Ovarian Hyperstimulation Syndrome Clinical Presentation

  • Author: Joanna Horwitz, MD; Chief Editor: Richard Scott Lucidi, MD   more...
 
Updated: Mar 23, 2012
 

History

The patient who has ovarian hyperstimulation syndrome (OHSS) is a woman who recently had gonadotropin stimulation to induce ovulation or one who was treated with assisted reproductive technologies such as in vitro fertilization.

Early OHSS is usually moderate or severe and manifests 3-7 days after the administration of hCG. Late OHSS is usually severe and occurs 12-17 days after hCG treatment.[12] The former type is due to exogenously administered hormone, and the latter often occurs during an implanting or implanted pregnancy because pregnancy hCG exacerbates the disease.[13]

Signs of OHSS

Signs of OHSS include the features listed below.[9, 14] (Percentages refer to all classes of OHSS.)

Symptoms of OHSS

Symptoms of OHSS include those listed below.[9, 14] (Percentages refer to cases of severe OHSS.)

  • Shortness of breath (92%)
  • Abdominal discomfort (99%)
  • GI disturbances - Nausea, vomiting, diarrhea (54%)
  • Oliguria (30%)
  • Peripheral edema (13%)
  • Lethargy
  • Rapid weight gain

Although OHSS usually manifests with a constellation of symptoms, atypical presentations can occur. Rare presentations such as thromboembolism, both venous and arterial, have been observed. Atypical locations of venous thromboembolism include the internal jugular vein, the subclavian vein, the inferior vena cava, the ileofemoral veins, and the intracerebral veins.[15]

Other abnormal forms of presentation include isolated hydrothorax and isolated thromboembolism. Additional situations leading to elevated hCG concentrations, such as in molar pregnancy and gonadotroph adenomas may lead to mild forms of OHSS in rare cases.[16]

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Physical

Physical findings of ovarian hyperstimulation syndrome include right or left lower quadrant pain below the umbilicus, as well as edema.

Of note, abdominal palpation must be performed gently to avoid the possibility of rupturing a large cyst. Pelvic examination should be deferred in favor of ultrasonography of the pelvis.

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Causes

No single cause of ovarian hyperstimulation syndrome has been identified. The etiology appears to be multifactorial, though the cardinal events are ovarian enlargement, ascites, and hypovolemia.

The hormone hCG and its analogs estrogen, estradiol, histamine, TNF-alpha, endothelin-1, and especially VEGF have all been implicated in OHSS.[17] Increased vascular permeability in periovarian vasculature brought about by the factors described above plays an important role in OHSS.[13] A young age, a decreased body mass index, and a history of OHSS increase the risk.

Exogenous induction agents (recombinant hCG) precipitates OHSS more than endogenous agents (gonadotropin-releasing hormone [GnRH] analogs). Other precipitating factors are induction in a hyperestrogenic state and poor timing.

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Contributor Information and Disclosures
Author

Joanna Horwitz, MD  Staff Physician, Department of Obstetrics and Gynecology, Loyola University Medical Center

Joanna Horwitz, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ramesh S Pundi, MD  Attending Physician, Department of Obstetrics and Gynecology, Genesis Health System, Davenport, Iowa

Ramesh S Pundi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Indian Medical Association

Disclosure: Nothing to disclose.

Josef Blankstein, MD  Chairman, Department of Obstetrics and Gynecology, Rosalind Franklin University of Health Sciences, Chicago Medical School

Josef Blankstein, MD is a member of the following medical societies: Academy of Medicine Cleveland/Northern Ohio Medical Assn, American College of Obstetricians and Gynecologists, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Suzanne R Trupin, MD, FACOG  Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD  Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

For their industrious work in collecting articles and research, Estello Escudero, MA LibSc, Mt Sinai Hospital Library, and Merly Arceo, BA LibSc, Mt Sinai Hospital; and, for his unstinting support and encouragement, Dr Jos Blankstein.

References

  1. Myrianthefs P, Ladakis C, Lappas V, et al. Ovarian hyperstimulation syndrome (OHSS): diagnosis and management. Intensive Care Med. May 2000;26(5):631-4. [Medline].

  2. Golan A, Ron-el R, Herman A, et al. Ovarian hyperstimulation syndrome: an update review. Obstet Gynecol Surv. Jun 1989;44(6):430-40. [Medline].

  3. Morris RS, Paulson RJ. Ovarian derived prorenin-angiotensin cascade in human reproduction. Fertil Steril. Dec 1994;62(6):1105-14. [Medline].

  4. Elchalal U, Schenker JG. The pathophysiology of ovarian hyperstimulation syndrome--views and ideas. Hum Reprod. Jun 1997;12(6):1129-37. [Medline].

  5. Zalel Y, Katz Z, Caspi B, et al. Spontaneous ovarian hyperstimulation syndrome concomitant with spontaneous pregnancy in a woman with polycystic ovary disease. Am J Obstet Gynecol. Jul 1992;167(1):122-4. [Medline].

  6. Beerendonk CC, van Dop PA, Braat DD, et al. Ovarian hyperstimulation syndrome: facts and fallacies. Obstet Gynecol Surv. Jul 1998;53(7):439-49. [Medline].

  7. Brinsden PR, Wada I, Tan SL, et al. Diagnosis, prevention and management of ovarian hyperstimulation syndrome. Br J Obstet Gynaecol. Oct 1995;102(10):767-72. [Medline].

  8. Insler V, Lunenfeld B. Pathogenesis of ovarian hyperstimulation syndrome. In: Gomel V, Leung PCK. In Vitro Fertilization and Assisted Reproduction. Bologna, Italy: Monduzzi Editore; 1997:433-9.

  9. Abramov Y, Elchalal U, Schenker JG. Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study. Fertil Steril. Apr 1999;71(4):645-51. [Medline].

  10. Polishuk WZ, Schenker JG. Ovarian overstimulation syndrome. Fertil Steril. May-Jun 1969;20(3):443-50. [Medline].

  11. Martin RA, Edraki B, Norris RL. Ovarian hyperstimulation syndrome in the emergency department: a case report. J Emerg Med. Jul-Aug 1994;12(4):481-4. [Medline].

  12. Lyons CA, Wheeler CA, Frishman GN, et al. Early and late presentation of the ovarian hyperstimulation syndrome: two distinct entities with different risk factors. Hum Reprod. May 1994;9(5):792-9. [Medline].

  13. Rutkowski A, Dubinsky I. Ovarian hyperstimulation syndrome: imperatives for the emergency physician. J Emerg Med. Jul-Aug 1999;17(4):669-72. [Medline].

  14. Delvigne A, Demoulin A, Smitz J, et al. The ovarian hyperstimulation syndrome in in-vitro fertilization: a Belgian multicentric study. I. Clinical and biological features. Hum Reprod. Sep 1993;8(9):1353-60. [Medline].

  15. Stewart JA, Hamilton PJ, Murdoch AP. Thromboembolic disease associated with ovarian stimulation and assisted conception techniques. Hum Reprod. Oct 1997;12(10):2167-73. [Medline].

  16. Speroff L, Fritz M. Clinical Gynecological Endocrinolgy and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:1999-1200.

  17. Levin ER, Rosen GF, Cassidenti DL, et al. Role of vascular endothelial cell growth factor in Ovarian Hyperstimulation Syndrome. J Clin Invest. Dec 1 1998;102(11):1978-85. [Medline].

  18. Whelan JG 3rd, Vlahos NF. The ovarian hyperstimulation syndrome. Fertil Steril. May 2000;73(5):883-96. [Medline].

  19. Wang TH, Horng SG, Chang CL, et al. Human chorionic gonadotropin-induced ovarian hyperstimulation syndrome is associated with up-regulation of vascular endothelial growth factor. J Clin Endocrinol Metab. Jul 2002;87(7):3300-8. [Medline].

  20. Blankstein J, Lunenfeld S, Mashiach S. Introduction of Ovulation and In Vitro Fertilization. Chicago, Ill: YearBook Medical; 1986.

  21. Levin I, Almog B, Avni A, et al. Effect of paracentesis of ascitic fluids on urinary output and blood indices in patients with severe ovarian hyperstimulation syndrome. Fertil Steril. May 2002;77(5):986-8. [Medline].

  22. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil Steril. Aug 1992;58(2):249-61. [Medline].

  23. Tang H, Hunter T, Hu Y, Zhai SD, Sheng X, Hart RJ. Cabergoline for preventing ovarian hyperstimulation syndrome. Cochrane Database Syst Rev. Feb 15 2012;2:CD008605. [Medline].

  24. Herman A, Raziel A, Strassburger D, et al. The benefits of mid-luteal addition of human chorionic gonadotrophin in in-vitro fertilization using a down-regulation protocol and luteal support with progesterone. Hum Reprod. Jul 1996;11(7):1552-7. [Medline].

  25. Lunenfeld B, Insler V, Glezerman M. Diagnosis and Treatment of Functional Infertility. 3rd ed. Berlin, Germany: Blackwell Wissenschaft; 1993:98.

 
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Ultrasonographic presentation of ovarian hyperstimulation syndrome.
 
 
 
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