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      Prevention of Ovarian Hyperstimulation Syndrome: A Review

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          Abstract

          The following review aims to examine the available evidence to guide best practice in preventing ovarian hyperstimulation syndrome (OHSS). As it stands, there is no single method to completely prevent OHSS. There seems to be a benefit, however, in categorizing women based on their risk of OHSS and individualizing treatments to curtail their chances of developing the syndrome. At present, both Anti-Müllerian Hormone and the antral follicle count seem to be promising in this regard. Both available and upcoming therapies are also reviewed to give a broad perspective to clinicians with regard to management options. At present, we recommend the use of a “step-up” regimen for ovulation induction, adjunct metformin utilization, utilizing a GnRH agonist as an ovulation trigger, and cabergoline usage. A summary of recommendations is also made available for ease of clinical application. In addition, areas for potential research are also identified where relevant.

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          Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review.

          Annick Delvigne, Serge Rozenberg (2015)
          Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy. Fortunately, the reported prevalence of the severe form of OHSS is small, ranging from 0.5 to 5%. Nevertheless, as this is an iatrogenic complication of a non-vital treatment with a potentially fatal outcome, the syndrome remains a serious problem for specialists dealing with infertility. The aim of this literature review was to determine whether it is possible to identify patients at risk, and which preventive method should be applied when an exaggerated ovarian response occurs. Data pertaining to the epidemiology and prevention of OHSS in women were searched using Medline, Current Contents and PubMed, and are summarized. Preventive strategies attempt either to limit the dose or concentration of hCG or to find a way to induce luteolysis without inducing a detrimental effect on endometrial and oocyte quality. The following particular preventive strategies were reviewed: cancelling the cycle; coasting; early unilateral ovarian follicular aspiration (EUFA); modifying the methods of ovulation triggering; administration of glucocorticoids, macromolecules and progesterone; cryopreservation of all embryos; and electrocautery or laser vaporization of one or both ovaries.
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            Incidence and prediction of ovarian hyperstimulation syndrome in women undergoing gonadotropin-releasing hormone antagonist in vitro fertilization cycles.

            H. Fatemi, Evangelos Papanikolaou, Efstratios Kolibianakis … (2005)
            To determine the incidence of ovarian hyperstimulation syndrome (OHSS) in a large series of GnRH antagonist-stimulated cycles and to assess the predictive value of E2 and the number of follicles on the day of hCG administration. Prospective cohort study of women undergoing IVF treatment with a GnRH antagonist protocol over a 2-year period. Tertiary university hospital. One thousand eight hundred one patients who underwent 2,524 cycles. Multifollicular ovarian stimulation with recombinant FSH and GnRH antagonist for IVF-ICSI treatment. Incidence of OHSS in GnRH antagonist cycles, predictive value of E2, and number of follicles on the day of hCG for OHSS occurrence. Fifty-three patients were hospitalized because of OHSS (2.1%; 95% confidence interval [CI]:1.6-2.8). Early OHSS presented in 31 patients (1.2%; 95% CI: 0.9-1.8), whereas the late type was a complication in 22 patients (0.9%; 95% CI: 0.5-1.3). Late OHSS cases compared with the early OHSS cases always occurred in a pregnancy cycle (100% vs. 40%); had higher probability of being severe (72.7% vs. 42%), and more often were related to a multiple pregnancy (40% vs. 0). Receiver operating characteristic curve analysis for several E2 concentrations and number of follicles with a diameter of > or =11 mm revealed that the predictive value of the optimal threshold of > or =13 follicles (85.5% sensitivity; 69% specificity) was statistically significantly superior to the optimal threshold of 2,560 ng/L for E2 concentrations (53% sensitivity, 77% specificity) in identifying patients at risk for OHSS. Considering that severe OHSS represents the most clinically significant pattern, the combination of a threshold of > or =18 follicles and/or E2 of > or =5,000 ng/L yields a 83% sensitivity rate with a specificity as high as 84% for the severe OHSS cases. Clinically significant OHSS still remains a limitation of multifollicular ovarian stimulation for IVF even with the use of GnRH antagonist protocols. The number of follicles can discriminate the patients who are at risk for developing OHSS, whereas E2 concentrations are less reliable for the purpose of prediction. There is more than ever an urgent need for alternative final oocyte maturation-triggering medication.
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              Preventing ovarian hyperstimulation syndrome: guidance for the clinician.

              Peter Humaidan, Jens Quartarolo, Evangelos Papanikolaou (2010)
              To reevaluate ovarian hyperstimulation syndrome (OHSS) prevention techniques and provide a classification system for grading OHSS and evidence-based treatment strategies for preventing OHSS. A literature search was conducted in PubMed for articles published in the last 5 years using the keywords "controlled ovarian stimulation," "controlled ovarian hyperstimulation," "ovarian hyperstimulation syndrome," "OHSS," "prevention," "chorionic gonadotropin," "hCG," "GnRH agonist," "GnRH antagonist," "coasting," and "cryopreservation." We reviewed randomized controlled trials (RCTs), retrospective studies, pilot studies, case studies, reviews, and meta-analyses. There is a shortage of large, prospective RCTs reporting OHSS prediction and prevention strategies. Our review showed that risk factors such as antral follicle count and baseline anti-Müllerian hormone level may identify women at high OHSS risk. Preventative strategies that appear highly effective at reducing or preventing OHSS include GnRH antagonist protocols and the use of GnRH agonists to trigger final oocyte maturation. Moreover, alternative therapies, such as dopamine receptor agonists (Cabergoline), have also emerged as potential new treatment modalities in the management of this disease. These findings suggest that current treatment guidelines should be updated to incorporate findings from recent literature that show that GnRH antagonist protocols consistently reduce OHSS and that GnRH agonist triggering has considerable promise in preventing OHSS, although further RCTs will be needed to confirm this. Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Obstet Gynecol Int
                Journal ID (iso-abbrev): Obstet Gynecol Int
                Journal ID (publisher-id): OGI
                Title: Obstetrics and Gynecology International
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 1687-9589
                ISSN (Electronic): 1687-9597
                Publication date (Print): 2015
                Publication date (Electronic): 14 May 2015
                Volume: 2015
                Electronic Location Identifier: 514159
                Affiliations
                1Alice Springs Hospital, Department of Obstetrics and Gynaecology, Alice Springs, NT 0870, Australia
                2Monash IVF, 252 Clayton Road, Clayton, VIC 3168, Australia
                3Monash Health, Women's and Children's Program, Monash Medical Centre, Clayton Road, Clayton, VIC 3168, Australia
                4Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
                Author notes

                Academic Editor: Curt W. Burger

                Author information
                http://orcid.org/0000-0001-6099-3671
                Article
                DOI: 10.1155/2015/514159
                PMC ID: 4446511
                PubMed ID: 26074966
                SO-VID: ed6d4222-58b2-4eb6-9be2-90ef996f0003
                Copyright © Copyright © 2015 Vinayak Smith et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 27 January 2015
                Date accepted : 29 April 2015
                Categories
                Subject: Review Article

                ScienceOpen disciplines: Obstetrics & Gynecology
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology

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