Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline

Purpose
To review and discuss the pathophysiology and prevention strategies for ovarian hyperstimulation syndrome (OHSS), which is a condition that may occur in up to 20% of the high risk women submitted to assisted reproductive technology cycles.

Ovarian hyperstimulation syndrome: pathophysiology and prevention

The role of progesterone signaling in the pathogenesis of uterine leiomyoma

Objective

To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS).



Methods

Two comprehensive systematic reviews were carried out: one examined methods of predicting either high ovarian response or OHSS and the other examined interventions aimed at reducing the occurrence of OHSS. Additionally, we describe the related pathophysiology and staging criteria.



Results

Seven studies examining methods of predicting OHSS and eight more examining methods of predicting high ovarian response to controlled ovarian stimulation were included. Current evidence shows that the best methods of predicting high response are antral follicle count and anti-Mullerian hormone levels, and that a high ovarian response (examined by the number of large follicles, estradiol concentration or the number of retrieved oocytes) is the best method of predicting the occurrence of OHSS. Ninety-seven randomized controlled trials examining the effect of several interventions for reducing the occurrence of OHSS were included. There was high-quality evidence that replacing human chorionic gonadotropin by gonadotropin-releasing hormone agonists or recombinant luteinizing hormone, and moderate-quality evidence that antagonist protocols, dopamine agonists and mild stimulation, reduce the occurrence of OHSS. The evidence for the effect of the other interventions was of low/very low quality. Additionally, we identified and described 12 different staging criteria.



Conclusions

There are useful predictive tools and several preventive interventions aimed at reducing the occurrence of OHSS. Acknowledging and understanding them are of crucial importance for planning the treatment of, and, ultimately, eliminating, OHSS while maintaining high pregnancy rates. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/uog.14684

Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention.

Immune regulatory network in successful pregnancy and reproductive failures.

Low-dose aspirin therapy to prevent ovarian hyperstimulation syndrome.

During implantation, maternal immunoactivation and tolerance are not only limited to the decidua but are also observed in the periphery, predominantly affecting the innate immune system. Since unexplained female infertility, as well as recurrent spontaneous abortion and implantation failure, are thought to be associated with pathological maternal immunotolerance mechanisms, this study focused on immune profile analysis of IVF candidates. Previous studies on peripheral natural killer (NK) cell characteristics of IVF patients have been limited to the comparison of blood samples taken prior to the IVF procedure. This study performed a follow-up study and compared patient's data obtained on the day of oocyte collection with the data 1 week after embryo transfer. The aim was to investigate phenotypic (subpopulations, CD69, T-cell immunoglobulin mucin 3 and NK-activating receptor expression) and functional (perforin and CD107a expression) changes in the peripheral NK and NK T (NKT)-like cell populations. During this short period of time around the IVF procedure, women with failed IVF reflected unfavourable Th1-oriented changes of NK and NKT-like cells. In comparison the follow-up data for women with successful conception remained principally constant. The observed peripheral changes during early pregnancy in the same individual may also have importance in successful embryo implantation.

https://www.rbmojournal.com/article/S1472-6483(10)00510-9/pdf

Possible role of natural killer and natural killer T-like cells in implantation failure after IVF

https://www.fertstert.org/article/S0015-0282(09)03461-X/pdf

Involvement of FKHR (FOXO1) transcription factor in human uterus leiomyoma growth.

In 1990, the worldwide accepted Shackleton [1] method, which provides a possibility of determining the steroid metabolites from urine, was adopted in our laboratory. The procedure is very useful in the diagnosis of different endocrine diseases and in the recognition of dysfunction or absence of enzymes with an important role in steroid metabolism, and it gives possibility to control the treatment in patients with these diseases. Besides the proximate clinical application, the method gives a convenient tool to study the steroid background of these disorders, helping us understand the mechanism of their development. In the last few years, we have examined the steroid profile of patients with hair (androgen alopecia /AA/, effluvium /E/), psychiatric problems (major depression /MD/, eating disorders /EDS/, especially anorexia nervosa and bulimia) and osteoporosis (OP). In all of the examined hair loss diseases, the levels of main androgen metabolites were increased, and elevated 5α-reductase activity were found. We could observe the alteration of the activity of 11β-hydroxysteroid dehydrogenase (11β-HSD) enzyme and marked gender differences in the changes of the steroid metabolism in patients with major depression (MD). In women with OP, the significantly decreased level of certain metabolites points to the role of testosterone, androstenedione and DHEA in postmenopausal bone loss in women. Our experiences contribute to the knowledge of the nature and steroid background of some endocrine and psychiatric diseases.

Urinary Steroid Measurements in Some Endocrine and Psychiatric Diseases

Objective The aim of the study was to compare the levels of urinary steroid metabolites of patients with successful in vitro fertilization and patients who failed to achieve pregnancy Design Comparison of urinary steroid profiles prior to oocyte pick-up and three weeks after embryo transfer Setting University hospital Sample Eleven women in the same age range with pregnancy after in vitro fertilization and eleven women who failed to achieve pregnancy Methods The standard “long” protocol was used for ovarian stimulation and intracytoplasmic sperm injection for assisted in vitro fertilization The steroid metabolites in urine samples collected for 24 h were determined by gas chromatography–mass spectrometry Main outcome measures Steroid metabolite levels in urine samples determined in the early pregnancy period Results The levels of androsterone, etiocholanolone, pregnanediol, tetrahydro-11-dehydrocorticosterone and tetrahydro-corticosterone were significantly higher (p < 005) in the urine of women with successful pregnancy three weeks after the embryo transfer, while the levels of tetrahydrocortisone, tetrahydrocortisol, allo-tetrahydrocortisol and α-cortolone became higher in the group of patients with unsuccessful pregnancy Conclusions The production of androgens, progesterone and corticoid steroid metabolites is altered in the early pregnancy period after in vitro fertilization

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0412.2012.01387.x

Ferenc Wilhelm

Papers

Low-dose aspirin therapy to prevent ovarian hyperstimulation syndrome.

Possible role of natural killer and natural killer T-like cells in implantation failure after IVF

Involvement of FKHR (FOXO1) transcription factor in human uterus leiomyoma growth.

Urinary Steroid Measurements in Some Endocrine and Psychiatric Diseases

Urinary steroid profile in early pregnancy after in vitro fertilization