OVARIAN HYPERSTIMULATION SYNDROME

1. ‫به‬
‫نام‬
‫خدا‬
Ovarian hyperstimulation syndrome
(OHSS)
Dr Marzieh Agha Hosseini,Infertility Department,Shariati
Hospital , Tehran University Of Medical Sciences

2.  OHSS is a iatrogenic complication of
controlled ovarian stimulation

3.  OHSS is a exaggerated response to this
process with use of gonadotropin

4. Incidence – severe
 Moderate to severe 3.1- 8 /20

5. pathophysiology
 Released of vasoactive mediator from hyper
stimulated ovaries increase permeability of capillary
 Extra vasation of fluid into third space –
hemoconcentration- hypercoagulability
 Reduced organ perfusion
 HCG is critical mediator
 Early OH.SS
 Late OH.SS

6.  HCG play a role in pathophysiology of OHSS
 Release VEGFA increase angiogenesis hyper
permeability
 VEGFA is increase after HCG administration

7. Another pathophysiology
 Intra ovarian renin angiotensin system (RAS)
 RAS – regulating vascular permeability
angiogenesis endothelial proliferation
prostaglandin released
 H.CG – strong activation of RAS
RAS + increasing VEGF level = OHSS

8. Prevention of OHSS
 No perfect strategy completely eliminate
OHSS
 But can reduce the incidence

9. Primary risk factor
 Identifying at risk women
young age
low body weight
PCOs
previous history of OHSS

10. Hormonal marker
 AMH = best predictor than …
estradiol

11. Ultra sonographic marker
 Antra follicle count (AFC) ≥ 24
 AFC = AMH

12. Secondary risk factor
 During COS ultrasound , serum E2 are vital
component
 ≥ 18 follicle 11mm on ultrasound
 E2 ≥ 5000 ng/L

13. Risk stratification
 Prevention : 1- primary
2-secondary

14. Primary prevention
 Treatment regimen modified in high risk
reduce gonadotropin dose
avoiding GNRH agonist protocol
reducing gonadotropin duration (antagonist
protocol)
metformin therapy

15. Individualising IVF treatment
regimen
 OHSS cancellation
 Age – AFC – FSH- calculation starting
FSH dose

16.  Avoiding HCG luteal phase support

17. Alternative for triggering ovulation
No agent completely eliminate risk OHSS
HCG long half life – luteotropic effect
dose HCG ??
GNRH agonist shorter midcycle surge(24-36 h)
Dual trigger 2000 IUHCG + GNRHa

18. Recombinant LH (RLH)
 Half life (10 h)
 OHSS not reduced
 Lower pregnancy not recommended

19. Secondary prevention
 coasting
 cryopreservation of embryo
GNRHa trigger+ freeze all
Cancellation with holding HCG

20. Alternative method of prevention
 Colloid infusion
 Albumin not recommended
 Hydroxy starch ( HES )
 Cabergoline dopamine agonist
VEGF vascular permeability
OHSS moderate pregnancy not changed
recommended HCG trigger

21.  Vasopressin induced VEGF
 Secretion blockade
 Vasopressin VIa receptor
antagonist(relcovapton)

30.  END OF PRESENTATION
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