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An OHSS – Free Clinic : to Manage ERROR – TERROR Dr. Sharda Jain , Dr. Jyor

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

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An OHSS – Free Clinic : to Manage ERROR – TERROR Dr. Sharda Jain , Dr. Jyor

  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 Director s
  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. Mortality due to critical OHSS in IVF is Unacceptable DEVROEY 2011
  6. 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. 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. 8. Aetiopathogenesis Exact Pathogenesis is not clear
  9. 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. 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. 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. 12. Classification (Clinical Forms)
  13. 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. 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. 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. 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. 17. Severe / Critical Cases are dreadful !! Life Threatening Massive Ascites • Hemoconcentration PCV > 45%, Hb > 15gm % • Venous thrombosis • Electrolyte imbalance Renal • Hepatic failure
  18. 18. The Truth is that OHSS MUST BE PREVENTED RATHER than treated
  19. 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. 20. HOW TO PREVENT IT ? • Steps Before stimulation • Step During Stimulation • Step on Impending Severe OHSS
  21. 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. 22. OHSS Monitoring should be • Easy • Reliable • Patient friendly • Not Expensive • Can be done by IVF Team
  23. 23. IDEA
  24. 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. 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. 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. 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. 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. 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. 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. 31. CDC Report 2008 Pregnancy Rate same in FRESH / FROZEN – thawed cycles
  32. 32. Endometrum Preparation in frozen – thawed cycles (A) Natural Cycle (B) GnRH agonists (Day 21) + E2 + progesterone from OPU Day
  33. 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. 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. 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. 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. 37. Future Strategy for Safe IVF Practice • 100% antagonist cycle • 100% freezing of embryos • 100% frozen-thawed IVF cycles Zero % OHSS Free Clinic
  38. 38. Thank You
  39. 39. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339, 011-22414049, WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com &

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