Presentation on theme: "Dr. Hakan ÖZÖRNEK EUROFERTIL Reproductive Health Center"— Presentation transcript:
1Dr. Hakan ÖZÖRNEK EUROFERTIL Reproductive Health Center
2OHSS OHSS is an iatrogenic complication of ovulation induction. The syndrom can result in serious life treatening complicationsThe syndrom charecterized by leakage of fluid from the intravascular compartment, with accumulation in the peritoneal and pleural cavities, resulting in hypotension and a decrease in renal blood flow and volume of urine.
3Classification Mild OHSS Moderate OHSS Severe OHSS Grade 1 Abdominal distention and discomfortGrade 2 + nausea, vomiting and/or diarrhoeaModerate OHSSGrade 3 + ultrasonic evidence of ascitesSevere OHSSGrade 4 + clinical evidence of ascites and/or hydrothorax or dyspnoeaGrade 5 + haemoconcentration, coagulation abnormalities, diminished renal perfusion
4Prevention 1. Step Identification of risk factors 2. Step Monitoring the ovarian response (US+E2)
5Risk factors for OHSS PCOS High number of antral follicles at day3 (>10/ovary)Enlarged ovarian volumeLH/FSH > 2HyperandrogenismYoung age < 35Low body weightPrevious ocurrence of OHSS
7Metformin No metformin (n=159) Metformin (n=128) Age 34.8 33 BMI 27.2 27.8HMG ampoules37.141.1Oocytes retrieved23.818.8Embryos tranferred2.83Clinical pregnancies37.630.5Moderate and severe OHSS*201Khattab, Reprod Biomed Online, 2006
8Prevention of OHSS Withholding hCG ‘cancelling’ Delaying hCG ‘coasting’Modification of methods to trigger ovulationEarly unilateral follicular aspirationProgesterone for luteal phase supportCryopreservation of all embryosGradual and slow hMG protocol in PCOSAlbumin administration at time of retrievalGlucocorticoid administration
9Canceling Cycles hCG triggers the development of OHSS Withholding hCG is the only method that totally avoids the risk of OHSSSerum E2 level upper limit 4000 pg/mlAfter stopping the gonadotrophin treatment the GnRH agonist or antagonist should be continiued until the ovaries recover to normal size
10Modification of methods to trigger ovulation Decrease in hCG doseIU vs IU or IU no differenceGnRHaUsed in antagonist cycle, as effective as hCG, decreased insidence of OHSS but significant less pregnancyrLHPRT multicenter hCG vs rLH significantly fewer moderate and severe cases of OHSSrhCG
11Folicular aspirationFolicular aspiration at the time of oocyte retrieval had no protective effect of OHSSUnilateral folikular aspiration prior to HCG also does not reduce the incidence of severe OHSS
12Glucocorticoid administration Methylprednisolon (n=50)Untreated (n=41)Age30.530.9E2 concentration* pg/ml48483727Oocytes retrieved*28.724Embryos transferred3.94.0OHSS*10%43.9%Because of conflicting reports in the literature there are currently insufficient data to recommend glucocorticoid administrationLainas et al., Fertil Steril, 2002
13Lutheal phase supportLutheal phase support with hCG increases the incidence of OHSS.Progesterone intravaginally or im should be used for the patients at risk of OHSS
14Coasting First described and applied by Sher et al in 1993 hCG administration postponed until the patients serum E2 level decreases to a safer zone.Significantly higher percentage of granulosa lutein cells become apoptotic after coasting. E2 levels usually to rise rapidly in the 48 h following initiation of the coasting period, then plateaued and began to fall h after the gonadotropins were stopped.
15CoastingCochrane review identified 13 studies of which only one trial met the inclusion criteria.There was no difference in the incidence of moderate and severe OHSS and in the clinical pregnancy rate between the groups.D’Angelo et al., Cochrane Library, 2002
17Coasting < 4 days (n=983) Coasting >4 days (n=240) Coasting durationCoasting < 4 days (n=983)Coasting >4 days (n=240)Age30.229.9Oocytes retrieved*16.514.9Mean no of embryos trans2.993.03Clin pregnancy rate*52.035.9Implantation rate*26.318.2Mansour, et al., Fertil Steril, 2005
18Coasting (Practical guidelines) Start atSerum E2>4500 pg/ml> 15 and < 30 mature folliclesMeasure E2 on a daily basis, do not skip any day to avoid sudden unexpected dropsGive hCG when E2 level falls to < 3500 pg/mlAbandone ifE2 level rises to >6500 pg/ml> 30 mature folliclesCoasting takes > 4 days
19CoastingCoasting is a good alternative that can avoid cycle cancellation in high responders, who have high risk of developing severe OHSSEven if OHSS develops after coasting both its incidence and severity will be diminished
20Cryopreservation of all embryos Insted of canceling the cycle after the administration of hCG retrieve the oocytes and than cryopreserve all embryosCochrane review identified 17 studies, two of which met the inclusion criteria.When elective cryopreservation was compared with fresh embryo transfer no difference was found between the two groups in the incidence of OHSS.There is insufficient evidence to support routine cryopreservation.D’Angelo et al., Cochrane Library, 2002
21Albumin administration Albumin is prevent the development of OHSS by increasing plasma oncotic pressure and binding of OHSS mediators of ovarian originThe cochrane review shows a clear benefit from administration of iv albumin at te time of oocyte retrieval in prevention of severe OHSS in high risk cases.For every 18 women at risk of severe OHSS albumin infusion will save one more caseAlbumin is a human product!D’Angelo et al., Cochrane Library, 2002
22HES (Hydroxyethyl starch solution) administration Synthetic macromolecules used to prevent OHSS and avoid the potential risks from using human products such as albuminHES is effective volume expander. It is as effective as albuminIt is cheaper and safer
23Conclusion OHSS is a serious complication of ovarian stimulation The identification of high risk patients and in particular PCOS patients and the use of low dose protocols of ovarian stimulation have an important role in the prevention of OHSSTo date no methods are available to completly prevent this complication except for withholding hCG.
24ConclusionCoasting for at least as long as 3 days can be successfully used in the prevention of OHSSIt appears that iv albumin administered at the time of oocyte retrieval may help the prevention of OHSSThe effect of combining methods which act at two different levels (eq. coasting and HES administration) helps for a better preventionThere is a clear need for large randomised studies