Albumin in the prevention of severe OHSS

T. Hillensjö, M. Wikland and M. Wood

Fertility Center Scandinavia, Carlanderska Hospital, Box 5418, S-40229 Göteborg, Sweden

Dear Sir,

We have read the recent interesting review on the role of i.v. albumin in the prevention of severe ovarian hyperstimulation syndrome (OHSS) and agree with the authors (Orvieto and Ben-Rafael, 1998Go) that further research is necessary to understand the fundamental cause of OHSS and to develop a reliable test for this condition. In the meantime we believe that a combined approach should be taken to avoid the condition developing. This would involve an individualized dose of follicle stimulating hormone (FSH)/human menopausal gonadotrophin (HMG), a reduced dose of human chorionic gonadotrophin HCG (5000 IU) for ovulation induction, and progesterone rather than HCG for luteal support. In patients at high risk, freezing of all embryos, coasting, or even cycle cancellation should be considered. We also think that i.v. albumin should be administered in connection with ovum retrieval in patients with a high risk of developing OHSS and, in our clinic, we routinely use it in cases with > 20 follicles. Early and regular follow-up of these patients is mandatory to allow early intervention if necessary. The incidence of severe OHSS requiring hospitalization has been 1 - 2% for the past 2 years.

As pointed out by Orvieto and Ben-Rafael (1998), it is difficult to draw firm conclusions from the published studies on the efficacy of albumin to prevent OHSS, as there are both positive and negative reports. The various studies have used different inclusion criteria and the end-points have not been uniform. The authors have divided the published studies into two categories: negative and positive studies, respectively. However, the data presented in Tables IGo and II in the article could be analysed in a different way; all data from the four prospective randomized studies and the only retrospective study including a control group could be compiled and the uncontrolled case reports could be excluded (see Table IGo).


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Table I. Data rearranged from Orvieto and Ben-Rafael (1998). Figures in parentheses are percentages
 
It can be seen in these controlled studies, that the rate of severe OHSS was reduced from 8.2 to 1.6% (5.1-fold reduction, P = 0.0092 with Fisher's exact test). Thus, by reading the article critically we arrive at a different conclusion than the authors. We believe that although no ideal studies have been conducted so far, current evidence presented in the review strongly suggests that albumin should be used to prevent severe OHSS

References

Isik, A.Z., Gokmen, O., Zeyneloglu, H.B. et al. (1996) Intravenous albumin prevents moderate–severe ovarian hyperstimulation in in vitro fertilization patients: a prospective randomized and controlled study. Eur. J. Obstet. Gynecol. Reprod. Biol., 70, 179–183.[ISI][Medline]

Ng, E., Leader, A., Claman, P. et al. (1995) Intravenous albumin does not prevent the development of severe ovarian hyperstimulation syndrome in an in-vitro fertilization programme. Hum. Reprod., 10, 807–810.[Abstract]

Orvieto, R. and Ben-Rafael, Z. (1998) Role of intravenous albumin in the prevention of severe ovarian hyperstimulation syndrome. Hum. Reprod., 13, 3306–3309.[Free Full Text]

Shaker, A.G., Zosmer, A., Dean, N. et al. (1996) Comparison between intravenous albumin and transfer of fresh embryos with cryopreservation of all embryos for subsequent transfer in prevention of ovarian hyperstimulation syndrome. Fertil. Steril., 65, 992–996.[ISI][Medline]

Shalev, E., Giladi, Y., Matiski, M. and Ben-Ami, M. (1995) Decreased incidence of severe ovarian hyperstimulation syndrome in high risk in-vitro fertilization patients receiving intravenous albumin. Hum. Reprod., 10, 807–810.[Abstract]

Shoham, Z., Weissman, A., Barash, A. et al. (1994) Intravenous albumin for the prevention of severe ovarian hyperstimulation syndrome in an in vitro fertilization program: a prospective randomized, placebo-controlled study. Fertil. Steril., 62, 137–142.[ISI][Medline]