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

2. OHSS is a iatrogenic complication of controlled ovarian stimulation

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

4. Incidence – severe
Moderate to severe /20

5. 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

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

7. 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

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

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

10. Hormonal marker
AMH = best predictor than …
estradiol

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

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

13. Risk stratification
Prevention : 1- primary
2-secondary

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

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

16. Avoiding HCG luteal phase support

17. 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

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

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

20. 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

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

30. END OF PRESENTATION
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