This document discusses prevention of ovarian hyperstimulation syndrome (OHSS). It defines OHSS and describes its incidence, classification, risk factors, pathophysiology, and prevention strategies. The primary prevention strategies discussed are reducing gonadotropin dose, using a GnRH antagonist protocol, metformin therapy, and avoiding hCG for luteal phase support. Secondary prevention strategies mentioned are coasting, cryopreservation of embryos, and cycle cancellation. Coasting involves withdrawing gonadotropins when certain criteria are met to delay the hCG trigger and reduce OHSS risk, though it may lower pregnancy rates.
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
Optimal protocols for Ovulation induction (Assisted Reproductive technologies)Anu Test Tube Baby Centre
Presentation given in Tirupati, India in 2018 on Ovulation Induction for assisted reproductive technologies. Dealing with infertility using Intra uterine insemination (IUI) and In vitro fertilization (IVF)
Update on LETROZOLE Current Guidelines for Ovulation Induction Dr. Sharda Jain Lifecare Centre
Update on LETROZOLE Current Guidelines for Ovulation Induction
LET NOT FORGET
WHY
??
LETROZOLE was withdrawn from
Indian market (2012)
“SAFETY ISSUES”
“Could Be Teratogenic In Human”?
Ovulation induction protocols for unexplained infertility new advances 2019 f...Anu Test Tube Baby Centre
What are the new advances in assisted reproductive technologies with respect to ovulation induction for unexplained infertility ? - Intra uterine insemination (IUI) and in vitro fertilization (IVF)
Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...Lifecare Centre
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION DR. SHARDA JAIN , DR. JYOTI AGARWAL
DR. JYOTI BHASKAR
DEFINITION
Unexplained infertility means that couple does not conceive after 1year of unprotected vaginal sexual intercourse, with basic infertility evaluation showing no obvious abnormality.
INCIDENCE
15%to 20% of infertile couples
UNEXPLAINED IS PRIMARILY A
DIAGNOSIS OF EXCLUSION
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
Optimal protocols for Ovulation induction (Assisted Reproductive technologies)Anu Test Tube Baby Centre
Presentation given in Tirupati, India in 2018 on Ovulation Induction for assisted reproductive technologies. Dealing with infertility using Intra uterine insemination (IUI) and In vitro fertilization (IVF)
Update on LETROZOLE Current Guidelines for Ovulation Induction Dr. Sharda Jain Lifecare Centre
Update on LETROZOLE Current Guidelines for Ovulation Induction
LET NOT FORGET
WHY
??
LETROZOLE was withdrawn from
Indian market (2012)
“SAFETY ISSUES”
“Could Be Teratogenic In Human”?
Ovulation induction protocols for unexplained infertility new advances 2019 f...Anu Test Tube Baby Centre
What are the new advances in assisted reproductive technologies with respect to ovulation induction for unexplained infertility ? - Intra uterine insemination (IUI) and in vitro fertilization (IVF)
Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...Lifecare Centre
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION DR. SHARDA JAIN , DR. JYOTI AGARWAL
DR. JYOTI BHASKAR
DEFINITION
Unexplained infertility means that couple does not conceive after 1year of unprotected vaginal sexual intercourse, with basic infertility evaluation showing no obvious abnormality.
INCIDENCE
15%to 20% of infertile couples
UNEXPLAINED IS PRIMARILY A
DIAGNOSIS OF EXCLUSION
Ovarian Hyperstimulation in Intrauterine InseminationElmar Breitbach
Intrauterine insemination is well established in the treatment of infertility. But which pretreatment leads to the best results? Do we have to trigger ovulation? What about luteal phase support? Whar patients do have the best chances? When do we have to switch to IVF?
Evidence based answers to these questions an a bit of experience based suggestions.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Definition
It is an iatrogenic complication of controlled ovarian
stimulation (COS).
COS is needed for production of multiple ovarian follicles
during assisted conception cycles to increase the number of
oocytes available for collection.
OHSS, however, is characterized by an exaggerated response
to this process.
3. Incidence
The incidence of moderate to severe OHSS is between
3.1 and 8% of in vitro fertilization (IVF) cycles but can be
as high as 20% in high risk women.
OHSS has been documented to arise spontaneously
either in conjunction with clomiphene or with
gonadotrophins use.
4. Navot et al. classification for OHSS
Mild OHSS
Abdominal bloating
Mild abdominal pain
Ovarian size usually < 8 cm
9. Dahl Lyons, 1994; Mathur, 2000
EARLY
OHSS
LATE
OHSS
hCG 3-9 days 10-17 days
Ovarian
response
Pregnancy
Classification:
hCG
10. Prevention is better than cure
Being aware of the risk factors for OHSS will allow
clinicians to predict its occurrence and so reduces its
incidence during ovulation induction wit gonadotrophins.
We have primary and secondary risk factors.
11. Primary Risk Factors
1. PCOS
2. Young age
3. Low body weight
4. Previous OHSS
5. AMH ( Anti-mullerian hormone)
6. AFC ( antral follicle count)
12. Secondary Risk Factors
1. Rapidly rising E2 level
2. large number of developing follicles on the day of hCG
administration
3. large number of oocytes retrieved
None of the above predictors are independently
predictive of OHSS.
14. Cutoff points for OHSS risk
1. AMH > 3.4 ng/ml.
2. AFC > 25.
3. development of > 25 follicles.
4. E2 > 3.500 pg/ml.
5. Oocytes retrieved > 25.
All are grade B evidence.
15. Primary Prevention of OHSS
1. Unifollicular Ovulation.
2. Individualizing COS Regimens ( i COS)
3. Alternatives for Triggering Ovulation
4. Avoiding hCG for Luteal Phase Support (LPS)
16. Unifollicular Ovulation
A. Reducing the Gonadotrophin Dose
B. GnRH Antagonist (GnRHan) protocol
C. Adjuvant MetforminTherapy
D. Aromatase Inhibitors (AIs)
17. Reducing the Gonadotrophin Dose
The minimum gonadotrophin dose should be used for OI
given its lower risk of OHSS. This favors a “step-up”
regimen over a “step-down” regimen.
In the “step-up” regimen, ovarian stimulation is initiated
with a low dose of FSH (i.e., 75 IU) and increases
every7days (i.e., 37.5 IU) until an ovarian response is
noted (follicle >10 mm).
This dose is then continued until the criteria for an
ovulatory trigger are met.
18. GnRH Antagonist (GnRHan) protocol
This allows less gonadotropin use than agonist protocol
and also less days of stimulation.
This allows avoiding hCG for ovulation triggering.
This protocol has a lower risk of OHSS and multiple
pregnancies and is cost effective
level 1b evidence
19. Adjuvant Metformin Therapy
Metformin exerts its influence in preventing OHSS by
inhibiting the secretion of vasoactive molecules, such as
VEGF, during OI, so modulates vascular permeability.
In the recent Cochrane Review by Tso et al, it was noted
that there was a lower risk of OHSS with metformin use.
20. Metformin reduced the risk of OHSS by 63% and
increased the clinical pregnancy rate without an effect
on live birth rates.
A daily dose between 1000 and 2000mg at least 2
months prior to COS is recommended for the purpose of
preventing OHSS.
21. Aromatase Inhibitors (AIs)
A recent Cochrane Review by Franik et al, failed to show
any difference in OHSS rates through utilization of AIs in
contrast to other methods of OI.
As such, AIs are not routinely recommended for
prevention of OHSS.
Letrozole can be used in luteal phase, in freeze-all cases,
to decrease the incidence of OHSS, but little evidence
available.
22. Individualised COS (iCOS)
One example of this can be seen through the study by La
Marca et al., where an algorithm was formulated based
on age, AFC, and FSH to calculate the FSH starting dose.
This algorithm was able to accurately predict ovarian
sensitivity and account for 30% of the variability of
ovaries to FSH.
Further research is required to prove cost- effectiveness
of this method.
23. Alternatives for Triggering Ovulation
The agent of choice for triggering ovulation should be
picked based on the risk of the woman for developing
OHSS.
No agent, however, completely eliminates the risk of
OHSS.
Exogenous hCG is the agent used for this purpose as it
mimics the ovulatory LH surge.
24. Exogenous hCG
Its long half-life (2.32 days) however causes prolonged
luteotrophic effects, multiple corpora lutea development,
and higher luteal phase P4 and E2 concentrations
There is a higher risk of OHSS and to solve this problem:
1. The lowest possible dose (i.e., 5000 IU) is used.
2. Avoid hCG in high risk women.
25. GnRH agonists (GnRHa) to trigger ovulation
It produces a more tempered and shorter midcycle
gonadotrophin surge (24–36 hours) in contrast to hCG by
stimulating pituitary LH secretion.
Theoretically, this LH surge should be sufficient to induce
ovulation without being prolonged enough to induce
hyperstimulation.
26. OHSS is virtually eliminated with GnRHa utilization
BUT in conjunction with a “freeze all” approach
which should be considered in high risk woman.
This is called OHSS – Free Clinic
27. There is good evidence that live birth rate (LBR) is lower
in fresh cycles after GnRHa trigger.
The mechanism for this:
1. Rapid and dramatic drop in hormonal LH support as
compared to hCG ( luteal phase insufficiency).
2. Poor final oocyte maturation.
28. Improve LBR with GnRHa
1. Freeze all embryos.
2. Co-trigger with 1500 IU hCG either:
A. Single dose--------------- reduced risk of OHSS.
B. 2 doses ( 2nd dose on day of OR or subsequent day),
increases risk of OHSS (3.4%).
3. Low dose of hCG for luteal support ( 1000, 500 or 250
IU every third day).
4. Estradiol supplementation in luteal phase.
29. Recombinant LH (rhLH)
It has a half-life of 10 hours, and a shorter and/or lower
LH peak, so this means:
it is expected to have a minimal risk of causing OHSS.
A Cochrane Review by Youssef et al. however, did not
show any difference in the risk for severe OHSS between
rhLH and urinary hCG.
It is associated with a lower pregnancy rate and a poor
cost benefit ratio.
Its routine use cannot be recommended for prevention of OHSS.
30. Avoiding hCG for Luteal Phase Support (LPS)
hCG, which is similar to LH in its physiological actions,
has been used effectively in LPS to improve LBR.
A Cochrane Review (M. van der Linden et al, 2011 ),
noted that it potentiated the risk of OHSS and also
showed no effect on live birth rate (LBR) and clinical
pregnancy rate (CPR).
In contrast, the use of progesterone (P) halves the OHSS
risk while significantly improving the LBR and CPR.
The routine use of progesterone over hCG is recommended for LPS.
31. Secondary Prevention of OHSS
It is directed to women who have undergone COS and
had an exaggerated response. The aim of interventions
in these cases is to prevent progression to OHSS.
This can be done by:
(A) Coasting.
(B) Cryopreservation of Embryos.
(C) Cycle Cancellation.
32. Coasting
Coasting is a preventative strategy by which
gonadotrophins are withdrawn when a certain E2
concentration and/or a critical number of follicles are
reached.
hCG trigger is subsequently delayed until E2 levels
significantly decrease or plateau.
Once the E2 reaches a “safe” level, hCG is administered
followed by oocyte retrieval and embryo transfer or
freezing depending on the E2 concentration.
33. It is generally employed for a period less than 3-4 days.
Coasting is a commonly used as a first line secondary
prevention strategy by clinicians.
Question marks remain however about the evidence
behind the procedure.
34. Coasting diminishes the granulosa cell cohort
Intheabsenceofgonadotropinstimulation,dominantfollicleswillcontinuetheir
growth,whileintermediateandsmalloneswillundergoatresia.
E2
35. • The granulosa cells aspirated from coasted
patients showed a ratio in favor of apoptosis,
especially in smaller follicles.
• VEGF protein secretion and gene expression in
granulosa cells especially in small and medium
follicles were reduced in coasting.
36. What happens when you start coasting?
Follicular growth will continue with the same rate.
E2 will continue to rise then will platform and then
decline.
When to stop gonadotropins?
When the leading follicles reach 14-16mm.
What is the safe E2 level?
< 3000 pg/ml.
37. Problems with coasting
1. Occasionally E2 drops markedly to very low levels and cycle
is canceled.
2. Difficulty in identification of oocytes in aspirated follicular
fluid after prolonged coasting.
3. Pregnancy rates appear to decrease while coasting during
prolonged gonadotropin-free periods.
Explanation for lower LBR:
because suspending gonadotropins may starve the granulosa
cells at a critical time of oocyte development when LH is
necessary.
38. D’Angelo et al., in their Cochrane Review, identified 4
RCTs which highlighted that there was no difference in
the incidence of moderate and severe OHSS with
coasting.
A lower number of oocytes were retrieved from the
coasting group, so they recommend that there was no
benefit of coasting in comparison to other interventions.
39. An earlier meta-analysis also came to the conclusion that
coasting may decrease the risk of OHSS in high risk
women but does not completely prevent it.
Coasting, however, seems to have no effect on live birth
rates and clinical pregnancy rates
40. Cryopreservation of Embryos
During cryopreservation, COS and subsequent oocyte
retrieval is performed followed by the cryopreservation
of embryos.
These are then transferred in a subsequent unstimulated
IVF cycle where the woman’s ovarian response to hCG
has normalized.
A Cochrane Review only identified 2 RCTs for analysis
and came to the conclusion that there was insufficient
evidence to support routine cryopreservation.
41. Recent evidence however strongly supports the use of a
GnRHa trigger followed by cryopreservation as being the
most effective method in preventing OHSS, best
illustrated by Devroey and colleagues through their
OHSS-Free Clinic.
42. A problem with cryopreserved embryos was the lower
pregnancy rates in contrast to fresh embryo transfers
related to older slow freezing methods.
With the modern techniques such as vitrification, there
is convincing evidence to suggest that cryopreservation
has better pregnancy rates than fresh embryo transfer as
well.
Based on these findings, the use of a GnRHa trigger
followed by cryopreservation is highly recommended for
prevention of OHSS.
43. Cycle Cancellation
Cycle cancellation and withholding of hCG are the only
definite methods of preventing OHSS.
However, it must be taken in context with the high
financial impact and psychological distress that it causes
to women.
It is the last resort for clinicians to prevent OHSS.
44. Alternative Methods of Prevention of OHSS
1. Cabergoline.
2. Colloid Infusion:
A. Albumin.
B. Hydroxyethyl Starch (HES).
3. IV calcium infusion.
4. Aspirin.
5. Vasopressin V1a receptor antagonist (relcovaptan).
6. In vitro maturation ( IVM).
45. Cabergoline.
It is a dopamine antagonist which prevents the excessive
increase in VEGF mediated vascular permeability
encountered with OHSS through its antiangiogenic
properties.
Tang et al., in their Cochrane Review of 230 women in 2
RCTs found cabergoline to be effective in significantly
reducing the incidence of moderate OHSS with no
significant effect on clinical pregnancy rate and
miscarriage rates.
This protective effect, however, did not extend to severe OHSS, possibly
due to the number of studies available for comparison.
46. A recent systemic review by Leitao at el., which took 7
RCTs into consideration, has further established its
efficacy in preventing the occurrence of moderate and
severe OHSS as well as without a negative impact on
clinical pregnancy or oocytes retrieved.
Therefore, the use of cabergoline is recommended and it
is suggested that treatment be commenced on the day
of hCG trigger at a dose of 0.5mg for 8 days.
47. Colloid Infusion
Colloid infusions are administered around the time of
oocyte retrieval as they are suspected to prevent OHSS
by binding to and deactivating the vasoactive mediators
of OHSS.
48. Albumin.
A Cochrane Review by Youssef et al. noted that there was
borderline statistically lower incidence of severe OHSS with
albumin utilization but there was marked heterogeneity in the
studies.
Another systematic review by Jee et al. also found that IV
albumin did not reduce the rate of severe OHSS and also
raised concerns regarding significantly reduced pregnancy
rates.
Factors such as the possibility of transmission of viral
infections (i.e., hepatitis B/C/HIV) and anaphylactic reactions
are risks that should not be overlooked.
On the basis of these factors, the routine use of IV albumin to prevent OHSS cannot be
recommended.
49. Hydroxyethyl Starch (HES).
HES is a plasma expander that has been used as an
alternative to albumin as it is non-biological and
therefore avoids the risks associated with albumin use.
The Cochrane Review by Youssef et al. found a
statistically significant decrease in severe OHSS with HES
use without any effect on pregnancy rates.
These findings were based on only 3 RCTs, so we need
more evidence to recommend its routine use.
50. IV calcium
Increased calcium inhibits cAMP- stimulated renin
secretion, which decreases angiotensin II synthesis and
subsequent effect on VEGF production.
10 ml of 10% Ca gluconate in 200 ml normal saline on
the day of OR and days 1, 2 and 3 after OR.
Little evidence available.
51. Aspirin
Increased platelet activation due to VEGF leads to the
release of many substances that can potentiate the
cascade of OHSS.
The use of 100 mg aspirin daily from the first day of
stimulation till day of pregnancy test or cardiac pulsation
detection can lower the incidence of severe OHSS.
No difference in pregnancy outcomes.
Low evidence available.
52. Vasopressin V1a receptor antagonist
(relcovaptan)
It inhibits VEGF by modulating vasoconstriction and vascular
smooth muscle proliferation.
In the hyperstimulated rat model, lower concentrations of
VEGF-A in the peritoneal fluid and lesser ovarian weight gain
and significant decreases in the number of corpora lutea in
contrast to control groups.
Further research is promising and may change the
management protocols for OHSS.
Not yet available for clinical use.
53. In vitro maturation (IVM)
IVM may be another primary preventive strategy for women
with high OHSS risk.
In contrast to the conventional IVF/ICSI-procedure, immature
oocytes are used for artificial reproductive techniques with IVM.
After a short FSH-priming, all antral follicles are punctured. All
mature oocytes are used for IVF/ ICSI at the day of oocyte
retrieval and immature oocytes after in vitro maturation in a
specific IVM-medium at the following day.
Although RCTs focusing on the use of IVM in women with PCOS
are currently in process, still no clear data are existent on the
value of IVM.
54. Conclusions
1. OHSS is an iatrogenic problem.
2. OHSS occurs when hCG is given.
3. Prediction and prevention should be always our goal.
4. Step-up protocol is better than step-down.
5. Antagonist protocol is better than agonist.
6. Metformin should be given for all PCOs patients.
7. GnRHa is better for ovulation triggering but together
with low dose hCG or freeze all.
55. Conclusions
8. Coasting needs more research to prove efficacy and
establish regimen.
9. Cryopreservation is recommended for high risk patients.
10. Cycle cancellation is the last resort if all measures
failed.
11. Cabergoline is recommended for prevention.
12. OHSS is a self- limited condition, but resolution is
delayed if pregnancy occurred.