Managing ovarian hyperstimulation syndrome: A qualitative interview study with women and healthcare professionals.

AIM: To explore the experiences of women who have had ovarian hyperstimulation syndrome, and healthcare professionals who care for them. BACKGROUND: Ovarian hyperstimulation syndrome is a side effect of fertility treatment. Little research exists internationally that explores the experiences of women who have had this condition, or the healthcare professionals who manage it. DESIGN: Qualitative study using semi-structured interviews. METHODS: Eighteen interviews with women who had experienced ovarian hyperstimulation syndrome (n = 10) and healthcare professionals (n = 8) in six UK fertility centres. Framework analysis was used. This paper is reported following COREQ guidelines. RESULTS: Women described a range of symptoms and severity, sometimes experiencing worrying physical health problems such as abdominal swelling and shortness of breath. The combination of the symptoms, and their management, on delaying future fertility treatment could cause emotional distress. Healthcare professionals at different centres described variation in practice, which generally involved 'active monitoring' until symptoms became severe, when women would be hospitalised. Women expressed feeling 'left in limbo' while waiting for symptoms to improve or worsen, and described a lack of control during this waiting period. Healthcare professionals felt they provided adequate information about ovarian hyperstimulation syndrome and its management. This, however, did not align with women's perceptions that information, including potential delays to their fertility treatment, was missing. There was similar mismatch between women's and healthcare professionals' views of decision-making about fertility treatment following ovarian hyperstimulation syndrome, including women's concerns about having to make rushed, unplanned decisions about their fertility treatment when they did not feel adequately informed to do so. CONCLUSION: Ovarian hyperstimulation syndrome and its management can have a significant physical and emotional impact on women, and influence their fertility treatment. Improvements could be made to the information women receive about this condition, its management and its implications for wider fertility treatment. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Nurses have the skills and knowledge to support women through the physical and emotional stresses of fertility treatment. Therefore, they are well placed to provide specialist information and support for OHSS and ensure women are fully informed about all aspects of the condition, including how its management might delay fertility treatment.

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.

Emergency department utilization for ovarian hyperstimulation syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is a rare, but serious, risk of assisted reproductive technologies. In severe cases, patients may present to the emergency department (ED) for assessment, treatment of related complications, and even in-patient admission. Significant effort has been made to reduce the incidence and complications of OHSS; however, it is unknown if these strategies have decreased patient presentation for treatment in the ED. PURPOSE: To assess ED utilization for OHSS over time and to examine admission rates, patient demographics, and charges. METHODS: Retrospective longitudinal study utilizing data from the Nationwide Emergency Department Sample Database and the National ART Surveillance System. All ED visits between 2006 and 2016 with an ICD-9 or -10 diagnosis of OHSS were included. Demographics including age, geographic location, and income quartile and alternative diagnoses, admission rates, overall charges, and number of stimulation cycles annually were assessed. RESULTS: The number of ovarian stimulation cycles steadily increased from 2006 (n = 110,183) to 2016 (n = 157,721), while the number of OHSS-related ED visits remained relatively stable (APC 2.08, p = 0.14). Admission rates for OHSS decreased from 52.7% in 2006 to 33.1% in 2016 (APC -4.43%, p < 0.01). The average charge for OHSS-related ED visits almost doubled from 2006 to 2016 (APC 8.53, p < 0.01) and was significantly higher than charges for non-OHSS-related visits for age-matched controls (p < 0.01). CONCLUSION: Despite an increase in total stimulation cycles, there was no significant change in the estimated number of patients presenting to the ED; however, admission rates significantly declined. These observations suggest a possible shift in the severity and/or management of OHSS during the study period.

Changes in thyroid function during controlled ovarian hyperstimulation (COH) and its impact on assisted reproduction technology (ART) outcomes: a systematic review and meta-analysis.

BACKGROUND: To investigate the thyroid function changes during controlled ovarian hyperstimulation (COH) and ascertain its impact on reproductive outcomes. METHODS: We conducted meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed to identify studies reported changes in thyroid parameters during COH. We analyzed thyroid-stimulating hormone (TSH) levels, free thyroxin (fT4) levels, changes in estrogens (E2), thyroxine-binding globulin (TBG), relative risks (RRs) of clinical pregnancy rate (CPR), live birth rate (LBR), and mean difference (MD) of TSH increment between the miscarriage group and ongoing pregnancy group. RESULTS: This meta-analysis included fifteen individual studies (n = 1665 subjects). At the end of COH, the mean TSH (2.53 mIU/L; 95% CI, 2.19 to 2.88; I2 = 92.9%) exceeded the upper limit (2.5 mIU/L) and remained above the threshold until one month following embryo transfer (ET). Thyroxin decreased from baseline to the end of COH (-0.18 ng/l; 95% CI, -0.35 to 0.00; I2 = 92.2%). The CPR and LBR of patients with TSH exceeding the cutoff after COH were significantly lower than those of patients with TSH below the threshold (CPR: RR, 0.62; 95% CI, 0.47 to 0.82; I2 = 0.0% and LBR: RR, 0.64; 95% CI, 0.44 to 0.92; I2 = 0.0%). The MD of the increment in TSH levels between the miscarriage and ongoing pregnancy groups was 0.40 mIU/L (95% CI, 0.15 to 0.65; I2 = 0.0%). CONCLUSIONS: This meta-analysis shows that TSH increases and fT4 decreases during COH. COH-induced thyroid disorder impairs reproductive outcomes.

Trends in ovarian hyperstimulation syndrome hospitalization rates in the USA: an ongoing concern.

Ovarian hyperstimulation syndrome (OHSS) is a serious, almost exclusively, iatrogenic complication of ovarian stimulation. Many techniques have been developed over the past 25 years to decrease OHSS risks, and most have been in common use for 15-20 years. In view of these techniques, it could be hypothesized that severe OHSS rates would decrease or almost disappear. According to the US National ART Surveillance System, rates did not change significantly between 2000 and 2009, at 106 OHSS cases per 10,000 IVF cycles annually. In the present study, OHSS-related hospital admissions were evaluated to establish whether a decline has occurred in OHSS admissions since the development of preventative strategies. A retrospective-population-based study was conducted using data from the Health-Care Cost and Utilization Project-Nationwide-Inpatient-Sample database between 2004 and 2014 inclusively. Between 2004 and 2008, admissions of OHSS decreased in absolute numbers and rates; however, these statistics plateaued, remaining stable between 2008 and 2014. Despite this, OHSS remains a concern and is clearly not a disease of the past. The financial burden of OHSS hospitalizations likely persists. Although techniques have resulted in a decrease in OHSS admissions since 2004, this change has plateaued, and therefore efforts to further reduce OHSS must continue.

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.

Point of Care Ultrasound in the Diagnosis and Management of Severe Ovarian Hyperstimulation Syndrome.

Presentation A 32year old woman, presented with a 5-day history of non-productive cough, chest pain, shortness of breath andabdominal bloating. She had undergone Embryo Transfer Treatment 6 days previously. Diagnosis A point of care ultrasound (POCUS) exam was performed as part of her initial investigations which showed right pleuraleffusion, ascites and cystic ovaries. Treatment She received Oxygen, IV Fluids and Antibiotics and was referred to the Obstetricians. Discussion Point of care ultrasound (POCUS) aided the prompt diagnosis of ovarian hyperstimulation syndrome (OHSS) in thispatient, making it possible for her to receive appropriate resuscitation and referral and an excellent outcome despitethis being a case of severe ovarian hyperstimulation syndrome.

Electroacupuncture facilitates implantation by enhancing endometrial angiogenesis in a rat model of ovarian hyperstimulation.

Controlled ovarian hyperstimulation (COH) impairs the synchronized development of endometrium and embryo, resulting in the failure of embryo implantation. Here, we investigated what effects electroacupuncture had on embryo implantation in COH rats. Female rats were randomly assigned to four groups: normal (N), model (M), electroacupuncture (EA), and electroacupuncture pretreatment (PEA). Rats in groups M, EA, PEA were injected with pregnant mare serum gonadotropin (PMSG) and human chorionic gonadotropin to establish the COH model. Rats in group EA received electroacupuncture treatment from the PMSG injection day to the 3rd day of pregnancy (D3), while those in group PEA received electroacupuncture treatment for 3 days before the PMSG day and continuing to D3. Furthermore, another 30 female rats who received the same treatment as the rats in group PEA were injected with siVEGFR2 into uterine lumen. The endometrial microvascular density (MVD) and the expression levels of vascular endothelial growth factor-A, angiopoietin-1, and fibroblast growth factor-2 were significantly lower in groups M than in groups N and PEA. The percentage of dolichos biflorus agglutinin positive uterine natural killer cells in groups N, EA and PEA was higher than that in group M. After the siVEGFR2 injection, the protein expression levels of vascular endothelial growth factor receptor 2 (VEGFR2), PI3K, p-AKT and p-ERK, the embryo number and the MVD were significantly reduced. In conclusion, electroacupuncture can facilitate embryo implantation in COH rats by activating the VEGFR2/PI3K/AKT and VEGFR2/ERK signaling pathways which have a positive relationship with endometrial angiogenesis.

Ovarian hyperstimulation syndrome: A review for emergency clinicians.

INTRODUCTION: A great deal of literature has recently evaluated the prevention and management of ovarian hyperstimulation syndrome (OHSS) in the outpatient setting, but there remains a dearth of research evaluating OHSS in the emergency department (ED) and its management. OBJECTIVE: This narrative review evaluates the underlying pathophysiology and clinical manifestations of OHSS and discusses approaches to patient care in the ED based on current literature. DISCUSSION: OHSS is an iatrogenic complication caused by an excessive response to controlled ovarian stimulation during assisted reproductive cycles (ART). OHSS complicates up to 30% of ART cycles, and many of these patients seek initial care in the ED. Risk factors for the development of OHSS include age < 35, history of polycystic ovarian syndrome or previous OHSS, and pregnancy. Emergency physicians will be faced with several complications including ascites, abdominal compartment syndrome, renal dysfunction, acute respiratory distress syndrome, thromboembolic disease, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary obstetrics/gynecology team is needed, which improves patient outcomes. This review provides several guiding principles for management of OHSS and associated complications. CONCLUSIONS: OHSS occurs in up to 30% of IVF cycles and carries a high morbidity. Effective care of the OHSS patient begins with early diagnosis while evaluating for other diseases and complications. Understanding these complications and an approach to the management of OHSS is essential to optimizing patient care.

Ovarian hyperstimulation syndrome. A new look at an old problem.

To analyze the management of severe ovarian hyperstimulation syndrome based on aspects of its etiology and pathogenesis a systematic review of the literature was done. An evaluation of clinical trials, meta-analysis, case-reports and reviews assessing the management of different conditions related to ovarian hyperstimulation syndrome was made using the following data sources: MEDLINE Pubmed (from 1966 to July 2018) and the Cochrane Controlled Clinical Trials Register, Embase (up to July 2018). The role of intra-abdominal hypertension in the development of the severe forms of ovarian hyperstimulation syndrome and its complicated outcomes was assessed. The pathophysiology and clinic of intra-abdominal hypertension syndrome are almost identical to moderate and severe forms of ovarian hyperstimulation syndrome and associated organ dysfunction. The classic triad (respiratory disorders, reduction in venous return, and restriction of perfusion in internal organs) is present in severe ovarian hyperstimulation syndrome as well as in intra-abdominal hypertension syndrome. This review provides recommendations for the management of ovarian hyperstimulation syndrome and insight into the different medical complaints of this syndrome. The principles of therapy for intra-abdominal hypertension syndrome might be considered in the treatment of severe forms of ovarian hyperstimulation syndrome.

Unilateral pleural effusion as the sole clinical presentation of severe ovarian hyperstimulation syndrome: a systematic review.

The pathophysiology of isolated pleural effusion in ovarian hyperstimulation syndrome (OHSS) is not well defined. The objective of the current review is to delineate the pathophysiology, risk factors, preventive measures, and therapeutic options of isolated pleural effusion in severe OHSS. Major databases were searched until June 2016. Studies evaluating women who presented with pleural effusion as the sole extra-ovarian manifestation of severe OHSS were included. Data were extracted from 24 articles encompassing 30 reported cases. Values were expressed as mean ± SEM. Patients were young (31.5 ± 0.8 years old) and 29.1% of them were diagnosed with polycystic ovary syndrome. All the patients received human chorionic gonadotropin to trigger oocyte maturation. Estradiol level was 3110 ± 330 pg/mL on the day of the ovulatory trigger. Dyspnea was the presenting symptom in 86.6% of the patients. Pleural effusion was predominantly on the right side (80%). Ninety percent of the patients underwent thoracentesis (4332 ± 769 mL): 66.7% exudate and 33.3% transudate. Fluid initially accumulates in the peritoneal cavity then enters the pleural space due to the pressure gradient through the thoracic duct and diaphragmatic defects, which are more common on the right side. The risk factors, prevention, and management, which are also discussed in this review, are similar to those of severe OHSS.

[Pathophysiology and current clinical approach of ovarian hyperstimulation syndrome]. / Az ovarialis hiperstimulációs szindróma kórélettana és korszeru klinikuma.

During assisted reproduction technologies, controlled hyperstimulation of the ovaries occurs. Ovarian hyperstimulation syndrome is an excessive overreaction of the ovaries complicating pharmacological ovulation induction. Rarely other causes, such as the mutation of the follicle-stimulating hormone receptor may also be in the background. Ovarian hyperstimulation syndrome is clinically characterized by a massive ovarian enlargement associated with an acute third-space fluid shift responsible for the development of ascites, and sometimes pleural or pericardial effusion. Associated arterial or venous thromboembolic symptoms are also common. Ovarian hyperstimulation syndrome is an iatrogenic and potentially life-threatening condition in the form of ischemic stroke or circulatory insufficiency of the limbs. Recently some new methods have been developed for the prevention of the disease. The syndrome affects young, healthy patients. It also has an important economic burden due to the absence from work, bed rest, or hospitalization and intensive medical management of more severe cases. Supportive therapy, anticoagulant prophylaxis and close monitoring are the main approach for the syndrome. However, hospitalization or intervention should not be delayed for patients with severe or critical conditions. Orv Hetil. 2018; 159(34): 1390-1398.

Cardiovascular health of 9-year-old IVF offspring: no association with ovarian hyperstimulation and the in vitro procedure.

STUDY QUESTION: Are the in vitro procedure, ovarian hyperstimulation or a combination of these two associated with blood pressure (BP) of 9-year-old IVF children born to subfertile couples? SUMMARY ANSWER: Our study demonstrates that ovarian hyperstimulation and the in vitro procedure are not associated with BP values in 9-year-old children born to subfertile couples. WHAT IS KNOWN ALREADY: Possible long-term effects of IVF on child health and development have been studied relatively little. This is surprising, as it is known that environmental conditions may influence embryonic and foetal development which may result in health related problems in later life. Some studies suggested that IVF is associated with higher BP at pre-school age. Yet, it is unclear whether this may be also true for older children and if so, which component of IVF, i.e. the ovarian hyperstimulation, the embryo culture or a combination of these, attributes to this potentially less favourable BP. STUDY DESIGN, SIZE, DURATION: The Groningen Assisted Reproductive Technology cohort-study is a prospective assessor-blinded study of children followed from before birth onwards. In total, 170 children were assessed at the age of 9 years. The attrition rate up until the 9-year-old assessment was 21%. PARTICIPANTS/MATERIALS, SETTING, METHODS: We evaluated cardiovascular health, focusing on BP (in mmHg and the internationally recognized percentiles of the US National High BP Education Program), heart rate and anthropometrics of 57 children born following controlled ovarian hyperstimulation-IVF/ICSI (COH-IVF/ICSI); 47 children born after modified natural cycle-IVF/ICSI (MNC-IVF/ICSI); and 66 children who were conceived naturally by subfertile couples (Sub-NC). Cardiovascular parameters were measured multiple times on one day. In addition, anthropometric data, including BMI and skinfold thickness, were collected. MAIN RESULTS AND THE ROLE OF CHANCE: Systolic BP in mmHg did not differ between the COH-IVF/ICSI (mean 106.9, SD 6.7), MNC-IVF/ICSI (mean 104.8, SD 5.9) and Sub-NC (mean 106.3, SD 5.3) groups. In addition, systolic BP percentiles did not differ between the groups: COH-IVF/ICSI (mean 62.4, SD 20.2); MNC-IVF/ICSI (mean 56.3, SD 19.3); and Sub-NC (mean 62.3, SD17.8). Also, after adjustment for confounders BP in the three groups was similar. Heart rate and anthropometric values in the three groups did not differ. For instance, BMI values in the COH-IVF/ICSI-children were 16.3 (median value, range 13.0-24.7), in MNC-IVF/ICSI-children 16.1 (range 12.7-22.5) and in Sub-NC children 16.3 (range 12.7-24.0). LIMITATIONS, REASONS FOR CAUTION: The size of our study groups does not allow for pertinent conclusions on the effect of ovarian hyperstimulation and the in vitro procedure. The lack of a fertile control group may be regarded as another limitation. WIDER IMPLICATIONS OF THE FINDINGS: Our study suggests that ovarian hyperstimulation and in vitro procedures are not associated with cardiovascular health in 9-year-old. Yet, BP percentiles of the three groups were higher than the expected 50th percentile. This might indicate that children of subfertile couples have a higher BP than naturally conceived children. STUDY FUNDING/COMPETING INTEREST(S): The study was financially supported by the University Medical Center Groningen (UMCG), the two graduate schools of the UMCG, BCN, SHARE and the Cornelia Stichting. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. The authors have no conflicts of interest to declare.

Interventions for the prevention of OHSS in ART cycles: an overview of Cochrane reviews.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) in assisted reproductive technology (ART) cycles is a treatment-induced disease that has an estimated prevalence of 20% to 33% in its mild form and 3% to 8% in its moderate or severe form. These numbers might even be higher for high-risk women such as those with polycystic ovaries or a high oocyte yield from ovum pickup. OBJECTIVES: The objective of this overview is to identify and summarise all evidence from Cochrane systematic reviews on interventions for prevention or treatment of moderate, severe and overall OHSS in couples with subfertility who are undergoing ART cycles. METHODS: Published Cochrane systematic reviews reporting on moderate, severe or overall OHSS as an outcome in ART cycles were eligible for inclusion in this overview. We also identified Cochrane submitted protocols and title registrations for future inclusion in the overview. The evidence is current to 12 December 2016. We identified reviews, protocols and titles by searching the Cochrane Gynaecology and Fertility Group Database of Systematic Reviews and Archie (the Cochrane information management system) in July 2016 on the effectiveness of interventions for outcomes of moderate, severe and overall OHSS. We undertook in duplicate selection of systematic reviews, data extraction and quality assessment. We used the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the quality of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS: We included a total of 27 reviews in this overview. The reviews were generally of high quality according to AMSTAR ratings, and included studies provided evidence that ranged from very low to high in quality. Ten reviews had not been updated in the past three years. Seven reviews described interventions that provided a beneficial effect in reducing OHSS rates, and we categorised one additional review as 'promising'. Of the effective interventions, all except one had no detrimental effect on pregnancy outcomes. Evidence of at least moderate quality indicates that clinicians should consider the following interventions in ART cycles to reduce OHSS rates.• Metformin treatment before and during an ART cycle for women with PCOS (moderate-quality evidence).• Gonadotrophin-releasing hormone (GnRH) antagonist protocol in ART cycles (moderate-quality evidence).• GnRH agonist (GnRHa) trigger in donor oocyte or 'freeze-all' programmes (moderate-quality evidence). Evidence of low or very low quality suggests that clinicians should consider the following interventions in ART cycles to reduce OHSS rates.• Clomiphene citrate for controlled ovarian stimulation in ART cycles (low-quality evidence).• Cabergoline around the time of human chorionic gonadotrophin (hCG) administration or oocyte pickup in ART cycles (low-quality evidence).• Intravenous fluids (plasma expanders) around the time of hCG administration or oocyte pickup in ART cycles (very low-quality evidence).• Progesterone for luteal phase support in ART cycles (low-quality evidence).• Coasting (withholding gonadotrophins) - a promising intervention that needs to be researched further for reduction of OHSS.On the basis of this overview, we must conclude that evidence is currently insufficient to support the widespread practice of embryo cryopreservation. AUTHORS' CONCLUSIONS: Currently, 27 reviews in the Cochrane Library were conducted to report on or to try to report on OHSS in ART cycles. We identified four review protocols but no new registered titles that can potentially be included in this overview in the future. This overview provides the most up-to-date evidence on prevention of OHSS in ART cycles from all currently published Cochrane reviews on ART. Clinicians can use the evidence summarised in this overview to choose the best treatment regimen for individual patients - a regimen that not only reduces the chance of developing OHSS but does not compromise other outcomes such as pregnancy or live birth rate. Review results, however, are limited by the lack of recent primary studies or updated reviews. Furthermore, this overview can be used by policymakers in developing local and regional protocols or guidelines and can reveal knowledge gaps for future research.

Severe ovarian hyperstimulation syndrome after combined GnRH-agonist and low-dose human chorionic gonadotropin trigger in a patient with a single kidney.

Ovarian hyperstimulation syndrome (OHSS) following gonadotropin-releasing hormone agonist (GnRH-a) trigger is rare. Here, we report a case of severe OHSS after combined GnRH-a and low-dose human chorionic gonadotropin (hCG) trigger in a patient with a single kidney. The patient is a 32-year-old women with a two-year history of infertility. The patient's history was significant for a single kidney, that is, she had donated a kidney to a family member three years ago. The patient underwent controlled ovarian stimulation (COS) for in vitro fertilization (IVF) and received a combined 2 mg GnRH-a and 1500 IU hCG ovulatory trigger. Estradiol (E2) levels on the day of and after the trigger were 3800 pg/mL and 4001 pg/mL, respectively. Four days after the trigger, the patient began experiencing nausea, abdominal distention and dyspnea, and her blood testing revealed hemoconcentration (hemoglobin: 16.9 g/dL; hematocrit: 51.0%) and an elevated creatinine level (1.16 mg/dL). Fresh embryo transfer was deferred. The patient was admitted to the hospital for fluid monitoring and prophylactic anticoagulation. Following inpatient management, her hemoglobin, hematocrit and creatinine levels normalized. The current report highlights that the systemic effects of OHSS can be accentuated in patients with preexisting renal disease or a single kidney.

Severe ovarian hyperstimulation syndrome in a naturally conceived singleton pregnancy after ovulation induction: a case report.

OBJECTIVE: To present a case of severe ovarian hyperstimulation syndrome (OHSS) in a naturally conceived singleton pregnancy after ovulation induction. CASE: A 31-year-old woman with polycystic ovarian syndrome (PCOS) underwent ovulation induction therapy. Six days later, she was admitted to the present hospital with the symptoms of OHSS. Ultrasonography confirmed the single live intrauterine pregnancy, as well as enlarged multicystic ovaries and marked ascites that required abdominal paracentesis. The woman was treated with intravenous infusion, exogenous colloid supplementation, essentiale liver treatment, rocephin anti-infective therapy for skin lymphangitis of left lower limb, and drainage of the ascites. She recovered by day 45 of admission. CONCLUSION: Severe OHSS may develop in women with PCOS who undergo ovulation induction therapy. Serious complications may develop rapidly and therefore OHSS must be treated urgently and with multidisciplinary management.

Life-threatening Medical Complications Due to Ovarian Hyperstimulation Syndrome: A Hidden Etiology.

Ovarian hyperstimulation syndrome is usually an iatrogenic complication in women taking ovulation induction medications during assisted reproduction. We hereby report the case of a 25 years old female who presented with hypertension, polyserositis with tense ascites and large cystic ovaries. She developed sigmoid and transverse sinus thrombosis. She had undergone a clandestine ovulation induction therapy as a commercial ovum donor. She fitted in severe category of ovarian hyperstimulation syndrome.

Variation in antral follicle counts at different times in the menstrual cycle: does it matter?

Antral follicle count (AFC) variation was examined across the menstural cycle and its effect on clinical management assessed. In 79 women, AFC was documented in early (iAFC) and late follicular phase (sAFC). Absolute agreement between iAFC and sAFC and agreement for classification into categories of risk of extremes of ovarian response were examined. Ovarian stimulation protocols designed with iAFC and sAFC, and the predictive value of iAFC and sAFC for extremes of ovarian response, were compared in women undergoing ovarian stimulation. Significant differences were found between iAFC and sAFC (16 [IQR 9-24] versus 13 [IQR 7- 21]; P = 0.001), with moderate agreement for the classification into at risk of extremes of response (k = 0.525). Agreement for protocol selection based on either AFC (k = 0.750) and starting gonadotrophin dose was good (concordance correlation coefficient 0.970 [95% CI 0.951 to 0.982]). Predictive value for iAFC and sAFC was maintained for poor ovarian response and risk of ovarian hyperstimulation syndrome (OR 0.634 [0.427 to 0.920], 0.467 [0.233 to 0.935]) and (OR 1.049 [0.974 to 1.131], 1.140 [1.011 to 1.285]). Across the cycle, AFC varies but does not significantly affect ovarian stimulation protocol design and prediction of extreme ovarian response.

Pathophysiology, treatment and prevention of ovarian hyperstimulation syndrome.

PURPOSE OF REVIEW: Severe ovarian hyperstimulation syndrome (OHSS) is an iatrogenic condition that affects 1% of women that undergo treatment with assisted reproductive technology. The review aims to summarize recent evidence on pathophysiology, treatment, and prevention of OHSS. RECENT FINDINGS: The pathophysiology is still not completely understood; however, vascular endothelial growth factor is likely to be an important mediator. Human chorionic gonadotropin was previously thought to be necessary for OHSS to occur; however, recent case reports have proven otherwise. The contribution of an attenuated anti-Mullerian hormone signalling pathway and CD11c + HLA-DR + dendritic cells and associated interleukins has been explored recently as contributors to pathogenesis.Treatment is largely supportive and is based mainly on consensus statements rather than evidence. Therefore, it is important to prevent this condition by identifying women at risk, allowing the clinician to implement preventive strategies, including the use of GnRH antagonist cycles with agonist triggers. SUMMARY: More research is required to elucidate the pathophysiology behind the condition. Clinicians should employ strategies to prevent OHSS.

Effect of cervical conization on pregnancy outcome of in-vitro fertilization/intracytoplasmic sperm injection treatment: a retrospective cohort study.

AIMS: To investigate the effect of cervical conization on the outcome of in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment. Materials andMethods: The authors performed a retrospective, database-searched cohort study based on patients undergoing controlled ovarian hyperstimulation and IVF/ICSI between 2009 and 2013 in the present hospital. Cervical intraepithelial neoplasia (CIN) or cervical cancer was carefully confirmed by transvaginal ultrasound, hysteroscopy, and biopsy. High-quality case-control study with strict inclusion criteria was conducted. The authors analyzed basic characters and main IVF/ICSI outcomes between both groups. RESULTS: The authors included 48 patients with a history of cervical conization who underwent IVF/ICSI and control group without cervical conization. No significant differences were found in IVF/ICSI outcomes between both groups. No obvious evidence was found indicating that cervical stenosis could impact IVF operation. CONCLUSIONS: The present results suggest that cervical conization does not affect IVF/ICSI outcomes. Patients can receive cervical conization before undertaking assisted reproductive technology.