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

1. OVARIAN HYPERSTIMULATION
SYNDROME (OHSS)
SIMPLE PROTOCOL of
MANAGEMENT
DR. SHARDA JAIN
DR. JYOTI AGARWAL
…Caring hearts, healing hands

3. 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%

4. <10 >10

5. Pathogenesis is
still unclear

6. 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

7. 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

8. The Truth is that
OHSS MUST
BE PREVENTED RATHER than
treated

9. 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

10. 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

11. 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

12. 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

13. 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

14. OTHER GOOD PRACTICES
to PREVENT OHSS

15. Starting Metformin 1-2
month prior in PCOD patients
is good practice
METFORMIN

16. INDIVIDUALIZING
STIMULATION PROTOCOL
Avoidance of excessive
gonadotropin stimulation ..
Individualizing dose- low dose step
up protocol is what we follow

17. 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 )

18. *Natural cycle ART
* In vitro maturation
Are few other alternatives

19. 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.

20. 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

21. 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

22. Clinical GUIDELINES
OF MANAGEMENT
of OHSS

23. A. Vital signs
B. Weight chart
C. Abdominal girth measurement
D. Strict intake / output chart
1.General condition it is
monitored by regular charting

24. 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

25. is done to evaluate
A.Ovarian size
B.Amount of ascites.
C.Presence of ascites.
D.Pregnancy, whether single or
multiple.
3.ULTRASONOGRAPHIC
EXAMINATION :

26. 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

27. 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

28. Again Reminding you
Management is
according
to severity of OHSS

29. 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

30. MILD OHSS
6.Analgesics and antiemetic's.
7.Intake output monitoring .
8.Drug therapy –carbogoline
9. Abstinence is must

31. 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

32. SEVERE OHSS

33. 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

34. 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.

35. 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

36. Thank You

37. 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