Should we explore OHSS full clinical scope?...

Shahar Kol

Department of Obstetrics and Gynecology, Rambam Medical Center, PO Box 9602, Haifa, Israel 31096 E-mail: skol{at}rambam.health.gov.il

Dear Sir,

A rather impressive number of publications can be found in recent years describing `interesting' clinical manifestations of ovarian hyperstimulation syndrome (OHSS) (Lesny et al., 1999Go; Khalaf et al., 2000Go; Lamon et al., 2000Go; Loret de Mola et al., 2000Go; Rabinerson et al., 2000Go; Semba et al., 2000Go; Tang et al., 2000Go). One may have the impression that we are haunted by a morbid desire to explore the full scope of OHSS clinical manifestations, while mumbling the inevitable mantra: `...severe OHSS still cannot be completely eliminated' (Tang et al., 2000Go). It is time to change our attitude.

Let us take a closer look at the most recent publication cited above (Tang et al., 2000Go). An IVF patient had a cycle during which the oestradiol concentration had reached 17504pmol/l on the day of administration of human chorionic gonadotrophin (HCG) and 19 oocytes were retrieved, clearly, a `high responder' patient at risk of developing OHSS. Since pregnancy was not achieved, a second stimulation was performed, using the same protocol as the first. This time around, oestradiol reached 20808 pmol/l on the day of HCG and 20 oocytes were retrieved. A transfer of two embryos led to pregnancy and severe OHSS. It is time to admit: this outcome is unacceptable. Either all embryos should have been frozen, or coasting be applied. Yet, a better approach in a known `high responder' patient is to utilize a GnRH antagonist-based stimulation protocol and a bolus of GnRH agonist to trigger ovulation as was recently described (Itskovitz-Eldor et al., 2000Go; Kol and Itskovitz- Eldor 2000), eliminating any risk of clinically significant OHSS.

In summary, based on currently available medications and protocols, severe OHSS should be a disease of the past. The relentless quest of exploring its wide range clinical manifestations should be stopped.

References

Itskovitz-Eldor, J., Kol, S. and Mannaerts, B (2000) Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report: Short communication. Hum. Reprod., 15, 1965–1961.[Abstract/Free Full Text]

Khalaf, Y., Elkington, N., Anderson, H. et al. (2000) Ovarian hyperstimulation syndrome and its effect on renal function in a renal transplant patient undergoing IVF treatment: case report. Hum. Reprod., 15, 1275–1277.[Abstract/Free Full Text]

. and Itskovitz-Eldor, J. (2000) Severe OHSS: Yes, there is a strategy to prevent it! Hum. Reprod., 15, 2266–2267.[Abstract/Free Full Text]

Lamon, D., Chang, C.K., Hruska, L. et al. (2000) Superior vena cava thrombosis after in vitro fertilization: case report and review of the literature. Ann. Vasc. Surg., 14, 283–285.[ISI][Medline]

Lesny, P., Maguiness, S.D., Hay, D.M. et al. (1999) Ovarian hyperstimulation syndrome and benign intracranial hypertension in pregnancy after in-vitro fertilization and embryo transfer: case report. Hum. Reprod., 14, 1953–1955.[Abstract/Free Full Text]

Loret de Mola, J.R., Kiwi, R., Austin, C. and Goldfarb, J.M. (2000) Subclavian deep vein thrombosis associated with the use of recombinant follicle-stimulating hormone (Gonal-F) complicating mild ovarian hyperstimulation syndrome. Fertil. Steril., 73, 1253–1256.[ISI][Medline]

Rabinerson, D., Shalev, J., Royburt, M. et al. (2000) A severe unilateral hydrothorax as the only manifestation of the ovarian hyperstimulation syndrome. Gynecol. Obstet. Invest., 49, 140–142.[ISI][Medline]

Semba, S., Moriya, T., Youssef, E.M. and Sasano, H. (2000) An autopsy case of ovarian hyperstimulation syndrome with massive pulmonary edema and pleural effusion. Pathol. Int., 50, 549–552.[ISI][Medline]

Tang, O.S., Ng, E.H.Y., Cheng, P. W. and Ho, P.C. (2000) Cortical vein thrombosis misinterpreted as intracranial haemorrhage in severe ovarian hyperstimulation syndrome. [Case report.] Hum. Reprod., 15, 1913–1916.


 

Dear Sir,

Oi-Shan Tang

Department of Obstetrics and Gynaecology, University of Hong Kong, Queen Mary Hospital, 6/F Professional Block, 102 Pokfulam Road, Pokfulam, Hong Kong

I would like to thank Dr Kol for his interest and comments on our paper. The aim of the case report is to make us aware of the possible presentation of OHSS so that we will not miss it in case this rare condition occurs.

While I agree that the clinicians should try their best to minimize the risk of severe ovarian hyperstimulation syndrome (OHSS), there is still doubt as to whether it can be completely prevented. We are certainly aware of the various proposed methods of prevention of OHSS. The fact that there are still rather impressive numbers of publications in the recent years means that this condition still exists. We did mention in our paper that the dose of human menopausal gonadotrophin (HMG) could perhaps be reduced in the second cycle. While the strategy of elective cryopreservation of all embryos or coasting may reduce the risk of severe OHSS, the risk is not eliminated entirely (Queenan et al., 1997Go; Lee et al., 1998Go). The use of GnRH antagonist is an interesting development. However, in the paper mentioned by Dr Kol (Itskovitz-Eldor et al., 2000Go), only eight patients were studied. Even the authors themselves said: `... further studies are needed to establish this potential advantage'. More studies with the GnRH antagonist are required before a firm conclusion can be drawn as to whether OHSS can be completely prevented.

References

Itskovitz-Eldor, J., Kol, S. and Mannaerts, B. (2000) Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction with special reference to prevention of ovarian hyperstimulation: preliminary report. Hum. Reprod., 15, 1965–1968.[Abstract/Free Full Text]

Lee, C., Tummon, I., Martin, J. et al. (1998) Does withholding gonadotrophin administration prevent OHSS? Hum. Reprod., 13, 1157–1158.[Abstract]

Queenan Jr, J.T., Vreeck, L.L., Toner, J.P. et al. (1997) Cryopreservation of all prezygotes in patients at risk of severe hyperstimulation does not eliminate the syndrome, but the chances of pregnancy are excellent with subsequent frozen–thaw transfers. Hum. Reprod., 12, 1573–1576.[Abstract]





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