Management of ovarian hyperstimulation syndrome
- Cristiano E Busso, MD
Cristiano E Busso, MD
- Infertility Specialist
- Projeto ALFA, Brazil
- Sérgio Reis Soares, MD
Sérgio Reis Soares, MD
- Valencian Infertility Institute (IVI) - Lisbon, Portugal
- Antonio Pellicer, MD
Antonio Pellicer, MD
- Instituto Valenciano de Infertilidad (IVI)
Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian hyperstimulation (COH) for assisted reproduction. It is characterized by a broad spectrum of signs and symptoms that includes abdominal distention and discomfort, enlarged ovaries, ascites, and other complications of enhanced vascular permeability. The syndrome can be strictly defined as the shift of serum from the intravascular space to the third space, mainly to the abdominal cavity, in the context of enlarged ovaries due to follicular stimulation. In its very severe form, OHSS is a life-threatening condition.
The management of OHSS will be reviewed here. The pathogenesis, clinical manifestations, and prevention of OHSS are discussed separately. (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome" and "Prevention of ovarian hyperstimulation syndrome".)
OHSS is an iatrogenic and potentially life-threatening condition that affects young, healthy women [1,2]. In addition, there is an important economic burden associated with OHSS due to absence from work, bed rest, or hospitalization and intensive medical management of severe cases.
The pathophysiology of OHSS is not fully understood, but increased capillary permeability with the resulting loss of fluid into the third space is its main feature. In the susceptible patient, human chorionic gonadotropin (hCG) administration for final follicular maturation and triggering of ovulation is the pivotal stimulus for OHSS, leading to overexpression of vascular endothelial growth factor (VEGF) in the ovary, release of vasoactive-angiogenic substances, increased vascular permeability, loss of fluid to the third space, and full-blown OHSS (algorithm 1).
There are two clinical forms of OHSS, both hCG related: the early-onset form (occurring on the first eight days after exogenous hCG administration) and the late-onset form (occurring nine or more days after hCG administration, related to pregnancy-induced hCG production) . (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome", section on 'Onset'.)
- Golan A, Ron-el R, Herman A, et al. Ovarian hyperstimulation syndrome: an update review. Obstet Gynecol Surv 1989; 44:430.
- Whelan JG 3rd, Vlahos NF. The ovarian hyperstimulation syndrome. Fertil Steril 2000; 73:883.
- Lyons CA, Wheeler CA, Frishman GN, et al. Early and late presentation of the ovarian hyperstimulation syndrome: two distinct entities with different risk factors. Hum Reprod 1994; 9:792.
- http://www.rcpi.ie/content/docs/000001/654_5_media.pdf (Accessed on May 11, 2015).
- Practice Committee of American Society for Reproductive Medicine. Ovarian hyperstimulation syndrome. Fertil Steril 2008; 90:S188.
- Joint Society of Obstetricians and Gynaecologists of Canada-Canadian Fertility Andrology Society Clinical Practice Guidelines Committee, Reproductive Endocrinology and Infertility Committee of the SOGC, Executive and Council of the Society of Obstetricians, et al. The diagnosis and management of ovarian hyperstimulation syndrome. J Obstet Gynaecol Can 2011; 33:1156.
- Levin I, Almog B, Avni A, et al. Effect of paracentesis of ascitic fluids on urinary output and blood indices in patients with severe ovarian hyperstimulation syndrome. Fertil Steril 2002; 77:986.
- Maslovitz S, Jaffa A, Eytan O, et al. Renal blood flow alteration after paracentesis in women with ovarian hyperstimulation. Obstet Gynecol 2004; 104:321.
- Manno M, Tomei F, Marchesan E, Adamo V. Cabergoline: a safe, easy, cheap, and effective drug for prevention/treatment of ovarian hyperstimulation syndrome? Eur J Obstet Gynecol Reprod Biol 2005; 122:127.
- Rollene NL, Amols MH, Hudson SB, Coddington CC. Treatment of ovarian hyperstimulation syndrome using a dopamine agonist and gonadotropin releasing hormone antagonist: a case series. Fertil Steril 2009; 92:1169.e15.
- Tsunoda T, Shibahara H, Hirano Y, et al. Treatment for ovarian hyperstimulation syndrome using an oral dopamine prodrug, docarpamine. Gynecol Endocrinol 2003; 17:281.
- Tang H, Mourad S, Zhai SD, Hart RJ. Dopamine agonists for preventing ovarian hyperstimulation syndrome. Cochrane Database Syst Rev 2016; 11:CD008605.
- Busso CE, Garcia-Velasco JA, Gomez R, et al. Ovarian hyperstimulation syndrome. In: Infertility and assisted reproduction, Rizk B, Garcia-Velasco JA, Sallam HM, Makrigiannakis A (Eds), Cambridge University Press, Cambridge, UK 2008. p.243.
- Nouri K, Tempfer CB, Lenart C, et al. Predictive factors for recovery time in patients suffering from severe OHSS. Reprod Biol Endocrinol 2014; 12:59.
- Abramov Y, Elchalal U, Schenker JG. Obstetric outcome of in vitro fertilized pregnancies complicated by severe ovarian hyperstimulation syndrome: a multicenter study. Fertil Steril 1998; 70:1070.
- Mathur RS, Jenkins JM. Is ovarian hyperstimulation syndrome associated with a poor obstetric outcome? BJOG 2000; 107:943.
- Wiser A, Levron J, Kreizer D, et al. Outcome of pregnancies complicated by severe ovarian hyperstimulation syndrome (OHSS): a follow-up beyond the second trimester. Hum Reprod 2005; 20:910.