Value of measuring serum FSH in addition to serum estradiol in a coasting programme to prevent severe OHSS

Does the serum E2 level change following coasting treatment strategy to prevent ovarian hyperstimulation syndrome impact cycle outcomes during controlled ovarian hyperstimulation and in vitro fertilization procedure?

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) remains as a clinical problem for hyperresponder patients during controlled ovarian hyperstimulation and in vitro fertilization (COH-IVF) procedure. Herein, we aimed to evaluate the COH-IVF outcomes in hyperresponder patients managed with coasting treatment strategy for OHSS prevention regarding the establishment of clinical pregnancy as an endpoint of the treatment cycle.

MATERIALS AND METHODS

The medical records related to the COH-IVF outcome in 119 hyperresponder patients who have exhibited a serum estradiol level greater than or equal to 3000 pg/mL were evaluated. The study was conducted on a total of 119 patients, 98 of whom have been treated by coasting or coasting with GnRH antagonist co-treatment strategies, while the remaining 21 women (control group) have not been managed with coasting treatment. The COH and IVF-ET outcomes in the 119 patients were compared based on the coasting treatment situation.

RESULTS

Among the women who received coasting treatment, the number of patients demonstrating E2 level decrement and also E2 level decrement rate after coasting were similar between patients with and without clinical pregnancy. Total gonadotropin dose, 2PN number, embryo number, and fertilization rate were significantly higher in the patients with a clinical pregnancy.

CONCLUSION

The coasting treatment is a clinically useful preventive strategy for OHSS avoidance. GnRH antagonist co-treatment decreases the duration of coasting although any detrimental or ameliorating impact of this effect on pregnancy rates have not been seen. The E2 level decrement or increment following coasting treatment seems not to be related to cycle outcomes.

Serum FSH Levels in Coasting Programmes on the hCG Day and Their Clinical Outcomes in IVF ± ICSI Cycles

Introduction. Coasting is the most commonly used strategy in prevention of severe OHSS. Serum FSH levels measurements during coasting may aid in optimizing the duration of coasting. Objective(s). To study live birth rates (LBRs), clinical pregnancy rates (CPRs), and optimal duration of coasting based on serum FSH levels on the hCG day. Materials and Methods. It is a retrospective study performed between 2005 and 2008 at Barts and The London Centre for Reproductive Medicine, NHS Trust, London, UK, on 349-coasted women undergoing controlled ovarian stimulation (COS) for IVF ± ICSI. The serum FSH level measurements on the hCG day during coasting programme were analysed to predict the LBR and CPR. Result(s). LBR and CPR were significantly higher when the FSH levels on the hCG day were >2.5 IU/L (LBR: 32.5%, P = 0.045 and CPR: 36.9%, P = 0.027) compared to FSH <2.5 IU/L. The optimal FSH cut-off level for LBR and CPR is 5.6 IU/L on the hCG day. The optimal cutoff for coasting is 4 days. Conclusion(s). Coasting may be continued as long as either serum FSH level is > 2.5 IU/L on the hCG day without compromising the LBR and CPR or to maximum of 4 days.

Unexpected pregnancy despite extremely decreased estradiol levels during ovarian stimulation

OBJECTIVE

To report two patients with ongoing pregnancies despite a dramatically sharp decrease in E(2) levels after coasting.

DESIGN

Case report.

SETTING

Reproductive endocrinology and assisted reproduction unit of university hospital.

PATIENT(S)

One 30-year-old and one 25-year-old woman, both with unexplained infertility, in whom E(2) levels increased up to 6345 and 14,275 pg/mL during ovarian hyperstimulation and decreased by 79.5% and 75.5%, respectively, after coasting.

INTERVENTION(S)

Two IVF treatments during which coasting was performed after high E(2) levels were observed. IVF cycles were carried out despite abrupt E(2) decrease.

MAIN OUTCOME MEASUREMENT(S)

Development of ovarian hyperstimulation syndrome (OHSS) or fertilization, cleavage, implantation, and pregnancy rates.

RESULT(S)

Two embryos (one grade A and one grade B) were transferred into the 30-year-old patient and three embryos (all grade A) were transferred into the 25-year-old patient. Neither woman developed OHSS. Two pregnancies on going at gestational weeks 20 and 14, respectively.

CONCLUSION(S)

Coasting is practiced to avoid severe complications of ovarian hyperstimulation during IVF cycles and is achieved by withholding gonadotropins. The aim of coasting is to lower E(2) levels to a safer range; however, there has been no consistency with respect to the time of coasting or the safety rates of E(2) decrease. We believe that high rates of E(2) decrease after coasting do not have deleterious effects on implantation.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Coasting for the prevention of ovarian hyperstimulation syndrome: much ado about nothing?

OBJECTIVE

To review and critique the literature and our own experience regarding coasting as a strategy to prevent ovarian hyperstimulation syndrome (OHSS).

DESIGN

Identification of relevant clinical literature through PubMed and EMBASE databases, as well as the experience of our institution with this approach.

CONCLUSION(S)

Coasting is a rescue procedure that can be avoided by carefully adjusting the gonadotropin dosage. It is a good alternative that can be used to avoid cycle cancellation in extremely high responders to controlled ovarian hyperstimulation, who have a high risk of developing severe OHSS. Even if OHSS develops after coasting, both its incidence and severity will be diminished. Each case should be individually counseled to determine whether the patient should be coasted, and her hypothetical risks and benefits should be evaluated. Until the multifactorial etiopathogenesis of OHSS is completely understood, absolute prevention will not be possible, but coasting is definitely of great benefit.

[Coasting and ovarian stimulation protocols in high-responder patients undergoing assisted conception]

Over-responsive patients are at risk of ovarian hyperstimulation, which may lead to severe complications. The choice of ovarian stimulation protocol or the use of a coasting (gonadotrophins suspension) with its associated risk of too strong ovarian response will be discussed herein. As for in vitro fertilization stimulation protocols, the best are probably those which use steadily increasing low doses of gonadotrophins, associated to GnRH agonists (low-dose protocols) or those which complete a double hypophyseal inhibition (estro-progestative association and GnRH agonists). GnRH antagonists may also reduce the risk of ovarian hyperstimulation, by estradiol drop. Outside the context of in vitro fertilization GnRH continuous administration or low -dose gonadotrophin stimulation are the best options. A coasting will be performed when an excess follicle response is documented. Under strict hormonal follow-up and within four days it allows achieving a high rate of pregnancy with a lower risk of hyperstimulation. Compared to other therapies of hyperstimulation syndrome, the coasting allows to avoid cycle cancellation or freezing of all embryos.

Criteria of a successful coasting protocol for the prevention of severe ovarian hyperstimulation syndrome

BACKGROUND

The aim of this study is to report a large series of patients (n = 1223) at risk of developing ovarian hyperstimulation syndrome (OHSS) who underwent coasting.

METHODS

Coasting started when the leading follicle reached 16 mm and continued until the estradiol (E2) level fell to 3000 pg/ml.

RESULTS

The E2 level at the start of coasting was (mean +/ SD) 6408 +/- 446 and it fell to 2755 +/- 650 on the day of HCG injection, after (mean +/- SD) 2.89 +/- 0.94 days. The results were analysed according to the duration of coasting (< or = 3 days, group I: n = 983; >3 days, group II: n = 240). The number of oocytes retrieved was (mean SD) 16.45 +/- 6.25 and 14.93 +/- 6.01 in groups I and II respectively (P < 0.05). The fertilization rates were 63 and 65% in groups I and II respectively (P > 0.05). The implantation and clinical pregnancy rates were 26 and 52% in group I compared to 18 and 36% in group II respectively (P < 0.05). Severe OHSS occurred in 16 cases, which represented 0.13% of all stimulated cycles, and 1.3% of patients who were at risk of developing OHSS.

CONCLUSIONS

Our protocol of coasting was an effective measure in the prevention of OHSS, without jeopardizing the ICSI outcome. Coasting for >3 days is associated with a moderate decrease in the pregnancy rate.

Prevention and treatment of ovarian hyperstimulation syndrome

The ovarian hyperstimulation syndrome (OHSS) is a potentially fatal condition with a pathophysiology that is not clearly understood. A shift in fluid from the extravascular space occurs, thought to be induced by cytokines and/or vascular endothelial growth factor. Human chorionic gonadotrophin (hCG), exogenous or endogenous, seems to be the triggering mechanism, resulting in early and late development of the syndrome, respectively. The management of the syndrome is mainly symptomatic. Preventive strategies are being developed and constantly refined. Women at increased risk of OHSS need to be on the lowest possible dose of gonadotrophin with the aim of reducing the granulosa/luteal cell mass. Ultrasound and serum oestradiol (E2) measurements are, at present, the main methods used to identify and monitor those at risk during controlled ovarian hyperstimulation (COH). Withholding gonadotrophin stimulation (coasting), but continuing down-regulation, when a large number of follicles (greater than 20) and a rising serum oestradiol level are seen, is the most widely favoured and used preventive measure and the most cost effective. Management is symptomatic and aimed at achieving fluid balance, restoring plasma volume and improving renal function. This may be combined with an early resort to ascitic fluid aspiration, which will improve the feeling of wellbeing and may remove those agents responsible for the syndrome. Heparin, to prevent the risk of thromboembolism as a result of haemoconcentration, is important.