Assisted Reproductive Technology in the Presence of Polycystic Ovary Syndrome: Current Evidence and Knowledge Gaps.

OBJECTIVE: In this narrative review, we discuss the current evidence as well as the knowledge gaps concerning assisted reproductive technology (ART) indications, protocols, and results in the presence of polycystic ovary syndrome (PCOS). METHODS: An electronic literature search was performed for English-language publications in the last decade in databases such as PubMed, Medline, the Web of Sciences, Embase, and Scopus. RESULTS: We found evidence that ovarian steroidogenesis and folliculogenesis are deeply altered by PCOS; however, the oocyte quality and pregnancy rates after ART are not affected. Patients with PCOS are more sensitive to the action of exogenous gonadotropins and more likely to develop ovarian hyperstimulation syndrome. This risk can be mitigated by the adoption of the gonadotropin-releasing hormone antagonist protocols for pituitary blockade and ovarian stimulation, along with frozen embryo transfer, without compromising the odds of achieving a live birth. Pregnancy complications, such as miscarriage, gestational diabetes, preeclampsia, and very preterm birth, are more frequent in the presence of PCOS, requiring more intense prenatal care. It remains uncertain whether weight reduction or insulin sensitizers used before ART are beneficial for the treatment outcomes. CONCLUSION: Although PCOS is not a drawback for ART treatments, the patients need special care to avoid complications. More in-depth studies are needed to uncover the mechanisms of follicular growth, gamete maturation, and endometrial differentiation during ART procedures in the presence of PCOS.

Ovarian hyperstimulation syndrome with carotid artery dissection and cerebral infarction: a case report.

BACKGROUND AND PURPOSE: Ovarian hyperstimulation syndrome (OHSS) is one of the most serious iatrogenic complications in assisted reproductive technology, which seem rarely associated with cerebrovascular diseases. We reported a patient diagnosed with OHSS combined with carotid artery dissection and massive cerebral infarction. CASE PRESENTATION: We reported a unique case of a 31-year-old woman who experienced abdominal pain, blurred consciousness, and speech inability after 15-day continuous injection of human gonadotropin for infertility. Imaging examination showed hyperacute cerebral infarction in the left frontotemporal island parietal lobe and left internal carotid artery dissection. After therapeutic use of low-molecular-weight heparin calcium anticoagulation and other conventional cerebrovascular treatments, she eventually achieved a good prognosis. CONCLUSIONS: OHSS seemd rarely associated with cerebrovascular diseases, such as infarction and carotid artery dissection. Encountering abdominal symptoms combined with neurologic symptoms, a detailed history and a thorough examination are essential. It is necessary to comprehensively analyze the pathogenesis and formulate individualized therapy according to the specific conditions of patients.

Intrahepatic cholestasis of pregnancy after ovarian hyperstimulation syndrome with wild-type ABCB4 gene: a peculiar case and literature review.

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) in the first trimester occurring after ovarian hyperstimulation syndrome (OHSS) is a rare condition and few cases are reported in the literature. Hyperestrogenism may explain this problem in genetically predisposed women. The objective of this article is to report one of these rare cases and offer an overview of the other published cases. CASE PRESENTATION: We report a case of severe OHSS followed by ICP in the first trimester. The patient was admitted to the intensive care unit and was treated according to the guidelines for the management of OHSS. Moreover, the patient also received ursodeoxycholic acid for ICP, which brought to an improvement of her clinical conditions. The pregnancy continued without other complications until the 36th week of gestation, when the patient developed ICP in the third trimester and underwent cesarean section for increased bile acid levels and cardiotocographic (CTG) pathologic alterations. The newborn was a healthy baby weighing 2500 gr. We also reviewed other case reports published by other authors about this clinical condition. We present what is, to our knowledge, the first case of ICP developed in the first trimester of pregnancy after OHSS in which genetic polymorphisms of ABCB4 (MDR3) have been investigated. CONCLUSIONS: ICP in the first trimester might be induced by elevated serum estrogen levels after OHSS in genetically predisposed women. In these women, it might be useful to check for genetic polymorphisms to know if they have a predisposition for ICP recurrence in the third trimester of pregnancy.

Cocktail treatment by GnRH-antagonist, letrozole, and mifepristone for the prevention of ovarian hyperstimulation syndrome: a prospective randomized trial.

OBJECTIVE: This study is aimed to determine the efficacy of a cocktail style treatment by combining GnRH-antagonist, letrozole, and mifepristone on the prevention of ovarian hyperstimulation syndrome (OHSS) in high-risk women. METHODS: This prospective, randomized controlled clinical trial was performed between January 2018 and December 2018. A total of 170 women who identified as high risk of OHSS during the ovarian hyperstimulation and underwent cryopreservation of whole embryos. On the day of oocyte retrieval, the combination group received 0.25 mg Cetrorelix for 3 d, 5 mg letrozole for 5 d, and 50 mg mifepristone for 3 d, the mifepristone group received 50 mg mifepristone for 3 d. A total of 156 cases were included in final analysis. All the frozen embryo transfer (FET) cycles were followed up until December 2021. RESULTS: The combination group showed significantly decreased incidence of moderate and severe OHSS than mifepristone group (20.5% vs. 42.3%), with remarkably reduced serum estradiol level on hCG + 3 and + 5 d, decreased ovarian diameter, and shortened luteal phase. Oocyte retrieval number, levels of estradiol on hCG + 0 and VEGF, and ovarian diameter on hCG + 5 were associated with the severity of the symptoms. There was no significant difference in cumulative live birth rates (LBRs) between the combination and mifepristone group (74.4% vs. 76.9%). CONCLUSIONS: The combination treatment effectively reduces the incidence of moderate/severe OHSS in high-risk women.

The Association between Ovarian Hyperstimulation Syndrome and Pregnancy Complications following Fertility Treatments.

OBJECTIVE: This study was aimed to assess the association between ovarian hyperstimulation syndrome (OHSS) and pregnancy complications among women who conceived following fertility treatment. STUDY DESIGN: A retrospective population-based cohort study, including all singleton deliveries of patients conceived following ovulation induction (OI) or in vitro fertilization (IVF) between 1988 and 2016, was conducted. All births occurred in a single tertiary medical center. A comparison was performed between deliveries of women who had experienced OHSS at early gestation and subsequently had a pregnancy and women without OHSS. Women lacking prenatal care, multiple gestations, and stillbirths were excluded from the analyses. A multivariable logistic regression model was used to control for confounders. RESULTS: During the study period, 351,373 deliveries met the inclusion criteria, of which 6,748 were deliveries of infants who were conceived by either IVF or OI. Of this study population, 105 cases (1.6%) composed the exposed group, that is, women who had experienced OHSS with a subsequent live birth. In the multivariate analyses, after controlling for confounders, OHSS was not found as an independent risk factor for preeclampsia, gestational diabetes mellitus (GDM), intrauterine growth restriction (IUGR), preterm delivery (both <37 and <34 weeks), low birth weight (LBW), very LBW (VLBW), small for gestational age (SGA), and caesarean delivery. In a subanalysis conducted solely on the IVF population, similar results were found, aside from the association between OHSS and preterm delivery before 34 weeks of gestation which was statistically significant (adjusted odds ratio [AOR] = 2.3 95% confidence interval [CI]: 1.0-5.3, p = 0.049). CONCLUSION: In our population, OHSS was not found as a risk factor for adverse pregnancy and perinatal outcome. In IVF patients, OHSS is a risk factor for preterm delivery before 34 weeks of gestation. KEY POINTS: · OHSS is not a risk factor for pregnancy complications.. · Complications investigated were preeclampsia, GDM, prematurity, and others.. · In IVF patients, OHSS is a risk factor for preterm delivery..

Ovarian Hyperstimulation Syndrome: A Case Report.

BACKGROUND: Ovarian hyperstimulation syndrome is a rare, life-threatening obstetric emergency. Early recognition and prompt treatment of ovarian hyperstimulation syndrome are essential owing to the risk of long-term complications associated with this condition. CASE PRESENTATION: A 30-year-old female presented to the emergency department with a chief complaint of abdominal pain. After assessment and diagnostic testing, she was diagnosed as having ovarian hyperstimulation syndrome. The patient was admitted for 24-hour observation. The patient was discharged home with instructions to follow up with an outpatient reproductive medicine clinic. One month after her visit to the emergency department, the patient has not had any complications related to the diagnosis. CONCLUSION: This manuscript outlines the case of a patient presenting to the emergency department with ovarian hyperstimulation syndrome that was promptly recognized and treated. It is important for emergency nurses to quickly identify the risk factors and clinical presentation of ovarian hyperstimulation syndrome to decrease the risk of long-term complications.

Myoinositol versus metformin pretreatment in GnRH-antagonist cycle for women with PCOS undergoing IVF: a double-blinded randomized controlled study.

OBJECTIVE: To study the effects of myoinositol (Myo) in comparison to metformin (Met), in reducing the risk of OHSS and improving ART outcome in PCOS women undergoing IVF. DESIGN: Double-blinded randomized controlled trial (CTRI/2018/05/014196). SETTING: ART Clinic, AIIMS, New Delhi patients: 102 infertile PCOS women undergoing IVF cycles were enrolled after evaluating for eligibility and allotted as 50 in group 1 (Myo) and 52 in group 2 (Met) after randomization. INTERVENTIONS: Recruited patients received Myo 2 g twice daily (group 1) and Met 850 mg twice daily (group 2). Pre- and post-treatment clinical (menstrual pattern, BMI), hormonal profile (LH, FSH, testosterone, prolactin [PRL], and AMH), biochemical parameters (HOMA IR, fasting glucose, and insulin), ovarian with antral follicle count (AFC) and side effect profile were assessed. After 3 months of therapy, patients were recruited for IVF cycle by antagonist protocol was involving controlled ovarian stimulation, cycle monitoring, oocyte recovery, insemination of oocytes and follow up with fertilization, cleavage, transfer of good grade cleavage embryos, or blastocysts pregnancy outcomes and OHSS incidence and medications was continued until the day of OPU. MAIN OUTCOME MEASURES: Primary outcome was OHSS and clinical pregnancy rate including spontaneous, IVF, and cumulative pregnancy rate including FET. Secondary outcome was ART outcomes and the change in biochemistry and hormonal profile between groups and inter group after medications at 12 weeks. RESULTS: Incidence of OHSS (Myo 5 (10.0) (n = 50), Met 10 (20.0) (n = 50) p .07) was not statistically different between groups. Clinical pregnancy rate (Myo 18 (36.0) (n = 50), Met 9 (18.0) (n = 50) p .04) cumulative pregnancy rate including FET (Myo 16 (43.2) (n = 37) vs. Met 10) 22.7) (n = 44) p .05) and spontaneous conception (prior to IVF) Myo 13 (26.0) (n = 50), Met 6 (12.0) (n = 50) p .07) was significantly high in Myo group. No between group difference in ovarian stimulation outcomes including duration and dosage of gonadotropins, E2, P4 levels, number of follicles >14 mm on day of trigger. Number of oocytes retrieved and grade of maturity were similar between groups. Fertilization, cleavage and number of good grade embryos were significantly higher in Myo group. However, implantation rate and number of embryos for freezing were similar between groups. Myo had improvement in fasting insulin, HOMA, Sr.AMH, and SHBG suggesting decreased insulin resistance. CONCLUSIONS: Myo is equally beneficial as Met in reducing the risk of OHSS and has better ART outcome in PCOS women undergoing antagonist cycles.

Ovarian Hyperstimulation Syndrome Complicating Spontaneous Molar Pregnancy: A Case Report and Review of the Literature.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is traditionally associated with fertility treatments and results in elevated human chorionic gonadotropin (ßhCG) levels and fluid shifts to extravascular compartments. Rarely, spontaneous pregnancies with significant ßhCG elevations, such as molar pregnancies, can give rise to OHSS. CASE: A 24-year-old woman was diagnosed as having a molar pregnancy at approximately 12 weeks gestation following spontaneous conception. Her initial ßhCG was over 1 million IU/L. There was no evidence of metastatic disease. She underwent an uncomplicated dilation and curettage. Three days later, she presented with chest pain, shortness of breath, and abdominal discomfort. Massively enlarged ovaries were identified with bilateral pleural effusions requiring repeated thoracentesis. CONCLUSION: This case demonstrates rare sequelae of molar pregnancy. Treatment is mainly supportive, and close observation is required to manage complications. In patients with extremely elevated ßhCG levels, clinicians must remain vigilant for signs suggesting OHSS, even following evacuation of the uterus.

The influence of obesity on incidence of complications in patients hospitalized with ovarian hyperstimulation syndrome.

OBJECTIVE: To study the impact of body habitus on risk of complications resulting from ovarian hyperstimulation syndrome (OHSS) in hospitalized patients. METHODS: This is a retrospective observational study examining the National Inpatient Sample between January 2012 and September 2015. Patients were women < 50 years of age diagnosed with OHSS, classified as non-obese, class I-II obesity, or class III obesity. Intervention included multinomial logistic regression to identify factors associated with obesity and binary logistic regression for independent risk factors for complications. Main outcome measures were incidence of (i) any or (ii) multiple complication(s). RESULTS: Of 2745 women hospitalized with OHSS, 2440 (88.9%) were non-obese, 155 (5.6%) had class I-II obesity, and 150 (5.5%) had class III obesity. Obese women (either class I-II or III) had a higher degree of comorbidity, had lower incomes, and were less likely to have private insurance than non-obese women (all P < 0.001). Obese women had lower rates of OHSS-related complications than non-obese women (any complication: non-obese 65.2%, class I-II 54.8%, and class III 46.7%, P < 0.001; and multiple complications: non-obese 38.5%, class I-II 32.3%, and class III 20.0%, P < 0.001). In the multivariable model, obesity remained independently associated with a decreased risk of complications (class I-II odds ratio 0.57, 95% confidence interval 0.39-0.83, P = 0.003; class III odds ratio 0.30, 95% confidence interval 0.20-0.44, P < 0.001). Obese women were also less likely to require paracentesis (non-obese 32.8%, class I-II 9.7%, and class III 13.3%, P < 0.001). CONCLUSION: Our study suggests that obesity is associated with decreased OHSS-related complication rates in hospitalized patients.

Fluidothorax as an atypical symptom of late ovarian hyperstimulation syndrome.

OBJECTIVE: To present a case of isolated fluidothorax as a symptom of atypical late ovarian hyperstimulation syndrome. METHODS: Review of available information and presentation of our case observed at the Department of Obstetrics and Gynaecology, 1st Faculty of Medicine, Charles University and University Hospital Bulovka. GnRH antagonist protocol was used to stimulate the patient and fresh embryo transfer was performed. Sixteenth day after the oocyte retrieval the patient was examined due to dyspnoea and lab exam proved ovarian hyperstimulation syndrome. CONCLUSION: Late ovarian hyperstimulation syndrome can lead to isolated fluidothorax in case of additional favourable conditions.

MULTIPLE ACUTE POSTERIOR CIRCULATION STROKE WITH LESIONS IN THE PONS AND BOTH HEMISPHERES OF THE CEREBELLUM ASSOCIATED WITH OVARIAN HYPERSTIMULATION SYNDROME: A CASE REPORT OF A WHITE EUROPEAN ADULT IN UKRAINE.

We have presented a brief literature overview of the disease, supported by a clinical case of multiple acute posterior circulation strokes with lesions in the pons and both hemispheres of the cerebellum associated with ovarian hyperstimulation syndrome in a white young European adult in Ukraine. Specific features of posterior circulation stroke associated with ovarian hyperstimulation syndrome were determined, analyzed, and described. Complex posterior circulation cerebral infarction in the pons and both hemispheres of the cerebellum associated with ovarian hyperstimulation syndrome has not been reported before but has devastating consequences for both mother and fetus. Strokes in patients with OHSS must be timely prevented, promptly diagnosed, and treated to avoid high morbidity and mortality associated with it.

Strangulated internal hernia following severe ovarian hyperstimulation syndrome: a case report.

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian stimulation. Herein, we report a rare case of strangulated internal hernia in a woman with severe OHSS following ovulation induction. A delay in the diagnosis and management of acute abdominal pain can lead to serious problems. The aim of this case report was to highlight the diagnostic difficulties of abdominal pain in women with OHSS, and emphasize the positive effects of imaging and a timely differential diagnosis in clinical practice.

Ischemic Stroke Associated With Ovarian Hyperstimulation Syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of assisted reproductive technology. Severe OHSS may be accompanied by thromboembolic events, such as pulmonary thromboembolism or acute respiratory distress syndrome. Ischemic stroke may occur in rare cases. CASE REPORT: We report a 32-year-old woman with a recent medical history of OHSS who presented to the emergency department (ED) with acute onset of impaired consciousness. Her initial Glasgow Coma Scale score was 10 (E3V3M4). History taking and a thorough physical examination were impossible because of the patient's mental status. Additional medical history was obtained with the assistance of the patient's husband. Ischemic stroke was confirmed on diffusion-weighted magnetic resonance imaging performed after a basic examination and confirmation of normal findings on a noncontrast brain computed tomography scan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the incidence of cerebral infarction is low in younger patients, emergency physicians treating young women in the ED who have recently undergone fertility treatment or have been diagnosed with OHSS should be aware of the possibility of complications caused by OHSS. Specifically, if these patients complain of traditional or nontraditional neurologic symptoms during an ED visit, stroke should be strongly suspected.. This awareness will reduce the incidence of sequelae through prompt examination and treatment.

Sudden Death Due to Severe Ovarian Hyperstimulation Syndrome: An Autopsy-Centric Case Report.

ABSTRACT: Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic disorder associated with controlled ovarian stimulation during assisted reproductive technology. Severe OHSS may impose serious complications, including pleural effusion, acute renal insufficiency, venous thrombosis, and even death, although lethal outcomes are rare in forensic practice. The reported incidence of severe OHSS ranges from 0.008% to 10%. Herein, we present the case of a 29-year-old woman who diagnosed with polycystic ovary syndrome and infertility chose to undergo assisted reproduction. She received leuprorelin acetate and follicle stimulating hormone prior to egg retrieval. Three days after the retrieval procedure, she developed abdominal pain and distension. Later that same day, she died unexpectedly. The subsequent autopsy revealed turbid effusions of pleural and peritoneal cavities, abnormal ovarian enlargement, and duskiness of multiple organ surfaces. Microscopic examination disclosed edema and hemorrhage in follicles of both ovaries, thrombosis within the myocardial matrix, and massive pulmonary edema. Routine toxicology screening was negative. The death was attributed to severe OHSS. This case provides a morphologic reference for clinical and forensic work. Autopsy findings in instances of severe OHSS provide valuable insight into the mechanisms and pathogenesis of this disease.

Assisted reproduction and thromboembolic risk in the COVID-19 pandemic.

The COVID-19 pandemic has significantly increased mortality in many countries, with the number of infected cases increasing exponentially worldwide. One of the main determining factors of the poor prognosis in these patients is the development of coagulopathy. Moreover, it is well known that assisted reproductive technology procedures confer a risk of thromboembolic complications. This commentary analyses specific aspects coexisting between the thrombotic risk described during virus infection and that reported in the context of assisted reproduction treatments. Based on known pathophysiological aspects of virus infection and of ovarian stimulation, there are common elements that deserve to be taken into account. In the present context, any risk of hyperstimulation should be avoided. Gonadotrophin-releasing hormone agonist triggering should be mandatory in high-responder patients and/or those with COVID-19 infection. In both cases, the cycle should be segmented. A proposal is made for the use of prophylactic low molecular weight heparin not only in those cases in which oocyte retrieval has been performed, but also in those in which cancellation has been decided. In addition, endometrial preparation for frozen-thawed embryo transfers should use the transdermal route in order to minimize the higher thrombotic risk associated with the oral route.

Alternative strategies for the management of ovarian hyperstimulation syndrome, the role of intra-abdominal hypertension control.

The aim of this study is to analyze the methods for reducing intra-abdominal pressure (IAP) in the management of the moderate and severe forms of ovarian hyperstimulation syndrome (OHSS). We carried out a systematic review of the literature. An evaluation of clinical trials, meta-analysis, case-reports, and reviews assessing the management of conditions associated with OHSS and intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) was made using the following data sources: MEDLINE Pubmed (from 1966 to July 2019) and the Cochrane Controlled Clinical Trials Register, Embase (up to July 2019). The principles of treatment of IAH syndrome can be considered in the treatment of moderate and severe forms of OHSS. Medical treatment of patients with increased IAP in OHSS should be started early to prevent further organ dysfunction and avoid a transition to a more severe stage of IAH and ACS. Some of the new, non-surgical methods, such as continuous negative extra-abdominal pressure, are a promising option in specific groups of patients with OHSS. This review provides suggestions for the management of OHSS based on the principles of therapy for IAH syndrome. Further well-designed studies are needed to confirm these initial data.

Whether Letrozole could reduce the incidence of early ovary hyperstimulation syndrome after assisted reproductive technology? A systematic review and meta-analysis.

BACKGROUND: Letrozole can significantly decrease the estrogen level, and has been administrated to prevent the incidence of early ovary hyperstimulation syndrome (OHSS). However, the effect of Letrozole on prevention of OHSS reached to controversial conclusions. The present meta-analysis aim to examine whether Letrozole could reduce the incidence of early OHSS after assisted reproductive technology (ART). METHODS: An exhaustive electronic literature search was conducted on MEDLINE, Google Scholar, CNKI and WANFANG MED ONLINE, from inception until May 2018. We include clinical trials that examined the effect of Letrozole on the prevention of early OHSS. The main outcome measures were the incidence of total early OHSS, mild early OHSS, moderate early OHSS, and severe early OHSS. RESULTS: Eight studies included in the review. Of these, five publications evaluated the effect of Letrozolel on the prevention of total, mild, moderate, and severe OHSS, respectively. The results indicated that there was a significantly decreased incidence of total OHSS with Letrozole compared with control group, and there were no significantly differences in the incidence of mild, moderate, and severe OHSS between study group with Letrozole and control group. Eight studies reported the incidence of moderate + severe OHSS. We found a significant decrease in incidence of moderate + severe OHSS in high-risk women with Letrozole. CONCLUSIONS: Letrozole has no beneficial effect on the prevention of mild, moderate, and severe OHSS, individually; Letrozole should not be considered as the first-line treatment for prevention of OHSS. Further cohort studies are required to explore the effect of Letrozole on the prevention of OHSS. This study aimed to examine whether Letrozole could reduce the incidence of early OHSS after assisted reproductive technology (ART). A meta-analysis including 8 studies was conducted. There were no significantly differences in the incidence of mild, moderate, and severe OHSS between study group with Letrozole and control group. Letrozole has no beneficial effect on the prevention of mild, moderate, and severe OHSS, individually.

Risk of gestational hypertension in pregnancies complicated with ovarian hyperstimulation syndrome.

OBJECTIVE: Ovarian hyperstimulation syndrome (OHSS) is the most common iatrogenic complication due to ovulation stimulation during assisted reproductive technology. Pathophysiology of this syndrome is not completely clarified, and there is no some specific treatment. Human chorionic gonadotropin is considered as the most significant factor in etiopathogenesis of OHSS. The results of some clinical studies related to influence of OHSS on pregnancy are variable. The aim of this study was to investigate hypertensive disease of pregnancies in patients admitted to hospital due to severe forms of OHSS with reference to maternal characteristics. METHODOLOGY: A case control study was conducted at the Obstetrics and Gynaecology Clinic "Narodni Front" and involved 50 patients admitted to hospital due to severe form of OHSS during a period from January 2008 to March 2015. A control group was created based on age and it involved 59 patients with pregnancy achieved with IVF/ICSI during the same period, but in which OHSS did not occur. For comparing mean values of continuous variables, Independent samples t test was applied. RESULTS: Patients with pregnancy complicated by OHSS, had considerably higher rate of hypertension (14% vs. 3.2 %, p=0.046). CONCLUSIONS: Pregnancies achieved by IVF/ICSI, being complicated with severe OHSS could be related to gestational hypertension.

Acute Kidney Injury Due to Ovarian Hyperstimulation Syndrome.

Ovarian hyperstimulation syndrome (OHSS) is a complication of assisted reproductive treatments such as in vitro fertilization (IVF). The pathophysiology of severe OHSS includes a humorally mediated capillary leak syndrome that is predominantly centered on the intra-abdominal space. Severe OHSS is frequently complicated by acute kidney injury (AKI), which can be due to any of a variety of mechanisms, each requiring a different management strategy. Mechanisms of AKI in severe OHSS include intravascular volume depletion, kidney edema due to capillary leak, intra-abdominal hypertension or compartment syndrome, and obstructive uropathy due to ovarian enlargement. We present a teaching case of severe OHSS complicated by AKI in a woman with underlying stage 4 chronic kidney disease. She had been undergoing IVF with plans to subsequently use a gestational carrier (surrogate) for pregnancy. We use this case to review the presentation and pathophysiology of OHSS complicated by AKI. In addition, we review the management of AKI in OHSS, in particular, the role of paracentesis and/or culdocentesis to manage tense ascites. Last, we highlight that similar cases may occur more frequently in the future given that IVF with subsequent use of a gestational carrier is increasingly being used for patients with comorbid conditions that can be exacerbated by pregnancy, such as advanced chronic kidney disease.

Life-threatening complications among women with severe ovarian hyperstimulation syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome is a potentially life-threatening clinical condition. OBJECTIVE: The objective of this study was to evaluate risk factors for life-threatening complications for patients with severe ovarian hyperstimulation syndrome in a United States nationwide sample. MATERIALS AND METHODS: Ovarian hyperstimulation syndrome admissions from 2002 to 2011 from the Nationwide Inpatient Sample were included in this study. The association between patient and hospital factors and life-threatening complications (deep vein thrombosis/pulmonary embolism, acute respiratory distress syndrome, acute renal failure, intubation), nonroutine discharge (discharge to skilled nursing facility, transfer hospital), prolonged length of stay, and total hospital charges were analyzed. Survey-adjusted multivariable logistic regression analyses were performed for these outcomes, controlling for risk factors, with adjusted odds ratios with 95% confidence intervals as the measures of effect. RESULTS: A total of 11,562 patients were hospitalized with severe ovarian hyperstimulation syndrome from 2002 to 2011. The majority were white (55.7%), with private insurance (87.7%), aged 25-39 years (84.6%), and hospitalized in an urban location (95%). In all, 19.3% of patients had medical comorbidities including hypertension, diabetes, obesity, hypothyroidism, and anemia. Life-threatening complications occurred in 4.4% of patients (deep vein thrombosis/pulmonary embolism, 2.2%; acute renal failure; acute respiratory distress syndrome, 0.9%; intubation, 0.5%). Patients ≥40 years old (odds ratio, 4.02; 95% confidence interval, 1.37, 11.76), those with comorbidities (odds ratio, 2.29; 95% confidence interval, 1.46, 3.57), and African American patients (odds ratio, 2.15; 95% confidence interval, 1.25, 3.70) were more likely to develop life-threatening conditions. Patients with medical comorbidities (odds ratio, 0.39; 95% confidence interval, 0.24, 0.63) were also less likely to be routinely discharged from the hospital. Adjusting for patient and hospital demographics, patients with comorbidities were more likely to develop deep vein thrombosis/pulmonary embolism (adjusted odds ratio, 2.44; 95% confidence interval, 1.28, 4.65) and acute renal failure (adjusted odds ratio, 2.26; 95% confidence interval, 1.21, 4.23). Patients who developed life-threatening complications had longer hospital length of stay (adjusted odds ratio, 3.72; 95% confidence interval, 2.28, 6.07) and higher hospital costs (adjusted odds ratio, 5.20; 95% confidence interval, 3.22,8.39). CONCLUSION: Patients with common medical comorbidities are at higher risk for life-threatening complications in the setting of severe ovarian hyperstimulation syndrome. Furthermore, these complications are associated with high hospital costs and hospital burden. Given the increasing number of in vitro fertilization patients with medical comorbidities, closer monitoring of at-risk patients may be indicated. As assisted reproductive technology practice changes in recent years with strategies designed to reduce ovarian hyperstimulation syndrome risk, future studies are needed to assess the impact of these changes on hospitalization and complication risk.