Ovarian hyperstimulation syndrome: an update review

Advances in the evaluation and treatment of the infertile man

Numerous advances in technology have been made in the last several years in the diagnosis and treatment of the infertile man. Using case presentations, this article highlights these important new developments and reviews the basics of a comprehensive male infertility evaluation. The use of ultrasound as a critical, indispensable, yet noninvasive tool in the evaluation of possible male reproductive tract obstruction is discussed. Since assisted reproductive techniques (ARTs) have become increasingly important in the management of the otherwise untreatable infertile man, specialized testing of sperm function, e.g., the sperm penetration assay (SPA), and strict morphology assessment are often useful prior to the initiation of some of these assisted reproductive procedures such as intrauterine insemination (IUI) or in vitro fertilization (IVF). Testicular touch preparation cytology and image analysis are also important additions to routine testicular biopsy for quantifying the extent of spermatogenesis. Finally, the revolutionary micromanipulation procedure of intracytoplasmic sperm injection (ICSI) has forever changed the practice of andrology by enabling men previously thought to be irreversibly infertile the chance to initiate their own biologic pregnancy.

Oocyte quality in patients with severe ovarian hyperstimulation syndrome

OBJECTIVE

To study the oocyte quality in patients with ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective study.

SETTING

The Egyptian IVF-ET Center.

PATIENT(S)

Forty-two patients who developed severe OHSS (group A) were studied for the mean number of oocytes retrieved, percentage of high-quality oocytes, embryo quality, and fertilization, implantation, and pregnancy rates; these patients were compared with an age-matched control group who did not develop OHSS (group B; n = 183) after superstimulation for IVF or intracytoplasmic sperm injection.

INTERVENTION(S)

In vitro fertilization and ICSI.

MAIN OUTCOME MEASURE(S)

Fertilization and pregnancy rates.

RESULT(S)

In group A, the mean number of oocytes retrieved was significantly higher, whereas the percentage of high-quality oocytes and the fertilization rate were significantly lower than that in group B. There were no statistically significant differences in the quality of embryos transferred or the implantation or pregnancy rate between the groups. The percentage of high-quality oocytes and the fertilization rate were significantly lower in patients with polycystic ovaries (PCO) in both groups.

CONCLUSION(S)

The inferior quality and maturity of oocytes in OHSS reduced the fertilization rate but did not affect the quality or the number of embryos transferred or the pregnancy rate. The effect on oocyte quality could be due to the prevalence of PCO in this group of patients.

Severe ovarian hyperstimulation syndrome: is it really preventable by prophylactic intravenous albumin?

OBJECTIVE

To evaluate the effectiveness of i.v. albumin in preventing severe ovarian hyperstimulation syndrome (OHSS) in patients at risk.

DESIGN

Retrospective review and data analysis.

SETTING

University-based tertiary referral center for assisted reproductive technologies (ART).

PATIENT(S)

Sixty women at high risk of developing severe OHSS after superovulation for ART.

INTERVENTION(S)

One liter of albumin (4.5%) administered i.v. during oocyte retrieval and immediately afterward.

RESULT(S)

Of the 60 women who had prophylactic i.v. albumin, 5 (8%) developed severe OHSS, which led to hospitalization. Eight (13%) developed moderate OHSS. Forty-seven (78%) did not develop any symptoms. Four of the 5 women who developed severe OHSS had ET and 3 of them (75%) were pregnant (1 twin and 2 singletons).

CONCLUSION(S)

Intravenous albumin administered at oocyte retrieval does not prevent the occurrence of severe OHSS, especially in cases associated with pregnancy. It is important that clinicians are not lured into a false sense of security by the early report, full of promise, on the use of i.v. albumin to prevent severe OHSS.

Elevated levels of interleukin-6 in the follicular fluid at the time of oocyte retrieval for in vitro fertilization may predict the development of early-form ovarian hyperstimulation syndrome

OBJECTIVE

To determine the possible predictive role of interleukin-2 (IL-2), IL-6, and tumor necrosis factor (TNF-alpha) in the development of early-form ovarian hyperstimulation syndrome (OHSS).

DESIGN

Nested, case-control study.

SETTING

An IVF unit, university-based program.

PATIENT(S)

Follicular fluid (FF) was obtained from 322 high responders. The study group and control group comprised 10 patients who developed early, severe OHSS and 10 who did not develop OHSS, respectively. An additional control group included 10 low-responder patients who did not develop OHSS.

INTERVENTION(S)

Ovulation induction with hMG combined with GnRH analogue.

MAIN OUTCOME MEASURE(S)

All FF samples were tested for IL-2, IL-6, and TNF-alpha. The patient's serum was tested for mean E2 and P concentrations.

RESULT(S)

Interleukin-6 levels in the FF were significantly higher in the OHSS group than in the two control groups, whereas no differences were found in IL-2 and TNF-alpha. No correlation was found between the FF concentrations of IL-2, IL-6, and TNF-alpha and the mean serum E2 levels or the number of oocytes retrieved.

CONCLUSION(S)

Elevated levels of IL-6 in the preovulatory FF at the time of oocyte retrieval for IVF may predict the development of early-form OHSS in high responders.

The ovarian renin-angiotensin system in reproductive physiology

The identification of the presence of prorenin, renin, angiotensinogen, angiotensin-converting enzyme, angiotensin II (Ang II), and Ang II receptors in the ovary suggests that there is a functional ovarian renin-angiotensin system (RAS). It could play a significant role in such areas of ovarian physiology as follicular development, steroidogenesis, oocyte maturation, ovulation, and follicle atresia. Expression of the ovarian RAS is regulated by gonadotropins. Ang II, a bioactive octapeptide of RAS, has important effects as a paracrine/autocrine regulator at different stages of the reproductive cycle. Ang II modulates ovarian steroidogenesis and formation of the corpus luteum and also stimulates oocyte maturation and ovulation via Ang II receptors on granulosa cells. In addition, increasing evidence demonstrates that Ang II is a major factor in regulating the function of atretic follicles. In any physiologic system, aberrations result in the development of pathologic states. Disturbances in the ovarian RAS can be the cause or the result of such reproductive disorders as polycystic ovary syndrome, ovarian hyperstimulation syndrome, ovarian tumors, and ectopic pregnancy. Data support the concept of an active and regulated RAS in ovarian follicles. Species differences observed in the expression of ovarian RAS suggest varying functional roles among species with respect to ovarian physiology.

Hyperreactio luteinalis differentiated from severe ovarian hyperstimulation syndrome in a spontaneously conceived pregnancy

The clinical presentation of hyperreactio luteinalis can mimic ovarian hyperstimulation. Historically, though, the former most often leads to unnecessary surgery whereas the latter is treated supportively. We present a case of a 32-year-old woman who was initially seen with markedly enlarged multicystic ovaries, ascites, and pleural effusions in the tenth week of a spontaneously conceived gestation. Despite a noniatrogenic cause, the patient received supportive management, as would be given with ovarian hyperstimulation syndrome. Making the distinction between hyperreactio luteinalis and ovarian hyperstimulation syndrome has important consequences for diagnosis and management.

Increased angiotensin II in ascites during severe ovarian hyperstimulation syndrome: role of early pregnancy and ovarian gonadotropin stimulation

OBJECTIVE

To investigate the implications of the ovarian renin-angiotensin system (RAS) in the pathophysiology of the ovarian hyperstimulation syndrome (OHSS) in relation to gonadotropin stimulation and early pregnancy.

DESIGN

A controlled clinical study comparing blood and simultaneously sampled peritoneal fluid (PF) from patients with severe OHSS and from controls without OHSS.

SETTING

University Hospitals.

PATIENT(S)

Eleven patients with severe OHSS, 8 patients with ascites of other origin, 9 patients with a first-trimester pregnancy, and 15 patients stimulated with gonadotropins for IVF.

MAIN OUTCOME MEASURE(S)

Angiotensin II immunoreactivity was measured in blood and PF and analyzed by high-performance liquid chromatography (HPLC) in ascites from OHSS.

RESULT(S)

Angiotensin II immunoreactivity (pg/mL; mean +/- SE) was highest in the ascites from pregnant OHSS (1,669 +/- 418), reaching levels 5 times higher than in the plasma (331 +/- 61) and 100 times higher than in control ascites (17 +/- 6.7). Angiotensin II immunoreactivity was elevated in the PF during early pregnancy (211 +/- 68) and after gonadotropin stimulation (244 +/- 41) and was higher than in the plasma in both groups. Analysis by HPLC showed that the majority of Ang II immunoreactivity in the ascites of OHSS was because of true Ang II.

CONCLUSION(S)

Severe forms of OHSS, especially those associated with pregnancy, are consistently characterized by huge concentrations of Ang II immunoreactivity in the ascites, proved to be true Ang II by HPLC analysis. This may be due to the synergistic effects of exogenous and endogenous hCG on the ovarian RAS.

Low intraovarian vascular resistance: a marker for severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess intraovarian blood flow in relation to the severity of ovarian hyperstimulation syndrome (OHSS) after controlled ovarian hyperstimulation.

DESIGN

A prospective study.

SETTING

Monash IVF, Clayton, Victoria, Australia.

PATIENT(S)

Thirty patients with OHSS after embryo or gamete transfer who also had sonographic evidence of ascites.

MAIN OUTCOME MEASURE(S)

The resistance to blood flow within the ovaries of 11 patients with severe OHSS and 19 patients with mild OHSS was measured by using transabdominal ultrasonography with color flow and pulsed Doppler imaging.

RESULT(S)

The pulsatility index (PI), resistance index (RI), and the S-D ratio, all measures of downstream vascular impedance, were significantly lower in those patients with severe OHSS. In cases with RI < 0.48, more than two thirds of the patients had a pleural effusion, whereas patients with either PI < 0.75 or S-D < 1.92 had pleural effusion in over one half of the cases. It was notable that blood flow velocity did not differ significantly between the two groups despite the changes in vascular impedance.

CONCLUSION(S)

There appears to be a close correlation between the severity of OHSS and the resistance to blood flow within the stimulated ovaries. Measurement of intraovarian vascular resistance before gamete transfer or ET in patients undergoing controlled ovarian hyperstimulation may help in predicting those patients at particular risk of developing severe OHSS.

Ovarian hyperstimulation syndrome

A case of severe ovarian hyperstimulation syndrome (OHSS) prompted us to review our experience of the condition, and to critically evaluate its clinical associations and treatment. Severe OHSS complicated 1.8% of gamete intra-Fallopian transfer (GIFT) cycles, but none of the ovulation induction and artificial insemination by husband (OI/AIH) cycles. It is difficult to establish whether the higher pregnancy rate observed with OHSS was attributable to pregnancy increasing the risk of OHSS, or if it was the development of OHSS which increased the likelihood of pregnancy. Monitoring serum oestradiol levels and ultrasonographic evaluation of growing follicles may be helpful in identifying women at risk. Strategies for reducing the risk of developing severe OHSS were considered.

Intravenous albumin prevents moderate-severe ovarian hyperstimulation in in-vitro fertilization patients: a prospective, randomized and controlled study

OBJECTIVE

To assess the effectiveness of intravenous administration of albumin in prevention of ovarian hyperstimulation syndrome (OHSS) in patients of an in-vitro fertilization program.

STUDY DESIGN

Prospective randomized study. Patients with hCG day E2 levels are 11010 pmol/l (3000 pg/ml) or more were recruited into two groups. Group A (n = 27) received 10 g 20%, 50 ml human albumin infusion before oocyte pick-up and no medication was administered in Group B (n = 28).

RESULTS

Patients were similar in terms of cycle characteristics. No moderate-severe OHSS developed in Group A whereas one severe OHSS case and four moderate OHSS cases developed in Group B. Statistical analysis revealed a significant (P < 0.05) protection in albumin treated group.

CONCLUSION

Human albumin proves effectiveness in prevention of moderate-severe OHSS.

Recombinant follicle-stimulating hormone in the treatment of patients with history of severe ovarian hyperstimulation syndrome

OBJECTIVE

To compare the low-dose recombinant FSH and hMG protocols in treatment of patients with history of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A prospective study on 22 patients with history of severe OHSS. Group A (n = 14) was treated with low-dose recombinant FSH 40 cycles and group B (n = 8) was treated with low-dose hMG in 26 cycles.

SETTING

The Egyptian IVF-ET Center, Cairo, Egypt.

PATIENT(S)

Twenty-two patients with a history of severe OHSS.

INTERVENTION(S)

Ovulation induction.

MAIN OUTCOME MEASURE(S)

Estradiol, number of follicles, number of hMG ampules, pregnancy rate (PR), and the development of OHSS.

RESULT(S)

The cancellation rate, mean E2 level on day of hCG, mean number of days of stimulation, and the mean number of ampules per cycle were 10%, 523 +/- 166 pg/mL (conversion factor to SI unit, 3.671), 17.8 +/- 5.4, and 19 +/- 6.5 in group A and 19.2%, 554 +/- 152 pg/mL, 14.6 +/- 2.5, and 16.1 +/- 3.6 in group B, respectively. Treatment resulted in eight pregnancies (20% per cycle) and two abortions (25%) in group A. In group B, four pregnancies resulted (15.4% per cycle) and two patients aborted (50%). No cases of OHSS developed in both groups. There were no significant differences in all parameters between the two groups.

CONCLUSION(S)

Recombinant FSH low-dose protocol proved to be as effective as low-dose hMG in producing reasonable ovulation and PRS in polycystic ovary syndrome patients with a history of severe OHSS and the protocol was safe concerning the risk of development of OHSS.

Status of the coagulation and fibrinolytic systems in ovarian hyperstimulation syndrome

OBJECTIVE

To elucidate characteristic changes of plasma hemostatic markers in ovarian hyperstimulation syndrome (OHSS) cycles.

DESIGN

Prospective study.

SETTING

The IVF-ET program of the Department of Obstetrics and Gynecology, The University of Akita, School of Medicine.

PATIENTS

Forty cycles of 40 IVF patients, including 12 cycles in which a severe form of OHSS occurred.

INTERVENTIONS

Blood samples were taken during IVF treatment to determine the levels of blood markers that reflect activation of the coagulation and fibrinolytic systems.

MAIN OUTCOME MEASURES

Thrombin-antithrombin III complexes, plasmin-alpha 2 antiplasmin complexes, and other hemostatic markers related to the coagulation and fibrinolytic system activation.

RESULTS

In the OHSS cycles, the levels of thrombin-antithrombin III and plasmin-alpha 2 antiplasmin complexes in the plasma began to rise within a few days after hCG administration and demonstrated significantly higher levels during the midluteal phase. In OHSS cycles with pregnancy, elevation of these markers continued for > or = 3 weeks after the onset of disease. There were some characteristic changes in OHSS cycles in other hemostatic markers, such as a decrease in the levels of antithrombin III and prekallikrein and shortened activated partial thromboplastin time.

CONCLUSION

These data demonstrate the status of the coagulation and fibrinolytic systems in OHSS cycles and provide insight into the mechanism of activation in the hemostatic system.

The safety and effectiveness of stepwise and low-dose administration of follicle stimulating hormone in WHO group II anovulatory infertile women: evidence from a large multicenter study in Spain

PURPOSE

Our goal was to investigate the safety, effectiveness, and feasibility for the practicing physician of stepwise and low-dose administration of FSH in WHO group II anovulatory infertile women.

METHODS

Infertile female patients (n = 234) suffering from WHO group II anovulation, and who failed to became pregnant with clomiphene citrate, were included in a multicenter, prospective, clinical study of treatment with a protocol of chronic low-dose and small incremental rises with urinary purified or highly purified FSH. Follicular development was monitored with ultrasonographic scans.

RESULTS

The 234 patients received a total of 534 cycles of treatment, for a mean number of 2.3 treated cycles per patient. hCG was withheld in 65 (12.2%) cyles because of no response and in 28 (5.2%) cycles because of hyperresponse. Of the remaining 441 cycles, 419 (95%) were ovulatory, and in 198 (47.3%) of these cycles a single dominant follicle developed. There were 93 pregnancies (39.7% per patient), for a cycle fecundity rate of 17.4%. Cumulative conception rate after two treated cycles was 33.5%. There were 14 (15%) pairs of twins and 10 (10.8%) spontaneous miscarriages. The prevalence of complications was low with no cases of severe OHSS. Basal LH/FSH ratio was significantly higher in the pregnant group of patients than in nonpregnant women.

CONCLUSIONS

Stepwise and chronic low-dose administration of FSH is a safe and effective method for treatment of WHO group II anovulatory infertility, mainly in those patients having high LH/FSH ratios.

Elective cryopreservation of all embryos in women at risk of developing ovarian hyperstimulation syndrome may not prevent the condition but reduces the live birth rate

OBJECTIVE

Our goal was to evaluate the use of elective cryopreservation of all embryos to prevent the development of ovarian hyperstimulation syndrome in patients at risk while undergoing in vitro fertilization treatment.

DESIGN

We analyzed 117 treatment cycles in which the serum E2 concentration on the day of hCG administration was > 10,000 pM and in whom > or = 15 oocytes were retrieved at ultrasound-directed follicle aspiration. The incidence of ovarian hyperstimulation syndrome, pregnancy, and live birth in 65 patients who had elective cryopreservation of all embryos and 52 patients who had fresh embryo transfer were compared. Independent t test and chi-square test (with Yates' correction) was used as appropriate.

RESULTS

The clinical pregnancy (35 vs 17%; P < 0.03) and the live birth (27 vs 12%; P < 0.05) rates in patients receiving fresh embryo transfer was significantly higher than in those who had elective cryopreservation of all embryos. The incidence of moderate and severe ovarian hyperstimulation syndrome was similar in both groups (3.8 and 6.2%).

CONCLUSIONS

Elective cryopreservation of all embryos does not reliably protect against the development of ovarian hyperstimulation syndrome but may reduce the clinical pregnancy and live birth rate.

Intrafollicular hemodynamics before the administration of human chorionic gonadotropin in women at risk of the ovarian hyperstimulation syndrome

OBJECTIVE

To test the hypothesis that alteration of intrafollicular hemodynamics precedes the ovarian hyperstimulation syndrome (OHSS).

DESIGN

A prospective study.

SETTING

The IVF unit and the Doppler imaging laboratory of King's College Hospital, London.

PATIENTS

Twenty-four women undergoing IVF and considered to have an exaggerated response to ovarian stimulation and hence at risk of OHSS.

INTERVENTIONS

Transvaginal Doppler imaging of the intrafollicular blood flow was performed before hCG administration to determine the indexes of intrafollicular hemodynamics.

MAIN OUTCOME MEASURES

Moderate or severe OHSS.

RESULTS

There was no statistically significant difference in mean age (32.63 +/- 1.77 versus 31.48 +/- 3.87), duration of infertility (6.00 +/- 2.19 versus 5.29 +/- 2.73), maximum peak systolic velocity (0.25 +/- 0.16 versus 0.26 +/- 0.21 m/s), mean of six maximal peak systolic velocity (0.15 +/- 0.04 versus 0.21 +/- 0.10), minimum pulsatility index (0.76 +/- 0.26 versus 0.59 +/- 0.23), mean of six minimal pulsatility indexes (0.89 +/- 0.30 versus 0.79 +/- 0.14), minimum resistance index (0.47 +/- 0.06 versus 0.41 +/- 0.10), and mean of six minimal resistance indexes (0.56 +/- 0.05 versus 0.53 +/- 0.06) of intrafollicular blood flow between the women who developed moderate or severe OHSS and matched controls.

CONCLUSION

Measurement of intrafollicular hemodynamics before hCG administration does not predict the development of the OHSS.

Rare occurrence of ovarian hyperstimulation syndrome in oocyte donors

OBJECTIVES

To define the incidence and severity of ovarian hyperstimulation syndrome (OHSS) occurring in oocyte donors.

METHODS

Women (n = 149) aged 31.3 +/- 4.8 years (mean +/- S.D., range 21-41 years) participated as designated oocyte donors and underwent 400 consecutive cycles of controlled ovarian stimulation using human menopausal gonadotropin following pituitary downregulation with gonadotropin-releasing agonist. Patients were monitored by serial transvaginal ultrasound examinations and serum estradiol (E2) determinations. Oocytes (15.6 +/- 7.5 per aspiration; range 2-57) were harvested by ultrasound-directed transvaginal follicle aspiration 36 h following the intramuscular injection of human chorionic gonadotropin (hCG). Follow-up examination occurred 1 and 2 weeks post-aspiration.

RESULTS

On the day of hCG injection E2 levels ranged from 512 to 13,502 pg/ml (mean 2902.7 +/- 1486.9 pg/ml). Over the next few weeks the degree of hyperstimulation in donors was staged: mild 65% (grade I, n = 98; grade II, n = 162); moderate 33.5% (grade III, n = 120; grade IV, n = 14); severe 1.5% (grade V, n = 6; grade VI, n = 0). Associated preaspiration E2 levels were: grade I, 1120 +/- 424 pg/ml; grade II, 2084 +/- 613 pg/ml; grade III, 3785 +/- 1713 pg/ml; grade IV, 5370 +/- 1264 pg/ml; grade V, 4286 +/- 1100 pg/ml. Worsening OHSS was associated with increasing levels of E2. There were no serious complications and hospitalization was not required. All symptoms resolved within 30 days of aspiration, disappearing by the time of the first menstrual flow in women of grade-III or lower stage.

CONCLUSION

Although oocyte donors commonly experienced exaggerated levels of serum E2 they rarely (< 2%) developed severe OHSS. This may be attributable to their lack of embryo transfer which avoids exacerbating the illness.

The effect of ovulation induction on the concentration of maternal serum relaxin in twin pregnancies

OBJECTIVE

Our purpose was to determine the effects of fetal number, various ovulation induction treatments, and placental hormones on the concentration of maternal serum relaxin.

STUDY DESIGN

The concentrations of relaxin, human chorionic gonadotropin, estriol, and alpha-fetoprotein were determined in blood samples drawn at 16 to 18 weeks for prenatal diagnosis in 72 singleton and 115 twin pregnancies and analyzed by one-way analysis of variance, correlation analysis, and stepwise multiple linear regression of the log-transformed data.

RESULTS

The maternal serum concentrations of each of the four measured hormones were significantly higher in the twin pregnancies than in the singleton pregnancies: 1.4-fold for relaxin, 1.9-fold for human chorionic gonadotropin, 1.9-fold for estriol, and 2.2-fold for alpha-fetoprotein (all p < 0.01). The concentrations of each of the four hormones were significantly correlated with each of the others and with the number of fetuses (p < 0.01), except that estriol was not significantly correlated with human chorionic gonadotropin. The serum relaxin concentration in twin pregnancies after treatment with follicle-stimulating hormone and luteinizing hormone (menotropins) (n = 10) was 3.3-fold that in twins resulting from spontaneous ovulation (n = 89, p < 0.01). In twins resulting from in vitro fertilization or gamete intrafallopian transfer (n = 9) the serum relaxin concentration was 2.6-fold higher than in twins resulting from spontaneous ovulation (p < 0.01). The effect of clomiphene citrate (1.2-fold, n = 7) failed to reach statistical significance.

CONCLUSIONS

The second fetus causes a 1.4-fold increase in the concentration of maternal serum relaxin in twin pregnancies. Induction of ovulation with menotropins causes an additional 3.3-fold increase, whereas in vitro fertilization or gamete intrafallopian transfer treatment causes an additional 2.6-fold increase over that seen in twin pregnancies that followed spontaneous ovulation.

A severe case of ovarian hyperstimulation syndrome: 65 liters of ascites aspirated in an on-going IVF-ET twin pregnancy

Ovarian hyperstimulation syndrome (OHSS) is the most serious life-threatening iatrogenic complication of ovulation induction. Presented here is an unusual case where 62 l of intraperitoneal and 3.2 l of intrapleural fluid were aspirated in order to stabilize a severe life-threatening case of OHSS resulting from an on-going IVF-ET twin pregnancy.

Recurrent spontaneous ovarian hyperstimulation syndrome associated with polycystic ovary syndrome

Ovarian hyperstimulation syndrome (OHSS) is the most serious potentially life-threatening iatrogenic complication of ovulation induction. Presented here is the first reported case of recurrent severe OHSS which developed spontaneously in a women with polycystic ovary syndrome, diagnosed early in her second pregnancy, and necessitated intensive fluid and colloid therapy.

Prorenin is elevated in polycystic ovary syndrome and may reflect hyperandrogenism

OBJECTIVE

To examine the null hypothesis that women with polycystic ovary syndrome (PCOS) produce similar levels of prorenin and other components of the ovarian-derived prorenin to angiotensin cascade (ODPAC) at baseline and after stimulation with clomiphene citrate (CC) or hMG when compared with normal age- and weight-matched ovulatory controls.

DESIGN

Prospective controlled clinical trial.

SETTING

Infertility clinic in a university-based county hospital and a hospital-based private infertility practice.

PATIENTS

Twenty-eight infertile women aged 18 to 35 years. Thirteen patients were diagnosed with PCOS. Fifteen normal ovulatory patients who were matched for age and weight served as controls.

INTERVENTIONS

Twenty patients were stimulated with CC and eight were stimulated with hMG.

MAIN OUTCOME MEASURES

Serum E2, P, T, androstenedione (A), DHEAS, LH, FSH, and plasma prorenin, active renin, and angiotensin II (Ang II) were measured at baseline and during the preovulatory and midluteal phases of the stimulation cycles.

RESULTS

Baseline plasma prorenin in PCOS was higher than that of follicular phase controls. Plasma prorenin correlated significantly with peripheral androgen levels. Prorenin, active renin, and Ang II increased in response to gonadotropins with the largest increases occurring in control patients receiving CC. An association was seen between ovulation with CC and lower baseline levels of active renin.

CONCLUSIONS

The null hypothesis was rejected. Infertile women with PCOS have higher baseline prorenin levels when compared with age- and weight-matched ovulatory controls. There is a significant correlation between prorenin and the peripheral levels of androgens produced during ovarian stimulation. Baseline active renin levels may be predictive of ovulation with CC.

A fatal case of ovarian hyperstimulation syndrome with cerebral infarction

The ovarian hyperstimulation syndrome (OHSS) as a cause of death in infertile patients involved in in vitro fertilization is an extremely rare phenomenon. Reported here are the clinical and pathological feature of just such a case together with a discussion of the pathophysiology thought to be involved.

Diagnosis, prevention and management of ovarian hyperstimulation syndrome

The overall incidence of clinically important (moderate to severe) OHSS ranges from 1% to 10% of IVF cycles, but only a small proportion (0.5% to 2%) of the cases are severe. In extreme but rare cases, secondary complications such as deep vein thrombosis, respiratory distress and acute hepato-renal failure may occur. The main risk factors are the presence of polycystic ovaries, high ovarian response to superovulation therapy, the use of hCG to trigger the ovulatory process or for luteal phase support, and the endogenous production of hCG by an early pregnancy. The pathogenesis of OHSS is unknown, although the predominant biochemical mediator is thought to be the renin-angiotensin system. Ovarian stimulation should always be carefully monitored to identify those women at risk. In IVF cycles, the hCG injection should be withheld if the risk is judged to be too great. Some women will benefit from a policy of proceeding to collect oocytes, but electively cryopreserving any resulting embryos, thus allowing the ovarian stimulation cycle not to be wasted. The administration of albumin at the time of oocyte collection will reduce the chance of severe OHSS occurring. If a decision is made to proceed with oocyte recovery and embryo transfer, it may be advisable to give 5000 IU of hCG, rather than 10,000 IU, as the ovulatory trigger. Progesterone, and not hCG, should be given in the luteal phase. Women developing mild or moderate OHSS should be kept under outpatient surveillance to detect the minority that may progress to severe OHSS. Those with severe OHSS should be hospitalised for fluid and electrolyte management. Paracentesis under ultrasound guidance is recommended where there are tense ascites, but further surgical intervention should rarely be undertaken and only when there is good clinical evidence of ovarian torsion or haemorrhage.

The role of the immune system in severe ovarian hyperstimulation syndrome

The ovarian hyperstimulation syndrome is a serious, and potentially life-threatening, complication of ovulation induction. Hitherto, there has been no reliable test which will predict patients who will subsequently develop ovarian hyperstimulation syndrome. Recently, evidences have accumulated concerning the interaction between the immune and reproductive systems which results from sharing certain lymphohaematopoietic cytokines and their receptors. Furthermore, several cytokines have been implicated in the prediction and pathophysiology of ovarian hyperstimulation syndrome. If this is true, it may be possible to modify the patients' immunological homeostasis by passive immunization with intravenous immunoglobulin (IVIg) and thus to prevent ovarian hyperstimulation syndrome.

Minimal monitoring of ovarian hyperstimulation: a useful simplification of the clinical phase of in vitro fertilization treatment

OBJECTIVE

To investigate the feasibility of IVF treatment with minimal monitoring during ovarian hyperstimulation.

DESIGN

Retrospective analysis and prospective study with real-time control group.

SETTING

Transport IVF program with transport clinic and satellite clinics.

PATIENTS

One hundred consecutive IVF cycles monitored at a transport clinic and 100 concurrent consecutive cycles monitored at satellite clinics, using the same stimulation-monitoring protocol and resulting in oocyte aspiration, are compared retrospectively for the number of ultrasound (US) measurements carried out during monitoring and for results of IVF treatment. No patient selection took place. After introduction of a minimal monitoring protocol at a transport clinic, a prospective study was started comparing 100 minimal monitoring cycles at a transport clinic with 100 concurrent conventional monitoring cycles at satellite clinics, all resulting in oocyte aspiration. Patients entered the retrospective or prospective study only once. In all cases the same laboratory facility was used. Monitoring of ovarian hyperstimulation was done with US measurements only. Cycles were canceled for impending ovarian hyperstimulation syndrome (OHSS) when > 35 follicles were seen to develop during hyperstimulation.

RESULTS

Retrospective analysis shows no difference for the average number of US measurements at transport and satellite clinics (2.8 +/- 0.9 and 3.0 +/- 1.0; mean +/- SD). No differences were found in the number of ongoing pregnancies obtained in the two groups: 22 and 18, respectively. One case of severe OHSS occurred in the satellite clinic group. Introduction of minimal monitoring at the transport clinic gives a significant reduction of the average number of US measurements at the transport clinic compared with satellite clinics, where conventional monitoring continued to be used (1.5 +/- 0.8 versus 2.8 +/- 0.9). Ongoing pregnancies at transport and satellite clinics numbered 33 and 26, respectively. In both groups one patient developed severe OHSS. Sixty-two percent of cycles at the transport clinic were monitored with one US measurement only. No cancellations for impending OHSS occurred during the study period.

CONCLUSION

A large group of patients need only one US measurement during monitoring of ovarian hyperstimulation. Minimal monitoring gives a useful further simplification of the clinical phase of IVF treatment, without adverse effects on treatment outcome and incidence of OHSS.

The luteinizing hormone surge--the final stage in ovulation induction: modern aspects of ovulation triggering

OBJECTIVE

To compile updated information regarding gonadotropin secretion, specifically the physiology of the midcycle LH surge, in natural cycles and under various ovulation induction protocols.

DATA IDENTIFICATION AND SELECTION

Studies that deal with the clinical aspects of LH surge manipulation or substitution were identified through literature and Medline searches.

RESULTS

Three major regulatory factors have been identified as participants in the induction of the midcycle gonadotropin surge. These are hypothalamic GnRH secretion, ovarian and adrenal steroids, and less well-characterized ovarian peptide hormones. Gonadotropin-releasing hormone pulsatility is regulated by a complex mechanism that integrates multiple neurotransmitters and sex steroids. Estradiol plays a central role in the pituitary secretion of LH, which also is influenced by P concentrations. Gonadotropin surge attenuating factor also has been implicated in the regulation of timing and amplitude of the LH surge. Human chorionic gonadotropin is used extensively as a LH surrogate, but its use is associated with a number of disadvantages. Induction of an endogenous LH surge through use of the flare effect of GnRH analogues has been examined more recently and has been found to have several advantages. Recombinant human LH is in the final stages of clinical testing.

CONCLUSION

Although much is known about the physiology of the midcycle LH surge and its variations under different clinical conditions, new approaches to the induction or substitution of the LH surge currently are being examined and learned. The introduction of recombinant gonadotropins into clinical practice is likely to influence ovulation induction and IVF practice to a significant degree in the near future.

Laser vaporization of the ovarian surface in polycystic ovary disease results in reduced ovarian hyperstimulation and improved pregnancy rates

OBJECTIVE

Our purpose was to examine the efficacy of laser vaporization of the ovarian surface in polycystic ovary disease to reduce repeated ovarian hyperstimulation syndrome and thereby improve pregnancy outcome.

STUDY DESIGN

Twenty-six infertile patients with polycystic ovary disease who previously had ovarian hyperstimulation syndrome after stimulation with human menopausal gonadotropin and who failed to conceive were studied. All patients were treated by potassium titanyl phosphate and neodymium-yttrium-aluminum-garnet laser and evaluated. Patients not ovulating spontaneously after vaporization were treated with either clomiphene citrate or human menopausal gonadotropin.

RESULTS

After vaporization spontaneous ovulation was confirmed in six patients. For ovulation induction three patients received clomiphene citrate and 17 received human menopausal gonadotropin. Of the patients treated with human menopausal gonadotropin, mild ovarian hyperstimulation syndrome was found in three patients, and the incidence of ovarian hyperstimulation syndrome decreased significantly. Pregnancy was confirmed in 19 of 26 patients.

CONCLUSION

Laser vaporization is promising for the prevention of ovarian hyperstimulation syndrome and improving pregnancy outcome in patients with polycystic ovary disease who have previously had ovarian hyperstimulation syndrome.

The effect of cryopreservation in prevention of ovarian hyperstimulation syndrome

OBJECTIVE

To evaluate the effect of elective cryopreservation of all embryos in the prevention of severe ovarian hyperstimulation syndrome in women at increased risk, following superovulation for in vitro fertilisation.

DESIGN

Three hundred and ninety women undergoing superovulation for in vitro fertilisation between September 1991 and December 1992.

SETTING

University Infertility Clinic, Helsinki, Finland.

INTERVENTIONS

Twenty-three women were considered to have an increased risk of developing ovarian hyperstimulation syndrome. They were characterised by more than 20 retrieved oocytes and/or by serum oestradiol levels exceeding 10,000 pmol/l on the day of administration of human chorionic gonadotrophin. Instead of cancelling the cycle the oocytes were harvested and fertilised, and all good quality embryos were cryopreserved. The embryos were thawed and replaced during subsequent natural cycles.

MAIN OUTCOME MEASURES

Occurrence of ovarian hyperstimulation syndrome and pregnancy rate.

RESULTS

One out of the 23 patients at increased risk developed a moderate degree ovarian hyperstimulation syndrome, while the others had only mild symptoms. Two of the remaining 367 women with no risk developed ovarian hyperstimulation syndrome, both during early pregnancy. Among the 23 patients at increased risk there have been 15 clinical pregnancies after transfer of two to three frozen-thawed embryos in natural cycles, with a 32.6% pregnancy rate.

CONCLUSIONS

Withholding embryo replacement and elective cryopreservation of the embryos is effective in preventing severe ovarian hyperstimulation syndrome. After subsequent replacement in natural cycles the implantation rate per embryo is good (22.7%).

Native gonadotropin-releasing hormone for triggering follicular maturation in polycystic ovary syndrome patients undergoing human menopausal gonadotropin ovulation induction

OBJECTIVE

To evaluate the role of GnRH administration instead of hCG for triggering follicular maturation in patients with polycystic ovaries (PCO) undergoing hMG ovulation induction when the late follicular 17-beta-E2 levels are > 1,600 pg/mL (> 6,000 pmol/L).

DESIGN

Prospective study.

SETTING

Infertility outpatient clinic of Rambam Medical Center (general hospital), Haifa, Israel.

PATIENTS AND INTERVENTIONS

High serum E2 concentrations from 1,600 to > 3,600 pg/mL (2,800 +/- 68, mean +/- SD [6,000 to > 13,000 pmol/L, 10,279 +/- 2,500]) were experienced in 44 hMG cycles. The number of preovulatory follicles visualized by transvaginal sonography was between 8 and 25. An IV injection of 200 micrograms GnRH was administered for triggering final follicular maturation and ovulation, instead of 10,000 IU IM hCG, usually injected for this purpose, when the E2 levels are < or = 1,600 pg/mL (6,000 pmol/L). Serum E2 and P levels were monitored in the luteal phase. In cycles where E2 decreased to < or = 1,360 pg/mL (5,000 pmol/L), 2,500 IU hCG was administered once or twice at 3-day intervals for luteal support.

MAIN OUTCOME MEASURES

Pregnancy and abortion rates and the rate of ovarian hyperstimulation syndrome (OHSS).

RESULTS

Ten pregnancies were generated by the hMG and GnRH co-treatment in 32 patients (31.2%), in 44 cycles (23%). Two pregnancies aborted (20%), and eight generated eight healthy neonates. Ovarian hyperstimulation syndrome occurred in two cycles of patients who were both pregnant. All but two of these PCO patients also have undergone 69 hMG and hCG cycles. Only 7 patients conceived (23%) 10 times (10/69, 14.5%); 5 of these pregnancies (50%) were multiple gestations (3 twins, 1 sextuplet, and 1 heptuplet gestation). The pregnancy wastage rate was 30% (3/10).

CONCLUSION

The use of native GnRH to trigger ovulation in PCO patients with late follicular E2 levels > 1,600 pg/mL (6,000 pmol/L) appears to be comparable with prior hMG and hCG cycles in terms of pregnancy rate, pregnancy wastage, risk of multiple gestation, and incidence of severe ovarian hyperstimulation. Unlike hMG and GnRH-agonist, which is associated with luteal phase dysfunction, hMG and GnRH offers a preferable alternative due to the ability of hCG luteal support and rescue, providing the E2 levels are not dangerously increased.

Intravenous albumin for the prevention of severe ovarian hyperstimulation syndrome in an in vitro fertilization program: a prospective, randomized, placebo-controlled study

OBJECTIVE

To evaluate the efficacy of i.v. administration of human albumin solution for the prevention of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A prospective, randomized, placebo-controlled study comparing the effects of i.v. administration of human albumin solution versus sodium chloride 0.9% solution at the time of oocyte retrieval with patients undergoing IVF-ET who are at high risk for the development of severe OHSS.

SETTING

Specialized assisted reproduction unit.

PATIENTS

Thirty-one patients undergoing IVF-ET who had serum E2 levels of 1,906 pg/mL (> 7,000 pmol/L) and multiple follicular development on the day of hCG administration.

INTERVENTIONS

After hCG administration, patients were randomized to receive i.v., either 50 g of human albumin diluted in 500 mL of sodium chloride 0.9% or 500 mL of sodium chloride 0.9% at the time of oocyte retrieval.

MAIN OUTCOME MEASURES

Ovarian size as measured by pelvic ultrasonography, development of ascites, serum E2 concentrations during the luteal phase, and results of the IVF-ET cycles.

RESULTS

Although no patient who had received human albumin solution developed severe OHSS, there were four such cases in the control group. All four were hospitalized with marked ascites and ovarian enlargement. There were no significant differences between the two groups comparing serum E2 levels on the day of hCG administration and during the luteal phase, the number of oocytes retrieved, fertilization, and pregnancy rates.

CONCLUSIONS

Our preliminary results suggest that the administration of human albumin solution may help to prevent the development of severe OHSS in high-risk patients. Further research is needed to assess the potential of this novel approach.

Ovarian hyperstimulation syndrome in the emergency department: a case report

The Ovarian Hyperstimulation Syndrome (OHSS) is a complication of ovulation enhancing technologies that is becoming more prevalent with increasing use of these techniques in infertile women. In this report, we describe a 36-year-old woman who presented to the Emergency Department with hemodynamic compromise secondary to OHSS. The OHSS is characterized by ovarian enlargement, ascites, electrolyte disturbances, hypotension, and thromboembolic events. This case illustrates a serious complication of techniques used to enhance fertility.

Gonadotropin-releasing hormone agonist versus human chorionic gonadotropin as a trigger of ovulation in polycystic ovarian disease gonadotropin hyperstimulated cycles

OBJECTIVE

To compare the use of GnRH agonist (GnRH-a) versus hCG in triggering the follicular rupture in patients with polycystic ovarian disease (PCOD) in whom ovulation was induced by gonadotropins.

DESIGN

Polycystic ovarian disease gonadotropin hyperstimulated cycles outcome was investigated in a prospective study.

PATIENTS AND INTERVENTIONS

Thirty-three PCOD patients (40 cycles) with gonadotropin-induced mild to moderate degree of ovarian hyperstimulation received 5,000 IU IM hCG or 200 microg [corrected] SC GnRH-a. A subgroup of GnRH-a-treated patients received P for luteal support. Five GnRH-a-treated patients underwent a GnRH test during luteal phase.

MAIN OUTCOME MEASURES

Echographic and endocrine characteristics both during the therapy and the luteal phase.

RESULTS

There was a similar percentage of ovulation and pregnancy rate in both groups of patients. The ovarian enlargement during the luteal phase in the GnRH-a-treated patients was lower than in the hCG group. Progesterone plasma levels (at midluteal phase) and the length of luteal phase was significantly lower in GnRH-a-treated patients with respect to the hCG-treated group. These differences disappeared in patients receiving luteal support. After GnRH injection, LH secretion decreased in GnRH-a-treated patients with respect to controls; however, corpus luteum was able to respond with a normal increase of P production.

CONCLUSION

The GnRH-a appears to be an effective alternative to hCG for inducing the follicular rupture in stimulated cycles in women who are at risk for developing ovarian hyperstimulation syndrome. However, GnRH-a administration can induce short luteal phase. This defect may be ascribed to the pituitary desensitization rather than to a direct effect on corpus luteum. Luteal phase support is needed to prevent luteal phase deficiency.

Controlled ovarian hyperstimulation: an adjunct to assisted reproductive technology

Controlled ovarian hyperstimulation was given to a study group consisting of male factor, endometriosis, and unexplained infertility. The aim of the study was to determine whether COH might be of value for such couples in a setting lacking ART facilities. When compared with their own spontaneous cycles or with a control group (untreated but scanned), COH proved significantly better for unexplained infertility. However, COH was not significantly effective for male factor infertility. This study shows that COH should be offered routinely in general hospitals to couples on long-term waiting lists for ART (especially those facing enforced expectant management).

Increased ascitic fluid prorenin in the ovarian hyperstimulation syndrome

Three patients developed severe ovarian hyperstimulation syndrome (OHS) as a complication of ovarian hyperstimulation for in vitro fertilization. These patients presented with ovarian enlargement, vascular volume depletion, pleural effusions, and exudative ascites. A unique feature of the ascites in OHS was the markedly elevated renin concentration, the majority of which was prorenin. We speculate the renin-angiotensin system (RAS) may play a pathophysiologic role in the localized capillary leak that develops in OHS.

Ovarian hyperstimulation syndrome: protocols for nursing care

One of the few life-threatening conditions encountered by the nurse caring for reproductive endocrinology and infertility patients is ovarian hyperstimulation syndrome (OHS). Having protocols for the nursing care of the patient with OHS enhances patient safety and quality of care. Model OHS protocols for outpatient and inpatient settings are presented. The collaborative nursing role in patient care also is discussed.

[Thrombosis of the internal jugular vein in ovarian hyperstimulation syndrome]

Severe ovarian hyperstimulation syndrome is a rare complication of assisted reproductive technologies. It presents with massive ovarian enlargement, fluid accumulation in peritoneal, pleural cavities and thromboembolic diseases. The authors report an exceptional case of internal jugular vein thrombosis in an ovarian hyperstimulation syndrome. Pathogenesis of this event is discussed.

Complications of ovulation induction

Induction of ovulation has its own risks. Since this treatment is elective the physician should be convinced that it is really indicated for the specific patient. Multiple pregnancies still occur in 4 to 15% in in vivo treatment and in 15 to 20% in assisted reproduction. Abortions occur in 20% of the pregnancies achieved. These numbers demonstrate the complexity of induction of ovulation. In recent years the average age of the treated patient has increased, but it is too early to see whether this influences the frequency of complications. The physician should be aware of the possible complications and should remain in contact with the patients at risk after completion of the treatment. The patient should be well informed about the possible complications before starting treatment. At the end of the treatment she should be able to recognize any clinical warning signs of OHSS and inform her physician, in order to be treated appropriately. Further studies of the pathogenesis of OHSS in the future will hopefully lead to more specific treatments or even prevention of this phenomenon. The increasing experience in selective fetal reduction seems to be a practical solution to high rank multifetal gestation, preventing extreme prematurity and its sequelae.

The step-down principle in gonadotrophin treatment and the role of GnRH analogues

This chapter has focused on the step-down principle for gonadotrophin induction of ovulation in women suffering from clomiphene-resistant anovulation. The physiological rationale of this approach has been highlighted. Under normal conditions, FHS levels surpassing the FSH threshold initiate gonadotrophin-dependent growth of a cohort of follicles (this process is referred to as 'recruitment'). Due to negative feedback actions, the FSH levels decrease and FSH is above the threshold for only a limited number of days (the 'FSH window'). Around the mid-follicular phase, selection of a dominant follicle takes place; in addition to relatively low serum FSH concentrations, intraovarian regulation appears to be important for this process. In the conventional step-up or low dose step-up protocols for gonadotrophin induction of ovulation, administered doses are kept constant once an 'adequate' ovarian response is observed, resulting in high FSH serum levels in the late follicular phase and a broad FSH window. This contradicts normal circumstances and may give rise to unintended interference with the selection process by continuously stimulating follicles to enter the growing pool. This may result in multiple follicle development which, in turn, may be related to higher rates of multiple pregnancies and ovarian hyperstimulation. Potential mechanisms underlying arrested follicle maturation in PCOS are also discussed since they appear to be of relevance for the induction of ovulation. Disturbed selection can be overcome in the majority of cases by elevating the serum FSH concentrations through the administration of exogenous gonadotrophins to surpass the elevated FSH threshold in these patients. Data obtained by our group so far suggest that in PCOS patients treated with gonadotrophins in a step-down fashion, follicles continue to mature and can be stimulated to ovulation. Moreover, the number of functionally active medium-sized follicles seems to be reduced. If monofollicular development is observed in these patients, growth rates and oestrogen serum levels are indistinguishable from unstimulated normal development of the dominant follicle. In our initial series of over 200 cycles of gonadotrophin treatment according to the step-down principle in clomiphene-resistant anovulatory patients, 84% of cycles were ovulatory and pregnancy was achieved in 18% of the cycles (giving a cumulative pregnancy rate of 51%). Moreover, the overall complication rate appears to be low. The potential advantages and critical points of adjuvant treatment with GnRH analogues is also discussed. It has been clearly demonstrated that premature luteinization can be prevented effectively. Various other potential advantages of cotreatment seems to justify adjuvant medication with GnRH agonists.(ABSTRACT TRUNCATED AT 400 WORDS)

Ovarian cyst aspiration: a therapeutic approach to ovarian hyperstimulation syndrome

Ultrasonographically guided transvaginal aspiration of ovarian cysts in women with severe OHSS after GIFT or IVF was safe and has resulted in immediate relief of symptoms, a shorter disease process, and outpatient treatment. The patients were allowed to go back to normal activity after the procedure. The progression of the disease was interrupted and six of seven patients carried beyond 20 weeks' gestation.