Value of the serum estradiol level for preventing ovarian hyperstimulation syndrome: a retrospective case control study

Bilateral massive bloody pleural effusions as a rare presentation of ovarian hyperstimulation syndrome: A case report and literature review

OBJECTIVE

Pulmonary complications related to ovarian hyperstimulation syndrome (OHSS) can occur following assisted reproductive technologies (ART). However, bloody pleural effusions are exceedingly rare. We present a case of a patient who underwent ART treatment and developed OHSS, subsequently experiencing bilateral massive bloody pleural effusion.

CASE REPORT

A 32-year-old woman with primary infertility underwent in vitro fertilization (IVF) treatment. After oocyte retrieval, she presented to the emergency department with a chief complaint of abdominal distention and chest pain. Ovarian hyperstimulation syndrome, complicated by bilateral massive bloody pleural effusion (exudative), was diagnosed. Her d-dimer was initially elevated, then decreased gradually, and her shortness of breath improved. The patient was discharged without any clinical sequelae.

CONCLUSION

OHSS can lead to life-threatening complications such as pleural effusion and, in rare cases, bloody pleural effusion. Following oocyte retrieval, an elevated d-dimer level has no specific diagnostic role and should only be used to rule out thromboembolic events.

Repeated ovarian hyperstimulation promotes depression-like behavior in female mice

Controlled ovarian hyperstimulation (COH) is a common step for treating infertile couples undergoing assisted reproductive technologies and in female fertility preservation cycles. In some cases, undergoing multiple COHs is required for couples to conceive. Behavioral changes such as anxiety and depression can be caused by ovulation-inducing drugs. Sex steroids play a role in locomotor activity, behavioral changes, and nociception, specifically during fluctuations and sudden drops in estrogen levels. This study evaluated the effect of repeated ovarian hyperstimulation (ROH) on weight, locomotor activity, anxiety-like and depression-like behavior, and nociception in female mice. The animals were divided into two groups: control (placebo; Control) and treated (ROH; Treatment). Ovulation was induced once weekly for 10 consecutive weeks. Locomotor activity (open field test), anxiety-like behavior (elevated plus maze, hole board, and marble burying tests), depression-like behavior (splash and forced swim tests), and nociception (hot plate and Von Frey tests) were evaluated before and after ROH. Statistical analysis was conducted using two-way analysis of variance to evaluate the effects of ROH, age of mice, and their interaction. The results suggested that ROH contributed to weight gain, increased locomotor activity, and induced depression-like behavior in female mice. Furthermore, the age of the mouse contributed to weight gain, increased locomotor activity, and induced anxiety-like and depression-like behavior in female mice. ROH could change the behavior of female mice, particularly inducing depression-like behavior. Further studies are required to evaluate various COH protocols, specifically with drugs that prevent fluctuations and drastic drops in estrogen levels, such as aromatase inhibitors.

GnRH agonist-triggering ovulation in women with advanced age

This study evaluates the effect of GnRH agonist (GnRHa) trigger for ovulation induction among women with advanced maternal age (AMA). This is a retrospective study performed at a single assisted reproductive technology centre, 2012 to 2020. A total of 306 patients with 515 IVF cycles who were triggered with GnRHa for Ovum Pick Up (OPU), were divided into two groups according to maternal age: age ≥ 40 and age < 40. The groups were compared for demographics, stimulation parameters of IVF treatment and IVF treatment outcomes. The patients in the age < 40 group were approximately 10 years younger than the patients in the age ≥ 40 group (31 ± 5.4 vs. 41.5 ± 1.3 years, p < 0.001). The age ≥ 40 group had significantly higher mean E2/retrieved oocytes ratio, compared to the age < 40 group (310.3 ± 200.6 pg/ml vs. 239 ± 168.2 pg/ml, p = 0.003), and a lower mean MII/retrieved oocyte (35 ± 37.8 vs. 43.4 ± 35.9, p = 0.05, respectively). Multivariable logistic regression analysis for E2/retrieved oocytes demonstrated that age < 40 and total dose of gonadotropins were significant variables. In conclusion, GnRHa for ovulation triggering in high responder patients prior to OPU appears to be a good option for AMA. However, this population is characterized by different parameters of ovarian response that require further evaluation.

Sudden Death Due to Severe Ovarian Hyperstimulation Syndrome: An Autopsy-Centric Case Report

Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic disorder associated with controlled ovarian stimulation during assisted reproductive technology. Severe OHSS may impose serious complications, including pleural effusion, acute renal insufficiency, venous thrombosis, and even death, although lethal outcomes are rare in forensic practice. The reported incidence of severe OHSS ranges from 0.008% to 10%. Herein, we present the case of a 29-year-old woman who diagnosed with polycystic ovary syndrome and infertility chose to undergo assisted reproduction. She received leuprorelin acetate and follicle stimulating hormone prior to egg retrieval. Three days after the retrieval procedure, she developed abdominal pain and distension. Later that same day, she died unexpectedly. The subsequent autopsy revealed turbid effusions of pleural and peritoneal cavities, abnormal ovarian enlargement, and duskiness of multiple organ surfaces. Microscopic examination disclosed edema and hemorrhage in follicles of both ovaries, thrombosis within the myocardial matrix, and massive pulmonary edema. Routine toxicology screening was negative. The death was attributed to severe OHSS. This case provides a morphologic reference for clinical and forensic work. Autopsy findings in instances of severe OHSS provide valuable insight into the mechanisms and pathogenesis of this disease.

Effect of GnRH-antagonist, mifepristone and letrozole on preventing ovarian hyperstimulation syndrome in rat model

RESEARCH QUESTION

Can luteolysis-targeted drugs, gonadotrophin-releasing hormone antagonist (GnRH-ant), mifepristone and letrozole, administered separately or in combination, prevent the progression of ovarian hyperstimulation syndrome (OHSS) in a rat model?

DESIGN

Thirty-six female Wistar rats were randomly divided into six groups, including control group (OHSS group, ovarian hyperstimulation-induced OHSS); GnRH-ant group (OHSS with GnRH-ant treatment); mifepristone group (OHSS with mifepristone treatment); letrozole group (OHSS with letrozole treatment); combination group (OHSS with GnRH-ant, mifepristone and letrozole treatment in combination). The main outcomes were the alterations in OHSS-related indices, including ovarian weight, vascular permeability, serum oestradiol and progesterone levels, corpus luteum proportion and diameter, ovarian vascular endothelial growth factor (VEGF), interleukin 6 (IL-6), caspase-3 and cleaved caspase-3 levels.

RESULTS

No significant difference was found in body weight gain among the six groups. Compared with the control group, the OHSS group showed significant increases in all OHSS-related indices. GnRH-ant treatment showed decreases in vascular permeability, serum oestradiol level, corpus luteum diameter, ovarian VEGF /IL-6 mRNA levels, and increases in ovarian caspase-3 and cleaved caspase-3 levels. Mifepristone treatment demonstrated reduction in serum progesterone level and corpus luteum diameter, and elevation in ovarian caspase-3 and cleaved caspase-3 levels. Letrozole treatment displayed a decline in serum oestradiol level and corpus luteum diameter, and up-regulation in ovarian caspase-3 and cleaved caspase-3 levels. The combination treatment by GnRH-ant, mifepristone and letrozole showed enhanced synergistic effect on reducing OHSS-related indices.

CONCLUSIONS

GnRH-ant, mifepristone and letrozole are beneficial in preventing the progression of OHSS through different luteolytic mechanisms. Cocktail style treatment shows enhanced synergistic effect on preventing the progression of OHSS.

Right neck venous thrombosis following ovarian hyperstimulation syndrome in a patient with protein S deficiency: A case report and review of literature

OBJECTIVE

The risk of venous thromboembolism in pregnancies increased in ovarian hyperstimulation syndrome (OHSS) after assisted reproductive technologies (ART). We present a rare case with protein S deficiency receiving ART treatment with OHSS, following right neck venous thromboembolism.

CASE REPORT

A 34-year-old women with primary infertility underwent IVF treatment and presented with OHSS. However, thromboembolism in the right jugular and subclavian veins was diagnosed at eight weeks of gestation. She was continuously treated with low molecular weight heparin (LMWH) since eight weeks of gestation and the diagnosis of protein S deficiency was made. Due to placenta previa with massive bleeding, she gave live birth to two healthy babies via cesarean section at 34 weeks of gestation.

CONCLUSION

Thromboembolism is one of life-threatening complications among women with OHSS. Although inherited thrombophilia is rare diseases, thrombophilia workup may be taken into consideration for women with thrombotic events.

The importance of estradiol measurement in patients undergoing in vitro fertilization

Successful outcomes of in vitro fertilization (IVF) are dependent in part on successful oocyte maturation and retrieval during a controlled ovarian stimulation process, which is guided by serial ultrasound and estradiol measurements. Yet, laboratory analysis of estradiol poses challenges due to the need for accuracy and specificity across concentrations that span multiple orders of magnitude. The Endocrine Society released a 2013 position statement that called for improvements in methods to analyze estradiol, and while some progress has been made in standardization and assay specificity, further work is needed to meet the needs of patients in both the IVF setting and in other clinical contexts. This review highlights the capabilities and challenges of current laboratory methods for the analysis of estradiol in the IVF setting, including automated immunoassays and liquid chromatography-tandem mass spectrometry, and discusses current efforts to improve the analytical sensitivity and standardization of estradiol assays. Clinical laboratorians should be aware of the limitations of current estradiol assays and select appropriate methods for the measurement of estradiol in their patient population.

What is the best predictor of severe ovarian hyperstimulation syndrome in IVF? A cohort study

PURPOSE

The purpose of the present study is to study what is the best predictor of severe ovarian hyperstimulation syndrome (OHSS) in IVF.

METHODS

This is a retrospective analysis of all consecutive IVF/intracytoplasmic injection cycles performed during a 5-year period (2009-2014) in a single university fertility centre. All fresh IVF cycles where ovarian stimulation was performed with gonadotrophins and GnRH agonists or antagonists and triggering of final oocyte maturation was induced with the administration of urinary or recombinant hCG were analyzed (2982 patients undergoing 5493 cycles). Because some patients contributed more than one cycle, the analysis of the data was performed with the use of generalized estimating equation (GEE).

RESULTS

Severe OHSS was diagnosed in 20 cycles (0.36%, 95% CI 0.20-0.52). The number of follicles ≥10 mm on the day of triggering final oocyte maturation represents the best predictor of severe OHSS in IVF cycles. The cutoff in the number of follicles ≥10 mm with the best capacity to discriminate between women that will and will not develop severe OHSS was ≥15.

CONCLUSION

The presence of more than 15 follicles ≥10 mm on the day of triggering final oocyte maturation represents the best predictor of severe OHSS in IVF cycles.

Salivary estradiol as a surrogate marker for serum estradiol in assisted reproduction treatment

INTRODUCTION

Controlled ovarian hyper-stimulation for in vitro fertilization or intra cytoplasmatic sperm injection necessitates close monitoring using ultrasound and estradiol measurements. Monitoring is also important to prevent or limit the severity of ovarian hyper stimulation syndrome, an iatrogenic and potentially life-threatening complication. Self-operated endovaginal telemonitoring has been shown to offer an attractive and less costly alternative to classic consultation and saliva estradiol measurements could be a stress-free and practical alternative to serial blood determinations. Objectives were to evaluate whether saliva can be a surrogate marker for serum estradiol and its potential applicability in assisted reproduction treatment monitoring.

MATERIAL AND METHODS

Serial blood and saliva samples were collected from 31 patients undergoing ovarian hyper-stimulation. All patients were followed-up using in-house serial vaginal sonograms and immunoassay serum estradiol measurements. Afterwards estradiol was determined in saliva and serum by LC-MS/MS. For a subset equilibrium dialysis and measurement of free serum estradiol was performed.

RESULTS

About 1% of estradiol is present in serum in its free, unbound, form. Salivary estradiol correlates well to both serum free estradiol and serum total estradiol (r=0.80). The concentration of salivary estradiol corresponds to the unbound concentration in serum. The dynamics observed in serum monitoring during treatment are closely mimicked in saliva. ROC analysis on the current limited dataset suggested a saliva cut-off of 22pg/mL (81pmol/L) could help predict risk for OHSS.

CONCLUSIONS

Salivary E2 can be considered a surrogate marker for free serum estradiol and total serum estradiol in assisted reproduction treatment. Additionally there might be a role as a prediction marker for OHSS although this finding has to be validated in larger datasets.

Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline

Ovarian hyperstimulation syndrome (OHSS) is an uncommon but serious complication associated with assisted reproductive technology (ART). This systematic review aims to identify who is at high risk, how to prevent OHSS, and the treatment for existing OHSS.

A case of severe ovarian hyperstimulation syndrome

Ovulation induction has been an important mode of treatment of infertility. Ovarian stimulation may result in a supraphysiologic response leading to an iatrogenic complication known as the ovarian hyperstimulation syndrome (OHSS). This syndrome is potentially a lethal condition, the pathophysiologic hallmark of which is the accumulation of massive extravascular exudate combined with profound intravascular volume depletion and hemoconcentration. We report a case of severe OHSS with very large ovaries in a 35 year old case of embryo transfer. The patient presented to the emergency department with abdominal pain, massive ascites, respiratory distress and amenorrhea. The patient was managed symptomatically with no complications. Although ovarian hyperstimulation is a rare entity, it is important that the physician recognizes this condition. Prompt diagnosis and successful management is likely to avoid serious and rapid development of complications.

Detection of small molecule diagnostic markers with phage-based open-sandwich immuno-PCR

Open sandwich immunoassay (OS-IA) utilizes antigen-dependent stabilization of antibody variable region to quantify various antigens, enabling noncompetitive detection of small molecules with a broad working range. To further improve its detection sensitivity, here we employed phage-based immuno-PCR approach, wherein OS-IA and quantitative PCR methodologies were combined with the use of immobilized V(L) fusion protein and filamentous phages displaying V(H) fragment, whose DNA was extracted for PCR amplification. This approach significantly enhanced the assay sensitivity for small molecule antigens osteocalcin (BGP) peptide and 17beta-estradiol.

IVF outcome in women with PCOS, PCO and normal ovarian morphology

OBJECTIVE

To examine the outcome of IVF in women who have normal ovaries, ovulatory PCO or PCOS.

STUDY DESIGN

Analysis of a prospectively collected database in an assisted conception unit in a university teaching hospital including 290 women <37 years of age undergoing their first IVF cycle. The main outcome measure was severe OHSS requiring hospitalization.

RESULTS

Severe OHSS rates were significantly higher in women with PCO (12.6%) and PCOS (15.4%) compared to those with normal ovaries (2.7%). Coasting was used significantly more often. Live birth rates per cycle started are similar among women with PCO (38%), PCOS (37%) and normal ovaries (40%).

CONCLUSION

Women with ovaries of polycystic morphology are at increased risk of developing severe OHSS and of requiring avoidance techniques such as coasting, regardless of ovulatory status. However, live birth rates per cycle are similar to women with normal ovaries.

Odds of ovarian hyperstimulation syndrome (OHSS) - time for reassessment

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of Assisted Reproductive Technology (ART) treatment. The objective of this study was to assess the odds of OHSS hospital admission in relation to oestradiol levels on day of hCG administration and number of oocytes collected.

METHODS

We performed a 24 months retrospective analysis of a cohort of patients receiving ART treatment in a University teaching hospital including all patients requiring admission due to OHSS. Main outcome measures were oestradiol levels, number of oocytes collected and incidence of admission with OHSS.

RESULTS

OHSS requiring admission to hospital occurred in 1.8% of cases. While no patients with an oestradiol level at hCG </=15,000 pmol/L developed OHSS, those with oestradiol levels >/=15,000 pmol/L had different risks of admission according to the number of oocytes collected: those with >30 oocytes were 6.7 times more likely to be admitted that those with <20 oocytes.

CONCLUSIONS

This study identifies an oestradiol level (>/=15,000 pmol/L) and number of oocytes (>/=20) above which the odds of being admitted with OHSS increases significantly. Although OHSS cannot always be prevented, these measurable parameters should be used to allow appropriate counselling and subsequent safe management of ART patients.

Incidence and prediction of ovarian hyperstimulation syndrome in women undergoing gonadotropin-releasing hormone antagonist in vitro fertilization cycles

OBJECTIVE

To determine the incidence of ovarian hyperstimulation syndrome (OHSS) in a large series of GnRH antagonist-stimulated cycles and to assess the predictive value of E2 and the number of follicles on the day of hCG administration.

DESIGN

Prospective cohort study of women undergoing IVF treatment with a GnRH antagonist protocol over a 2-year period.

SETTING

Tertiary university hospital.

PATIENT(S)

One thousand eight hundred one patients who underwent 2,524 cycles.

INTERVENTION(S)

Multifollicular ovarian stimulation with recombinant FSH and GnRH antagonist for IVF-ICSI treatment.

MAIN OUTCOME MEASURE(S)

Incidence of OHSS in GnRH antagonist cycles, predictive value of E2, and number of follicles on the day of hCG for OHSS occurrence.

RESULT(S)

Fifty-three patients were hospitalized because of OHSS (2.1%; 95% confidence interval [CI]:1.6-2.8). Early OHSS presented in 31 patients (1.2%; 95% CI: 0.9-1.8), whereas the late type was a complication in 22 patients (0.9%; 95% CI: 0.5-1.3). Late OHSS cases compared with the early OHSS cases always occurred in a pregnancy cycle (100% vs. 40%); had higher probability of being severe (72.7% vs. 42%), and more often were related to a multiple pregnancy (40% vs. 0). Receiver operating characteristic curve analysis for several E2 concentrations and number of follicles with a diameter of > or =11 mm revealed that the predictive value of the optimal threshold of > or =13 follicles (85.5% sensitivity; 69% specificity) was statistically significantly superior to the optimal threshold of 2,560 ng/L for E2 concentrations (53% sensitivity, 77% specificity) in identifying patients at risk for OHSS. Considering that severe OHSS represents the most clinically significant pattern, the combination of a threshold of > or =18 follicles and/or E2 of > or =5,000 ng/L yields a 83% sensitivity rate with a specificity as high as 84% for the severe OHSS cases.

CONCLUSION(S)

Clinically significant OHSS still remains a limitation of multifollicular ovarian stimulation for IVF even with the use of GnRH antagonist protocols. The number of follicles can discriminate the patients who are at risk for developing OHSS, whereas E2 concentrations are less reliable for the purpose of prediction. There is more than ever an urgent need for alternative final oocyte maturation-triggering medication.

Vascular endothelial growth factor response to exogenous chorionic gonadotropic hormone in the luteal phase of women with a history of severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a severe complication of ovarian stimulation. No reliable test exists to predict the syndrome. The objective of the present prospective observational study was to examine vascular endothelial growth factor (VEGF) secretion after human chorionic gonadotropin (hCG) administration in the luteal phase of a spontaneous cycle of women with a history of severe OHSS. Five women with a history of severe OHSS were administered 250 mug recombinant hCG intravenously on day 21 of a spontaneous menstrual cycle. Plasma samples were collected at regular intervals from 15 min before hCG to 6 h thereafter and the free VEGF plasma concentrations were determined. Plasma levels of free VEGF remained at the lower detection limit of the assay throughout the observational period. Women with previous severe OHSS do not show a significant short-time response of VEGF secretion upon hCG administration. No evidence was found to support the notion that women inclined to develop a severe form of the syndrome after ovarian stimulation could possibly be identified by the VEGF short-time secretory response to exogenous hCG in the luteal phase of a spontaneous cycle.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.

Association of estradiol levels on the day of hCG administration and pregnancy achievement in IVF: a systematic review

BACKGROUND

Evaluation of the association between estradiol (E2) levels on the day of hCG administration and pregnancy achievement in IVF has so far yielded conflicting results. The purpose of the present study was to systematically review the above association in cycles down-regulated with GnRH analogues.

METHODS

Literature search was performed using Medline, Embase (1978-2004) and the Cochrane Library. Additionally, references of retrieved articles were hand-searched. Only full articles published in peer-reviewed medical journals were considered for analysis.

RESULTS

All the eligible studies (n=9) involved the use of GnRH agonists and were retrospective. Two studies (including 191 patients) suggested that the higher the E2 levels on the day of hCG administration, the higher the probability of pregnancy. However, five studies (including 1875 patients), did not support an association between E2 levels on the day of hCG administration and pregnancy rates. Moreover, two of the studies including (1286 patients) suggested that high E2 levels on the day of hCG administration are associated with a decreased probability of pregnancy. If we consider only studies in which criteria used for administering hCG include follicular development but not E2 levels (including 2687 patients), there is no study suggesting a positive association between E2 levels on the day of hCG administration and pregnancy achievement.

CONCLUSIONS

Currently there is no high-quality evidence to support or deny the value of E2 determination on the day of hCG administration for pregnancy achievement in IVF cycles, where pituitary down-regulation is performed with GnRH agonists. Existing retrospective studies suggest that there is no positive association. However, in order to arrive at recommendations for clinical practice, there is a need to perform well-designed prospective studies in both agonist and antagonist cycles.