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Can we eliminate severe ovarian hyperstimulation syndrome?
Human Reproduction, 2005
The desire of some couples for children is so strong that they are willing to accept a modicum of risk to treat their infertility. Ideally, assisted reproduction technology practitioners seek a balance between optimum ovarian stimulation and successful treatment outcome with minimal rate of severe ovarian hyperstimulation syndrome (OHSS) or multiple pregnancies. However, despite many years of clinical experience, there are no precise methods to completely prevent severe OHSS, except by withholding the ovulation-inducing trigger of hCG. Individualization of treatment according to the specific risk factor and the specific response in the current cycle with the option of freezing of all embryos, or replacement of only a single embryo, has the potential of reducing the risk and the severity of the syndrome in susceptible cases. We offer a triage aimed at eliminating the occurrence of severe ovarian hyperstimulation syndrome on the basis of several clinical observations, including the role of GnRH antagonist in controlled ovarian stimulation protocols, the option of freezing of all embryos, or replacement of only a single embryo in the blastocyst stage.
Human Reproduction, 1991
In a retrospective analysis of 637 cycles of ovarian stimulation and transvaginal follicular aspiration for various assisted reproductive technologies, severe ovarian hyperstimulation syndrome (SOH) occurred in six (0.94%) cycles. The patients at a high risk of developing SOH in cycles of assisted reproduction were those who had excessive serum oestradiol levels on the day of human chorionk gonadotrophin (HCG) administration (oestradiol > 6000 pg/ml; 38% SOH) and a high number of oocytes obtained (>30 oocytes; 23% SOH). In those patients with both oestradiol > 6000 pg/ml on the day of HCG administration and >30 eggs retrieved, the chance of developing SOH was 80%. The higher the serum oestradiol levels and the more eggs retrieved, the higher the pregnancy rates observed. High oestradiol level did not appear to have a detrimental effect on pregnancy rates and outcome. Furthermore, our results are not consistent with suggestions that the addition of gonadotrophin-releasing hormone agonist to ovarian stimulation protocols, follicular aspiration and/or luteal support with progesterone may reduce the incidence of ovarian hyperstimulation syndrome.
Ovarian hyperstimulation syndrome- an optimal solution for an unresolved enigma
Journal of ovarian research, 2013
Ovarian hyperstimulation syndrome (OHSS) is a serious complication of controlled ovarian hyperstimulation (COH). The syndrome almost always presents either after hCG administration in susceptible patients or during early pregnancy. Despite many years of clinical experience, there are no precise methods to completely prevent severe OHSS, except by withholding the ovulation-inducing trigger of hCG. Recently, COH which combining GnRH antagonist co-treatment and GnRH agonist trigger has become a common tool aiming to eliminate severe early OHSS. However, the observed decrease in implantation and pregnancy rates following this approach has encouraged different modifications of luteal support aiming to improve outcome. One of the suggest approach is the 1500 IU hCG luteal rescue, which appears to be a promising protocol, aiming to reduce (rather than eliminating) severe early OHSS, without compromising outcome. In the present paper we discuss the different suggested strategies and offer a...
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.
An update on the prevention of ovarian hyperstimulation syndrome
Women's Health, 2016
Ovarian hyperstimulation syndrome is a potentially life-threatening, but preventable iatrogenic complication of in vitro fertilisation treatment. In recent years, new strategies have been developed to minimise the risk of ovarian hyperstimulation syndrome after in vitro fertilisation, including better at-risk patient identification prior to starting treatment, the use of a lower human chorionic gonadotrophin dose or alternative medication instead of human chorionic gonadotrophin to induce final oocyte maturation such as gonadotrophin-releasing hormone agonist and kisspeptin in antagonist cycles, cryopreservation of all embryos and delayed embryo transfer, and the use of oral dopamine agonists after oocyte retrieval. In this article, the advantages and limitations of those new developments are discussed and future directions towards establishment of an ovarian hyperstimulation syndrome–free in vitro fertilisation clinic are explored.
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. #
Human Reproduction, 2012
background: Triggering ovulation by GnRH agonist (GnRHa) in GnRH antagonist IVF protocols coupled with adequate luteal phase support has recently been suggested as a means to prevent ovarian hyperstimulation syndrome (OHSS). Our objective was to examine the outcome of fresh embryo transfer (f-ET) after triggering ovulation by GnRHa and providing intensive luteal phase supplementation, compared with that of the next first frozen-thawed embryo transfer (ft-ET) after cycles with the same protocol and cryopreservation of all the embryos. methods: We performed a cohort study at a university-based IVF clinic. The study population was patients at high risk for OHSS. A daily dose of 50 mg i.m. progesterone in oil and 6 mg of oral 17-b-estradiol initiated on oocyte retrieval day in the f-ET group (n ¼ 70). In the ft-ET group (n ¼ 40) the embryos were cryopreserved and transferred in the next cycle. results: The live birth rate per f-ET was 27.1 versus 20% in the ft-ET groups [P ¼ 0.4; rate ratio ¼ 1.36 (0.65-2.81)]. The implantation, pregnancy and spontaneous abortion rates were comparable in both groups. None of the patients developed OHSS. conclusions: In this observational cohort study, we showed that triggering ovulation with GnRHa and intensive luteal phase support is a promising new modality to prevent OHSS without the cost of cycle cancellation, ET deferral and reduced clinical pregnancy rates. Confirmation of these findings by RCTs is now required.
Current Medical Strategies in the Prevention of Ovarian Hyperstimulation Syndrome
ACTA CLINICA CROATICA
-Th e purpose of this review is to analyze current medical strategies in the prevention of ovarian hyperstimulation syndrome (OHSS) during ovarian stimulation for in vitro fertilization. Owing to contemporary preventive measures of OHSS, the incidence of moderate and severe forms of the syndrome varies between 0.18% and 1.40%. Although none of medical strategies is completely eff ective, there is high-quality evidence that replacing human chorionic gonadotropin (hCG) by gonadotropin-releasing hormone (GnRH) agonists after GnRH antagonists and moderate-quality evidence that GnRH antagonist protocols, dopamine agonists and mild protocols reduce the occurrence of OHSS. Among various GnRH agonists, buserelin 0.5 mg, triptorelin 0.2 mg and leuprolide acetate (0.5-4 mg) have been mostly utilized. Although GnRH trigger is currently regarded as the best tool for OHSS prevention, intensive luteal support with exogenous administration of estradiol and progesterone or low-dose hCG on the day of oocyte retrieval or on the day of GnRH agonist trigger are required to achieve optimal conception rates due to early luteolysis. Among currently available dopamine agonists, cabergoline, quinagolide and bromocriptine are the most common drugs that should be used for prevention of both early and late OHSS. Mild stimulation protocols off er attractive option in OHSS prevention with satisfactory pregnancy rates.
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.