An ohss – free clinic salide share

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An ohss – free clinic salide share

  1. 1. An OHSS – Free Clinic : to Manage ERROR – TERROR International conference on Reproduction fertility &surrogacy AIIMS, New Delhi 24-25 may 2014 Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Aruna Saxena Dr Abhishek S. Parihar Directors:
  2. 2. An OHSS – Free Clinic to Manage ERROR – TERROR Review this Lecture at: Slideshare.net :
  3. 3. Goals of Ovulation induction in IUI / IVF Minimize Complications & Risk AIM Ideal Outcome Singleton live Birth at term Cycle Cancellation Multiple Pregnancy OHSS
  4. 4. OHSS – Risk is a reality OHSS - Mortality is also a reality - Grossly Underestimated (Bewley et al 2011) DEVROEY 2011 OHSS is ↑ in numbers with ↑in IVF /ICSI cycles all over the globe
  5. 5. are RARE but Is a REALITY !!! (Though not reported) FATAL CASES
  6. 6. Mortality due to critical OHSS in IVF is Unacceptable DEVROEY 2011
  7. 7. Clinics providing ovarian stimulation with Gonadotrophins for IUI/IVF - Protocol should be in place for preventing, diagnosing and managing Ovarian Hyperstimulation Syndrome Nice Guideline 2004
  8. 8. Classification
  9. 9. Early < 10Early < 10  Correlated to ovarian response to stimulation.  Acute effect of exogenous hCG administration  Occurs within 10 days after oocyte retrieval LATE <10LATE <10 1. Poorly correlated to the ovarian response 2. More correlated to the endogenous hCG produced by the implanting embryos 3. Administration of hCG for LPS 4. After the initial 10 Mathur et al - 2005.
  10. 10. Mild Mild abdominal pain Abdominal bloating Ovarian size usually <8 cm Moderate Moderate abdominal pain Nausea +/- Vomiting Ultrasound Evidence of ascites Ovarian size 8-12 cm HCT > 41% , WBC>15,000, Hypoproteinemia Grading
  11. 11. Mild Mild abdominal pain Abdominal bloating Ovarian size usually <8 cm Moderate Moderate abdominal pain Nausea +/- Vomiting Ultrasound Evidence of ascites Ovarian size 8-12 cm Grading
  12. 12. Severe N & V ++, pain ++ , Clinical ascites (rarely hydrothrorax) Ovarian size > 12 cm, Oliguria heamoconcentration - HEAMATOCRIT > 45% Hypoproteinaemia Critical Ovarian size > 12 cm TENSE ASCITES ± HYDROTHORAX WHITE CELL COUNT > 25 000/ ML PCV > 55 gm % OLIGURIA / ANURIA Venous thrombosis ± Thromboembolism Acute respiratory distress syndrome
  13. 13. • Mild OHSS is common (~33% of stimulated IVF cycles Almost all in IVF normal & hyper responders) • moderate (3 - 6%) • severe (0.3 – 2%) - uncommon. 13 Incidence of OHSS in IVF Cycles Most Serious Complications of OI (Dreadful – Hospitalisation & ? Death) (Papanikolaou et al.2005)
  14. 14. MATERNAL MORTALITY RATES Due to OHSS Netherland & UK – 2007 MORTALITY : 3 / 1,00,000 CYCLES 1 Aboulghar. Fertil Steril. 2012;97:523-6; 2 Confidential Enquiry into Maternal and Child Health, 2007; 1-5 million IVF cycles / year 500 death (last 10 years) Grossly Underreported
  15. 15. Aetiopathogenesis Exact Pathogenesis is not clear
  16. 16. IMPORTANCE of OHSS WHAT IT means to ME & to You ? • Totally IATROGENIC problem of OI with GT Induced by clinician • 100% PREVENTION IMPOSSIBLE • Profound Economical impact • Profound Psychological Impact Without HCG Trigger OHSS is extremely rare.
  17. 17. 3 Facts • HCG Triggerfor ovulation creates HAVOC • Long protocol of Down regulation With GnRH agonist in IVF is associated ↑ OHSS – Compels IVF experts to use long protocol Supposedly ↑ PR With long protocol
  18. 18. HCG Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod. 2000;15:1037; Gómez et al. Endocrinology. 2002;143:4339
  19. 19. hypovolemia ascites hemoconcentration ovarian volume (cysts, edema) albumine loss pleural/pericardial effusion hydro ureter anasarca Vascularcompartiment 3th space 19Dr Razia S
  20. 20. The Truth is that OHSS MUST BE PREVENTED RATHER than treated
  21. 21. Dale Carnegi Said “The successful man profits from his mistake and tries again in a different way”. “That’s true for errors of OHSS events in IVF – a dangerous emergency
  22. 22. HOW TO PREVENT IT ? • Steps Before stimulation • Step During Stimulation • Step on Impending Severe OHSS
  23. 23. 23Dr Razia S
  24. 24. Young patients Lean women Polycystic Ovarian PCOS Previous OHSS • High number of follicle in both ovaries at the quiescent state before Stimulation (>- 10 follicle of 4-10mm in each ovary) • Raised AMH Easily Recognized WHO are AT HIGH RISK BEFORE OI – IUI & IVF PRIMARY RISK FACTORS SENSITIVE OVARIES 25.0 pmol/l for a high response ( >7 ng/ml
  25. 25. OHSS Monitoring should be • Easy • Reliable • Patient friendly • Not Expensive • Can be done by IVF Team
  26. 26. IDEA
  27. 27. Welcome Protocol to manage Error Terror Paul Devrory et al -2011 Human Reproduction An OHSS-Free Clinic by segmentation of IVF Treatment OHSS
  28. 28. Proposed Protocol of Zero% OHSS • The use of the GnRH antagonist protocol for OI instead of long protocol • Ovulation Triggering with GnRH agonist Instead of HCG trigger • Cryopreservation of all oocytes and embryos ↓ ET in frozen – thawed cycle 3 Steps
  29. 29. STEP - 1 Use of GnRH antagonist Protocol for OI • Patients friendly - Fewer injection of OI - Short duration of stimulation - Absence of side effects Uses • ↓↓ OHSS rate • No difference in Term LB Rates Between antagonist & agonist Al- Inany et al 2006- 20011, Kolibisnskis et al 2006 Devroey et al 2009 2011
  30. 30. STEP - II Ovulation Triggering - ↓↓↓↓ OHSS Rate - but can’t eliminate it all together GOLD STANDARD as ovulation triggering agent because of long half life with levels remaining elevated even after six days of administrations NO HCG TRIGGER Antagonist protocol GnRH Agonist trigger For triggering final Oocyte maturation • Effective in preventing OHSS (Segal and Casper ,1992
  31. 31. ZERO % OHSS (Severe / Critical) is achieved • Incidence of Severe OHSS is GnRH antagonist cycles is 0% when triggered with a GnRH agonist. • This was tested in OOCYTE DONORS (Melo et al ,2009) Major Disadvantages ↑ Luteal phase defect & significant ↓ Pregnancy Rate
  32. 32. It is EASIER Said Than Done to cancel a cycle !! ↓ GnRH AGONIST as a triggering agent Luteal phase defect - ↓ PR Negative effect on corpus luteum function Negative effect on function of endometrium BY GIVING HCG1500 units on O.P.U. day – P.R. ↑ (NORMALISED) ↑ Cryo Preservation ↑
  33. 33. Step III CRYO PRESERVATION of oocytes & embryo A valuable modality… But Skill - is the key Oocyte / embryo vitrification – ↑ P.R. (40% - 80%) ↓ Severe OHSS to 0% Results better than COASTING Ethical Issue of freezing embryo
  34. 34. CDC Report 2008 Pregnancy Rate same in FRESH / FROZEN – thawed cycles
  35. 35. Endometrum Preparation in frozen – thawed cycles (A) Natural Cycle (B) GnRH agonists (Day 21) + E2 + progesterone from OPU Day
  36. 36. SPECIAL TIPS for Donar stimulation • Always use GnRH ANTAGONIST PROTOCOL • Give GnRH AGONIST TRIGGER for ovulation • If Suspicious of Moderate OHSS * Give cabergoline before trigger * After OPU give antagonist inj. for 2-3 days * Give progesterone withdral inj MPA Before discharge or Tablets. * Follow - up is must
  37. 37. Key : Take Home messages • SAFETY OF PATIENT in IVF is public & doctors TOP PRIORITY Concept has to be accepted sooner than later by FOGSI / ICMR Strict guidelines to follow OHSS FREE IVF CLINIC Can be reality ? Yes ofcourse Hospitalization / ICU care can be prevented!!
  38. 38. Replace Long protocol of GnRH agonist with short antagonist protocol + Agonist ovulation trigger + Oocyte & embryo freezing + ET in Natural cycle Or Artificially prepared Endometrium Key Take Home Messages
  39. 39. OHSS : an IATROGENIC problem must never hold you back if you face it. Instead - these problems can help you shine brighter in the next take off – of your PROFESSIONAL MATURITY & support OHSS Free Clinic
  40. 40. Future Strategy for Safe IVF Practice • 100% antagonist cycle • 100% freezing of embryos • 100% frozen-thawed IVF cycles Zero % OHSS Free Clinic
  41. 41. IS A REALITY
  42. 42. Thank You

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