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

OHSS is a iatrogenic complication of controlled ovarian stimulation

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

Incidence – severe Moderate to severe 3.1- 8 /20

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

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

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

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

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

Hormonal marker AMH = best predictor than … estradiol

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

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

Risk stratification Prevention : 1- primary 2-secondary

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

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

Avoiding HCG luteal phase support

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

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

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

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

Vasopressin induced VEGF Secretion blockade Vasopressin VIa receptor antagonist(relcovapton)

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