Prevention 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 technologies (ART). 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 prevention of OHSS will be reviewed here. The pathogenesis, clinical manifestations, and management of established OHSS are discussed separately. (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome" and "Management of ovarian hyperstimulation syndrome".)
Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian hyperstimulation (COH) for assisted reproduction technologies (ART). It is a broad spectrum of signs and symptoms that include abdominal distention and discomfort, enlarged ovaries, ascites, and other complications of enhanced vascular permeability [1,2]. OHSS is an iatrogenic and potentially life-threatening condition that affects young, healthy women. 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 (see "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation syndrome"). 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 in the first eight days after 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'.)
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- PREVENTION OF OHSS
- Keys to prevention
- Ovarian stimulation protocol
- - Gonadotropin dose and type
- - Addition of GnRH agonist or antagonist
- - Coasting
- - Withholding hCG (cycle cancellation)
- - Pretreatment with metformin
- - Luteal phase support
- Ovulatory triggers
- - Low versus standard-dose hCG
- - Recombinant LH/recombinant hCG
- - GnRH agonist trigger
- Other interventions
- - In vitro oocyte maturation
- - Embryo cryopreservation
- - Intravenous albumin
- - Dopamine agonists
- - Low-dose aspirin
- SUMMARY AND RECOMMENDATIONS