Ovarian hyperstimulation syndrome: an update review

Embryo freezing for preventing Ovarian Hyperstimulation Syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic potentially life threatening condition resulting from an excessive ovarian stimulation. Its reported incidence varies from 1% to 10% of in vitro fertilization (IVF) cycles. The factors leading to this syndrome have not been completely explained. It seems likely that the release of vasoactive substances, secreted by the ovaries under human chorionic gonadotropin (hCG) stimulation plays a key role in triggering this syndrome. The hallmark of this condition, is a massive shift of fluid from the intra-vascular compartment to the third space resulting in profound intra-vascular depletion and hemoconcentration.

OBJECTIVES

To evaluate (i) the effectiveness of cryopreservation (embryo freezing) for the prevention of OHSS when compared with human intra-venous albumin infusion and (ii) the effectiveness of the elective cryopreservation (embryo freezing ) of all embryos for the prevention of OHSS when compared with fresh embryo transfer.

SEARCH STRATEGY

Publications in the literature that describe or may describe randomised controlled trials of both human intra-venous albumin and freezing of all embryos in the management of OHSS as consequence of the superovulation in assisted reproduction techniques (ART) cycles were searched. The Cochrane Menstrual Disorders and Subfertility Review Group specialised register of controlled trials was searched. In addition, MEDLINE (PUBMED 1985 to 2001), EMBASE (1985 to 2001), CINHAL (1985 to 2001) and the National Research Register were searched

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which either human intra-venous albumin or cryopreservation of all embryos were used as a therapeutic approach to OHSS were included. The participants were women of reproductive age who were down regulated by gonadotrophin-releasing hormone-analogue (GnRH-a), undergoing superovulation in in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) cycles.

DATA COLLECTION AND ANALYSIS

Two reviewers, Mr N.N. Amso (NNA) and Dr A. D'Angelo (ADA) scanned the titles and the abstracts of the reports identified by electronic searching in order to find relevant papers. One reviewer (ADA) obtained copies of the full text articles and made copies for the other reviewer (NNA) in which details of authors, institution, results and discussion were removed in order to assess their eligibility for inclusion. Then, both reviewers extracted data independently using forms designed according to Cochrane guidelines. Disagreements were resolved by discussion. Additional information on the trial methodology or data were requested by writing to the corresponding authors directly. The interventions compared were cryopreservation (embryo freezing) versus intra-venous human albumin administration and elective cryopreservation of all embryos versus fresh embryo transfer. The primary outcomes were: incidence of moderate and severe OHSS versus nil/mild OHSS, clinical pregnancies/woman. The secondary outcomes were: number of oocytes retrieved, number of oocytes fertilized, number of embryos transferred, number of embryos frozen, multiple pregnancy rate, live birth rate, number of women admitted to the hospital as inpatient or outpatient and time to the next menstrual period (resolution time). Statistical analysis was performed in accordance with the Cochrane Menstrual Disorders and Subfertility Group guidelines.

MAIN RESULTS

Seventeen studies were identified, two of which met our inclusion criteria. One study was included where cryopreservation (embryo freezing) was compared with intra-venous human albumin administration (Shaker 1996) and one study was included where elective cryopreservation of all embryos was compared with fresh embryo transfer (Ferraretti 1999). When cryopreservation was compared with intra-venous human albumin administration no difference was found in all the outcomes examined between the two groups. When elective cryopreservation of all embryos was compared with fresh embryo transfer no difference was found in all the outcomes examined between the two groups.

REVIEWER'S CONCLUSIONS

This review has showed that there is insufficient evidence to support routine cryopreservation and insufficient evidence for the relative merits of intra-venous albumin versus cryopreservation.

The effectiveness and safety of recombinant human LH to support follicular development induced by recombinant human FSH in WHO group I anovulation: evidence from a multicentre study in Spain

BACKGROUND

Until recently, human menopausal gonadotrophin (HMG), a urinary extract containing a fixed combination of LH and FSH, was the only source of exogenous LH for women with hypogonadotrophic hypogonadism undergoing ovulation induction with gonadotrophins. Recombinant human LH (rLH) is now available for clinical use, providing a new treatment option but clinical data on its use are scanty. Therefore, the aim of the present study was to investigate the efficacy and safety of rLH combined with recombinant FSH (rFSH) to induce follicular development and ovulation in World Health Organization (WHO) group I anovulatory women.

METHODS

We included in this multicentre study 38 hypogonadotrophic anovulatory (WHO group I) women. Patients received 150 IU/day rFSH and 75 IU/day rLH (with the possibility of dose adjustment) as a single s.c. injection for up to three cycles with a total of 84 treatment cycles.

RESULTS

Sufficient follicular growth was observed in 79 (94%) out of 84 initiated cycles. The 75 IU rLH dose was found to be effective in most treatment cycles (94%) and only five cycles in three patients required daily dose increase. Overall, HCG was administered to trigger ovulation in 67 (80%) of the 84 cycles while it was withheld in 12 cycles (14%) due to ovarian hyper-response and five cycles (6%) were cancelled for insufficient follicular growth. The pregnancy rate per started treatment cycle and per cycle given HCG was 18 and 22.4% respectively. Pregnancy was achieved by 15 (39.5%) of the 38 patients. Mild to moderate ovarian hyperstimulation syndrome occurred in three patients. Local tolerance was good.

CONCLUSIONS

This study confirms that combined rFSH and rLH treatment induces follicular growth, ovulation and pregnancy in a good proportion of hypogonadotrophic anovulatory patients and is well tolerated. The doses of 150 IU rFSH and 75 IU rLH daily seem the most appropriate but in a small minority of patients doses >75 IU rLH/day may be necessary.

Elevated interleukin-10 and sex steroid levels in peritoneal fluid of patients with ovarian hyperstimulation syndrome

BACKGROUND

The ovarian hyperstimulation syndrome (OHSS) following ovulation induction is characterized by a cystic enlargement of the ovaries with an acute third space fluid sequestration. Inflammatory cytokines mediate the inflammatory response (IL-1, IL-2, IL-6, IL-8, TNFalpha) and play a crucial role in the pathogenesis of OHSS.

OBJECTIVE

To determine the role of the anti-inflammatory cytokine interleukin-10 (IL-10) in OHSS and to examine its correlation with 17beta-estradiol and progesterone.

STUDY DESIGN

Peritoneal fluid and serum samples were collected from 9 patients with severe OHSS after ovulation induction by administration of GnRH-analogues followed by hMG (n=5) or recombinant FSH (n=4). Patients (n=19) without pathological findings at laparoscopy served as non-pregnant controls and pregnant women (n=14) between 7 and 16 weeks of gestation served as positive controls. Samples were assayed for IL-10 by commercially available ELISA and for for 17beta-estradiol and progesterone by RIA. Statistical analysis was performed by non-parametric Mann-Whitney U-test and results are presented as the median and range.

RESULTS

OHSS patients had significantly higher peritoneal fluid IL-10, 17beta-estradiol and progesterone levels than patients during early pregnancy and than the control group. No correlation was found between peritoneal fluid or serum IL-10 and 17beta-estradiol or progesterone in the different groups. Serum 17beta-estradiol and progesterone, but not serum IL-10 levels were elevated in OHSS and during early pregnancy.

CONCLUSIONS

High concentrations of IL-10 in peritoneal fluid suggest a role of this anti-inflammatory cytokine during OHSS. 17beta-estradiol and progesterone were elevated in peritoneal fluid and serum during OHSS but no correlation with IL-10 concentrations was found. Therefore, we assume that IL-10 has a role in OHSS as a local mediator of inflammation, however, it presents different aspects of the OHSS than the sex steroids 17beta-estradiol and progesterone.

Naltrexone effect on pulsatile GnRH therapy for ovulation induction in polycystic ovary syndrome: a pilot prospective study

The aim of the present study was to analyze the opioid influence on LH pulsatility in polycystic ovary syndrome (PCOS) patients and to evaluate the effectiveness of a long-term opioid antagonist (naltrexone) treatment in improving the pulsatile GnRH therapy which is successful in this syndrome. Ten obese women affected by PCOS participated in the study. Patients were hospitalized during the early follicular phase and underwent an oral glucose tolerance test (OGTT) with 75 g of glucose and a pulse pattern study followed by a GnRH test (100 pg i.v.). All patients were then treated for ovulation induction with pulsatile administration of GnRH (5 microg/bolus every 90 min). Since pregnancies did not occurr in any patient, after spontaneous or progestin-induced menstrual cycles, all patients received naltrexone at a dose of 50 mg/day orally for 8 weeks and during treatment repeated the basal protocol study and the ovulation induction cycle with the same modalities. The naltrexone treatment significantly reduced the insulin response to OGTT and the LH response to GnRH bolus, whereas it did not affect the FSH and LH pulsatility patterns. Concerning the ovulation induction by pulsatile GnRH, naltrexone treatment was able to improve, although not significantly, the ovulation rate (60% pre-treatment vs 90% post-treatment). Furthermore, the maximum diameter of the dominant follicle and the pre-ovulatory estradiol concentration were higher after long-term opioid blockade (follicular diameter 19.5+/-1.76 mm pre-treatment vs 21.6+/-2.19 mm post-treatment, p<0.001; maximum estradiol level 728.7+/-288.5 pmol/l pre-treatment vs 986.4+/-382.1 pmol/l post-treatment, p<0.05). During the naltrexone-pulsatile GnRH co-treatment two pregnancies occurred. In conclusion, our data show that naltrexone-pulsatile GnRH co-treatment is able to improve the ovarian responsiveness to ovulation induction in obese PCOS patients when compared to pulsatile GnRH alone. This action seems to be related to a decrease of insulin secretion. Further randomized studies should be performed in order to obtain significant conclusions on the possible clinical application.

OVARIAN HYPERSTIMULATION SYNDROME DURING INDUCTION OF OVULATION FOR INTRA UTERINE INSEMINATION

Ovarian Hyperstimulation Syndrome (OHSS) is a known iatrogenic complication of ovulation induction. Our experience of such complication while managing basic assisted conception cycles has been analysed in the present study. 12 such cases were identified in 976 cycles studied giving an overall incidence of 1.22%. All the cases were of mild to moderate variety and were managed conservatively. The duration of the complication ranged between 10 days to 6 weeks. Polycystic ovarian disease, LH: FSH ratio of more than 1, presence of four or more secondary follicles were found to be important predictive criteria. Identification of predictive factors of OHSS can be helpful in taking due care while using ovulation inducing drugs. Conception does worsen OHSS, but termination is usually not necessary.

Soluble ICAM-1 and E-selectin levels correlate with clinical and biological aspects of severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of the soluble endothelial cell-leukocyte adhesion molecules E-selectin and intercellular adhesion molecule-1 (ICAM-1) in the pathophysiology of capillary hyperpermeability in the ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled clinical study.

SETTING

Women hospitalized for severe OHSS after ovulation induction for IVF at two tertiary medical centers.

PATIENT(S)

Eleven patients with severe OHSS undergoing IVF and 20 controls who had received a similar ovulation induction regimen and did not develop OHSS.

INTERVENTION(S)

Serial serum samples were obtained from all patients with OHSS from admission until discharge. Ascitic fluid was obtained from all patients by therapeutic paracentesis. Serum was obtained from all controls 4-8 days after ET.

MAIN OUTCOME MEASURE(S)

Samples were assayed for soluble E-selectin and soluble ICAM-1 by using enzyme-linked immunosorbent assay and results were correlated with clinical and biological aspects of OHSS.

RESULT(S)

Compared with controls, patients with severe OHSS had higher levels of soluble ICAM-1 and lower levels of soluble E-selectin detected in serum and ascites. Serum levels of soluble ICAM-1 decreased, while soluble E-selectin levels increased along with clinical and biological improvement. Serum soluble ICAM-1 showed significant positive correlation and serum soluble E-selectin showed significant negative correlation with clinical and biological aspects of severe OHSS.

CONCLUSION(S)

Soluble ICAM-1 and soluble E-selectin seem to be involved in the pathophysiology of capillary hyperpermeability in severe OHSS.

Hydroxyethylstarch versus human albumin for the treatment of severe ovarian hyperstimulation syndrome: a preliminary report

OBJECTIVE

To compare the efficacy and safety of 6% hydroxyethylstarch and human albumin as colloid solutions for treatment of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled cohort study.

SETTING

Tertiary medical center.

PATIENT(S)

Sixteen patients with severe OHSS.

INTERVENTION(S)

Six percent hydroxyethylstarch (6 patients) and human albumin (10 patients).

MAIN OUTCOME MEASURE(S)

Urine output, number of abdominal and pleural drainage procedures, complications, duration of hospitalization, and perinatal outcome.

RESULT(S)

Patients who received 6% hydroxyethylstarch had higher urine output, needed fewer abdominal and pleural paracenteses, and had a shorter hospital stay than those who received human albumin. In each group, no adverse effects or congenital malformations were observed and the rates of miscarriage were similar.

CONCLUSION(S)

These results suggest that 6% hydroxyethylstarch may be superior to albumin as a colloid solution for the treatment of severe OHSS.

Human recombinant luteinizing hormone is as effective as, but safer than, urinary human chorionic gonadotropin in inducing final follicular maturation and ovulation in in vitro fertilization procedures: results of a multicenter double-blind study

In a prospective, comparative, dose-finding study, the minimal effective dose of recombinant human LH (rhLH) required to induce final follicular maturation and early luteinization in patients undergoing in vitro fertilization and embryo transfer was determined. In addition, the efficacy and safety of rhLH were compared with urinary human CG (u-hCG). A total of 259 infertile women, aged 18-39 yr, were enrolled in the study. After pituitary desensitization using a GnRH agonist, rhFSH was administered for ovarian stimulation. Patients then received either rhLH or u-hCG to achieve final follicular maturation. The doses of rhLH administered were 5,000, 15,000, 30,000, or 15,000 + 10,000 IU (second injection administered 3 days after the first injection; 129 patients), and those of u-hCG were consistently 5,000 IU (121 patients). Ovum pick-up was performed 34--38 h after rhLH or u-hCG injection. After fertilization in vitro, up to three embryos were replaced in the uterine cavity. The numbers of oocytes retrieved after u-hCG or rhLH administration were not significantly different between the four different doses of rhLH, when compared with each corresponding u-hCG group, nor when compared with the pool of all u-hCG groups. Similarly, there were no statistically significant differences in: the number of oocytes retrieved per follicle with a diameter of over 10 mm on the day of u-hCG or rhLH administration; the number of patients with at least one oocyte retrieved; oocyte nuclear maturity; oocyte potential for fertilization; the number of embryos; the number of total, biochemical, and clinical pregnancies; and the embryo implantation rate. However, in many of these parameters, the lowest dose of rhLH seemed suboptimal when compared with the higher dose. In terms of safety, rhLH was well tolerated at a dose of up to 30,000 IU. Moderate ovarian hyperstimulation syndrome (OHSS) was reported in 12.4% of patients who received u-hCG and 12.0% of patients who received two injections of rhLH. No moderate or severe OHSS was reported in patients who received a single dose of rhLH up to 30,000 IU. The results show that a single dose of rhLH is effective in inducing final follicular maturation and early luteinization in in vitro fertilization and embryo transfer patients and is comparable with 5,000 IU u-hCG. A single dose of rhLH results in a highly significant reduction in OHSS compared with hCG. The dose of rhLH giving the highest efficacy to safety ratio was between 15,000 and 30,000 IU.

Correctly timed coasting reduces the risk of ovarian hyperstimulation syndrome and gives good cycle outcome in an in vitro fertilization program

One hundred and twelve severely overstimulated in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) patients were treated with coasting when estradiol concentration was > 3000 pg/ml and the leading follicles had attained > or = 18 mm in diameter. Gonadotropin withholding was offered to them as a promising method for the prevention of both cycle cancellation and complications associated with severe ovarian hyperstimulation syndrome (OHSS). The duration of prolonged coasting prior to human chorionic gonadotropin (hCG) administration ranged from 2 to 9 days (mean 3.5). hCG was administered when the serum estradiol dropped to < 3000 pg/ml and at least three growing follicles > or = 20 mm in diameter were present. Fertilization failure was noted in six couples and in another 10 cases freezing of all embryos was decided, therefore embryo transfer was performed on 96 patients. There were 31 clinical pregnancies (five twins) giving a pregnancy rate per patient and per embryo transfer of 30.4% and 32.3%, respectively, with an implantation rate of 18.1%. With regard to all 112 coasted patients, six developed moderate and two severe OHSS. This study shows that withholding gonadotropin administration in high-risk IVF patients results in a good cycle outcome and a very low risk of severe OHSS, and also demonstrates the importance of both the timing of coasting initiation and the timing of hCG administration.

Ovarian hyperstimulation syndrome complicating a spontaneous singleton pregnancy: a case report

It has been known that most cases of ovarian hyperstimulation syndrome (OHSS) are associated with the use of exogenous gonadotropins to induce multiple ovulation. However, OHSS is infrequently associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism, or polycystic ovarian syndrome. We report a case of severe OHSS in a spontaneously pregnant woman with no underlying disease.

Dynamics of immunoreactive endothelin plasma levels during ovarian stimulation for in vitro fertilization with and without dietary sodium restriction

OBJECTIVE

To investigate the correlation between immunoreactive endothelin plasma levels and both the number and size of follicles and its relationship with the development of ovarian hyperstimulation syndrome, in in vitro fertilization cycles, with and without dietary sodium restriction.

STUDY DESIGN

Randomized study in an assisted reproduction unit of a large teaching hospital. Data of 88 women form the basis of this report (45 ad libitum sodium intake and 43 dietary sodium restriction). Non-parametric tests were used for statistical analysis.

RESULTS

Immunoreactive endothelin plasma levels neither correlate with the number of follicles, independent of their size, nor with the grade of ovarian hyperstimulation syndrome. Immunoreactive endothelin plasma levels decrease significantly in the luteal phase. These results are the same in both sodium diet groups.

CONCLUSIONS

Immunoreactive endothelin plasma levels do not correlate with the number and size of follicles and they are not related to the development of ovarian hyperstimulation syndrome. These findings are independent of sodium intake.

Does laparoscopic ovarian diathermy affect the outcome of IVF-embryo transfer in women with polycystic ovarian syndrome? A retrospective comparative study

Controlled ovarian stimulation for IVF and embryo transfer and outcome parameters were compared retrospectively in 31 women with clomiphene-resistant polycystic ovarian syndrome (PCOS). Of these women, 15 had previously undergone laparoscopic ovarian diathermy before IVF (group A, total 22 cycles) and 16 had not had surgical treatment (group B, total 24 cycles). No statistically significant differences were observed in the number of oocytes retrieved, although the number of embryos available for transfer was significantly higher in group B (7.1 +/- 3.8 versus 4.6 +/- 2.7, P < 0.01). The clinical pregnancy rate per embryo transfer appeared to be higher in group B (63.2 versus 41.2%), as did the miscarriage rate (66.7 versus 28.6%), giving an apparent improved ongoing pregnancy rate per embryo transfer in group A (29.4 versus 10.5%), but this was not statistically significantly different. The incidence of severe ovarian hyperstimulation syndrome (OHSS) was apparently higher in group B (4.2 versus 0%), but this difference was not statistically significant. No cases of severe OHSS were seen in group A. Ovarian diathermy does not appear to have a deleterious effect on controlled ovarian stimulation, and the outcome of IVF-embryo transfer may be beneficial in decreasing the risk of severe OHSS and improving the ongoing clinical pregnancy rate.

Low peripheral blood levels of the immunosuppressive cytokine interleukin 10 (IL-10) at the start of gonadotrophin stimulation indicates increased risk for development of ovarian hyperstimulation syndrome (OHSS)

Our hypothesis was that patients developing ovarian hyperstimulation syndrome (OHSS) might have a disturbed responsiveness or delayed activation of the immunosuppresive cytokine system. In a prospective cohort study, women (n=428) undergoing in vitro fertilisation (IVF) treatment were subjected to repeated blood sampling and collection of clinical data. Fifteen patients, who developed severe OHSS, were compared with matched (age, follicle numbers, pregnancy) control patients. Samples of serum and plasma were collected throughout the stimulation and up to 7 days after embryo transfer as well as during hospitalisation for OHSS. Levels of IL-4, IL-10, IL-13, oestradiol and progesterone were measured. Significantly lower levels of IL-10 were seen at the start of gonadotrophin stimulation in OHSS patients, with an increase seen after the development of OHSS. In these OHSS patients, a negative correlation between IL-10 levels and number of follicles at time of aspiration existed, but there were no correlations between steroid and IL-10 levels. Levels of IL-13 and IL-4 were low in both groups and did not change during stimulation. The lower levels of IL-10 at start of stimulation in OHSS patients, as compared with controls, may be of pathophysiological importance by allowing for an enhanced Th-1 type immune response during gonadotrophin stimulation and thereby increased and generalised inflammation. The increase in IL-10 after development of OHSS indicates that IL-10 at that time is induced in a systemic attempt to suppress the inflammation of OHSS.

Embryo freezing to prevent ovarian hyperstimulation syndrome

One of the primary goals of ART is to achieve some degree of supraphysiologic ovarian stimulation. Too vigorous a response can lead to ovarian hyperstimulation syndrome (OHSS), which is potentially life threatening. The incidence of severe OHSS is low, yet global proliferation of ART suggests that the absolute number of cases will be increasing. The clinical course of OHSS is more severe in patients who conceive. Should gonadotropin therapy induce too great a response, OHSS can best be prevented via cycle cancellation and withholding HCG. An alternative, which would not forfeit oocyte retrieval, is to perform elective cryopreservation of all resulting pre-embryos. This requires a strategy to identify patients at risk accurately. Several centers have bypassed fresh embryo transfer to lessen the risk of OHSS. By consensus it appears that this approach reduces but does not eliminate the risk of severe OHSS. Chances of pregnancy are excellent in subsequent cryo thaw transfers.

Role of vascular endothelial growth factor in ovarian physiology and pathology

OBJECTIVE

To review the current literature on the role of vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) in ovarian physiology and pathology.

DESIGN

A computerized search was conducted to identify relevant in vitro and in vivo studies published in English. MEDLINE, Current Contents, and the Index Medicus were searched for studies published before January 2000.

RESULT(S)

VEGF/VPF is an angiogenic factor and a potent mitogen for vascular endothelium. During reproductive life, VEGF/VPF plays a role in the cyclic growth of ovarian follicles and corpus luteum development and maintenance, mediating ovarian angiogenesis. VEGF/VPF expression and secretion are induced by both FSH and LH/hCG receptor-activated pathways.

CONCLUSION(S)

VEGF/VPF expression and production within the ovary are critical for normal reproductive function. Defects in angiogenesis may contribute to a variety of disorders including anovulation and infertility, pregnancy loss, ovarian hyperstimulation syndrome, and ovarian neoplasms.

Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report: short communication

A new treatment option for patients undergoing ovarian stimulation is the gonadotrophin-releasing hormone (GnRH) antagonist protocol, with the possibility to trigger a mid-cycle LH surge using a single bolus of GnRH agonist, reducing the risk of developing ovarian hyperstimulation syndrome (OHSS) in high responders and the chance of cycle cancellation. This report describes the use of 0.2 mg triptorelin (Decapeptyl) to trigger ovulation in eight patients who underwent controlled ovarian hyperstimulation with recombinant FSH (rFSH, Puregon) and concomitant treatment with the GnRH antagonist ganirelix (Orgalutran) for the prevention of premature LH surges. All patients were considered to have an increased risk for developing OHSS (at least 20 follicles > or =11 mm and/or serum oestradiol at least 3000 pg/ml). On the day of triggering the LH surge, the mean number of follicles > or =11 mm was 25.1 +/- 4.5 and the median serum oestradiol concentration was 3675 (range 2980-7670) pg/ml. After GnRH agonist injection, endogenous serum LH and FSH surges were observed with median peak values of 219 and 19 IU/l respectively, measured 4 h after injection. The mean number of oocytes obtained was 23.4 +/- 15.4, of which 83% were mature (metaphase II). None of the patients developed any signs or symptoms of OHSS. So far, four clinical pregnancies have been achieved from the embryos obtained during these cycles, including the first birth following this approach. It is concluded that GnRH agonist effectively triggers an endogenous LH surge for final oocyte maturation after ganirelix treatment in stimulated cycles. Our preliminary results suggest that this regimen may prove effective in triggering ovulation and could be said to prevent OHSS in high responders. The efficacy and safety of such new treatment regimen needs to be established in comparative randomized studies.

An uncommon etiology of isolated pleural effusion. The ovarian hyperstimulation syndrome

We report three cases of pleural effusion in the context of ovarian stimulation for in vitro fertilization. The ovarian hyperstimulation syndrome usually causes pleural effusion and ascites. When the latter is lacking, an isolated pleural effusion in a pregnant patient can be mistaken for pulmonary embolism. Early recognition of the condition should allow for an appropriate diagnostic and therapeutic management. Except for some rare but life-threatening complications, such as major hypovolemia or respiratory distress syndrome, the spontaneous outcome is usually favorable. The pathogenesis of this condition may involve an increase of capillary permeability due to the release of vasoactive mediators.

Occupational asthma caused by pyrazolone derivative used in silver halide photographic paper

Occupational asthma has been documented in workers exposed to a wide variety of chemical compounds. Reactive dyes have been described as causing occupational asthma in textile industry workers. We report a case of occupational asthma resulting from exposure to pyrazolone dye used in silver halide photographic paper. There is a need for both further surveys of workers exposed to other reactive dyes and careful preventive measures in the handling of such compounds.

The ovarian hyperstimulation syndrome

OBJECTIVE

To review the up-to-date literature concerning the pathogenesis of, risk factors for, prevention of, and therapy for the ovarian hyperstimulation syndrome, and to provide suggestions for management of this syndrome.

DESIGN

Literature review combined with on-site clinical experiences at the authors' institution of practice.

PATIENT(S)

Women who have risk factors for or manifest the ovarian hyperstimulation syndrome.

INTERVENTION(S)

Intravenous fluid management, thrombosis prevention techniques, paracentesis techniques, and critical care management protocols.

MAIN OUTCOME MEASURE(S)

Staging system of the ovarian hyperstimulation syndrome, criteria for outpatient versus hospitalization management, and indications for varying levels of interventional management.

RESULT(S)

The ovarian hyperstimulation syndrome, unique to the field of assisted reproductive technology, remains a largely elusive and unpredictable iatrogenic physiologic complication in the course of pharmacologic ovarian stimulation. Reliable information on risk factors, possible physiologic mechanisms, prevention techniques, and management is fortunately progressing, and overall advances are being made in this field. The present review is an attempt to summarize the modern literature regarding this syndrome and to use this current knowledge to provide a basis for acceptable management regimens.

CONCLUSION(S)

Ovarian hyperstimulation syndrome is a serious complication of assisted reproductive technology, with potential for critical morbidity and death. Physicians who prescribe medications known to be associated with this syndrome should be familiar with identifiable risk factors, means of prevention, and a system for staging and treating the disease and have a current knowledge base for putative models of pathogenesis.

Distinction between early and late ovarian hyperstimulation syndrome

OBJECTIVE

To compare patient and cycle characteristics among three study groups: early ovarian hyperstimulation syndrome (OHSS), late OHSS, and non-OHSS.

DESIGN

Prospective observational study.

SETTING

University assisted conception service.

PATIENT(S)

Women undergoing in vitro fertilization, intracytoplasmic sperm injection or gamete intrafallopian transfer treatment at Bristol University In Vitro Fertilization Service between January 1, 1995, and December 31, 1998.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Patient age, prevalence of polycystic ovaries, gonadotropin requirement, peak serum estradiol (E(2)) concentration, number of oocytes retrieved, clinical pregnancy rate, number of gestation sacs, and severity of OHSS.

RESULT(S)

Women with early OHSS had significantly higher serum E(2) levels and lower gonadotropin requirements than did the other groups. Cycles with either early or late OHSS had significantly more oocytes collected than those without OHSS. Serum E(2) and oocyte numbers did not accurately predict the risk of developing late OHSS. Clinical pregnancies occurred in all cycles with late OHSS, and multiple pregnancies were significantly more frequent in the late OHSS group than in the other groups. Late OHSS was more likely than early OHSS to be severe.

CONCLUSION(S)

Early OHSS relates to "excessive" preovulatory response to stimulation, whereas late OHSS depends on the occurrence of pregnancy, is likelier to be severe, and is only poorly related to preovulatory events.

Thromboembolic complications associated with reproductive endocrinologic procedures

Thromboembolism as a complication of hormonal ovarian stimulation in the context of artificial reproductive techniques is rare and seems to occur when OHS is present. Although accompanied by high serum estrogen concentrations, hCG seems to play a central role in the development of OHS, which has been observed in women with 17,18-desmolase deficiency who have low estrogen levels after induction of ovulation with hGC. Although there is some evidence that hormonal ovarian stimulation with HMG, leading to elevated estrogen levels, and ovulation induction with hCG in preparation for in vitro fertilization are associated with a state of hypercoagulability, the exact role of estrogens, hCG and the physicochemical changes (fluid shift into third spaces) involved in OHS remain to be elucidated.

Androgen excess contributes to altered growth hormone/insulin-like growth factor-1 axis in nonobese women with polycystic ovary syndrome

OBJECTIVE

To investigate the relationship between ovarian androgen excess and impaired growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis in nonobese women with polycystic ovary syndrome (PCOS).

DESIGN

A prospective, controlled clinical study.

SETTING

Reproductive Endocrine Unit, Department of Obstetrics and Gynecology, Jinling Hospital, Nanjing University School of Clinical Medicine.

PATIENT(S)

Six patients with PCOS with both clomiphene resistance and gonadotropin hyperreponsiveness and six controls with regular cycles, matched for age and body mass index (BMI).

INTERVENTION(S)

Bilateral ovarian wedge resection (OWR) was performed to induce ovulation surgically for these refractory women with PCOS. A GH stimulation test with oral L-dopa was arranged for controls and for patients with PCOS before and again 6 months later after OWR.

MAIN OUTCOME MEASURE(S)

Plasma GH, IGF-1, FSH, LH, testosterone, androstenedione, estradiol, progesterone, prolactin, insulin, and glucose.

RESULT(S)

Basal levels and areas under the response curve of GH and GH-IGF-1 ratio to L-dopa were significantly lower in patients with PCOS before surgery than those of controls. The OWR in patients with PCOS obviously reduced their androstenedione and testosterone levels and insulin-glucose ratios, and increased the GH and GH-IGF-1 responses to L-dopa.

CONCLUSION(S)

Impaired somatotrophic axis caused by a defect in central dopaminergic activity may be responsible for severe anovulation in these women with PCOS, which could be reversed by removing excessive androgens with OWR.

Estradiol supplementation during the luteal phase may improve the pregnancy rate in patients undergoing in vitro fertilization-embryo transfer cycles

OBJECTIVE

To evaluate the effect of adding E(2) to progestin supplementation during the luteal phase on pregnancy and implantation rates in patients undergoing IVF cycles.

DESIGN

Prospective, randomized study.

SETTING

An IVF unit in a university hospital.

PATIENT(S)

Patients who were undergoing IVF with controlled ovarian hyperstimulation using a GnRH analog and who had E(2)2,500 pg/dL at the time of hCG administration.

INTERVENTION(S)

Serum concentrations of E(2) and progesterone were measured in all patients on days 7, 10, and 12 after ET.

MAIN OUTCOME MEASURE(S)

The E(2) and progesterone profiles of the luteal phase and the pregnancy and implantation rates were documented. Data were analyzed for the entire study population and further stratified according to the GnRH analog protocol used (short or long).

RESULT(S)

Significantly higher E(2) levels were found during the luteal phase in the group that received E(2) supplementation. This effect was more pronounced in the patients who were treated with the long GnRH analog protocol. Significantly higher pregnancy and implantation rates were recorded in the patients who received E(2) supplementation and were treated with the long GnRH analog protocol.

CONCLUSION(S)

For patients who are treated with the long GnRH analog protocol for controlled ovarian hyperstimulation and for whom luteal support with hCG is contraindicated, the addition of E(2) to the progestin support regimen may have a beneficial effect on pregnancy and implantation rates.

Peripheral blood concentrations of inhibin B are elevated during gonadotrophin stimulation in patients who later develop ovarian OHSS and inhibin A concentrations are elevated after OHSS onset

Ovarian hyperstimulation syndrome (OHSS) is a serious side-effect of controlled ovarian stimulation. Inhibin A and inhibin B, as putative predictors of OHSS development in the same stimulation cycle, were evaluated. A cohort of 428 in-vitro fertilization (IVF) patients was followed. Fifteen patients with severe OHSS were compared with matched (age, follicle number) controls. Serum samples were obtained at five time points from the start of ovarian stimulation until >/= 3 days post-embryo transfer and analysed with specific enzyme-linked immunosorbent assays. Inhibin A in the OHSS group showed a continuous increase with a significant elevation 3 days prior to oocyte aspiration (ASP-3) and onwards. Maximal concentrations were detected at embryo transfer and the concentrations remained high at >/= 3 days post-embryo transfer. Inhibin A concentrations in the control group showed a transient elevation (significant increase at ASP and embryo transfer). Inhibin A in the OHSS group was significantly higher than in controls only at the time point where OHSS had developed (>/= 3 days post-embryo transfer), and declined during OHSS treatment. Overall, there was a positive correlation between the number of follicles and inhibin A concentrations at ASP-3 until embryo transfer in the control group but not in the OHSS group. The concentrations of inhibin B in both groups increased from the start of ovarian stimulation, with peak values at ASP-3, and then a decline. Inhibin B was significantly higher in OHSS patients at ASP-3 and at ASP. Inhibin B at ASP-3 was correlated with the total number of follicles in both the OHSS group and the control group.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is an iatrogenic complication of assisted reproduction. In its most severe form, it is potentially fatal. The major clinical components are marked ovarian enlargement and increased capillary permeability leading to ascites, hydrothorax and pericardial effusion. Severe cases are associated with thromboembolic phenomena, respiratory distress and renal failure. The definitive pathophysiology is unknown. The available evidence would support a central role for inflammatory cytokines and angiogenic growth factors. Ultrasound examination and serum oestradiol values are currently used to predict patients at risk. The ideal treatment is prevention, but there has been only limited success. The main aims of treatment are to correct fluid imbalance, maintain renal perfusion and support the patient until the condition resolves. Drug therapy has a limited role, although anticytokine agents may prove useful.

Gonadotrophin therapy for ovulation induction in subfertility associated with polycystic ovary syndrome

BACKGROUND

Approximately 15% of patients with PCOS remain anovulatory despite treatment with oral anti-oestrogen medications such as clomiphene citrate. In addition, about half of women with PCOS ovulating on anti-oestrogen treatment fail to conceive. Gonadotrophin stimulation is the next step in treatment for women who are "clomiphene resistant", however, results of gonadotrophin stimulation in women with PCOS are less successful. In PCOS associated with hypersecretion of LH, purified urinary follicle-stimulating hormone (u-FSH) preparations have theoretical advantages over the use of human menopausal gonadotrophin (hMG) preparations (containing both FSH and LH), but whether this claimed advantage extends into clinical practice remains uncertain. In addition, the use of gonadotrophin-releasing hormone analogues (GnRH-a) to produce pituitary desensitisation prior to ovulation induction in PCOS has been claimed to increase the success rates of treatment as well as reduce complications such as OHSS and multiple pregnancy. Gonadotrophin preparations have also been administered via different routes (intramuscular or subcutaneous), or using different stimulation regimens and protocols (step-up or standard) in an attempt to improve efficacy.

OBJECTIVES

To determine the effectiveness of urinary-derived gonadotrophins as ovulation induction agents in patients with PCOS trying to conceive. In particular, to assess the effectiveness of (1) different gonadotrophin preparations, (2) the addition of a gonadotrophin-releasing hormone agonist (GnRH-a) to gonadotrophin stimulation and (3) different modalities of gonadotrophin administration.

SEARCH STRATEGY

The search strategy to identify RCTs consisted of (1) the Group's Specialised Register of Controlled Trials using the search strategy developed for the Menstrual Disorders and Subfertility Group as a whole (see the Review Group details for more information), (2) additional specific electronic Medline searches and (3) bibliographies of identified studies and narrative reviews.

SELECTION CRITERIA

RCTs in which urinary-derived gonadotrophins were used for ovulation induction in patients with primary or secondary subfertility attributable to PCOS.

DATA COLLECTION AND ANALYSIS

Twenty three RCTs were identified, 9 of which were excluded from analysis. The data were extracted independently by 2 authors. The following criteria were assessed: (1) the methodological characteristics of the trials, (2) the baseline characteristics of the studied groups and (3) the outcomes of interest: pregnancy rate (per cycle), ovulation rate (per cycle), miscarriage rate (per pregnancy), multiple pregnancy rate (per pregnancy), overstimulation rate (per cycle) and ovarian hyperstimulation syndrome (OHSS) rate (per cycle). Where suitable, meta-analysis was performed using Peto's OR with 95% CI with the fixed effect Mantel-Haentszel equation.

MAIN RESULTS

(1) A reduction in the incidence of OHSS with FSH compared to hMG in stimulation cycles without the concomitant use of a GnRH-a (OR 0.20; 95% CI 0.08-0.46) and (2) a higher overstimulation rate when a GnRH-a is added to gonadotrophins (OR 3.15; 95% CI 1.48-6.70).

REVIEWER'S CONCLUSIONS

Although 14 RCTs were included in this review, few dealt with the same comparisons, all were small to moderate size and their methodological quality was generally poor. Any conclusions, therefore, remain tentative as they are based on a limited amount of data and will require further RCTs to substantiate them. In none of the comparisons was there a significant improvement in pregnancy rate but this may be due to the lack of power (i.e. insufficient patients randomised to demonstrate a significant difference between treatments). There was a trend towards better pregnancy rates with the addition of a GnRH-a to gonadotrophin stimulation and these interventions warrant further study. Despite theoretical advantages, urinary-derived FSH preparations did not improve pregnancy rates when compared to traditional and cheaper hMG preparations; their only demonstrable benefit was a reduced risk of OHSS in cycles when administered without the concomitant use of a GnRH-a. No conclusions can be drawn on miscarriage and multiple pregnancy rates due to insufficient reporting of these outcomes in the trials.

Serum vascular endothelial growth factor levels before starting gonadotropin treatment in women who have developed moderate forms of ovarian hyperstimulation syndrome

The study aims to evaluate whether serum vascular endothelial growth factor (VEGF) levels, before treatment with gonadotropins, may be considered a predictive marker of moderate ovarian hyperstimulation syndrome (OHSS). At the University of Pisa hospital infertility unit we have retrospectively selected 10 patients who developed moderate forms of OHSS and 30 control patients who presented a normal response to ovarian stimulation among 400 women undergoing in vitro fertilization (IVF). Serum samples were collected before starting pFSH administration (150-300 IU/day). VEGF levels in serum were measured. No statistically significant difference was found between the serum VEGF levels of patients who developed moderate forms of OHSS and women without any symptoms of the syndrome. Further, serum VEGF concentrations were not significantly correlated with the age of the patients, the number of international units of FSH administered during the cycle of stimulation, the follicle and oocyte numbers counted on the day of the egg retrieval or estradiol levels detected on the same day. This study demonstrates that serum VEGF levels, before starting gonadotropin treatment, are not predictive of the subsequent development of moderate forms of ovarian hyperstimulation syndrome.

Spontaneous ovarian hyperstimulation syndrome and deep vein thrombosis in pregnancy: case report

This report describes a case of spontaneous ovarian hyperstimulation syndrome (OHSS) occurring in a pregnant woman carrying the factor V Leiden mutation. Even though prophylactic treatment for thrombo-embolism was adopted by administering low molecular weight heparin, the pregnancy was complicated by thromboses of the left subclavian, axillary, humeral and internal jugular veins during the second trimester of gestation. The pregnancy was managed conservatively and a healthy newborn was delivered at term. In order to avoid unnecessary laparotomy, we emphasize the importance of careful diagnosis in order to differentiate spontaneous OHSS from ovarian carcinoma, as well as the necessity to look for the presence of coagulation disorders in women affected by OHSS.

Ovarian hyperstimulation syndrome and benign intracranial hypertension in pregnancy after in-vitro fertilization and embryo transfer: case report

Ovarian hyperstimulation syndrome (OHSS) is a dangerous and sometimes life-threatening complication of ovulation induction with exogenous gonadotrophins. While many complications of severe OHSS are recognized we have only identified one review detailing neurological problems. This report concerns a 32-year-old patient with bilateral tubal blockage who achieved her first pregnancy following in-vitro fertilization (IVF) and embryo transfer. Shortly after embryo transfer she developed clinical signs of moderate OHSS with symptoms which were later diagnosed as benign intracranial hypertension (BIH). The BIH was treated effectively using repeated lumbar puncture and diuretics. Spontaneous labour and delivery occurred at 40 weeks' gestation. There was no neurological sequel and no recurrence of the BIH 2 years after the pregnancy. The possible link between OHSS and BIH is discussed as well as the risks of further pregnancy.

Ovarian hyperstimulation syndrome: imperatives for the emergency physician

Ovarian Hyperstimulation Syndrome (OHSS) is a serious disorder complicating the use of ovary-stimulating drugs in assisted reproduction programs. While its pathogenesis is not fully understood, it is believed that human chorionic gonadotropin (hCG) stimulation is vital to the development of OHSS. Further evidence suggests that the renin-angiotensin pathway, vascular endothelial growth factor, endothelin-1, and cytokines all play a role in altering ovarian capillary permeability, leading to increased interstitial fluid. OHSS can produce a myriad of symptoms and signs involving numerous body systems, up to and including hypovolemic shock and acute renal failure. As growing numbers of women opt for assisted reproduction, it becomes increasingly important for emergency physicians to be able to recognize this condition. Clinical classification into mild, moderate, severe, and critical forms of OHSS can help the physician plan appropriate investigations, admission requirements, and acute management. Two cases of OHSS, representing the spectrum of this problem, are presented along with a review of the literature.

Luteal phase and clinical outcome after human menopausal gonadotrophin/gonadotrophin releasing hormone antagonist treatment for ovarian stimulation in in-vitro fertilization/intracytoplasmic sperm injection cycles

The luteal phase hormonal profile and the clinical outcome of 69 patients undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) after ovarian stimulation with human menopausal gonadotrophin (HMG) and the gonadotrophin-releasing hormone (GnRH) antagonist Cetrorelix were analysed. Twenty-four patients received Cetrorelix 0.5 mg (group I) while in 45 patients Cetrorelix 0.25 mg was administered (group II). Human chorionic gonadotrophin (HCG) was used as luteal support. Nine clinical pregnancies were obtained in group I (37.5%) and 12 in group II (26. 6%). These results were not significantly different. Serum progesterone and oestradiol concentrations did not differ between the two groups either in pregnant or non-pregnant patients. An expected decrease of the same hormones was observed 8 days after the pre-ovulatory HCG injection in non-pregnant women. With regard to serum luteinizing hormone concentrations, a decrease was observed 2 days after the pre-ovulatory HCG injection and was maintained at almost undetectable levels throughout the entire luteal phase in both conception and non-conception cycles of group I and group II. This study demonstrates that different doses of GnRH antagonist do not have any impact on the luteal phase of IVF/ICSI cycles when hormonal support is given.

Levels of soluble vascular cell adhesion molecule-1 and soluble intercellular adhesion molecule-1 are increased in women with ovarian hyperstimulation syndrome

OBJECTIVE

To determine whether plasma and peritoneal fluid levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble intercellular adhesion molecule-1 (sICAM-1) are altered in women with ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective, case-control study.

SETTING

Lis Maternity Hospital and the Sara Racine IVF Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

PATIENT(S)

The study group comprised 16 women with severe OHSS. The control groups comprised 10 women treated with controlled ovarian hyperstimulation and 8 women with normal findings at diagnostic laparoscopy.

INTERVENTION(S)

Plasma samples were obtained from the study group and the first control group. Peritoneal fluid samples were obtained during paracentesis from the study group and during diagnostic laparoscopy from the second control group.

MAIN OUTCOME MEASURE(S)

Samples were assayed by specific ELISA for sVCAM-1 and sICAM-1.

RESULT(S)

The mean peritoneal fluid levels of sVCAM-1 and sICAM-1 and the mean plasma levels of sVCAM-1 were significantly higher in the women with OHSS than in the control groups. However, the mean plasma levels of sICAM-1 were comparable. A positive correlation was demonstrated between the levels of sVCAM-1 and plasma E2 at the time of hCG administration and between the levels of sICAM-1 and number of ova retrieved.

CONCLUSION(S)

Our findings suggest that soluble cell adhesion molecules may have a role in the pathogenesis and progression of OHSS.

Prospective study of the clinical and laboratory parameters of patients in whom ovarian hyperstimulation syndrome developed during controlled ovarian hyperstimulation for in vitro fertilization

OBJECTIVE

To compare patient characteristics and clinical and laboratory parameters in patients in whom ovarian hyperstimulation syndrome (OHSS) develops with those in whom it does not develop.

DESIGN

Prospective cohort study.

SETTING

Reproductive medicine unit at a university medical center.

PATIENT(S)

All patients undergoing IVF (n = 428) who received controlled ovarian hyperstimulation during a 6-month period.

INTERVENTION(S)

Prospective data collection.

MAIN OUTCOME MEASURE(S)

Patient characteristics (age, body mass index, medical history, smoking habits) and clinical and laboratory data obtained during controlled ovarian hyperstimulation were evaluated in patients who had severe OHSS, any degree of OHSS, or a significant risk of OHSS and compared with the remaining populations.

RESULT(S)

Severe OHSS developed in 18 patients (4.2%) and mild or moderate OHSS developed in 7.3%. As a group, all the patients with OHSS were significantly younger, received lower doses of gonadotropins, had ovaries containing a higher number of total and large follicles, had a higher number of retrieved oocytes, and had a higher pregnancy rate than the patients without OHSS. The patients with severe OHSS also had an increased prevalence of allergy (56% versus 21%) and were more likely to ultimately give birth.

CONCLUSION(S)

The observed differences may be useful in elucidating the pathophysiology of OHSS and identifying patients who are at increased risk for OHSS.

Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE

To assess the pulmonary manifestations of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective nationwide 10-year multicenter study.

SETTING

Sixteen of 19 tertiary medical centers in Israel.

PATIENT(S)

All patients hospitalized at these centers for severe OHSS between January 1987 and December 1996.

MAIN OUTCOME MEASURE(S)

Clinical presentation, arterial blood gases on room air, and chest roentgenogram results.

RESULT(S)

Of 209 patients, 4% had lobar pneumonia, 2% had adult respiratory distress syndrome (ARDS), and 2% had pulmonary thromboembolism. Most patients had dyspnea, tachypnea, moderate hypoxemia, increased alveolar-arterial oxygen difference, hypocarbia, respiratory alkalosis, and metabolic compensation. The most common findings on chest roentgenogram were bilateral elevation of the diaphragm, pleural effusion, and pulmonary atelectasis. Patients with pulmonary thromboembolism, ARDS, and pneumonia presented with severe hypoxemia and alveolar-arterial oxygen difference and distinct radiographic findings.

CONCLUSION(S)

Severe OHSS is characterized by an extraparenchymal restrictive type of pulmonary dysfunction, attributed to intraabdominal or pleural fluid accumulation, which limits descent of the diaphragm and expansion of the thoracic cage. This may induce uncoordinated lung ventilation and atelectasis with subsequent ventilation-perfusion mismatch and hypoxemia. The clinical picture may deteriorate further because of pulmonary infection, pulmonary thromboembolism, or ARDS, all of which have distinct clinical, radiographic, and blood gas characteristics.

Ascites and liver test abnormalities during severe ovarian hyperstimulation syndrome

OBJECTIVE

Severe ovarian hyperstimulation syndrome is an uncommon cause of ascites that is being increasingly recognized because of the high number of women undergoing assisted reproductive techniques, mainly in vitro fertilization. This prospective study investigates the clinical and biochemical characteristics of a large series of patients with this syndrome and ascites, including renal and electrolyte abnormalities, activity of neurohormonal systems participating in the regulation of extracellular fluid volume, and liver function tests.

METHODS

This was a prospective longitudinal study including 50 consecutive patients with ascites due to severe ovarian hyperstimulation syndrome. Renal function, serum electrolytes, body weight, mean arterial pressure, pulse rate, plasma renin activity, plasma concentration of aldosterone, norepinephrine, antidiuretic hormone and atrial natriuretic peptide, and standard liver function tests were measured during the syndrome and 4-5 wk after recovery. A sample of ascitic fluid was obtained from eight patients for protein measurement and cell count.

RESULTS

At diagnosis, patients had ascites associated with low urinary sodium excretion, oliguria, and hyponatremia. They had also markedly low arterial pressure and increased pulse rate in association with marked activation of vasoconstrictor and antinatriuretic factors. The ascitic fluid was characterized by a high protein concentration, low leukocyte count, and relatively high number of red blood cells. Fifteen (30%) patients had abnormal liver tests characterized by mild to moderate increases in AST (mean 103 +/- 17.1 IU/L) and ALT (76 +/- 8.3 IU/L), which were associated in some cases with increases in gamma-glutamyl transpeptidase or alkaline phosphatase. All abnormalities reverted to normal after the resolution of the syndrome.

CONCLUSIONS

With the increasing use of assisted reproductive techniques, physicians should be aware of severe ovarian hyperstimulation syndrome as a cause of ascites. The syndrome is associated with sodium retention, hyponatremia, arterial hypotension, and marked activation of vasoconstrictor and antinatriuretic systems. In one third of patients, liver tests abnormalities are present.

Octreotide is not useful for clomiphene citrate resistance in patients with polycystic ovary syndrome but may reduce the likelihood of ovarian hyperstimulation syndrome

OBJECTIVE

To determine whether octreotide is effective for ovulation induction in patients with polycystic ovary syndrome (PCOS) and clomiphene citrate resistance or for reduction of the risk of ovarian hyperstimulation syndrome (OHSS) with gonadotropin therapy.

DESIGN

Prospective, double-blind, placebo-controlled, crossover trial.

SETTING

Private infertility practice.

PATIENT(S)

Twelve patients with PCOS undergoing therapy for infertility.

INTERVENTION(S)

The patients were assigned randomly to receive either octreotide or placebo. Those with clomiphene citrate-resistant PCOS received clomiphene citrate, 150 mg. Patients at risk for the development of OHSS received urinary FSH for ovulation induction.

MAIN OUTCOME MEASURE(S)

Ovulation, pregnancy, the development of OHSS, and levels of fasting insulin, insulin-like growth factor 1, insulin-like growth factor binding proteins 1 and 3, testosterone, androstenedione, DHEAS, E2, LH, and FSH.

RESULT(S)

Octreotide significantly reduced levels of fasting insulin, insulin-like growth factor 1, and LH in both clomiphene citrate- and urinary FSH-stimulated cycles. Levels of insulin-like growth factor binding protein 3 were increased. Two of six clomiphene citrate-stimulated cycles reached ovulation with the use of either octreotide or placebo. In urinary FSH-stimulated cycles, patients who received octreotide had significantly lower E2 levels at the time of hCG administration and fewer mature follicles. No cases of OHSS occurred in either group. One pregnancy occurred in each group.

CONCLUSION(S)

Octreotide was no more effective than placebo for clomiphene citrate resistance in patients with PCOS, but it did reduce E2 levels and follicle numbers when combined with urinary FSH. Thus, octreotide may reduce the incidence of OHSS in patients with PCOS.

Serum vascular endothelial growth factor concentrations in in vitro fertilization cycles predict the risk of ovarian hyperstimulation syndrome

OBJECTIVE

To explore the value of serum vascular endothelial growth factor (VEGF) concentrations during IVF cycles in predicting the risk of ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective study.

SETTING

London Women's Clinic.

PATIENT(S)

One hundred seven women undergoing IVF. Mild OHSS developed in 10 women, moderate OHSS in 7, and severe OHSS in 3.

INTERVENTION(S)

Serum VEGF concentrations were measured before treatment, after pituitary desensitization, and on the days of hCG administration, oocyte collection, and ET.

MAIN OUTCOME MEASURE(S)

Serum VEGF concentrations.

RESULT(S)

Serum VEGF concentrations were higher in women in whom OHSS developed. The increase in the VEGF concentration that occurred between the day of hCG administration and the day of oocyte collection (the "VEGF rise") was an important marker of OHSS. The VEGF rise was higher in women in whom OHSS developed. A higher VEGF rise predicted all cases of OHSS and moderate/severe cases of OHSS with a sensitivity of 100% and a specificity of 60%. A likelihood ratio test showed that adding the VEGF rise or the VEGF concentration on the day of oocyte collection to a regression model as a continuous variable to the number of follicles, the E2 concentration, and the presence of polycystic ovaries significantly contributed to predicting the risk of OHSS.

CONCLUSION(S)

The results support the role of VEGF as an important nonsteroidal index of ovarian response. The VEGF rise may have an advantage over the E2 concentration, the number of follicles, and the number of oocytes, which individually predict only 15%-25% of cases of OHSS.

Withholding gonadotropins ("coasting") to minimize the risk of ovarian hyperstimulation during superovulation and in vitro fertilization-embryo transfer cycles

OBJECTIVE

To evaluate superovulation (SOV) and IVF-ET cycles in which E2 levels were allowed to decrease to restrain rapid follicular growth and minimize the risk of ovarian hyperstimulation syndrome.

DESIGN

Retrospective series.

SETTING

Tertiary care infertility practice.

PATIENT(S)

Women who underwent SOV (n = 51) and IVF-ET (n = 93) treatment and who were at risk for OHSS.

INTERVENTION(S)

In SOV cycles, hMG was withheld (coasting) for >3 days before hCG administration, until follicular maturity was attained (> or = 3 follicles of > or = 18 mm) and E2 levels decreased. In IVF-ET cycles, either follicular maturity was attained before coasting (n = 63), allowing hCG administration after E2 levels decreased by >25%, or coasting occurred before follicular maturation (n = 30), necessitating the administration of additional hMG after coasting.

MAIN OUTCOME MEASURE(S)

Estradiol concentrations, follicle size, and pregnancy rates.

RESULT(S)

Estradiol concentrations usually rose for > or = 1 day after coasting began, then fell by > or = 25% while follicle numbers and mean diameters increased. No spontaneous LH surges occurred, although four SOV cycles were canceled because of excessive follicular development. Of the women who received hCG,11 of 47 (23% per cycle) conceived during SOV and 35 of 93 (37.6% per cycle) conceived during IVF-ET. Severe ovarian hyperstimulation syndrome developed in 1 woman who underwent IVF-ET.

CONCLUSION(S)

Coasting can safely rescue overstimulated SOV and IVF-ET cycles characterized by an excessive rise in E2 levels and/or numerous incompletely mature follicles.

Obstetric outcome of in vitro fertilized pregnancies complicated by severe ovarian hyperstimulation syndrome: a multicenter study

OBJECTIVE

To assess the outcome of pregnancies conceived with the use of IVF that are complicated by severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A retrospective nationwide multicenter study.

SETTING

Sixteen of 19 tertiary care medical centers in Israel.

PATIENT(S)

All patients undergoing IVF who were hospitalized for severe OHSS between January 1987 and December 1996.

MAIN OUTCOME MEASURE(S)

Pregnancy rate (PR) and rates of multiple gestation, miscarriage, ectopic pregnancy, obstetric complications, and intervention.

RESULT(S)

A total of 163 patients who had severe OHSS after IVF treatment were identified, of whom 142 (87.1%) had undergone ET. The clinical PR was 73.2%; 42.3% were singletons, 33.6% were twins, 17.3% were triplets, and 6.7% were quadruplets. The miscarriage rate was 29.8%, whereas the incidence of ectopic pregnancy was 1.9%. Forty-four percent of all births were premature, and 62.1% of all newborns had low birth weight. The most common antenatal complications were pregnancy-induced hypertension (13.2%), gestational diabetes (5.9%), and placental abruption (4.4%). The rate of cesarean section was 44.1%.

CONCLUSION(S)

Among patients who have severe OHSS after IVF treatment, the pregnancy rate and the rates of multiple gestation, miscarriage, prematurity, low birth weight, pregnancy-induced hypertension, gestational diabetes, and placental abruption are significantly higher than those reported previously for pregnancies conceived with the use of assisted reproductive techniques.

Serum vascular endothelial growth factor and Doppler blood flow velocities in in vitro fertilization: relevance to ovarian hyperstimulation syndrome and polycystic ovaries

OBJECTIVE

To relate changes in serum and follicular fluid vascular endothelial growth factor (VEGF) concentrations to Doppler blood flow velocities within ovarian and uterine blood vessels during IVF cycles and to assess their relation to ovarian hyperstimulation syndrome (OHSS) and polycystic ovaries (PCO)/polycystic ovary syndrome (PCOS).

DESIGN

Prospective descriptive study.

SETTING

The London Women's Clinic.

PATIENT(S)

One hundred seven patients receiving a "long" stimulation protocol of IVF.

INTERVENTION(S)

Doppler blood flows were recorded in ovarian stromal and uterine arteries; serum VEGF was measured in the early follicular phase, after pituitary desensitization, on the day of hCG administration, on the day of oocyte retrieval, and on the day of ET.

MAIN OUTCOME MEASURE(S)

Serum and follicular fluid VEGF concentrations and Doppler blood flow measurements.

RESULT(S)

Serum VEGF concentrations rose after hCG administration. The rise was higher in women in whom OHSS developed. Women with PCO/PCOS had higher serum VEGF concentrations throughout the IVF cycle irrespective of whether OHSS developed. Follicular fluid VEGF concentrations were higher in women in whom OHSS developed and in women with PCO/PCOS. Doppler blood flow velocities in the ovarian blood vessels were higher in women in whom OHSS developed. Within ovarian and uterine blood vessels, blood flow velocities were higher in the early follicular phase and on the day of hCG administration in women with PCO/PCOS. A positive correlation was observed between the serum VEGF and E2 concentrations on the days of hCG administration and oocyte retrieval and between the serum VEGF concentration and Doppler blood flow velocities throughout the IVF cycle.

CONCLUSION(S)

Our results support the role of VEGF as a mediator of OHSS and establish a possible link between VEGF, OHSS, and PCO.

Changes in vascular endothelial growth factor levels and the risk of ovarian hyperstimulation syndrome in women enrolled in an in vitro fertilization program

OBJECTIVE

To evaluate plasma and follicular fluid levels of vascular endothelial growth factor (VEGF) in women undergoing controlled ovarian hyperstimulation to establish the possible role of this growth factor as a predictive marker of ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective observational study.

SETTING

University hospital infertility unit.

PATIENT(S)

Fifteen women at risk of OHSS and 15 controls.

INTERVENTION(S)

An IM injection of hCG was administered; plasma and follicular fluid samples were collected 34-38 hours after administration of hCG.

MAIN OUTCOME MEASURE(S)

VEGF levels in plasma and in follicular fluid.

RESULT(S)

VEGF levels increased after hCG administration in the patients at risk of developing OHSS and in those who developed OHSS. Further, on the day of the oocyte retrieval the increase in the VEGF levels in the plasma of the patients who developed OHSS was statistically significant compared with the increase in the levels in the women who did not. On the same day, the levels of VEGF in follicular fluid were 10 times greater than those in plasma.

CONCLUSION(S)

Plasma levels of VEGF peak after hCG administration and are related to the risk of developing OHSS.

Ovarian hyperstimulation syndrome: facts and fallacies

Severe or critical ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian hyperstimulation for assisted reproduction techniques (ART). The syndrome is characterized by cystic enlargement of the ovaries and fluid shifts from the intravascular to the third space. The morbidity in OHSS is mainly determined by the hemodynamic changes caused by increased capillary permeability. The incidence of OHSS depends on definitions, risk factors, ovarian stimulation protocols, luteal support and conception. Currently, research on the pathogenesis of OHSS is focused on increased capillary permeability. Several theories are reviewed. Until the pathogenesis of OHSS becomes clear, treatment is restricted to supportive therapy. The various proposals for management of OHSS are discussed and, based on the available data, directions for the management of various grades of OHSS are summarized. However, prevention and early recognition are still the most important tools to handle OHSS. A flowchart with preventive measures for OHSS is presented derived from the available literature.

Short-term medical complications of 1500 oocyte retrievals for in vitro fertilization and embryo transfer

OBJECTIVE

To evaluate the different short-term complications after in vitro fertilization and embryo transfer.

DESIGN

a retrospective study on 7 years in the fertility clinic of an university hospital.

MATERIALS AND METHODS

Short-term medical complications were analysed after 1500 transvaginal ultrasonographically guided oocyte retrievals.

RESULTS

Ovarian hyperstimulation syndrome (1.8%), pelvic infections (0.4%), intraperitoneal bleeding (0.2%) and adnexal torsions (0.13%) were observed. One case of adnexal torsion occurred during pregnancy (0.18%). Two unusual case of bowel endometriosis were encountered (0.13%).

CONCLUSIONS

Short-term medical complications after in vitro fertilization and embryo transfer are rare (2.8%). This contrast with the high rate of multifetal pregnancies which increases maternal and perinatal morbidity and mortality and must be considered as the major complication of in vitro fertilization treatment.

"Coasting" does not adversely affect cycle outcome in a subset of highly responsive in vitro fertilization patients

OBJECTIVE

To study the effect of postponing hCG administration while continuing daily GnRH agonist therapy ("coasting") on highly responsive patients undergoing IVF-ET.

DESIGN

Retrospective analysis.

SETTING

University-affiliated Center for Fertility and Reproductive Medicine.

PATIENT(S)

Patients undergoing IVF-ET from March 1995 to March 1997.

INTERVENTION(S)

Three groups of IVF-ET patients were compared to explore the effect of coasting on cycle outcome: a group of highly responsive coasted patients, a group of equally responsive noncoasted patients, and an age-matched normally responsive control group. Two groups of coasted patients were also compared to assess the effect of E2 levels at the time that they met the follicular criteria for hCG administration. Last, the effect of varying coast duration was examined by regression analysis.

MAIN OUTCOME MEASURE(S)

Patient characteristics, outcome parameters, and incidence of ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

Coasting had no detrimental effect on cycle outcome in the subset studied. Regression analysis, however, suggests an inverse relationship between coast duration and the number of mature oocytes retrieved as well as the clinical pregnancy rate.

CONCLUSION(S)

Coasting in the studied subset of IVF patients did not adversely affect cycle outcome parameters or the incidence of OHSS, but prolonged coasting intervals may impair IVF cycle outcome.