Bilateral partial oophorectomy in the management of severe ovarian hyperstimulation syndrome (OHSS)

Ovarian mutilating surgery is not an option in the management of severe OHSS

José Bellver, Ernesto Escudero and Antonio Pellicer1

Departments of Infertility and Maternal-Fetal Medicine, Instituto Valenciano de Infertilidad (IVI), Plaza de la Policía Local, 3, 46015, Valencia, Spain

1 To whom correspondence should be addressed. e-mail: apellicer{at}ivi.es


    Abstract
 Top
 Abstract
 Introduction
 Management of OHSS
 References
 
Ovarian mutilating surgery is not an option in the management of ovarian hyperstimulation syndrome (OHSS), except in cases with evident tissue necrosis after torsion. When severe OHSS occurs, preservation of fertility must be the target. Therefore, conservative management should be the only feasible approach, as recommended in literature worldwide. Individualization of controlled ovarian hyperstimulation, and an early active management when OHSS initiates, are the most effective measures for reducing the incidence and severity of this disease.

Keywords: conservative management/literature review/oophorectomy/ovarian hyperstimulation syndrome/surgery


    Introduction
 Top
 Abstract
 Introduction
 Management of OHSS
 References
 
The ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening physiological complication, classically encountered in patients undergoing controlled ovarian hyperstimulation (COH) cycles (Whelan and Vlahos, 2000Go), among whom an incidence of 0.6 to 14% of IVF cycles with embryo transfer has been recorded (Brinsden et al., 1995Go; Al-Ramahi, 1999Go; Fluker et al., 2000Go). OHSS is usually associated with regimens of exogenous gonadotrophins and its clinical consequences occur in the post-ovulatory phase (after oocyte retrieval). The pathophysiology of this syndrome is not yet well established, but different factors related to an increased capillary permeability have been suggested (Albert et al., 2002Go; Gómez et al., 2002Go).

The self-limiting course of the disease is well known (Whelan and Vlahos, 2000Go), especially when pregnancy is not achieved. The severe form of OHSS, present in about 0.2–5% of cases (Navot et al., 1992Go; Al-Ramahi, 1999Go; Forman, 1999Go; Graf and Fischer, 1999Go), includes many serious manifestations, both clinical and biochemical (Balasch et al., 1998Go; Al-Ramahi, 1999Go; Murdoch and Evbuomwan, 1999Go; Whelan and Vlahos, 2000Go). A multiple organ failure is expected in some patients, and a few cases of death have been reported (Cluroe and Synek, 1995Go; Semba et al., 2000Go). The estimated mortality associated with OHSS has been calculated as 1/450 000–500 000 (Brinsden et al., 1995Go).

The best treatment in OHSS is really prevention (Navot et al., 1992Go). Several risk factors for this disease, some of them debatable, have been described before and during COH, as shown in Table I. Preventive measures should be taken as soon as these factors are identified. Many approaches have been reported to date (Table II). The success rates of these preventive protocols have varied, some of them proven to be effective not only for avoiding OHSS but also for reducing its severity.


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Table I. Risk factors of ovarian hyperstimulation syndrome
 

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Table II. Preventive measures in ovarian hyperstimulation syndrome
 

    Management of OHSS
 Top
 Abstract
 Introduction
 Management of OHSS
 References
 
The development of a severe form of OHSS, despite preventive measures, is the key problem. The accepted approach, followed worldwide, consists of a conservative management until the disease becomes self-limited. In cases of early OHSS (Lyons et al., 1994Go; Mathur et al., 2000Go) this time is short, usually no more than 14 days. In cases of pregnancy, it can be longer. If OHSS is severe, a close clinical and laboratory monitoring is mandatory, often in a hospital. The measures applied depend on the state of health of the patient. It is essential to maintain a correct balance of fluids, through an appropriate intravenous intake of crystalloids and albumin and an adequate urine output (Navot et al., 1992Go; Balasch et al., 1996Go; Whelan and Vlahos, 2000Go). In this way, haemoconcentration, electrolyte imbalance, hypotension and oligouria can be reduced or avoided, as well as their consequences (renal failure, impaired perfusion of vital tissues, cardiac arrhythmia, etc.). On the other hand, an adequate thromboprophylaxis is often necessary for preventing thromboembolic events, usually avoided with good hydration, leg massage, compression or mobilization, and low molecular weight heparin (Brinsden et al., 1995Go; Al-Ramahi, 1999Go; Whelan and Vlahos, 2000Go). Paracentesis (transvaginal or transabdominal) has been described as the best single therapy for reversing severe pain or discomfort, anxiety, pulmonary compromise and renal impairment not responding to medical management, improving the homeostatic condition and haemoconcentration, thereby leading to a faster recovery (Aboulghar et al., 1990Go; 1993; Padilla et al., 1990Go; Navot et al., 1992Go; Whelan and Vlahos, 2000Go). Diuretics are commonly used for preventing renal failure when oliguria is not associated with significant hypotension or haemoconcentration (Whelan and Vlahos, 2000Go). Different conservative attitudes have been adopted in more severe complications (thromboembolic phenomena, renal failure, hepatic damage or severe pulmonary compromise), a close monitoring in an intensive care unit being mandatory.

Alternative approaches have been proposed. Re-infusion or autotransfusion of ascitic fluid, similar to that applied in cirrhotic patients, has shown limited but promising results (Fukaya et al., 1994Go; Koike et al., 2000Go; Takamizawa et al., 2002Go). In other cases of severe OHSS, aspiration of the corpus lutea (Fakih and Bello, 1992Go; Oleszczuk et al., 2002Go) and even termination of pregnancy (Reed et al., 1990Go; Whelan and Vlahos, 2000Go) have halted the disease.

As cited above, all the therapies for OHSS described in the literature are conservative. We should bear in mind that most women who undergo COH are infertile and, therefore, the possibility of their becoming pregnant must always be the foremost aim. This is especially crucial in cases of oocyte donors whose fertility potential can be adversely affected after an aggressive treatment when OHSS occurs. Of the many cases of severe OHSS encountered every year in fertility clinics, only a very few cases of death have been reported (Cluroe and Synek, 1995Go; Semba et al., 2000Go). To date, no author has ever proposed an irreversible surgical solution for the treatment of this syndrome. Therefore, we do not believe that oophorectomy (total or partial) is an option in severe OHSS, as suggested by Amarin (2003Go), except for cases of irreversible ovarian damage after adnexal torsion (Pryor et al., 1995Go; Sills et al., 2000Go).

For many years, it has been shown that any surgical procedure resulting in loss of viable ovarian cortex could reduce the ovarian reserve, leading to a decreased response to gonadotrophins and to a shortening of the life span of the ovarian tissue (Donnez et al., 1996Go; Chang et al., 1998Go; Hemmings et al., 1998Go; Saleh and Tulandi, 1999Go). It is also known that women with only one ovary show reduced ovarian reserve due to the depletion of the total number of primordial follicles and may have a shorter reproductive life span (Lass, 1999Go). Moreover, surgical techniques in reproduction such as ovarian wedge resection, carried out in PCOS women, were abandoned because of the risk of post-surgical adhesion formation (Farquhar et al., 2001Go). Among the different surgical treatments described in gynaecology, oophorectomy is one of the most aggressive. Surgeons prefer to avoid it in benign pathologies. It is important not to confuse mutilating surgery with procedures developed for improving the ovarian response. Laparoscopic ‘drilling’ of ovaries in PCOS women was designed to improve the follicular response and to reduce the risk of OHSS after COH (Rimington et al., 1997Go). Although its effectiveness as a primary treatment for subfertile patients with anovulation and PCOS is undetermined and does not seem to influence pregnancy or miscarriage rates following COH, this therapy does seem to reduce the risk of OHSS and has not been correlated with a later decreased fertility (Rimington et al., 1997Go; Farquhar et al., 2001Go; Amer et al., 2002Go). Hence, against what Amarin (2003Go) suggested, the long-term anatomical and physiological sequelae do not seem to be similar in ovarian ‘drilling’ and partial oophorectomy.

Partial or total oophorectomy should only be an option in severe OHSS if other therapies could not demonstrate good results. However, there are many effective conservative approaches employed in the battle against this syndrome. Even in cases of adnexal torsion, laparoscopic or laparotomic unwinding is the treatment of choice when the ovary remains viable and functional (Gorkemli et al., 2002Go), also in advanced gestation (Levy et al., 1995Go). An infertile woman or oocyte donor usually prefers to spend even some days in the intensive care unit of a hospital rather than have her fertility potential and ovary function adversely affected, or undergo a risky surgery such as partial oophorectomy in a hyperstimulated ovary. In addition, owing to the lack of experience, partial oophorectomy cannot be offered to the patient as a proven solution for severe OHSS. From a medical point of view, termination of pregnancy would be a better option in very severe late OHSS, as patients with this syndrome tend to be good responders and are likely to become pregnant again in a future cycle.

Our experience is in accordance with previous reports. We have collected all those cases of severe OHSS that occurred in our clinic in the last 2 years, thereby including the more recently described conservative strategies. From the beginning of January 2000 to the end of October 2002, 13 736 IVF cycles were carried out in the five Spanish clinics of the Instituto Valenciano de Infertilidad (Valencia, Madrid, Murcia, Sevilla, Almería). Only 144 cases of severe OHSS occurred, implying an incidence of 1.05%. The criteria used to classify OHSS as severe were the following: tense or painful ascites, difficulty in breathing, hydrothorax, pericardial effusion, oligouria, adnexal torsion, renal failure, hepatic damage, thrombo-embolic events, adult respiratory distress syndrome, haematocrit ≥45% or increased more than 30% over a previous one, ≥15 000 leukocytes/mm3, electrolyte imbalance (sodium <135 mEq/l and/or potassium >5 mEq/l), creatinine >1.0 g/dl, coagulation abnormalities or any serious organic complication. We tend towards an early active management in cases of moderate and severe OHSS on an outpatient basis, carrying out mainly isolated or repeated transvaginal paracentesis, oral and/or intravenous fluid balance, albumin infusion and close follow up. Hyperstimulated women at risk of thrombosis are put on a low molecular weight heparin regimen. Only when clinical or laboratory parameters are severely affected or when the patient’s condition fails to improve is hospitalization mandatory. The vast majority of our severe OHSS cases presented tense or abundant ascites, difficulty in breathing, oliguria and increased white or red blood cell counts; maybe due to early active therapy and close monitoring, only few of these presented truly life-threatening conditions. We performed aspiration of the corpus lutea in three women with twin pregnancies and OHSS not responding to medical management. One of these also underwent a laparoscopy in order to untwist an adnexal torsion at 7 weeks gestation, and another presented hydrothorax and sacral oedema. They showed a sudden recovery within 24 hours and there was no need for further conservative treatment. No case of death was registered and it was not necessary to perform mutilating ovarian surgery. Table III shows a summary of the management of our severely hyperstimulated patients.


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Table III. Management of severe OHSS in Instituto Valenciano de Infertilidad centres (January 1, 2000–October 30, 2002)
 
In conclusion, we do not consider ovarian mutilating surgery to be a viable option in the management of OHSS as proposed by Amarin (2003Go), except in cases with evident tissue necrosis. In our experience, and that of other experts worldwide, partial or total oophorectomy is not recommended in cases of OHSS. The preservation of fertility is paramount when we face a case of severe OHSS. Therefore, the only acceptable approach to OHSS must be a conservative one. Individualization of the COH regimen and an early active management when OHSS initiates are the keys for reducing the incidence and severity of this disease.


    Acknowledgements
 
The authors would like to thank Dr Juan Antonio García-Velasco (IVI-Madrid), Dr Agustín Ballesteros (IVI-Murcia), Dr José Navarro (IVI-Sevilla) and Dr Manuel Muñoz (IVI-Almería) for their collaboration in collection of data of the hyperstimulated patients.


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