Ovarian Hyper Stimulation Syndrome (OHSS) B.Rashidi. M.D Oct .2014

OHSS Pathophysiology Classification and Clinical presentation Prevention Management

Pathophysiology

VEGF is Crucial for OHSS Its expression in increased by hCG. Its effect on vascular permeability is clear and strong. The inhibition of its effect in hyper stimulated women blocks or attenuates the clinical manifestation of OHSS.

It should be remembered that OHSS is a dynamic situation. Classification Golan et al 1982 (mild, moderate ,severe) Mathur et al 2000 (early, late) ASRM practice committee 2003 (mild, worsening, serious) Grossman et al 2010 ( IAP ACS) It should be remembered that OHSS is a dynamic situation.

Prevention Identification of at risk patients. Organization of ovarian stimulation. Decreasing the developing follicles and rapid E2 increase. Prevention of pregnancy occurrence.

Phase I:Prediction Primary risk factors : Age PCOS AMH AFC Hx of OHSS BMI? Immunological sensitivity ?

Prediction Secondary risk factors: E2 level Number of follicles and oocytes Inhibin B VEGF

Identification of at risk patients iCOS

Phase II: iCOS Antagonist vs. Agonist Gonadotropin dose Rx Metformin Minimal stimulation protocol Dual suppression with OCP+Agonist

Phase III: Organization of ovarian stimulation Coasting Antagonist in agonist cycles(Coasting ,GnRH antagonist salvage) FSH co-trigger IVM Early administration of hCG HCG dose and alternatives( rLH, rhCG) Agonist trigger

Phase III: cont…….. Albumin administration Hydroxyethyl starch Dopamine agonist Steroid Aspirin Aromatase inhibitor Follicular aspiration Not recommended

Caberglin for prevention of ovarian hyperstimulation syndrome: systemic review and meta-analysis of randomized controlled trials. Valeria M.S.F&S 2014

Conclusion Cabergoline reduces the incidence of OHSS. Cabergoline probably does not have a clinically relevant impact on clinical pregnancy rates or on the number of retrieved oocytes. We are still uncertain of the effects of cabergoline on important outcomes, namely, live birth, miscarriage, and congenital abnormalities. Future research examining these outcomes should be encouraged.

Phase IV Cryopreservation ( freeze all embryos) Cycle cancellation

Papanikolaou et al. Repro Bio Endo 2011 Antagonist protocol+ Agonist trigger Cryopreservation Or Modified LPS Papanikolaou et al. Repro Bio Endo 2011

Management Out patient In patient Optimize fluid administration Use of hypertonic crystalloids Paracentesis Thromboprophylaxis

Conclusions Prevention of OHSS begins with tailoring an individual’s ovarian stimulation protocol based on their risk profile, through iCOS. Selecting one standardized preventative approach for all patients or a large cohort of patients undergoing COS is challenging, because the benefits and risks associated with each strategy vary between individuals. Identification of hormonal, functional and genetic markers of ovarian response will facilitate iCOS.