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SIMPLE PROTOCOL of MANAGEMENT OVARIAN HYPERSTIMULATION SYNDROME (OHSS)

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SIMPLE PROTOCOL of MANAGEMENT OVARIAN HYPERSTIMULATION SYNDROME (OHSS) DR. Sharda Jain Lifecare Centre

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SIMPLE PROTOCOL of MANAGEMENT OVARIAN HYPERSTIMULATION SYNDROME (OHSS)

  1. 1. OVARIAN HYPERSTIMULATION SYNDROME (OHSS) SIMPLE PROTOCOL of MANAGEMENT DR. SHARDA JAIN DR. JYOTI AGARWAL …Caring hearts, healing hands
  2. 2. OHSS is totally iotrogenic problem created by ART experts INCIDENCE Mild – 33% Now Omitted in IVF Cycles Moderate – 3-6% Severe – 2% Critical – 0.1 – 0.2%
  3. 3. <10 >10
  4. 4. Pathogenesis is still unclear
  5. 5. HCG is a biggest culprit Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod. 2000;15:1037; Gómez et al. Endocrinology. 2002;143:4339
  6. 6. OHSS does not develop if HCG is not administered in majority but in occasional case OHSS occurs when agonist trigger is given . Dr Razia S Our Findings also support
  7. 7. The Truth is that OHSS MUST BE PREVENTED RATHER than treated
  8. 8. PREVENTION is the best way to manage OHSS. Proper monitoring is essential and a balance between a conservative and aggressive approach is ideal to prevent unnecessary cycle cancellation due to OHSS and putting the women’s life at risk
  9. 9. PREVENTION 1. IDENTIFY PATIENTS WHO ARE AT HIGH RISK –FACTORS ARE RELATED TO INCREASED RISK * Size and number of follicles :>15/ovary, intermediate size follicles??. *Serum oestradiol:>3500 pg/ml. *Young & thin patient at risk OHSS *PCOD patient *OHSS in Previous cycle *Basal antimullerian hormone (AMH):>6.5ng /ml
  10. 10. PROTOCOL OF OVARIAN STIMULATION –GNRH AGONIST PROTOCOL This Protocol has higher risk of OHSS. There is myth in doctor’s mind that there is higher Pregnancy rate with this protocol. *HCG trigger is used for inducing follicular rupture ..which is the Biggest culprit of OHSS And often Hcg is used along with progesterone for luteal phase support which further puts the patient at risk PATIENTS WHO ARE AT HIGH RISK
  11. 11. CAUTIONS & SIX TIPS : knowing that HCG IS BIGGEST CULPRIT 1. WITHHOLDING /delaying or decreasing dose of hcg – is the key 2.The use of GnRH agonist as a trigger is another key 3.For Luteal phase support-use only progesterone not HCG
  12. 12. 4.Aspiration all follicles at OPU is recommended 5.Post oocyte retrieval - albumin or hydroxyethyl starch administration is good practice ( we use albumin when paracentesis is done for ascites ) 6.Cryopreservation of embryo and subsequent replacement of embryos in next cycle is usual practice with us. CAUTIONS & SIX TIPS : knowing that HCG IS BIGGEST CULPRIT
  13. 13. OTHER GOOD PRACTICES to PREVENT OHSS
  14. 14. Starting Metformin 1-2 month prior in PCOD patients is good practice METFORMIN
  15. 15. INDIVIDUALIZING STIMULATION PROTOCOL Avoidance of excessive gonadotropin stimulation .. Individualizing dose- low dose step up protocol is what we follow
  16. 16. DOPAMINE AGONISTS: Carbergoline 0.5 mg once daily for 6 to 8 days from day of trigger ( there is no unananimity on number of days Cabergoline to be used. Some groups use till the day of UPT )
  17. 17. *Natural cycle ART * In vitro maturation Are few other alternatives
  18. 18. TREATMENT of OHSS • REMEMBER, The condition usually resolves on its own within 10-14 days. • Management of OHSS is based on Severity Of The Disease.
  19. 19. MILD TO MODERATE SEVERE CRITICAL Ovarian enlargement 5-12cm >12cm Variable Abdominal distension Moderate Severe Tense Clinical ascites None Yes Tense Hydrothorax None Possible Yes Pericardial effusion NONE Infrequent Infrequent Decreased renal function None Infrequent Frequent Renal failure None None Possible Thromboembolism None None Possible
  20. 20. MILD TO MODERATE SEVERE CRITICAL ARDS None None possible Hemoconcentrati on(hematocrit) <45% 45-55% 55% WBC count <15,000 15,000-25,000 >25,000 Liver enzymes normal Elevated Elevated Creatinine (ng ml) <1.0 1.0-1.5 >1.6 Creatinine clearance >100 50-100 <50
  21. 21. Clinical GUIDELINES OF MANAGEMENT of OHSS
  22. 22. A. Vital signs B. Weight chart C. Abdominal girth measurement D. Strict intake / output chart 1.General condition it is monitored by regular charting
  23. 23. 2.Biochemical Tests: A. Haematocrit. B. Electrolytes. C. Liver function test . D. Kidney function test . E. Coagulation profile F. Blood gases and acid base balance . G. Serum beta Hcg to rule out pregnancy
  24. 24. is done to evaluate A.Ovarian size B.Amount of ascites. C.Presence of ascites. D.Pregnancy, whether single or multiple. 3.ULTRASONOGRAPHIC EXAMINATION :
  25. 25. Ultrasound evidence of ASCITES on day of IUI /IVF ..OPU PICKUP warns gynecologist to take action • Infact , Action should be taken on day of trigger itself PCOD Ascites
  26. 26. Do not do IUI if you find Ascites on IUI day DO NOT GIVE HCG TRIGGER PLEASE *IF THIS Asites is there.. freeze all EMBRYOES
  27. 27. Again Reminding you Management is according to severity of OHSS
  28. 28. MILD OHSS 1.Conservative at out patient level 2.Reassure the couple 3.Plenty of fluids 4.Counsel on warning signs-pain abdomen , weight gain (>2kg ), vomiting 5.Minimize physical activity
  29. 29. MILD OHSS 6.Analgesics and antiemetic's. 7.Intake output monitoring . 8.Drug therapy –carbogoline 9. Abstinence is must
  30. 30. INDICATIONS OF HOSPITALIZATION 1.Intolerable nausea and vomiting 2.Hypotension , respiratory difficulty 3.Signs of pleural effusion 4.Ascitis 5.Hematocrit >48% 6.Potassium level >5.0 mg /L 7.Serum creatinine > 1.2mg 8.All cases of severe and critical OHSS
  31. 31. SEVERE OHSS
  32. 32. HOSPITALISATION IS MUST 1. Maintenance of intravascular volume and electrolyte imbalance 2. Prevention of Thrombosis: LOW dose herparin 3. Management of Renal failure .Dopamine, CVP line Hemodialysis
  33. 33. 4.PULMONARY COMPROMISE: .Arterial blood gas monitoring .Thoraco centesis .Assisted ventilation 5.Management of Ascites: Paracentesis 6.Paracentesis of hydrothorax 7.Termination of pregnancy HOSPITALISATION IS MUST cond.
  34. 34. Future Strategy for Safe IVF Practice 7 avoid OHSS • 100% antagonist cycle • 100 % Agonist trigger for ovulation • 100% freezing of embryos • 100% frozen-thawed IVF cycles Zero % OHSS Free Clinic
  35. 35. Thank You
  36. 36. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339 9599044257 011-22414049 WEBSITE : www.lifecareivf.in www.lifecarecentre.in www.lifecareabs.in ISO 14001:2004 (EMS) …..Caring hearts, healing hands ISO 9001:2008 26 Year In your service

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