Ovarian Hyperstimulation Syndrome Follow-up

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

Deterrence/Prevention

Ovarian hyperstimulation syndrome (OHSS) is a self-limiting disease of the luteal phase. Without luteinizing hormone (LH) or its imitator hCG, ovulation or the luteal phase does not occur. Avoidance of hCG during ovarian stimulation offers an opportunity to prevent OHSS in high-risk patients. However, those patients do not conceive. Other options are delaying hCG (coasting) for 1-3 days until estradiol levels plateau or decline (< 2500 pg/mL), using a GnRH agonist to induce ovulation, or lowering doses of hCG.[16]

The best preventive method is to adapt the treatment and to closely monitor patients at risk. Remember that women at risk are those with high levels of estrogen and many follicles at the assumed time of ovulation. Patients with polycystic ovarian syndrome should be closely monitored as well.

Two trials, involving 230 women with moderate risk of bias, found evidence that a daily oral dose of 0.5 mg of the dopamine agonist cabergoline may reduce the risk of ovarian hyperstimulation in high-risk women with no influence on pregnancy outcome.[23]

Laboratory findings of a serum estradiol concentration greater than 2000 pg/mL and a progesterone concentration greater than 30 ng/mL in the early part of the luteal phase are warning signs of developing OHSS.[20]

Vaginal intercourse is restricted in women with any grade of OHSS because of the risk of rupturing a cyst. Patients should also avoid impact-type activities or strenuous exertion.

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Prognosis

The prognosis is excellent if ovarian hyperstimulation syndrome is mild or moderate. In severe OHSS, the prognosis is optimistic if good treatment is given.

Hypercoagulability may endanger the patient.

Death from OHSS is largely due to hypovolemic shock and electrolyte imbalance, hemorrhage, and thromboemboli. Estimated fatality rates are 1 per 400,000-500,000 stimulated cycles.

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Patient Education

Patients are instructed to record their weight on a daily basis, to avoid exercise and intercourse, and to maintain adequate hydration after in vitro fertilization. They should measure their abdominal girth, intake, and output, and they should report urinary output of less than 1000 mL in any 24-hour period.

Patients are educated to report progressive bloating, abdominal discomfort, decreases or increases in urination, cramping, dizziness, shortness of breath, and weight gain of more than 5 lb/wk.

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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

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  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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