Abstract
Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian stimulation (COS) as part of assisted reproductive technologies (ART). While the safety and efficacy of ART is well established, physicians should always be aware of the risk of OHSS in patients undergoing COS, as it can be fatal. This article will briefly present the pathophysiology of OHSS, including the key role of vascular endothelial growth factor (VEGF), to provide the foundation for an overview of current techniques for the prevention of OHSS. Risk factors and predictive factors for OHSS will be presented, as recognizing these risk factors and individualizing the COS protocol appropriately is the key to the primary prevention of OHSS, as the benefits and risks of each COS strategy vary among individuals. Individualized COS (iCOS) could effectively eradicate OHSS, and the identification of hormonal, functional and genetic markers of ovarian response will facilitate iCOS. However, if iCOS is not properly applied, various preventive measures can be instituted once COS has begun, including cancelling the cycle, coasting, individualizing the human chorionic gonadotropin trigger dose or using a gonadotropin-releasing hormone (GnRH) agonist (for those using a GnRH antagonist protocol), the use of intravenous fluids at the time of oocyte retrieval, and cryopreserving/vitrifying all embryos for subsequent transfer in an unstimulated cycle. Some of these techniques have been widely adopted, despite the scarcity of data from randomized clinical trials to support their use.
Highlights
There has been a rapid increase in the number of couples receiving treatment for infertility with assisted reproductive technology (ART) in recent years [1]
The expression of vascular endothelial growth factor (VEGF) and VEGF receptor 2 (VEGFR-2) mRNA increases significantly in response to human chorionic gonadotropin (hCG), and peak levels coincide with maximum vascular permeability [5]
The analysis reported increased embryo transfer rates (79–87 %, P = 0.002), pregnancy rate per cycle (17.9–27.7 %, P = 0.002) and live birth rate (15.9–23.9 %, P = 0.007) in those women on Anti-Müllerian hormone (AMH)-tailored protocols compared with conventional controlled ovarian stimulation (COS)
Summary
There has been a rapid increase in the number of couples receiving treatment for infertility with assisted reproductive technology (ART) in recent years [1]. Various preventative protocols have been proposed to reduce or minimize the risk of developing OHSS during COS, including in vitro oocyte maturation, coasting, decreasing the hCG trigger dose, and using a gonadotropinreleasing hormone agonist (GnRHa) trigger. An early Cochrane review of five RCTs clearly showed a benefit associated with the administration of IV albumin at the time of oocyte retrieval in patients at high risk of OHSS, with no effect on pregnancy rate [54]. The recent Cochrane review of studies using IV albumin analyzed the effects of HES at the time of oocyte retrieval in patients at high risk of OHSS in three RCTs [53]. Mild OHSS, which due to the very nature of COS occurs in most patients, and moderate OHSS with no clinical evidence of ascites or enlarged ovaries are not associated with complications and as a result do not require specific treatment. A recent review of the clinical aspects of OHSS provides detailed recommendations for management according to patient diagnosis and risk [79]
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