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

2. OHSS Pathophysiology Classification and Clinical presentation
Prevention
Management

3. Pathophysiology

4. 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.

5. 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.

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

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

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

9. Identification of at risk patients
iCOS

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

11. 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

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

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

14. 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.

15. Phase IV
Cryopreservation
( freeze all embryos)
Cycle cancellation

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

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

19. 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.