Much scientific research is now directed toward assessing the quality of embryos so that the live birth rate can be increased at the same time that multiple births are reduced. Advances in PGD and stem cell research show great promise for the future of human reproduction and the management of diseases of all organ systems.
WHAT THIS TRIBUTE MEANS FOR PRACTICE
The Nobel Committee’s recognition of Professor Robert Edwards’s extraordinary and visionary accomplishments marks the highest global acknowledgement of the efficacy, safety, and applicability of IVF, as well as its great promise for the future. All physicians should be aware of how this powerful technology can be used in caring for their patients.
Ovarian hyperstimulation can be tempered
through strategic management
Controlled ovarian stimulation is pharmacotherapy of the ovaries to produce more than one oocyte in non-ART cycles or to produce multiple oocytes for retrieval at follicular aspiration.7 Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, and potentially serious, complication of controlled ovarian stimulation. With vigilant management, however, its risks and sequelae can be reduced.
Best approach: Prevent OHSS
To reduce a woman’s risk of OHSS, identify her risk factors and employ the appropriate prevention strategies. The list of potential risk factors includes:
- age <33 years
- PCOS or its features
- high antral follicle count
- history of OHSS
- high basal anti-müllerian hormone level
- robust response to ovarian stimulation (≥18 follicles or estrogen level of 5,000 ng/dL, or both).
Once that patient’s risk is established, steps can be taken to judiciously manage her cycle and reduce the likelihood that she will develop OHSS.
Prevention strategies include:
- lowering the dosage of gonadotropin (consider a gonadotropin-releasing hormone [GnRH] antagonist protocol)
- coasting cycles until the estradiol level plateaus or decreases (reduce the dosage of human chorionic gonadotropin [hCG], use a GnRH agonist trigger for antagonist cycles, and avoid using hCG for luteal support)
- using an insulin-sensitizing agent such as metformin
- cryopreserving embryos for transfer at a later date (consider in vitro maturation instead of standard IVF [experimental]).8
Proposed clinical grading system for OHSS
| Criteria | How would OHSS be graded? | ||
|---|---|---|---|
| Mild | Moderate | Severe | |
| Objective findings | |||
| Fluid in pouch of Douglas |  | | |
| Fluid around uterus (major pelvis) | | | |
| Fluid around intestinal loops | | ||
| Hematocrit >45% | | | |
| White blood cells >15,000/mm3 | ±* | | |
| Low urine output <600 mL/24 h | ±* | | |
| Creatinine >1.5 mg/dL | ±* | ± | |
| Elevated transaminases | ±* | ± | |
| Clotting disorder | ±† | ||
| Pleural effusion | ±† | ||
| Subjective findings | |||
| Abdominal distention | | | |
| Pelvic discomfort | | | |
| Breathing disorder | ±** | ±** | |
| Acute pain | ±** | ±** | ±** |
| Nausea and vomiting | ± | ± | ± |
| Ovarian enlargement | | | |
| Pregnancy occurrence | ± | ± | |
| Note: ± indicates that the finding may or may not be present. | |||
| * If two of these are present, consider hospitalization | |||
| † If present, consider intensive care | |||
| ** If present, consider hospitalization | |||
| SOURCE: Humaidan P, et al.8 | |||
OHSS has usually been classified according to the signs and symptoms present.9 However, Humaidan and colleagues recently presented a new classification system for OHSS that is also based on objective vaginal US and laboratory parameters, as well as volume of fluid shifts (TABLE).8
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The most highly effective strategies for reducing OHSS include use of a GnRh antagonist protocol and use of a GnRH agonist as a trigger. Other prevention strategies, such as metformin administration and cryopreservation of embryos, can further reduce the risk of severe OHSS. Although absolute prevention is impossible, surveillance for risk factors and careful clinical management by all physicians, including, when appropriate, referral to specialists, can reduce the incidence and severity of this dangerous complication.
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