Ovarian hyperstimulation syndrome: steps to maximize success and minimize effect for assisted reproductive outcome

OBJECTIVE

To investigate the strategies used to decrease the risk of ovarian hyperstimulation syndrome (OHSS) and their impact on pregnancy and live birth rates.

DESIGN

Retrospective cohort analysis.

SETTING

University hospital.

PATIENT(S)

One hundred eighty-eight patients undergoing fresh in vitro fertilization (IVF) cycles between 2000 and 2004, with peak serum estradiol levels >2500 pg/mL and presumed to be at risk for OHSS.

INTERVENTION(S)

Coasting and elective embryo cryopreservation were evaluated for their effect on OHSS and live birth rates.

MAIN OUTCOME MEASURE(S)

Pregnancy, live birth rates, and OHSS incidence.

RESULT(S)

Out of 188 patients at risk for OHSS, 21 patients had their cycles coasted (group 1), and elective embryo cryopreservation was performed in 32 patients (group 2). In 135 patients with no other risk factors, ovulation was triggered with human chorionic gonadotropin and embryo transfer was performed (group 3). The incidence in our IVF population was 38 out of 1002 (3.8%). The overall incidence of OHSS for those who had an estradiol level >2500 pg/mL was 20.2% (38 out of 188), and none of the patients in group 1 developed OHSS; 13 out of 32 patients in group 2 (40.6%) and 25 out of 135 (18.5%) patients in group 3 developed OHSS. The live birth rate was 38%, 40%, and 45% in groups 1, 2, and 3, respectively, and the cumulative live birth rate was 52%, 75%, and 59%, respectively.

CONCLUSION(S)

Elective cryopreservation of embryos with subsequent frozen embryo transfer and coasting are effective ways of maximizing pregnancy and limiting severe OHSS.

Role of saline infusion sonography in uterine evaluation before frozen embryo transfer cycle

OBJECTIVE

To determine the role of saline infusion sonography (SIS) in uterine evaluation before a frozen embryo transfer (FET) cycle.

DESIGN

Retrospective cohort analysis.

SETTING

University hospital.

PATIENT(S)

Thirty-six patients who had uterine evaluation by SIS before FET cycle.

INTERVENTION(S)

The SIS was performed in the follicular phase of the menstrual cycle before the actual FET cycle.

MAIN OUTCOME MEASURE(S)

The SIS findings, clinical pregnancy rate (PR), ongoing PR, and correlation between positive SIS findings with and without subsequent treatment and pregnancy outcome.

RESULT(S)

Positive SIS findings were found in 11/36 patients (30.5%), which included uterine septum (9.0%), endometrial polyp (45.4%), intramural fibroid with normal cavity (9.0%), cystic endometrial changes (9.0%), cervical stenosis (18.1%), and calcification with normal cavity (9.0%). The overall clinical PR in all groups was 51.4%, with an ongoing PR of 45.7%. Patients with positive SIS finding who underwent subsequent hysteroscopic correction (7/11) had a clinical PR of 85.7% as compared to 54.1% in patients with normal uterine cavity (24/35). Patients with positive SIS findings and no operative hysteroscopy (4/11) had a clinical PR of 50% and pregnancy loss rate of 100%.

CONCLUSION(S)

Obtaining an SIS before the FET cycle can be helpful in the detection of uterine abnormalities. If time since uterine evaluation has been more than 1-2 years, performing an SIS is recommended as subsequent correction of the anomalies may improve FET outcome.

Comparison of FSH flare with and without pretreatment with oral contraceptive pills in poor responders undergoing in vitro fertilization

OBJECTIVE

To compare FSH, LH, estrogen, and P flare response following 1 mg lupron injection in poor responders with or without pretreatment with oral contraceptive pills (OCPs).

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Poor responders undergoing IVF flare protocol from October 2002 to November 2003.

INTERVENTION(S)

Patients were divided into group A, who received OCPs before IVF cycle (n = 12), and group B, who did not (n = 7). One milligram Lupron was injected SC after measuring day 2 serum FSH, LH, estrogen, and P. After 24 hours, serum hormones were measured before lupron administration.

MAIN OUTCOME MEASURE(S)

Serum FSH, LH, estrogen, and P before and after 1 mg lupron

RESULT(S)

Basal FSH was similar in both groups (8.6 +/- 4.5 vs. 9.6 +/- 2.9 mIU/mL). Group A patients had significantly lower day 2 FSH (3.6 +/- 3.6 vs. 10.1 +/- 4.2 mIU/mL; P<.05). After lupron, although both groups had a significant rise in FSH and LH, mean LH rise in group B was 39.5 +/- 31 mIU/mL versus 11.3 +/- 4.6 mIU/mL in group A (P<.05).

CONCLUSION(S)

Pretreatment with OCPs in GnRH agonist flare protocol suppresses pre-Lupron FSH but does not blunt FSH flare. It blunts LH flare, which may be beneficial.