2. What is this?
• Complication of pharmacological ovarian stimulation
• Ovarian response increase than expected extent causing morbidity &
mortality
• Mostly self limiting requiring supportive care
• Best mx is early recognition and Rx moderate to severe OHSS
3. Pathophysiology
• Exposure to HCG or LH following controlled ovarian stimulation by
FSH initiate the process
• Once hyper-stimulated ovaries exposed to HCG, lots of pro-
inflammatory cytokines released
• VEGF is the key player
• Increased vascular permeability and volume depletion lead
hemoconcentration causing pro-thrombotic state
• 3rd space fluid accumulation predominates
• Severe cases will show about 20% of volume depletion in CVS
4.
5. Cont..
Serum osmolality & sodium
depletion follows
hypovolemia
Paradoxical Hypovolemia –
Hypo osmolality will reset
the osmotic threshold of
human body
Thus vasopressin release &
thirst mechanisms sets to
function in this new system
Human body is now capable
of diluting & concentrating
urine in this new low
osmotic environment
6.
7. Incidence
• Ture incidence is unknown as most of mild-moderate cases were
under reported
• But it is possible in all women undergoing fertility treatment
• In conventional IVF-1/3rd of cycles affected with Mild OHSS
• Combined incidence of moderate to severe OHSS is about 3%-8%
• In USA, This is the commonest complication of IVF
• OHSS is rare with clomefene and Gonadotrophine monofollicular
inductions
• Very rarely reported as spontaneous cases related to pregnancy
8. Risk of OHSS
• Past OHSS
• PCOD
• Increased AFC
• High AMH
High risk of OHSS
9. Cont..
• Reduced risk of OHSS is noted with GnRH antagonists use rather than
agonist use in mono-follicular development
• Outcome of RX also influence incidence
• Thus incidence is high with cycles associated with successful
conception
• Also high with cycles associated with multifetal pregnancies signifying
role of endogenous HCG
12. • Typically pts. Present as abdominal distention after HCG injection
given for final follicular maturation before Oocyte retrieval in IVF
• Depend of time of trigger injection patients classified as
Early OHSS - <7 days after HCG & excessive ovarian response is seen
Late OHSS - > 10 days after HCG & usually due to endogenous HCG
Late is the worst
13.
14. Cont.
• No symptom or sign are pathognomonic
• No diagnostic test
• So exclude possible other causes for similar presentation (ectopic,
ovarian cyst accidents, appendicitis)
• Elevated hematocrit- low sodium-low serum osmolality will indicate
OHSS
• OHSS itself doesn’t cause ft of severe pain, peritonism & pyrexia
17. Which pts. Are suit for
OPD management &
How to manage
them?
18. • Mild , moderate & selected severe cases
• Educate pt about condition & provide written information
• Arrange access to hospital in emergencies
• IP/OP monitoring advise + Drink on thirst at least 1 L daily
• Stop NSAIDs as renal compromization is high
19. • LMWH for severe OHSS pts though no trials yet
• Paracentesis can be done as outpatient in TV/TA routes
• PCM/Codein is ok for pain
• Insufficient evidences are there for GnRH antagonist or Dopamine
agonist use for established OHSS to quicker regression
20. • R/W once in 2-3 days gap
• HCT & baseline Ixs repeat if symptoms worsening
• Mostly self limit over 7-10 days
• If conception takes place endogenous HCG may worsen OHSS
• if no conception happened complete recovery is expected by the
time of withdrawal bleeding
23. • MDT approach with O&G, Anesthesia, Nephrology teams
• HDU/ICU setting mx & monitoring may need
• At least daily assess for BW , AB Girth , IP-OP
• Daily FBC+HCT , SE ,LFT , serum Osmolality
• CRP has correlation to other clinical-Biochemical markers of OHSS
thus used to assess monitoring severity
24. Signs of worsening vs Resolving OHSS
• AB girth ???
• WT gain ???
• UOP as positive balance or negative with diuresis
• HCT rise or normalize
• Severe pain – ovarian torsion or rupture
25. • Analgesia + Antiemetics ok
• Avoid NSAIDs
• Drink on thirst
• Avoid routine diuretics use unless advised by MDT experts for
persistent oliguria in spite of adequate hydration or to address ascites
• Persistent hemoconcentration despite volume replacement with IV
colloids may need more invasive monitoring with anesthetist’s care
• Avoid vigorous crystalloids as increase vascular permeability may
worsen 3rd space loss
26. • Human albumin/Hexaethylstarch are used in pts with severe OHSS
• Priority is for 25% albumin as plasma expander(50-100 g over 4 hrs in
4-12hrly interval)
• Paracentesis for persistent oliguria or oral dopamine agonist for
severe OHSS still not evaluated with good clinical trials
28. • Guides aspiration avoids trauma to enlarged ovaries
• transAb route & catheter replacement avoid repeated aspirations
• Mostly attempted cases are transVAG & single aspirations
• No solid evidence for volume that should aspirate or time duration in
which procedure to be carried out
• Early drainage is associate with less Dx progression & lower risk of
complications in moderate to severe OHSS
• Aspiration >2 L is associated with significant renal vascular resistant
reduction with intrabdominal pressure
29. Autotransfusion of ultra
filtered ascitic fluid
• Less hemoconcentration
• Improve UOP
• Quicker recovery
• Replenish protein
• Reduce infections
• Lesser reaction than with Exogenous albumin
30. Thromboprophylaxis
• Incidence 0.7-10% related to OHSS
• Risk even high when OHSS associated with IVF pregnancy
• Severe OHSS pt need LMWH & individualize Rx duration
• Moderate OHSS need DVT stockings , if any risk factors for DVT
even consider LMWH
• Contact your hematology friend for opinion over LMWH
• Suspect VTE even pt present after recovery especially when
unusual neurological symptoms noted
• VTE in OHSS usually involves upper body & arterial system
31. Role of surgery
Only when OHSS is associated with
adnexal torsion , ovarian rupture or
ectopic pregnancy
32.
33. OHSS & Pregnancy
• Increased risk of PTL in singletons & Pre-eclampsia
• No increased risk of miscarriages in ART
complicated with OHSS
• Early but not late OHSS may have an association to
increased risk of pre clinical pregnancies loss
34. Prevention of OHSS
• Laparoscopic ovarian drilling prior IVF-No effect
• Low starting dose of FSH-75 iu-less cycle cancellation due to over
response especially with previous OHSS happened
• Type of FSH-No effect even recombinant
• GnRH antagonist-yes…rather agonist, less OHSS
• Rather than IM HCG, GnRH agonist for final follicular maturation after
antagonist induction protocol…as this is more physiological approach
35. • LH or HCG-no change. Both same in OHSS
• HCG dose-Obvious
• Coasting-yes… practice of withhold gonadotrophins while pituitary
suppression continues
• Avoid HCG to cancel cycle—obvious but who likes
• Avoid fresh embryo & cryopreserved embryo tranfer- will definitely
reduce late OHSS which is severe..but still Early OHSS may happen
36. • Metformin co treatment with gonadotropin stimulation-yes
metanalysis supports for lesser incidence of OHSS
• Cabergolin – dopamine agonists can prevent early OHSS but not late.
This needs more studies.
• IV albumin infusion around oocyte retrieval –no rationale or effect
• Luteal support with progesterone instead HCG-less OHSS
