were given. Correlations between mean laboratory results (haematocrit, c-reactive protein (CRP), white blood count, serum protein, serum albumin), ovarian size in ultrasound examination, abdominal circumference, and amount of albumin and hydroxyethyl starch transfused to the patient were assessed.

RESULTS

Significant correlation was observed between CRP concentration and abdominal circumference measured when the patient was admitted to the department, between CRP concentration and ovarian size measured during ultrasound examination at admission and between CRP concentration and body weight.

CONCLUSIONS

CRP can be a potential candidate to an indicator of OHSS severity.

Ovarian hyperstimulation syndrome (OHSS) due to mutations in the follicle-stimulating hormone receptor

Ovarian hyperstimulation syndrome (OHSS) is usually a complication of assisted reproductive techniques, more rarely an affection complicating a spontaneous gestation. The cause of hyper responsiveness of ovaries to the gonadotropins used in the controlled stimulation is still largely unknown. In contrast, a few cases of spontaneous hyperstimulation syndrome have been elucidated by the identification of mutations of the follicle-stimulating hormone (FSH) receptor, broadening its specificity and making it hypersensitive to human chorionic gonadotropin (hCG). Surprisingly, the mutations were located in the transmembrane domain of the receptor rather than in the extracellular hormone-binding site. No such mutation has been found in iatrogenic cases. However, allelic variants of the FSH receptors have been associated with the response to FSH in stimulation procedures, as well as with the severity of OHSS when present.

Spontaneous ovarian hyperstimuation syndrome in a naturally conceived singleton pregnancy

OBJECTIVE

To report the occurrence of a rare case of spontaneous ovarian hyperstimulation syndrome in a naturally conceived singleton pregnancy.

DESIGN

A case report.

SETTING

The Obstetric and Gynecology Department at King Fahd Central Hospital, Jazan City, Saudi Arabia.

PATIENT(S)

Our reported case was a middle-aged Egyptian woman presented in the second trimester of her first pregnancy with persistent abdominal pains, shortness of breath, vomiting, and diarrhea.

INTERVENTION(S)

The data were collected by full history taking, clinical examination, transabdominal ultrasonographic examination, and by revision of results of the patient's laboratory tests.

MAIN OUTCOME MEASURE(S)

The possible event of spontaneous ovarian hyperstimulation syndrome in a naturally conceived singleton pregnancy.

RESULT(S)

Our case was reported as a severe case of spontaneous ovarian hyperstimulation syndrome in a naturally conceived singleton pregnancy.

CONCLUSION(S)

This case report emphasizes the importance of thorough evaluation of all women presented with acute abdomen and ovarian masses during pregnancy. Although the condition is extremely rare, it is a potentially lethal in its severe form if not timely diagnosed and managed conservatively. With the increasing awareness of these conditions, more and more cases could be detected and reported.

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

The English-language literature was reviewed to examine the evidence base for strategies that have been used to prevent ovarian hyperstimulation syndrome (OHSS). Prediction of OHSS by pretreatment patient characteristics and ovarian response parameters is unreliable, with a significant number of OHSS cases occurring in patients not thought to be high risk, while the majority of 'high-risk' cycles do not result in OHSS. Alternatives to ovarian stimulation should always be considered, depending on the clinical situation. Monofollicular ovulation induction with a cautious step-up regime carries a lower risk of overstimulation than step-down regimes. In in vitro fertilization (IVF) cycles, a low starting dose of follicle-stimulating hormone (FSH) and the use of 5000 iu human chorionic gonadotrophin (hCG) for final follicular maturation may benefit patients at high risk of OHSS. The role of GnRH antagonists is unclear. In women with polycystic ovaries, who are undergoing ovarian stimulation for IVF, metformin co-treatment may reduce the risk of OHSS. Coasting of cycles with over-response is associated with a reduced risk of OHSS, although precise criteria for initiating and ending coasting are not definable at present. Elective cryopreservation of all embryos prevents late OHSS, but its value has been poorly researched. The literature does not support a role for intravenous albumin, administered around the time of oocyte retrieval, in preventing OHSS. Evidence is insufficient regarding a possible role for hexa-ethyl starch. hCG should not be used for luteal support, as it is associated with a higher risk of OHSS, and equivalent pregnancy rates are obtained with the use of progesterone.

Treatment for polycystic ovary syndrome: a critical appraisal of treatment options

The management of polycystic ovary syndrome (PCOS) usually spans a woman's reproductive years. While the treatment of symptoms is a primary concern, given its long-term nature, the benefits and potential risks need to be assessed and balanced. The variability of presentation coupled with the phenotypic diversity of this patient population, requires the individualization of treatment to each patient. Periodically, the regimen has to be modified owing to a desire for pregnancy, necessitating ovulation induction in this anovulatory group of women. Finally, for any treatment offered, consideration should be given to potential adverse effects on the fetus should spontaneous ovulation and unplanned pregnancy occur. This review highlights the current issues surrounding PCOS and provides a critical appraisal of treatment options.

Does elevated human chorionic gonadotropin alone trigger spontaneous ovarian hyperstimulation syndrome?

OBJECTIVE

To test whether elevated hCG alone triggers spontaneous ovarian hyperstimulation syndrome (sOHSS).

DESIGN

Retrospective analysis.

SETTING

Departments of obstetrics and gynecology and of medical genetics in an academic medical center.

PATIENT(S)

A patient with sOHSS and 109 patients with elevated hCG.

INTERVENTION(S)

Collecting blood samples.

MAIN OUTCOME MEASURE(S)

Follicle-stimulating hormone receptor gene sequence, levels of TSH and hCG.

RESULT(S)

We described a case of sporadic, nonfamilial sOHSS. Sequencing of the entire coding region the FSH gene revealed wild-type alleles for all the known mutations, and the A919G and A2039G polymorphisms, previously associated with good response to FSH stimulation and severe iatrogenic OHSS. We ruled out hypothyroidism. The level of hCG reached a peak of 344,350 IU/L (95th percentile). One hundred nine pregnancies with hCG of >150,000 IU/L were identified from 2001-2006. After patients with gestational trophoblastic diseases, multiple pregnancies, and iatrogenic OHSS were excluded, 27 patients remained. None of those patients experienced OHSS.

CONCLUSION(S)

Elevated hCG cannot be responsible for sOHSS as a single factor. Factors other than the hCG-FSH-receptor interaction additionally are involved in the pathogenesis of this syndrome. A combination of mechanisms may allow understanding of this enigmatic disorder. The pathophysiology of sOHSS, a rare phenomenon, has not yet been elucidated.

Prevention and management of ovarian hyperstimulation syndrome

The Ovarian Hyperstimulation Syndrome (OHSS) represents one of the biggest nightmares of all physicians involved in Assisted Reproductive Technologies (ART). Every year, several hundreds of women are hospitalized and to date several deaths have been reported. The pivotal event in the development of OHSS is the disruption of capillary integrity that results in leakage of intravascular fluid and proteins into third space. On the molecular level, human chorionic godadotropin (HCG) either exogenous or endogenous, functions as the triggering point for the production of vascular endothelial growth factor (VEGF) that is the main mediator to increase permeability on the vascular bed. Spontaneous OHSS has also been reported, either due to inappropriate activation of a mutant FSH receptor or due to very high levels of HCG during pregnancy. The available evidence on the several preventive and therapeutic approaches with special attention to level 1 evidence when available is also presented. OHSS is a self-resolving condition and the main role of the physician is to correct and maintain the intravascular volume, to support renal function and respiration and prevent thrombotic events. An algorithm on the management of OHSS on an outpatient basis and in the hospital is based on the previous mentioned principles.

Human albumin does not prevent ovarian hyperstimulation syndrome in assisted reproductive technology program: a prospective randomized placebo-controlled double blind study

We aimed to clarify the efficiency of IV human albumin in the prevention of ovarian hyperstimulation syndrome (OHSS). We found that human albumin at the described strength does not seem to either prevent or reduce the incidence of severe OHSS in high risk patients undergoing intracytoplasmic sperm injection (ICSI).

Estradiol induces heparanase-1 expression and heparan sulphate proteoglycan degradation in human endometrium

BACKGROUND

This study seeks to determine whether estrogen is able to regulate the expression of heparanase-1 (HPR1) in human endometrium.

METHODS

HPR1 expression and heparan sulphate (HS) deposition in the endometrium collected in various menstrual phases were analysed by immunohistochemical and immunofluorescence staining, respectively. HPR1 expression in the endometrial cells unexposed or exposed to estradiol was analysed by using RT-PCR and luciferase reporter assay. HPR1 activity was analysed by using a novel enzyme-linked immunosorbent assay (ELISA). Cell surface HS levels were analysed by flow cytometry. Serum HPR1 activity in women receiving follicle-stimulating hormone (FSH) for IVF was measured by ELISA.

RESULTS

HPR1 expression was rarely detected in the endometrium in the early and mid-proliferative phases but was increased in the late proliferative phase and in the secretory phases. HPR1 expression was negatively associated with HS in the basement membrane (BM) of the endometrial glands. HPR1 gene expression, HPR1 promoter activity and HPR1 enzymatic activity were increased in the endometrial cells when exposed to 17beta-estradiol (E(2)), whereas cell surface HS levels showed a decrease which could be blocked by PI-88, an HPR1 inhibitor. Serum HPR1 levels were increased in women with moderately elevated blood estrogen levels after receiving FSH.

CONCLUSIONS

HPR1 is differentially expressed in the endometrium in different menstrual phases. Estrogen plays an important role in inducing HPR1 expression, subsequently leading to HS degradation on the endometrial cell surface and in the BM of the endometrium.

Spontaneous Ovarian Hyperstimulation Syndrome in a Normal Singleton Pregnancy

OBJECTIVE

It is known that most cases of ovarian hyperstimulation syndrome (OHSS) are associated with the therapies for ovulation induction. However, OHSS may rarely be associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism or polycystic ovary syndrome.

CASE REPORT

A case of OHSS in a woman who became pregnant naturally and who had no underlying disease is presented here. The patient was managed expectantly with no complications.

CONCLUSION

Although spontaneous ovarian hyperstimulation is a rare entity, it is important to differentiate it from other causes of ovarian enlargement. Occasionally, life-threatening situations may occur, but it is usually a self-limiting process.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.