Abstract
BackgroundManagement of established severe OHSS requires prolonged hospitalization, occasionally in intensive care units, accompanied by multiple ascites punctures, correction of intravascular fluid volume and electrolyte imbalance. The aim of the present study was to evaluate whether it is feasible to manage women with severe OHSS as outpatients by treating them with GnRH antagonists in the luteal phase.MethodsThis is a single-centre, prospective, observational, cohort study. Forty patients diagnosed with severe OHSS, five days post oocyte retrieval, were managed as outpatients after administration of GnRH antagonist (0.25 mg) daily from days 5 to 8 post oocyte retrieval, combined with cryopreservation of all embryos. The primary outcome measure was the proportion of patients with severe OHSS, in whom outpatient management was not feasible.Results11.3% (95% CI 8.3%-15.0%) of patients (40/353) developed severe early OHSS. None of the 40 patients required hospitalization following luteal antagonist administration and embryo cryopreservation. Ovarian volume, ascites, hematocrit, WBC, serum oestradiol and progesterone decreased significantly (P < 0.001) by the end of the monitoring period, indicating rapid resolution of severe OHSS.ConclusionsThe current study suggests, for the first time, that successful outpatient management of severe OHSS with antagonist treatment in the luteal phase is feasible and is associated with rapid regression of the syndrome, challenging the dogma of inpatient management. The proposed management is a flexible approach that minimizes unnecessary embryo transfer cancellations in the majority (88.7%) of high risk for OHSS patients.
Highlights
Management of established severe Ovarian hyperstimulation syndrome (OHSS) requires prolonged hospitalization, occasionally in intensive care units, accompanied by multiple ascites punctures, correction of intravascular fluid volume and electrolyte imbalance
Patient management Patients were fully explained on the last day of stimulation the possible risks in case severe OHSS developed and were presented with the following options: (a) to withhold human chorionic gonadotrophin (hCG) and cancel the cycle, b) to use Gonadotrophin-releasing hormone (GnRH) agonist instead of hCG for triggering final oocyte maturation [14] combined with cryopreservation of all embryos, in case GnRH antagonists had been used to suppress premature Luteinizing hormone (LH) surge, and (c) to proceed at least to oocyte retrieval using 5000 IU hCG for triggering final oocyte maturation [16] and potentially to embryo transfer, if OHSS did not occur
From the cohort of 362 high risk patients included in the present study, triggering of final oocyte maturation was performed by administration of 5000 IU of hCG in 353 patients, or by administration of GnRH agonist in 9 patients (Figure 1)
Summary
Management of established severe OHSS requires prolonged hospitalization, occasionally in intensive care units, accompanied by multiple ascites punctures, correction of intravascular fluid volume and electrolyte imbalance. OHSS is induced by exogenous hCG administered for final oocyte maturation, usually occurring within 3–7 days post hCG [1,2]. Late OHSS is pregnancy-induced, occurs 12–17 days post hCG and is triggered by the endogenous hCG produced by an implanting blastocyst [1,2]. Mild OHSS lacks clinical significance, moderate OHSS requires careful patient monitoring, while severe OHSS may prove to be critical or even life-threatening, characterized by massive ovarian enlargement, ascites, pleural effusion, oliguria, haemoconcentration, adult respiratory distress syndrome and thromboembolic phenomena, and may require hospitalization in an intensive care unit [4,5]
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