Laparoscopic ovarian drilling versus GnRH antagonist combined with cabergoline as a prophylaxis against the re-development of ovarian hyperstimulation syndrome (original) (raw)
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DOAJ (DOAJ: Directory of Open Access Journals), 2016
Background: Recently the laparoscopic ovarian drilling (LOD) has been used as a surgical treatment for ovulation in women with polycystic ovarian syndrome (PCOS), although its mechanism and outcomes are still unclear. This study was undertaken to evaluate the in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes in clomiphene-resistant women with PCOS who were treated with LOD. Materials and Methods: In this retrospective study, we reviewed the medical records of 300 women between 20 to 35 years old with clomiphene-resistant PCOS who had an ovulatory infertility and who were nominated for IVF/ICSI. Based on their treatment history, they were located into the following two groups: group I (n=150) including PCOS women who had history of LOD at least 6 months to 3 years before IVF/ICSI, and group II (n=150) including PCOS patients without history of drilling. Both groups were treated with antagonist protocol in the assisted reproductive technology (ART) process. The duration of treatment cycles, number of oocytes and embryos obtained, chemical and clinical pregnancy rate, the number of embryos transferred, and presence of ovarian hyper stimulation syndrome (OHSS) were measured. To compare means and frequencies, Student's t test, Mann-whitney and chi-square tests were used. Results: Our results showed that ovarian cauterization before IVF/ICSI in patients with PCOS reduced the risk of OHSS (P=0.025). Despite the same pregnancy rate in both groups (P=0.604), more obtained oocytes and embryos were seen on women without ovarian drilling than women with LOD (P˂0.001 and P=0.033, respectively). Conclusion: There is no difference between the pregnancy rate in both groups. Due to significant reduction in OHSS in women undergoing LOD, this surgical treatment may be considered as a useful technique in the management of patients who have previously developed OHSS. However, there are ongoing concerns about long-term effects of LOD on ovarian function.
Human Reproduction, 2001
Ovarian hyperstimulation syndrome (OHSS) can be a severe and potentially life-threatening complication of ovarian stimulation for IVF. Coasting or withholding gonadotrophin stimulation relies on frequent estimation of serum oestradiol to identify patients at risk. A modified coasting protocol was developed in which identification of patients at risk of severe OHSS was based on ultrasound monitoring. Serum oestradiol concentrations were measured only in patients with >20 follicles on ultrasound (high risk). If serum oestradiol concentrations were <3000 pmol/l, the gonadotrophin dose was maintained; if concentrations were ≥3000 pmol/l but <13 200 pmol/l and ≥25% of the follicles had a diameter of ≥13 mm, the gonadotrophin dose was halved; and if serum oestradiol concentrations were ≥13 200 pmol/l and ≥25% of the follicles had a diameter of ≥15 mm, patients were coasted. In the latter group, human chorionic gonadotrophin (HCG) 10 000 IU was administered when at least three follicles had a diameter of ≥18 mm and serum oestradiol concentrations were <10 000 pmol/l. Over a 10 month period, serum oestradiol concentrations were measured in 123 out of 580 cycles (24%) and in 50 cycles, gonadotrophins were withheld. Overall, moderate OHSS occurred in three patients (0.7%) and severe OHSS in one patient (0.2%). The pregnancy rates in the cycles where the gonadotrophin dose was reduced or withheld were 39.6 and 40% per cycle respectively; corresponding implantation rates were 30.7 and 25.6%. It is concluded that the modified coasting strategy is associated with a low risk of moderate and severe OHSS to a minimum without compromising pregnancy rates. Identification of patients at risk by ultrasound reduces the number of serum oestradiol measurements and thus inconvenience to patients as well as costs and workload.
Middle East Fertility Society Journal, 2020
Background: The main objective of this randomized controlled trial was to study the impact of LOD on the pregnancy rate after ICSI-ET in PCOS. Results: The study was conducted in Egypt in the period 2015-2017 and included 212 clomiphene-resistant PCOS patients, with at least 1-year infertility. The study group was the drilling group who underwent LOD and then ICSI-ET, while the control group did not undergo LOD but directly proceeded to ICSI-ET. The primary outcome was the clinical pregnancy rate per ET cycle. The baseline characteristics and hormonal profiles were comparable (p > 0.05) between the two groups. Ovarian stimulation days were (p < 0.001) higher in the drilling group. Endometrial thickness, estradiol at triggering day, and the number of oocytes retrieved were (p < 0.001) lower in the drilling group. The numbers of embryos transferred were not different (p > 0.05). The clinical pregnancy rate per ET cycle was higher in the drilling group (51%) than in the control group (37%) (p = 0.046). Multiple pregnancies were not significantly (p = 0.265) different between groups. The rate of OHSS was (p = 0.046) higher in the control group. Coasting was (p < 0.001) higher in the control group (18%) compared to the drilling group (2%). Conclusion: Laparoscopic ovarian drilling for PCOS patients before ICSI-ET improves the clinical pregnancy rate with a reduction of OHSS.
Iranian Journal of Reproductive Medicine, 2023
The effect of laparoscopic ovarian drilling (LOD) before in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) cycles on pregnancy outcomes is an unclear and challenging subject. Objective: To evaluate the impact of LOD before IVF/ICSI cycles on controlled ovarian stimulation and pregnancy outcomes in polycystic ovary syndrome (PCOS) women with a history of more than 2 IVF failures. Materials and Methods: In this randomized clinical trial, women with PCOS diagnosis who referred to Arash Women's hospital, Tehran, Iran for IVF/ICSI cycle from August 2015-January 2018 were evaluated. Eligible participants were allocated into 2 groups randomly (n = 17/each group). The participants in the LOD group (intervention) were treated with laparoscopic couture, and after one month, they underwent IVF/ICSI cycles using the gonadotropin-releasing hormone antagonist protocol. The control group had no intervention. The oocyte and embryo qualities, ovarian hyperstimulation syndrome rate, the rates of chemical and clinical pregnancy and early miscarriage, live birth, and pregnancy complications, were compared between groups. Results: Finally, 34 participants were evaluated. The controlled ovarian stimulation outcomes were similar between groups. The ovarian hyperstimulation syndrome rate in the LOD group was significantly lower than in the control group (p = 0.04). One case of spontaneous pregnancy was reported in the LOD group. No significant difference was observed between groups in clinical pregnancy, miscarriage, and live birth rates. The rates of pregnancy complications (gestational diabetes mellitus, preeclampsia, and preterm birth) were similar between groups. Performing LOD before IVF/ICSI cycles did not improve the pregnancy outcomes in PCOS women, a clinical trial with a larger sample size is needed to prove these results.
Early and late ovarian hyperstimulation syndrome: early pregnancy outcome and profile
Human Reproduction, 2005
BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) in IVF/ICSI cycles may occur either as an early (early onset) or a late pattern (late onset). This observational study was designed to identify whether the onset pattern of OHSS is associated with the occurrence of pregnancy and the early pregnancy outcome. METHODS: Among 4376 consecutive IVF/ICSI cycles, 113 patients were hospitalized for OHSS after IVF/ICSI treatment and were included in the study. The setting was the Dutch-speaking Brussels Free University Hospital, between June 2000 and September 2002. RESULTS: Early OHSS occurred in 53 patients, and late OHSS complicated 60 patients. A total of 96.7% of the late OHSS cases occurred in a pregnancy cycle and were more likely to be severe than the early cases (P < 0.05). Although in the early group there initially was a 41.5% positive HCG rate per cycle, the clinical pregnancy rate fell to 28,3% as a result of a significantly (P < 0.05) increased preclinical pregnancy loss rate compared with the non-OHSS patients (31.8 versus 88.3%, respectively). The ongoing pregnancy rate per cycle was 14.4% in the early and 26.4% in the late group. Multiple pregnancy rates were high in both groups (40 and 45.5%, respectively), but only in the late group did the incidence reach significance compared with the non-OHSS population (45.5 versus 29.1%, P 5 0.02). Estradiol levels and number of follicles on the day of HCG were significantly higher in the early OHSS group. However, there was no difference in estradiol values on the day of hospital admittance between the two groups. In addition, the number of follicles on the day of HCG administration appears to be a better prognostic indicator for the occurrence of severe OHSS than the estradiol values (87% of the severe cases had 14orfolliclesofadiameter14 or follicles of a diameter 14orfolliclesofadiameter11 mm, whereas only 50% of them had an estradiol value $3000 ng/l). CONCLUSIONS: The early OHSS pattern is associated with exogenously administered HCG and a higher risk of preclinical miscarriage, whereas late OHSS may be closely associated with the conception cycles, especially multiple pregnancies, and is more likely to be severe. Further clarification of these two different clinical entities could have implications for research protocols as well as for preventive and management strategies for OHSS.
Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review
Human Reproduction Update, 2002
Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy. Fortunately, the reported prevalence of the severe form of OHSS is small, ranging from 0.5 to 5%. Nevertheless, as this is an iatrogenic complication of a non-vital treatment with a potentially fatal outcome, the syndrome remains a serious problem for specialists dealing with infertility. The aim of this literature review was to determine whether it is possible to identify patients at risk, and which preventive method should be applied when an exaggerated ovarian response occurs. Data pertaining to the epidemiology and prevention of OHSS in women were searched using Medline, Current Contents and PubMed, and are summarized. Preventive strategies attempt either to limit the dose or concentration of hCG or to ®nd a way to induce luteolysis without inducing a detrimental effect on endometrial and oocyte quality. The following particular preventive strategies were reviewed: cancelling the cycle; coasting; early unilateral ovarian follicular aspiration (EUFA); modifying the methods of ovulation triggering; administration of glucocorticoids, macromolecules and progesterone; cryopreservation of all embryos; and electrocautery or laser vaporization of one or both ovaries.
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2001
The purpose of this study was to evaluate the effectiveness of combined approach on the prevention of severe ovarian hyperstimulation syndrome (OHSS) in high risk patients undergoing controlled ovarian hyperstimulation for IVF. The combined approach consisted of: (1) step-down administration of gonadotropins; (2) lowering the dose of human chorionic gonadotropin; (3) intravenous albumin infusion at the time of oocyte retrieval and (4) progesterone use for luteal support. Total of 87 high risk patients with a serum estradiol level >11,010 pmol/ l or 3000 pg/ml on HCG day were managed by this combined approach and their results were compared with 274 low risk patients. In all high risk patients, the gonadotrophin dose were decreased starting as early as on day 4 of ovarian stimulation as necessary, ovulation was triggered by a decreased HCG dose of 5000±7000 IU according to the level of estradiol, intravenous infusion of 20% human albumin, 50± 100 ml were given just 1 h before the oocyte retrieval and luteal support was provided either by 50 mg progesterone in oil, IM or 600 mg micronized progesterone orally or vaginally until the day of b-HCG determination. All patients were followed by serial ultrasonographic examinations and complete blood count analysis after embryo transfer to detect the early signs of OHSS and to allow early intervention. Age and duration of infertility were similar in both groups. Although the number of gonadotrophin ampoules used (22:7 AE 4:7 versus 27:8 AE 3:7; P < 0:05) was signi®cantly lower, estradiol levels (16,764 AE 6936 pmol/l versus 8870 AE 2456 pmol/l; P < 0:05) and mean number of oocytes (18:3 AE 5:9 versus 10:6 AE 5:4; P < 0:05) were signi®cantly higher in study group. There was no signi®cant difference between groups in terms of the mean number of transferred embryos (3:2 AE 1:1 versus 3:4 AE 1:1) and rate of pregnancies (50.5% versus 40.1%). There was only one moderate and no severe OHSS case in the high risk group, while ®ve moderate and one severe OHSS cases developed in the control group consisting of low risk patients. In conclusion, intravenous albumin combined with low dose HCG, early stepdown administration of gonadotropins and progesterone use for luteal support, so called combined approach, proved to be effective in the prevention of severe ovarian hyperstimulation syndrome in documented high risk patients. #
Fertility and Sterility, 2006
To determine the incidence of ovarian hyperstimulation syndrome (OHSS) in a large series of GnRH antagonist-stimulated cycles and to assess the predictive value of E 2 and the number of follicles on the day of hCG administration. Design: Prospective cohort study of women undergoing IVF treatment with a GnRH antagonist protocol over a 2-year period. Setting: Tertiary university hospital. Patient(s): One thousand eight hundred one patients who underwent 2,524 cycles. Intervention(s): Multifollicular ovarian stimulation with recombinant FSH and GnRH antagonist for IVF-ICSI treatment. Main Outcome Measure(s): Incidence of OHSS in GnRH antagonist cycles, predictive value of E 2 , and number of follicles on the day of hCG for OHSS occurrence.
Increased early pregnancy loss in IVF patients with severe ovarian hyperstimulation syndrome
Human Reproduction, 2002
BACKGROUND: Since severe ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of assisted reproduction, the focus of attention in such cases is placed firmly upon the health of the patient, with the endeavour to achieve a pregnancy being considered of secondary importance. The aim of this study was to focus on the pregnancy rate and pregnancy outcome in IVF patients hospitalized for severe or critical OHSS, in one centre, during a period of 6 years. METHODS: We compared the characteristics of patients with severe OHSS: those who conceived with the ones who did not conceive, and among pregnant IVF patients, those with ongoing pregnancies with those that miscarried. RESULTS: Pregnancy was achieved in 60 of 104 (58%) patients with severe OHSS. Pregnancy continued until delivery in 37 of these 60 patients (62%), whereas the remaining 23 (38%) aborted. The pregnancy and abortion rates in patients with severe OHSS were significantly higher than those of IVF patients without OHSS, during the same time period [23% (1138/4922) and 15% (169/1138) respectively, P < 0.001]. The mean duration of hospitalization for OHSS was significantly shorter in those who delivered compared with those who aborted (5.9 ⍨ 3.2 versus 10.5 ⍨ 9.6 days, P < 0.01) and in the non-pregnant patients compared with the pregnant patients (5.2 ⍨ 3.2 versus 7.6 ⍨ 6.6 days, P < 0.02). CONCLUSIONS: The clinical pregnancy rate of IVF patients with severe OHSS was significantly higher than that of patients without the syndrome. A longer stay in hospital-reflecting a more severe form of OHSS-was correlated with a higher frequency of abortions. OHSS, necessitating hospitalization, is a detrimental clinical situation not only for the mother but also for the developing pregnancy.