Ovarian hyperstimulation syndrome: facts and fallacies

Ovarian hyperstimulation syndrome in a bitch caused by recombinant human chorionic gonadotropin treatment of suspected luteal insufficiency – a case report

Two bitches with a history of hypoluteoidism were treated by recombinant human chorionic gonadotropin (r-hCG) in repeated doses during early dioestrus. The level of progesterone increased, but the therapy led to hyperstimulation of the ovaries which resulted in ovarian hyperstimulation syndrome (OHSS), with subsequent development of oestrogen toxicity. This is the first case documenting OHSS in a canine after administration of r-hCG. Although manifested during dioestrus in our case report, the occurrence of OHSS is associated with similar administration of r-hCG to women. The described use of r-hCG is not appropriate for luteal insufficiency treatment, but seems to have a place in assisted reproduction technology because of its surprising effects. Further research of luteotrophic factors in bitches is warranted because of these unpredictable results. Lower doses and frequency of administration need to be considered for a better outcome.

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.

The hidden world of anti-phospholipid antibodies and female infertility: A literature appraisal

Even though the association of anti-phospholipid antibodies (aPL) with infertility is debated, infertile women are commonly screened for aPL. To review evidence, a systematic PubMed search was conducted to retrieve papers addressing (i) the association between aPL and infertility, (ii) the positivity rate of criteria and non-criteria aPL in women with infertility, (iii) the association between aPL and assisted reproduction technologies (ART) outcome, (iv) the efficacy of medical treatments on ART outcome, and (v) the effects of ART on thrombotic risk. A total of 46 papers were considered; several limitations emerged: (i) wide heterogeneity in study populations, (ii) non-prospective design in 90% of studies, and (iii) aPL cutoffs not conforming to international guidelines in more than 75% of studies; aPL positivity not confirmed in 89% of studies. Most studies evinced an association between infertility and anti-β2GPI antibodies and almost all non-criteria aPL. The association rate with infertility was below 50% for lupus anti-coagulant, anti-cardiolipin antibodies (aCL), and anti-phosphatidic acid antibodies. According to our estimates, overall positivity rates of criteria and non-criteria aPL tests are 6% and 3% among infertile women, 1% and 2% among controls, respectively. A significant difference in the positivity rate of patients versus controls emerged for aCL only. Five of 18 studies reported a detrimental effect of aPL on ART outcome. Only one of the six studies assessing the effects of treatment on ART outcome among aPL-positive infertile women reported a benefit. All relevant studies reported no increase in the rate of thrombosis among aPL-positive women undergoing ART.

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.

In vitro maturation of immature human oocytes for clinical application

Meiotic progression in the oocyte is defined as oocyte maturation from reinitiation of the first meiotic division from the germinal vesicle (GV) stage to the metaphase-II (M-II) stage (Fig. 1), (Cha and Chian, Hum Reprod Update 4:103-120, 1998). Priming with FSH or HCG prior to immature oocyte retrieval improves oocyte maturation and pregnancy rates. The size of follicles may be an important feature for IVM treatment. The combination of natural-cycle IVF with immature oocyte retrieval followed by IVM is an attractive treatment for young women with all types of infertility without recourse to ovarian stimulation with an acceptable pregnancy rate.

In vitro maturation: Clinical applications

Oocyte in vitro maturation (IVM) is an assisted reproductive technology in which oocytes are retrieved from the antral follicles of unstimulated or minimally stimulated ovaries. IVM of human oocytes has emerged as a promising procedure. This new technology has advantages over controlled ovarian stimulation such as reduction of costs, simplicity, and elimination of ovarian hyperstimulation syndrome. By elimination or reduction of gonadotropin stimulation, IVM offers eligible infertile couples a safe and convenient form of treatment, and IVM outcomes are currently comparable in safety and efficacy to those of conventional in vitro fertilization. IVM has been applied mainly in patients with polycystic ovary syndrome or ultrasound-only polycystic ovaries, but with time, the indications for IVM have expanded to other uncommon situations such as fertility preservation, as well as to normal responders. In this review, the current clinical experiences with IVM will be described.

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).

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of assisted reproduction technology. The syndrome is characterized by cystic enlargement of the ovaries and a fluid shift from the intravascular to the third space due to increased capillary permeability and ovarian neoangiogenesis. Its occurrence is dependent on the administration of human chorionic gonadotrophin (hCG). β-hCG and its analogs, estrogen, estradiol, prolactin, histamine and prostaglandins have all been implicated in OHSS but now it is increasingly better understood that the vasoactivesubstances such as interleukins, tumor necrosis factor-α, endothelin-1, and vascular endothelial growth factor (VEGF) secreted by the ovaries have been implicated in increasing vascular permeability. Enlargement of the ovaries causes abdominal pain, nausea and vomiting. Leakage of fluid from follicles, increased capillary permeability leading to third spacing (due to the release of vasoactive substances), or frank rupture of follicles can all cause ascites. Due to leakage of fluid through the impaired blood vessels both within and outside the ovary there is massive fluid-shift from the intra-vescular bed to the third compartment results in intravascular hypovolemia with concomitant development of edema, ascites, hydrothorax and/or hydropericardium. Low-dose gonadotrophin protocols have been implemented to reduce the risks of fertility treatment in polycystic ovary syndrome patients. Prophylactic albumin administration may interrupt the development of OHSS by increasing the plasma oncotic pressure and binding mediators of ovarian origin. OHSS is significantly lower in an antagonist protocol than in an agonist protocol. Cabergoline inhibits partially the VEGF receptor 2 phosphorylation levels and associated vascular permeability without affecting luteal angiogenesis reduces the 'early' (within the first 9 days after hCG) onset of OHSS. To prevent thrombosis, subcutaneous heparin 5000-7500 U/d is begun on the first day of admission. These patients need a hospital ward where the clinical picture is well understood and the personnel have expertise in its treatment and follow-up. Admission to an intensive care unit is necessary when critical OHSS develops.

Does supplementation with recombinant luteinizing hormone prevent ovarian hyperstimulation syndrome in down regulated patients undergoing recombinant follicle stimulating hormone multiple follicular stimulation for IVF/ET and reduces cancellation rate for high risk of hyperstimulation?

Aim of this study was to assess the efficacy of recombinant luteinizing hormone (rLH) supplementation in late follicular phase in multiple follicular stimulation with recombinant follicle stimulating hormone (rFSH) in Triptoreline down-regulated patients undergoing IVF, on preventing clinical OHSS and cycles cancellation for OHSS risk. Nine hundred ninety-nine patients aged ≤ 40 with basal FSH ≤ 12 mUI/Ml were down-regulated before starting rFSH stimulation for oocytes recovery. Patients were allocated in two groups: (A) (501 patients) treated with 150 IU of rFSH eventually adjusting rFSH dosage day 7 of stimulation until recombinant human chorionic gonadotropin (rhCG) administration, (B) (498 patients) treated with 150 IU of rFSH and 75 IU of rLH since day 7 of stimulation until rhCG administration and adjusting rFSH at the same day. E2 the day of rhCG was higher in group B (p < 0.0001); number of cycles cancelled in group A (42/8.3%) for risk of ovarian hyperstimulation syndrome (OHSS) was higher than group B (12/2.4%) (p < 0.000001). We observed an increase in pregnancies in group B compared with group A (16.8% vs 11.9%) (p < 0.05) and we observed also a larger number of clinical OHSS in group A than in group B (p < 0.05).

[Ovarian stimulation monitoring: past, present and perspectives]

Since the inception of Assisted Reproductive Technology (ART), knowing the moment of ovulation has always been a priority. Initially, the monitoring was accomplished by observing the luteinizing hormone (LH) surge just before ovulation. Currently, in all ART facilities, the monitoring of all stimulated ovulatory cycles is done by using the conventional two-dimensional (2D) ultrasound to measure follicle diameter and by drawing blood tests that measure estradiol, progesterone, and luteinizing hormone levels. These exams allow determination of the numbers and quality of growing ovarian follicles and evaluation of follicle maturity before choosing the appropriate time for ovulation triggering. The monitoring of ovulatory cycles has now become enhanced with the arrival of new software called SonoAVC. This software allows the utilization of 3D blocks to immediately calculate the total number and volume of the follicles inside the ovary. This automatic approach is faster, precise, and more efficient. It also has better reproducibility than the classical 2D diameters. Furthermore, certain ART professionals envision that by using the SonoVac technology, patients will no longer need to be monitored with regular ultrasounds and with systematic hormonal testing.

In Vitro Maturation of Human Immature Oocytes

Ovarian stimulation regimes may be hazardous to a small proportion of women or may result in side effects. For such women IVM is recommended. IVM technology can be divided into two main approaches, namely (i) FSH and (ii) hCG priming. These two approaches improve oocyte maturation and pregnancy rates when the immature oocytes are retrieved from women with PCOS. Although the size of follicles appears to be important for subsequent embryonic development however the developmental competence of oocytes derived from the small antral follicles seems not to be adversely affected by the presence of a dominant follicle. In general, the clinical pregnancy and implantation rates per ET are now in the order of 35–40% and 10–15% respectively in women with PCOS following IVM. The combination of natural cycle IVF with immature oocyte retrieval followed by IVM is an attractive treatment alternative for women with various forms of infertility without recourse to ovarian stimulation. Natural cycle IVF/M together with IVM alone can be used to treat more than half of the population of infertile patients with acceptable pregnancy rate. Approximately 2,000 healthy infants have been born following immature oocyte retrieval and IVM.

[Utilization of hyperestrogenic therapies in systemic lupus erythematosus]

The use of treatments that increase the estrogenic levels has been usually deemed risky in lupus patients. Past studies about the utilization of oral contraceptive drugs and hormone replacement therapy (HRT) have shown contradictory results. More recently, prospective studies about this issue suggest that either oral anticonceptive and HRT can be used in patients with stable disease without special risk for increments in clinical activity. Neither, it has been observed an association with the development of arterial or venous thrombosis. Although, to this regard, several methodological limitations preclude to establish definitive conclusions. Regarding to the use of assisted reproduction techniques in lupus patients, only retrospective data are available. Overall they indicate that the real risk of disease worsening is quite low, being the flares mostly mild when these procedures are performed in patients with stable disease.

Healthy live birth from vitrified blastocysts produced from natural cycle IVF/IVM

Natural-cycle IVF combined with in-vitro maturation (natural-cycle IVF/IVM) was used as a treatment for a 27-year-old woman. She was administered 10,000 IU of human chorionic gonadotrophin intramuscularly about 36 h prior to oocyte collection and oocyte collection was performed on day 11 of her menstrual cycle. One mature oocyte was retrieved from the leading follicle and another five mature oocytes and six immature oocytes were retrieved from the rest of the follicles. Out of 10 fertilized zygotes, eight of them cleaved. Three day-3 embryos derived from in-vivo matured oocytes (one was from the leading follicle) were transferred but failed to conceive. The remaining five embryos were continuously cultured until day 6 and four of them developed to the expanded blastocyst stage and vitrified for the storage. Six months later, two vitrified-warmed blastocysts derived from the immature oocytes were transferred and resulted in the full-term delivery of a healthy female infant. This case report for the first time indicates that blastocysts produced from the immature oocytes retrieved from the small follicles, when a leading follicle exists in the ovaries, can be vitrified to produce a healthy live birth, suggesting that natural-cycle IVF/IVM is an efficient infertility treatment.

A unique human chorionic gonadotropin antagonist suppresses ovarian hyperstimulation syndrome in rats

Ovarian hyperstimulation syndrome (OHSS) is a complication of in vitro fertilization associated with physiological changes after hCG administration to induce final oocyte maturation. It presents as widespread increases in vascular permeability and, in rare cases, results in cycle cancellation, multi-organ dysfunction, and pregnancy termination. These physiological changes are due primarily to activation of the vascular endothelial growth factor (VEGF) system in response to exogenous human chorionic gonadotropin (hCG). An hCG antagonist (hCG-Ant) could attenuate these effects by competitively binding to the LH/CG receptor, thereby blocking LH activity in vivo. We expressed a form of hCG that lacks three of its four N-linked glycosylation sites and tested its efficacy as an antagonist. The hCG-Ant binds the LH receptor with an affinity similar to native hCG and inhibits cAMP response in vitro. In a rat model for ovarian stimulation, hCG-Ant dramatically reduces ovulation and steroid hormone production. In a well-established rat OHSS model, vascular permeability and vascular endothelial growth factor (VEGF) expression are dramatically reduced after hCG-Ant treatment. Finally, hCG-Ant does not appear to alter blastocyst development when given after hCG in mice. These studies demonstrate that removing specific glycosylation sites on native hCG can produce an hCG-Ant that is capable of binding without activating the LH receptor and blocking the actions of hCG. Thus hCG-Ant will be investigated as a potential therapy for OHSS.

Prospective patient and physician preferences for stimulation or no stimulation in IVF

OBJECTIVE

The aim is to explore the preferences of female patients and physicians for IVF in three natural cycles compared to one stimulated cycle and to investigate which factors predict these preferences.

STUDY DESIGN

A questionnaire about IVF preference was administered initially to 105 patients between 36 and 42 years, who were on the waiting list for their first or second IVF attempt. In addition a questionnaire was sent to 56 physicians of Dutch IVF centres. The participants were asked for their preferences at different success rates based on treatment trade-off scenarios. Finally, information on demographic, psychological and other predictors for treatment choice were collected.

RESULTS

Complete data were obtained in 69 female patients (67%) and 27 physicians (49%). At a success rate for a life birth of 17% for both treatments, IVF in three natural cycles is preferred by 78% of the patients and physicians. Half of the patients and physicians still preferred natural cycle treatment at a success rate of 13%. Anxiety for hormone injections was the only significant predictor for patients' preferences.

CONCLUSION

There seems to be a latent demand for IVF in the natural cycle related to anxiety for hormone injections.

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

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

Morphological selection of gametes

Methods of selecting gametes before the intracytoplasmic sperm injection (ICSI) technique are of paramount importance, especially where for religious, ethical or legal reasons the production of supernumerary embryos has to be avoided. In these circumstances, in fact, the research has to be focused on the identification of early markers of embryo quality at the oocyte and sperm stage before fertilisation. Oocyte quality can be influenced by several factors such as controlled ovarian hyperstimulation protocols, pharmaceutical preparations and perifollicular vascularisation. Several intracytoplasmic and extracytoplasmic abnormalities have been described, but whether these abnormalities might be predictive of oocyte competence is controversial and the selection methods proposed are still poorly effective. Recently, we have observed that oocyte morphological abnormalities might be indicators of oocyte competence. An abnormal first polar body (but not fragmented), a large perivitelline space, increased cytoplasmic granularity, and the presence of a centrally located granular area seem to have a negative effect on the oocyte potential to fertilise, cleave, and/or develop into a viable embryo. Sperm morphology can be more accurately observed at high magnification using an inverted microscope equipped with Normarski optics (1000x magnification under mineral oil) and a digital system in order to reach a final magnification of approximately 6300x. Single sperm nuclear abnormalities based on strict selection criteria seems to have a clear negative association with ICSI outcome. The possibility of observing the spermatozoa in real time at higher magnification might also be a good opportunity to study the relationship between particular sperm defects and ICSI outcome. In addition to morphology, it has been suggested that spermatozoa selection might be performed on the basis of its biochemical ability to bind to solid hyaluronic acid. However, it must be underlined that prospective randomised studies are necessary to confirm the preliminary results regarding the efficacy of the described criteria proposed, to morphologically select gametes prior to in vitro insemination.

Meiotic arrest in human oocytes is maintained by a Gs signaling pathway

In mammalian oocytes, the maintenance of meiotic prophase I arrest prior to the surge of LH that stimulates meiotic maturation depends on a high level of cAMP within the oocyte. In mouse and rat, the cAMP is generated in the oocyte, and this requires the activity of a constitutively active, Gs-linked receptor, GPR3 or GPR12, respectively. To examine if human oocyte meiotic arrest depends on a similar pathway, we used RT-PCR and Western blotting to look at whether human oocytes express the same components for maintaining arrest as rodent oocytes. RNA encoding GPR3, but not GPR12, was expressed. RNA encoding adenylate cyclase type 3, which is the major adenylate cyclase required for maintaining meiotic arrest in the mouse oocyte, was also expressed, as was Galphas protein. To determine if this pathway is functional in the human oocyte, we examined the effect of injecting a function-blocking antibody against Galphas on meiotic resumption. This antibody stimulated meiotic resumption of human oocytes that were maintained at the prophase I stage using a phosphodiesterase inhibitor. These results demonstrate that human oocytes maintain meiotic arrest prior to the LH surge using a signaling pathway similar to that of rodent oocytes.

Hopes and facts about mild ovarian stimulation

Over the last two decades, easier and less expensive stimulation treatments have been largely replaced by more complex and more demanding protocols. Since the mid-nineties, long-term gonadotrophin-releasing hormone agonist stimulation protocols have been widely used. Such lengthy expensive regimens are not free from short- and long-term risks and complications. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotrophins used and the mean number of oocytes retrieved. The proportion of high quality and euploid embryos seems to be higher compared with conventional stimulation protocols and the pregnancy rate per embryo transfer is comparable. Moreover, the reduced costs, the better tolerability for patients and the less time needed to complete an IVF cycle make mild approaches clinically and cost-effective over a given period of time. However, further prospective randomized studies are needed to compare cumulative pregnancy rates between the two protocols. Natural cycle IVF, with minimal stimulation, has been recently proposed as an alternative to conventional stimulation protocols in normo- and poor responder patients. Although acceptable results have been reported, further large prospective randomized studies are needed to better evaluate the efficacy of these minimal regimens compared with conventional stimulation approaches.

The optimal length of 'coasting protocol' in women at risk of ovarian hyperstimulation syndrome undergoing in vitro fertilization

Ovarian hyperstimulation syndrome (OHSS) is a serious and potentially life-threatening complication following ovarian stimulation for in vitro fertilization (IVF). Coasting is the practice whereby the gonadotrophins are withheld and the administration of human chorionic gonadotrophin (hCG) is delayed until serum oestradiol (E2) has decreased to what is considered to be a safe level, to prevent the onset of OHSS. This study aimed to assess the length of coasting on the reproductive outcome in women at risk of developing OHSS. Coasting was undertaken when the serum E2 concentrations were > or = 17000 pmol/L but < 21000 pmol/L. Daily E2 measurements were performed and hCG was administered when hormone levels decreased to < 17000 pmol/L. Eighty-one women who had their stimulation cycles coasted were grouped according to the number of coasting days. Severe OHSS occurred in one case, which represented 1.2% of patients who underwent coasting because of an increased risk of developing the syndrome. No difference was found between cycles coasted for 1 - 3 days and cycles coasted for > or = 4 days in terms of oocyte maturity, fertilization and embryo cleavage rates. Women in whom coasting lasted for > or = 4 days had significantly fewer oocytes retrieved (P < 0.05) and decreased implantation rate (P < 0.05) compared to those coasted for 1 - 3 days. Pregnancy rate/embryo transfer and live birth rate did not differ between groups. In conclusion, coasting appears to decrease the risk of OHSS without compromising the IVF cycle pregnancy outcome. Prolonged coasting is, however, associated with reduced implantation rates, perhaps due to the deleterious effects on the endometrium rather than the oocytes.

New alternative to infertility treatment for women without ovarian stimulation

Natural cycle IVF produced the world first successful live birth, but slowly this treatment has been replaced by ovarian stimulated cycle IVF, because it has been believed ovarian stimulated cycle IVF will increase the number of available embryos for transfer. Therefore, it directly increases the chance of pregnancy from the treatment cycle. However, ovarian stimulation is always associated with side effects. The recovery of immature oocytes followed by in-vitro maturation (IVM) and IVF is an attractive alternative to stimulated cycle IVF. IVM treatment provides a successful option to infertile women with polycystic ovaries and polycystic ovary syndrome. It is now possible to combine natural cycle IVF with IVM as an alternative for a selected group of women with various causes of infertility without recourse to ovarian stimulation.

Oocyte Maturation in Assisted Reproductive Techniques

Human oocyte maturation is a long process during which nuclear maturation occurs resulting in germinal vesicle breakdown (transition from prophase I to metaphase II) and extrusion of the first polar body. During oocyte maturation, in parallel with nuclear maturation, a number of events take place in the oocyte cytoplasm that assist fertilization and early embryonic development. So far several attempts have been made to mature human oocytes in vitro. The main patient group to which in vitro maturation (IVM) has been applied is polycystic ovarian syndrome. In a concise review we present the techniques used for the IVM of oocytes and the role of hormones and growth factors in IVM and subsequent fertilization and early embryonic development.

Bone morphogenetic protein 15 (BMP15) alleles predict over-response to recombinant follicle stimulation hormone and iatrogenic ovarian hyperstimulation syndrome (OHSS)

OBJECTIVE

Controlled ovarian stimulation (COS) using recombinant follicle-stimulating hormone (rFSH) is the main treatment in assisted reproduction. We performed a pharmacogenetic analysis of bone morphogenetic protein 15 (BMP15) gene using single nucleotide polymorphisms (SNPs) in COS. We also investigated the role of the BMP15 gene in ovarian hyperstimulation syndrome (OHSS).

METHODS

We analysed different intragenic SNPs located within the BMP15 gene in 307 women treated with rFSH, evaluating its involvement in COS outcome.

RESULTS

First, we analysed two polymorphisms, by applying different tests for genetic association, and we found a minimum P-value in patients producing > or =12 follicles in COS (high responders) in both polymorphisms of the BMP15 gene. Using bi-directional DNA sequencing, we identified two additional single nucleotide DNA variants. Second, we conducted association studies with all polymorphisms together, and noticed that none of them seemed to fully explain the association of the BMP15 gene with over-response to rFSH. However, N103S missense mutation is predicted to disrupt the secondary structure of human BMP15 protein and is weakly associated with OHSS. This coding mutation of the BMP15 gene may partially explain the results obtained during our research. Using Thesias software, we reconstructed haplotypes with the four intragenic variants and calculated their frequencies in normal and over-responders to rFSH. The haplotype TGGA was over-represented in high responders when compared with the rest of patients. Moreover, this association was higher in patients with OHSS, with a significant global haplotypic effect of the BMP15 gene.

CONCLUSION

Our results suggest a direct relationship between increased follicle production during COS and BMP15 alleles in response to rFSH in humans. The use of BMP15 markers to prevent OHSS is also a possibility that requires thorough evaluation.

An immunohistochemical study in a fatality due to ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a complication occurring in the luteal phase of a menstrual cycle in which ovulation induction or ovarian hyperstimulation for assisted reproduction techniques has been performed. Our report concerns the death of a 31-year-old woman with primary infertility on recombinant follicle stimulating hormone therapy (Gonal-F) who developed a fatal adult respiratory distress syndrome. Immunohistochemical investigation of lung and uterine samples was performed utilizing monoclonal antibodies for antisurfactant apoprotein (PE-10) and polyclonal antibodies anti-IL-6, IL-8, IL-10, TNFalpha for lungs, and polyclonal antibodies anti-beta-HCG (human chorionic gonadotropin) for uterus. The knowledge of macroscopic and histologic findings should be of special interest for all those who perform autopsies in these victims. The exact pathogenesis of OHSS remains a mystery; so for the diagnosis of suspected OHSS, the forensic pathologist must use all the modern laboratory armament to validate the diagnosis in the extremely rare fatal cases due to this syndrome.

Estrogen therapy in systemic lupus erythematosus

Given the female preponderance of systemic lupus erythematosus (SLE) in humans, the adverse effects of female gender and sex hormones in murine lupus, and numerous reports (retrospective, often anecdotal and uncontrolled) that describe a temporal association between estrogen exposure and development or exacerbation of SLE, it is tempting to accept that estrogens and SLE simply do not mix. While there are valid concerns regarding the use of exogenous estrogens in women with SLE, there are also potential health benefits to be considered. Oral contraceptives (OCs) offer effective birth control and may be bone protective in corticosteroid-treated patients. Recent studies, albeit retrospective, suggest that OCs are well tolerated in patients with SLE. Several salutary effects of postmenopausal estrogens assume particular importance in SLE where the risks of osteoporosis, exaggerated by menopause (natural or cyclophosphamide-induced) and corticosteroids, are substantial. However, the results of the Women's Health Initiative trial significantly limit the use of hormone replacement therapy in the general population, and raise particular concern for SLE patients. Other exogenous hormones (clomifene, gonadotropins, gonadotropin-releasing hormones) may be used to elevate levels of endogenous estrogen and to stimulate ovulation in patients with diminished fertility. Patients with inactive or stable/moderate disease and at low risk for thrombosis may benefit from OCs and other hormonal therapies without a change in lupus activity. Large prospective, double-blind, placebo-controlled studies inclusive of all ethnic groups should provide the basis for more definitive recommendations.

NaturalIn VitroFertilization Cycles

Although the first in vitro fertilization (IVF) baby was born after a natural IVF cycle, very soon this procedure was almost abandoned mainly because of the very high cancellation rates, and controlled pharmacological ovarian hyperstimulation became the standard treatment in IVF cycles of normoresponder patients. However, in poor-responder patients, where only very few follicles can be recruited and very few oocytes, if any, can be retrieved after controlled ovarian hyperstimulation, natural IVF cycles may offer a comparable number of follicles, reduced costs, and less discomfort for the patients. In this group of patients, natural IVF cycle is a cost-effective approach.

State of the art in in-vitro oocyte maturation

PURPOSE OF REVIEW

The recovery of immature oocytes followed by in-vitro maturation (IVM) and in-vitro fertilization is an attractive alternative to conventional in-vitro fertilization treatment in which controlled ovarian stimulation with gonadotropins is used to increase the number of available oocytes and embryos. Significant progress has been made to improve pregnancy and implantation rates from in-vitro matured oocytes. This review summarizes current knowledge and achievements in human oocyte in-vitro maturation for clinical application, and will highlight recent advances reported in in-vitro maturation treatment.

RECENT FINDINGS

It has been demonstrated that priming of ovarian immature oocytes with follicle-stimulating hormone or human chorionic gonadotropin prior to immature oocyte retrieval improves oocyte maturation rates and embryo quality as well as pregnancy rates in infertile women with polycystic ovaries or polycystic ovary syndrome. The size of follicles may be important for the subsequent embryonic development, but the developmental competence of oocytes derived from the small antral follicles is not adversely affected by the presence of a dominant follicle. However oocyte maturation in vitro is profoundly affected by culture conditions. Currently more than 300 healthy infants have been born following immature oocyte retrieval and in-vitro maturation. In general, the clinical pregnancy and implantation rates have reached 30-35% and 10-15% respectively in infertile women with polycystic ovaries or polycystic ovary syndrome.

SUMMARY

In-vitro maturation treatment can now be offered as a successful option to infertile women with polycystic ovaries or polycystic ovary syndrome. It is possible to combine natural cycle in-vitro fertilization with immature oocyte retrieval followed by in-vitro maturation, and thus offer women with various causes of infertility reasonable pregnancy and implantation rates without recourse to ovarian stimulation. Further research remains to be done to address the mechanism of oocyte maturation in order to refine culture conditions and improve the implantation rate of oocytes matured in vitro.

Mild stimulation in in vitro fertilization

Current approaches to ovarian stimulation for in vitro fertilization (IVF) are aimed at optimizing the number of oocytes retrieved in a treatment cycle. This approach is not without risks. Moreover, as the true costs of multiple pregnancy become clearer, the need to produce multiple embryos for transfer is increasingly questioned. Increasing knowledge of the physiological mechanisms involved in follicular development and dominance has led to new strategies in ovarian stimulation for IVF. The clinical availability of GnRH antagonists allows the normal cycle to be harnessed and manipulated by mild interventions to produce sufficient oocytes for successful IVF treatment. Recent evidence suggests that oocyte quality after mild stimulation may be superior to that after conventional stimulation regimens.

Prevention of severe ovarian hyperstimulation syndrome (OHSS) in IVF patients by steroidal ovarian suppression--a prospective randomized study

Ovarian hyperstimulation syndrome (OHSS) is the major complication associated with artificial reproductive technologies. The aim of this study was to assess the potential of exogenous steroids to prevent OHSS without adversely affecting pregnancy rate. A prospective and randomized study including 945 consecutive cycles in 603 women (mean age 28.6 years) was carried out to evaluate the efficiency of high-dose progesterone and oestradiol administration during the luteal phase to prevent OHSS. After ovulation induction, patients were allocated by a series of computer-generated random numbers to receive either 5000 iu human chorionic gonadotrophin (hCG) 4 and 8 days after embryo transfer (group 1, n = 534) or 500 mg hydroxy-progesterone caproate and 10 mg oestradiol valerate on days 2, 6, 10 and 14 after embryo transfer (group 2, n = 411), by i.m. injection. Total pregnancy rate was 24% (97 of 411) and 23% (121 of 534), and median serum progesterone concentrations on day 15 after embryo transfer were 5.8 ng ml(-1) (range 0.1-298) and 0.1 ng ml(-1) (range 0.1-372) in groups 1 and 2, respectively (P = 0.001). One hundred and sixty-three (30.5%) women in group 1 and 22 (5.4%) women in group 2 developed signs of OHSS (P < 0.0001). These results indicate that steroidal ovarian suppression during the luteal phase is a promising tool to reduce the incidence and severity of OHSS in a high-risk population without compromising the pregnancy rate.

Ovarian hyperstimulation syndrome: strategies for prevention

Ovarian hyperstimulation syndrome (OHSS) is a serious, iatrogenic complication of ovarian stimulation. The following report is a review of traditional and new strategies to prevent the development of OHSS. Techniques such as reducing the ovarian stimulus, coasting and cryopreservation are discussed. Other more investigative strategies are also summarized, including follicular aspiration, in-vitro maturation of immature oocytes, the use of gonadotrophin-releasing hormone (GnRH) agonists to trigger ovulation and the use of volume expanders such as hydroxyethyl starch. In addition, a review of the internal experience with OHSS at the authors' institution is described. All these preventative approaches are based on current understanding of the physiologic mechanisms involved in the pathogenesis of OHSS.

The cost-effectiveness of treatment for varicocele related infertility

PURPOSE

We compared the cost-effectiveness of 4 treatment strategies for varicocele related infertility from the perspective of the health care payor and patient.

MATERIALS AND METHODS

Cost-effectiveness analysis was performed by studying 4 treatment strategies, namely observation, surgical varicocelectomy followed by in vitro fertilization (IVF) if unsuccessful, gonadotropin stimulated intrauterine insemination (IUI) followed by IVF if unsuccessful, and immediate IVF. The main outcome measure was incremental cost per live delivery of any number of newborns.

RESULTS

Immediate IVF cost more per live delivery and was less effective than varicocelectomy/IVF or IUI/IVF. When electing the latter 2 procedures, the preferred approach depended on the choice of perspective. From the health care payor viewpoint each additional birth that resulted from choosing varicocelectomy/IVF over observation cost $52,152, while each additional birth that occurred by electing IUI/IVF over varicocelectomy/IVF cost $561,423. From the patient perspective, while varicocelectomy/IVF resulted in improved outcomes over observation, a rational decision maker would always be willing to pay the slightly higher cost of IUI/IVF (incremental cost per live birth versus observation $27,371) for the added benefit in effectiveness if they were initially willing to invest in varicocelectomy/IVF (incremental cost per live birth versus observation $27,618).

CONCLUSIONS

The optimal choice of treatment for varicocele related infertility depends strongly on the decision maker perspective. Regardless of perspective the most technologically advanced treatment, that is immediate IVF, is never favored. The findings of this study should be used to counsel infertile patients with varicocele that immediate IVF is not cost-effective.

Stimulation of apoptosis in human granulosa cells from in vitro fertilization patients and its prevention by dexamethasone: involvement of cell contact and bcl-2 expression

Human granulosa cells obtained from in vitro fertilization patients are highly luteinized, but can still be stimulated by LH/cAMP for production of progesterone. This stimulation involved enhancement of apoptosis. Incubation of the cells with dexamethasone (Dex) reduced the apoptotic incidence compared with nontreated cells and completely abolished the increase in apoptosis stimulated by LH or forskolin, concomitantly with a pronounced increase in progesterone production. Organization of the actin cytoskeleton was dramatically reduced after LH/forskolin stimulation. In contrast, Dex prevented disorganization of the actin filament networks. LH and forskolin also decreased the organization of gap junctions, which could be prevented by Dex. However, the intracellular level of connexin 43 was elevated in the presence of LH, forskolin, and Dex. Endogenous levels of the survival gene protein Bcl-2 were significantly elevated in all cultures treated with Dex compared with either nonstimulated cultures or cultures stimulated with LH and forskolin. Our data suggest that LH/cAMP can stimulate steroidogenesis even during the initial stage of apoptosis of human granulosa cells, whereas Dex, which blocks apoptosis, could further elevate progesterone production. Moreover, the integrity of gap junctions and the actin cytoskeleton as well as elevated levels of Bcl-2 may play an important role in the suppression of apoptosis of human granulosa cells.

Reproductive health in SLE

Oral contraceptives containing oestrogens and hormone replacement therapy are generally not prescribed for women with systemic lupus erythematosus (SLE). The concern regarding oestrogens is based on the greater incidence of SLE in women, abnormalities of oestrogen metabolism, murine models of lupus, several anecdotes of patients having disease flares while receiving hormones, and one retrospective study in patients with pre-existing renal disease. For healthy women and those with SLE, there are clinical settings in which exogenous oestrogens provide benefit. For pre-menopausal women, these include provision of safe and effective birth control, protection against bone loss, and the consideration of oral contraceptives to preserve fertility in patients taking cyclophosphamide. For post-menopausal women, these include treatment of hot flushes and vaginal dryness, prevention of osteoporosis and, more controversial, prevention of atherosclerosis. Other exogenous hormones (clomiphene citrate, gonadotropins, gonadotropin-releasing hormones) may be used to elevate levels of endogenous oestrogen and stimulate ovulation in patients with diminished fertility. This chapter focuses on three broad categories: birth control, assisted reproduction and hormone replacement.

A novel approach for patients at risk for ovarian hyperstimulation syndrome: elective transfer of a single zona-free blastocyst on day 5

In this preliminary prospective randomized study of 420 patients undergoing ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI), 17 patients (4%) developed moderate to severe ovarian hyperstimulation syndrome (OHSS). Re-evaluation for OHSS on day 4 and 6 after oocyte retrieval identified one patient with continuous risk for severe OHSS, resulting in cancellation of the transfer (1/17, 5.8%). Prospectively, two of three patients had the zona pellucida of the blastocyst removed by pronase exposure prior to transfer. Significantly more patients became pregnant when a zona-free blastocyst was transferred in comparison to transfer of a single zona-intact embryo (9/11 or 82% versus 1/5 or 20%; P < 0.01). Higher ongoing singleton pregnancy rates were obtained when the zona pellucida was removed prior to the transfer (6/11 and 1/5 respectively). This preliminary prospective randomized study indicates that by prolonging the evaluation time for patients at risk of developing OHSS for up to 6 days after the oocyte retrieval, those patients at risk for developing severe OHSS can be identified. Transferring a single zona-free day 5 embryo (blastocyst) and freezing of the supernumerary embryos offers the patient with moderate OHSS an optimal chance for a singleton pregnancy, while avoiding the serious maternal complications of ovarian hyperstimulation syndrome.

Severe spontaneous ovarian hyperstimulation syndrome with MR findings

We describe a case of severe spontaneous ovarian hyperstimulation syndrome (OHSS) with MR findings. MR scans showed bilateral symmetric enlargement of ovaries with multiple cystic changes, giving the classic "wheel-spoke" appearance. There was no definite abnormally thickened or enhanced wall, but there was internal hemorrhage in some chambers. To avoid unnecessary laparotomy, we emphasize the importance of careful diagnosis to differentiate spontaneous OHSS from ovarian cystic neoplasms.