Treatment of severe ovarian hyperstimulation syndrome by ultrafiltration and reinfusion of ascitic fluid

Management of ovarian hyperstimulation syndrome with abdominal compartment syndrome, based on intravesical pressure measurement

There are few reports on abdominal compartment syndrome that are caused by ovarian hyperstimulation syndrome (OHSS). Here, a case of a 29 year old woman is reported in which intravesical pressure measurement was useful in the management of severe OHSS that had been complicated by abdominal compartment syndrome. The patient's urinary output and general condition did not improve after the initial treatment. The woman's intra-abdominal pressure was evaluated indirectly, based on her intravesical pressure, and was found to be significantly elevated. The patient's urinary volume increased after a 14 mm Hg decrease in the intravesical pressure was achieved by the drainage of ascitic fluid. Intravesical pressure measurement was useful in the management of the general condition of this patient with OHSS.

[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]

The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.

Ascites ultrafiltration and concentration-reinfusion in severe ovarian hyperstimulation syndrome

Mild forms of ovarian hyperstimulation syndrome are common in women undergoing in-vitro fertilization, affecting up to 33% of in-vitro fertilization cycles; 3-8% of cycles are complicated by moderate or severe ovarian hyperstimulation syndrome (Royal College of Obstetricians and Gynaecologists, 2006). To treat severe ovarian hyperstimulation syndrome, albumin and other colloid solutions are used intravenously to increase the perfusion pressure (Manaka et al, 1995; Balasch et al, 1996), heparin to restore coagulation (Balasch et al, 1996) and dopamine to increase renal blood flow (Brinsden et al, 1995), but these all have limited effects.

Prevention and management of ovarian hyperstimulation syndrome

The Ovarian Hyperstimulation Syndrome (OHSS) represents one of the biggest nightmares of all physicians involved in Assisted Reproductive Technologies (ART). Every year, several hundreds of women are hospitalized and to date several deaths have been reported. The pivotal event in the development of OHSS is the disruption of capillary integrity that results in leakage of intravascular fluid and proteins into third space. On the molecular level, human chorionic godadotropin (HCG) either exogenous or endogenous, functions as the triggering point for the production of vascular endothelial growth factor (VEGF) that is the main mediator to increase permeability on the vascular bed. Spontaneous OHSS has also been reported, either due to inappropriate activation of a mutant FSH receptor or due to very high levels of HCG during pregnancy. The available evidence on the several preventive and therapeutic approaches with special attention to level 1 evidence when available is also presented. OHSS is a self-resolving condition and the main role of the physician is to correct and maintain the intravascular volume, to support renal function and respiration and prevent thrombotic events. An algorithm on the management of OHSS on an outpatient basis and in the hospital is based on the previous mentioned principles.

Treatment for ovarian hyperstimulation syndrome using an oral dopamine prodrug, docarpamine

Dopamine treatment constitutes a major advance towards the management of severe ovarian hyperstimulation syndrome (OHSS) by causing renal and mesenteric vasodilatation as well as diuretic and positive inotropic actions. Docarpamine, an oral dopamine prodrug, is converted into dopamine after enteral administration, and the generated dopamine causes renal vasodilatation and diuresis. The purpose of this study was to assess whether docarpamine had beneficial effects in patients with OHSS. Twenty-seven patients, hospitalized because of OHSS and refractory to the initial therapy with intravenous albumin, were treated by docarpamine, after informed consent had been obtained. A 750-mg tablet of docarpamine was taken every 8 h. In some cases, the plasma levels of free dopamine were measured. The daily urinary outputs before and 1, 2, 3 and 4 days after the docarpamine treatment were 839 +/- 424 ml, 1121 +/- 608 ml, 1168 +/- 504 ml, 1325 +/- 815 ml and 1133 +/- 509 ml, respectively. There were significant differences between the first and each of the others (p < 0.05). In 19 (86.4%) of 22 patients treated, clinical symptoms associated with ascites were gradually improved after administrating docarpamine. The plasma free dopamine concentration rose to as high as 55.9 +/- 33.2 mg/ml during the first hour, which corresponded to the usual intravenous drip infusion treatment with dopamine. Moreover, there were no major adverse effects of docarpamine in this study. This was the first demonstration of docarpamine treatment in patients with intravenous albumin-resistant OHSS. Although no effect was seen in pregnant women, diuresis was increased in some women, and ascites decreased. These findings indicate that oral docarpamine administration could be one of the options in the management of patients with OHSS using dopamine therapy.

Dynamic changes of the immunoglobulins in patients with severe ovarian hyperstimulation syndrome: efficacy of a novel treatment using peritoneo-venous shunt

PROBLEM

To evaluate the efficacy of continuous auto-transfusion system of ascites (CATSA) for the treatment of patients with severe ovarian hyperstimulation syndrome (OHSS) at the risk of febrile morbidity, the dynamic changes of immunoglobulins in the sera and the peritoneal fluid from patients with severe OHSS treated by CATSA were estimated.

METHOD OF STUDY

Ten patients with severe OHSS after superovulation for in vitro fertilization-embryo transfer (IVF-ET) were treated by CATSA. Immunoglobulin concentrations were examined in the serum and in the peritoneal fluid before and after CATSA. As controls, serum samples from 15 infertile women, who did not develop OHSS after the same superovulation protocol, were obtained on the day of mid-luteal period (Control-1). Serum samples from 15 patients with OHSS, who were treated by albumin infusion without paracentesis, were also obtained before and after the treatment (Control-2).

RESULTS

Before the treatments, serum immunoglobulin G (IgG) concentrations in patients with severe OHSS treated with CATSA and those in patients of Control-2 were significantly lower than those in patients of Control-1 (P < 0.01). Following CATSA, the concentration of IgG increased in the sera, while it decreased in the peritoneal fluid.

CONCLUSIONS

Serum IgG in patients with severe OHSS exuded into their peritoneal cavity, indicating that they might be at the status of immunodeficiency and at the risk of febrile morbidity. However, non-infectious febrile morbidity attributed to endogenous pyrogenic mechanism might be considerable. It is also suggested that CATSA might be effective in improving hypoimmunoglobulinemia of the patients with severe OHSS by the peritoneo-venous shunt.

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.

Clinical efficacy of peritoneovenous shunting for the treatment of severe ovarian hyperstimulation syndrome

We investigated prospectively the clinical efficacy of a newly developed continuous autotransfusion system of ascites (CATSA) without protein supplement in patients with severe ovarian hyperstimulation syndrome (OHSS). Peritoneovenous shunting was used to recirculate ascites. The CATSA was performed for 5 h at a rate of 100-200 ml/h once a day. Eighteen patients were treated with the CATSA (CATSA group) and 36 were treated with an intravenous 37.5 g/day of albumin supplement (albumin group). Hospital stay was significantly shorter in the CATSA group than in the albumin group (10.0 +/- 5.7 versus 13.9 +/- 6.2 days, P < 0.01). Haematocrit value reached <40% significantly earlier in the CATSA group (on hospital days 3.9 +/- 3.2 versus 5.9 +/- 2.5, P < 0.01). Using a single procedure, haemoconcentration, urinary output and pulse pressure were markedly improved in the CATSA group compared with the albumin group. Discomfort due to massive ascites diminished promptly and did not recur in nine of 18 CATSA group patients, whereas it persisted in all 36 patients in the albumin group. The serum concentration of protein was maintained in the CATSA group, whereas it did not increase in the albumin group despite daily supplementation with 37. 5 g of albumin. Apparent adverse effects of each procedure were not observed in either group. The mean values of several parameters in the serum pertinent to the coagulation-fibrinolysis system did not change significantly in either group after the procedure. It was concluded that the CATSA procedure expanded circulating plasma volume without exogenous albumin and appeared to lead to a prompt recovery from severe conditions of OHSS.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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