An OHSS - Free Clinic : to Manage Error - Tarror Dr. Sharda Jain, Dr. Jyoti Agarwal, Dr. Jyoti Bhaskar

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
Director s

2. An OHSS – Free Clinic
to Manage
ERROR – TERROR
Review this Lecture at:
Slideshare.net :

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. 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. Mortality due to
critical OHSS
in IVF
is Unacceptable
DEVROEY 2011

6. OHSS IVF Cycles
Most Serious Complications of OI
PRIOR TO 2000 – ↑ OHSS
AFTER 2000
of OHSS is almost
always present with OI in
good & high responders
(Delvigne -2009)
(Dreadful – Hospitalisation & ? Death)
(Papanikolaou et al.2005)
Severe OHSS - 2%
Moderate OHSS - 5%
Mild form

7. 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

8. Aetiopathogenesis
Exact Pathogenesis is not clear

9. IMPORTANCE of OHSS
WHAT IT means to ME & to You ?
• Totally IATROGENIC problem of OI
Induced by clinician
• without Long Protocol & HCG Trigger OHSS is
extremely rare.
• 100% PREVENTION IMPOSSIBLE
• Profound Economical impact
• Profound Psychological Impact

10. 3 Facts
• Long protocol of Down regulation
With GnRH agonist in IVF is associated
↑ OHSS
• HCG Trigger for ovulation creates HAVOC
– Compels IVF experts to use
long protocol
Supposedly ↑ PR
With long protocol

11. 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

12. Classification (Clinical Forms)

13. Classification
Mathur et al - 2005.
• THE EARLY FORM (<10 days after the HCG
trigger.
• THE LATE FORM (>- 10 days after HCG).
• COMBINATION of the early form , followed
by pregnancy is SERIOUS AND LONG LASTING
(Papnikolaou et al., 2004)

14. 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

15. 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

16. Severe
Clinical ascites (rarely hydrothrorax)
Oliguria
heamoconcentration - HEAMATOCRIT >45%
Hypoproteinaemia
Critical
Ovarian size > 12 cm
TENSE ASCITES + HYDROTHORAX
WHITE CELL COUNT > 25 000/ ML
OLIGURIA / ANURIA
Thromboembolism
Acute respiratory distress syndrome

17. Severe / Critical Cases are dreadful !!
Life Threatening
Massive Ascites
• Hemoconcentration
PCV > 45%, Hb > 15gm %
• Venous thrombosis
• Electrolyte imbalance
Renal
• Hepatic failure

18. The Truth is that
OHSS MUST
BE PREVENTED RATHER
than treated

19. 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

20. HOW TO PREVENT IT ?
• Steps Before stimulation
• Step During Stimulation
• Step on Impending Severe OHSS

21. 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
(Delhi AMH H >7 ng/ml

22. OHSS Monitoring should be
• Easy
• Reliable
• Patient friendly
• Not Expensive
• Can be done by IVF Team

23. IDEA

24. Welcome Protocol
to manage Error Terror
Paul Devrory et al -2011
Human Reproduction
An OHSS-Free Clinic
by segmentation of IVF Treatment
OHSS

25. 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

26. 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

27. 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
HCG
Antagonist
protocol
GnRH
Agonist
trigger
For triggering final Oocyte maturation
• Effective in preventing OHSS
(Segal and Casper ,1992

28. 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

29. 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
↑

30. 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

31. CDC Report 2008
Pregnancy Rate same
in FRESH / FROZEN – thawed
cycles

32. Endometrum Preparation in
frozen – thawed cycles
(A) Natural Cycle
(B) GnRH agonists (Day 21)
+ E2
+ progesterone from OPU Day

33. 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

34. Key : Take Home messages
• SAFETY OF PATIENT in IVF is public
& doctors TOP PRIORITY
Concept of
has to be accepted sooner than later
FOGSI / ICMR
OHSS FREE CLINIC

35. 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

36. 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

37. Future Strategy for Safe IVF
Practice
• 100% antagonist cycle
• 100% freezing of
embryos
• 100% frozen-thawed
IVF cycles
Zero % OHSS Free Clinic

38. Thank You

39. ADDRESS
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Morh Flyover, Delhi - 51
CONTACT US
9650588339, 011-22414049,
WEBSITE :
www.lifecarecentre.in
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www.lifecareivf.com
E-MAIL ID
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info@lifecareivf.com
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