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PREVENTION OF SEVERE OHSS
16 follicles 12 mature oocytes 14 oocytes Extras frozen if good 2 to 3 transferred 9 fertilize normally 5 divide normally 30-40% of couples 4 stop dividing & sperm Typical progression
OHSS is a serious complication  of ovulation induction. In its severest forms, it is complicated by  hemoconcentration, venous thrombosis, electrolyte  imbalance and renal and hepatic failure. Shenker and Weinstein, 1978; Navot et al., 1992; Aboulghar et al., 1993
OHSS INCIDENCE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PATHOGENESIS OF SEVERE OHSS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],hCG  (LH) E 2
DIAGNOSIS OF SEVERE OHSS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
How to prevent  OHSS ? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Before Start ,[object Object],[object Object],[object Object],[object Object],[object Object]
METFORMIN COCHRANE REVIEW,  TSO  ET AL., 2008
LOW DOSE GONADOTROPİNS ,[object Object],[object Object],Second: COH
MILD STIMULATION PROTOCOL  ,[object Object],Karimzadah et al., 2010
HOW TO SUSPECT DURING COH  ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
  COCHRANE REVIEW,  AL-INANY ET AL., 2011
GNRHAGONIST FOR TRIGGERRING OVULATION YOUSSEF ET AL., 2010
[object Object],[object Object],[object Object]
  COCHRANE REVIEW,  D’ANGELO E.AL. 2010    Coasting vs. no coasting
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
GnRH antagonist In a Cochrane review by Al-Inany  et al (2011) comparing agonist and antagonist, significant difference in the incidence of OHSS was found.
WHY:  (AL-INANY ET AL, 2010)
CANCELLATION FOR RISK OF OHSS
[object Object]
BUT NOT ALL DOCTORS WOULD GO FOR ANTAGONIST
(GNRH) ANTAGONISTS: OFF LABEL INDICATION  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
VALUE ,[object Object]
 
OUR RESULTS Parameter Coasting (n = 96) Antagonist (n = 94) P-value Age (years) 30.0 ± 4.9 29.6 ± 4.6 NS Duration of infertility (years) 6.64 ± 4.45 7.07 ± 4.3 NS No. of HMG injections 30.52 ± 8.9 29.94 ± 8.8 NS Days of stimulation 1 9.1 ± 1.5 9.4 ± 1.5 NS Peak oestradiol (pg/ml) 5087 ± 1589 5305 ± 1680 NS Oestradiol on day of HCG (pg/ml) 2605 ± 790 2721 ± 699 NS Range of oestradiol on day of HCG (pg/ml)  1110–4136 1223–4093 NS Day of intervention 2.82 ± 0.97 1.74 ± 0.91 <0.0001 No. of oocytes 14.06 ± 5.20 16.5 ± 7.60 0.02 No. of MII oocytes  11.13 ± 4.60 13.14 ± 6.60 NS No. of fertilized oocytes    7.97 ± 3.80    9.14 ± 4.70 NS No. of high quality embryos    2.21 ± 1.10    2.87 ± 1.20 0.0001 No. of embryos transferred    2.83 ± 0.50    2.79 ± 0.40 NS No. of cryopreserved embryos    4.50 ± 3.93    5.77 ± 4.87 NS Clinical pregnancy (%) 46/96  (47.9) 52/94  (55.3) NS Multiple pregnancy (%) 15/46 (32.6) 17/52 (32.7) NS
[object Object],[object Object],[object Object],[object Object]
BACKGROUND ,[object Object],[object Object],[object Object],5/23
BACKGROUND ,[object Object],[object Object],7/23
RESULTS OF SEARCH 9/23 10 RCTs (n= 2048) 7 RCTs :  HA vs. P 1 RCT :  HES vs. P 2 RCTs :HA vs. HES vs. P No RCTs compared dextran or haemaccel vs placebo
IV FLUIDS VERSUS PLACEBO, SEVERE OHSS  18/23
AFTER OPU : DOPAMINE AGONIST : YOUSSEF ET AL., 2010
YOUSSEF ET AL., 2010
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Conclusion OHSS   is a preventable disease that  should not be allowed to happen
CONCLUSION ,[object Object],[object Object],[object Object]
THANK YOU Dr. Hesham Al-Inany  MD, PhD e-mail : hesham@khosoba.com

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High responders

  • 1.
  • 3. 16 follicles 12 mature oocytes 14 oocytes Extras frozen if good 2 to 3 transferred 9 fertilize normally 5 divide normally 30-40% of couples 4 stop dividing & sperm Typical progression
  • 4. OHSS is a serious complication of ovulation induction. In its severest forms, it is complicated by hemoconcentration, venous thrombosis, electrolyte imbalance and renal and hepatic failure. Shenker and Weinstein, 1978; Navot et al., 1992; Aboulghar et al., 1993
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11. METFORMIN COCHRANE REVIEW, TSO ET AL., 2008
  • 12.
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18. COCHRANE REVIEW, AL-INANY ET AL., 2011
  • 19. GNRHAGONIST FOR TRIGGERRING OVULATION YOUSSEF ET AL., 2010
  • 20.
  • 21. COCHRANE REVIEW, D’ANGELO E.AL. 2010 Coasting vs. no coasting
  • 22.
  • 23. GnRH antagonist In a Cochrane review by Al-Inany et al (2011) comparing agonist and antagonist, significant difference in the incidence of OHSS was found.
  • 24. WHY: (AL-INANY ET AL, 2010)
  • 26.
  • 27. BUT NOT ALL DOCTORS WOULD GO FOR ANTAGONIST
  • 28.
  • 29.
  • 30.  
  • 31. OUR RESULTS Parameter Coasting (n = 96) Antagonist (n = 94) P-value Age (years) 30.0 ± 4.9 29.6 ± 4.6 NS Duration of infertility (years) 6.64 ± 4.45 7.07 ± 4.3 NS No. of HMG injections 30.52 ± 8.9 29.94 ± 8.8 NS Days of stimulation 1 9.1 ± 1.5 9.4 ± 1.5 NS Peak oestradiol (pg/ml) 5087 ± 1589 5305 ± 1680 NS Oestradiol on day of HCG (pg/ml) 2605 ± 790 2721 ± 699 NS Range of oestradiol on day of HCG (pg/ml) 1110–4136 1223–4093 NS Day of intervention 2.82 ± 0.97 1.74 ± 0.91 <0.0001 No. of oocytes 14.06 ± 5.20 16.5 ± 7.60 0.02 No. of MII oocytes 11.13 ± 4.60 13.14 ± 6.60 NS No. of fertilized oocytes   7.97 ± 3.80   9.14 ± 4.70 NS No. of high quality embryos   2.21 ± 1.10   2.87 ± 1.20 0.0001 No. of embryos transferred   2.83 ± 0.50   2.79 ± 0.40 NS No. of cryopreserved embryos   4.50 ± 3.93   5.77 ± 4.87 NS Clinical pregnancy (%) 46/96 (47.9) 52/94 (55.3) NS Multiple pregnancy (%) 15/46 (32.6) 17/52 (32.7) NS
  • 32.
  • 33.
  • 34.
  • 35. RESULTS OF SEARCH 9/23 10 RCTs (n= 2048) 7 RCTs : HA vs. P 1 RCT : HES vs. P 2 RCTs :HA vs. HES vs. P No RCTs compared dextran or haemaccel vs placebo
  • 36. IV FLUIDS VERSUS PLACEBO, SEVERE OHSS 18/23
  • 37. AFTER OPU : DOPAMINE AGONIST : YOUSSEF ET AL., 2010
  • 39.
  • 40. Conclusion OHSS is a preventable disease that should not be allowed to happen
  • 41.
  • 42. THANK YOU Dr. Hesham Al-Inany MD, PhD e-mail : hesham@khosoba.com

Editor's Notes

  1. 8 8 8
  2. 37 27 27
  3. 15 14 14
  4. Pregnancy rate per transfer comparable with the long agonist protocol No severe OHSS in all studies This protocol should be considered as an option in patients with OHSS risk
  5. Oocyte triggering with HCG have some drawbacks as:….. , while oocyte triggering with GnRH agonist means……
  6. Oocyte triggering with HCG have some drawbacks as:….. , while oocyte triggering with GnRH agonist means……
  7. Oocyte triggering with HCG have some drawbacks as:….. , while oocyte triggering with GnRH agonist means……
  8. Oocyte triggering with HCG have some drawbacks as:….. , while oocyte triggering with GnRH agonist means……
  9. 31 21 21