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Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome The Practice Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama This Educational Bulletin discusses the pathophysiology, risk factors, clinical features, and management and pre-vention associated with ovarian hyperstimulation syndrome (OHSS). (Fertil Steril 2008;90:S188–93. 2008 byAmerican Society for Reproductive Medicine.) Ovarian hyperstimulation syndrome (OHSS) is an exagger- effects similar to those of OHSS that can be reversed with ated response to ovulation induction therapy. The OHSS is a specific antiserum ). Recent studies also indicate typically associated with exogenous gonadotropin stimula- that hCG increases VEGF expression in human granulosa tion and is only rarely observed with use of other agents cells and raises serum VEGF concentrations (). Numer- (clomiphene citrate [CC] and gonadotropin-releasing hor- ous other factors may be involved, acting directly or indi- mone [GnRH]). Clinicians who prescribe ovulation-inducing rectly via VEGF, including angiotensin II, insulin-like agents must be prepared to recognize and manage OHSS growth factor 1 (IGF-1), epidermal growth factor (EGF), transforming growth factors (TGF) a and b, basic broblastgrowth factor (BFGF), platelet-derived growth factor OHSS is a self-limiting disorder that usually resolves spon- (PDGF), interleukin-1b (IL-1b), and interleukin-6 (IL-6) taneously within several days, but may persist for longer du- rations, particularly in conception cycles. The syndrome hasa broad spectrum of clinical manifestations, from mild illnessneeding only careful observation to severe disease requiring hospitalization and intensive care. This guideline will discuss The following factors increase the risk independently for the pathophysiology of OHSS and its risk factors, clinical developing OHSS ): features, management, and prevention.
 young age low body weight  polycystic ovary syndrome (PCOS) The hallmark of OHSS is an increase in capillary permeabil-  higher doses of exogenous gonadotropins ity resulting in a fluid shift from the intravascular space to  high absolute or rapidly rising serum E2 levels third space compartments (Factors that have been im-  previous episodes of OHSS plicated in the process include: In addition, risk rises with the number of developing ovar-  increased secretion or exudation of protein-rich fluid ian follicles (and the number of oocytes retrieved in from enlarged ovaries or peritoneal surfaces () assisted reproductive technology (ART) cycles (  increased follicular fluid levels of prorenin and renin Risk increases when higher or repeated doses of exogenous hCG are administered in superovulation and ART cycles  angiotensin-mediated changes in capillary permeability (for ovulation induction or luteal phase support) and decreases when exogenous P, rather than hCG, is used to sup- Vascular endothelial growth factor (VEGF), also known as port the luteal phase ). Pregnancy increases the likelihood, vascular permeability factor, has emerged as one of the fac- duration, and severity of OHSS symptoms.
tors most likely involved in the pathophysiology of OHSS). VEGF is an angiogenic cytokine that is a potent stimu-lator of the vascular endothelium and appears to play an inte- CLINICAL FEATURES gral role in follicular growth, corpus luteum function, and The OHSS has traditionally been classified as mild, moder- ovarian angiogenesis. The VEGF levels correlate with the ate, or severe. However, the clinical symptoms and signs of severity of OHSS (and recombinant VEGF produces OHSS exhibit a continuum of scope and severity that de-fies attempts at specific classification or staging.
Educational Bulletin Mild manifestations of OHSS are relatively common and Reviewed June 2008.
Received July 14, 2003; revised and accepted July 14, 2003.
No reprints will be available.
 transient lower abdominal discomfort Correspondence to: Practice Committee, American Society for Reproduc- tive Medicine, 1209 Montgomery Highway, Birmingham, Alabama35216.
Fertility and Sterility Vol. 90, Suppl 3, November 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
 Strenuous physical activity should be avoided as risk of  abdominal distention (observed in up to a third of super- ovarian torsion increases when the ovaries are signifi- ovulation cycles) ( cantly enlarged. Light physical activity should bemaintained to the extent possible. Strict bed rest is un- Onset of symptoms typically occurs soon after ovulation warranted and may increase risk of thromboembolism.
(in superovulation cycles) or after oocyte retrieval in ART  Weight should be recorded daily, as well as the fre- cycles, but it may be delayed.
quency and/or volume of urine output. Weight gain of Progression of illness is recognized when symptoms per- R2 pounds per day or decreasing urinary frequency sist, worsen, or include ascites that may be demonstrated should prompt repeated physical examination, ultra- by increasing abdominal girth or ultrasound evaluation. Seri- sound, and laboratory evaluation to include hematocrit, ous illness exists when pain is accompanied by one or more of electrolytes, and serum creatinine.
 Pregnant patients with OHSS must be monitored very closely because risk of progressing to severe disease is  rapid weight gain particularly high for those further stimulated by rapidly rising serum concentrations of hCG.
 hemodynamic instability (orthostatic hypotension,  In ART cycles, it may be necessary to consider cryopre- serving all embryos and deferring transfer to a subse-  respiratory difficulty (tachypnea) quent cycle after symptoms have completely resolved.
 progressive oliguria Although pregnancy rates in frozen ET cycles are gener-  laboratory abnormalities ally lower than in fresh cycles, this approach may reduce Hypotension results from extravasation of protein-rich the risk for developing severe OHSS without a marked fluid and contraction of the vascular volume, oliguria/anuria decrease in pregnancy rates per cycle from reduced renal perfusion due to decreased vascular vol-ume and/or tense ascites, and pulmonary compromise from an elevated diaphragm and/or hydrothorax. Risk of thrombo- Serious illness requiring hospitalization is relatively uncom- embolism is increased as a result of hemoconcentration, di- mon but by no means rare. Hospitalization may be required minished peripheral blood flow, and inactivity due to based on severity of symptoms, analgesic requirements, abdominal distension and pain. Life-threatening complica- and other social considerations (availability of responsible tions of OHSS include renal failure, adult respiratory distress adult supervision, support, and assistance with child care).
syndrome (ARDS), hemorrhage from ovarian rupture, andthromboembolism ().
Given the scope and severity of symptoms and the poten- tial for complications, most women with OHSS who are se-riously ill merit hospitalization for more careful monitoring and aggressive treatment. No one symptom or sign is an ab- Outpatient Management solute indication, but hospitalization should be considered Patients with mild manifestations of OHSS can be managed when one or more of the following are present: on an outpatient basis. Treatment usually requires only oral  severe abdominal pain or peritoneal signs analgesics and counseling regarding the signs and symptoms  intractable nausea and vomiting that prevents ingestion of progressing illness. Intercourse is best avoided as it may be of food and adequate fluids painful and may increase the risk of ovarian rupture.
 severe oliguria or anuria Treatment of worsening OHSS typically requires anti- emetics and more potent analgesics. Most patients still can  dyspnea or tachypnea be effectively managed and monitored on an outpatient basis,  hypotension (relative to baseline), dizziness, or syncope but they require more careful evaluation including frequent  severe electrolyte imbalance (hyponatremia, hyperkale- physical and ultrasound examinations (to detect increasing ascites), daily weight measurements, and serial laboratory  hemoconcentration determinations of hematocrit, electrolytes, and serum creati-  abnormal liver function tests nine. Careful monitoring is essential and should include at Laboratory findings in women with serious illness result- least daily communication, if not examination, to ensure ing from OHSS include ( that progression to more severe disease is promptly recog-nized.
 hemoconcentration (hematocrit >45%) leukocytosis (white blood cell count >15,000) Recommendations for the outpatient management of  electrolyte imbalances (hyponatremia: sodium <135 persistent and worsening OHSS include: mEq/L; hyperkalemia: potassium >5.0 mEq/L)  Oral fluid intake should be maintained at no less than 1 L  elevated liver enzymes per day; any of the commercially available electrolyte-  decreased creatinine clearance (serum creatinine >1.2; supplemented drinks is preferable to other beverages.
creatinine clearance <50 mL/min) Fertility and Sterility Recommendations for the evaluation and monitoring of  Albumin (25%) in doses of 50–100 g, infused over 4 hospitalized patients with OHSS include the following: hours and repeated at 4- to 12-hour intervals as neces-sary, is an effective plasma expander when infusion of  vital signs (every 2–8 hours, according to clinical status) normal saline fails to achieve or maintain hemodynamic  weight (recorded daily) stability and adequate urine output. In general, albumin  complete physical examination (daily, avoiding biman- is the preferred plasma expander (although others ual examination of the ovaries due to risk of ovarian rup- (e.g., mannitol, fresh frozen plasma) may be used. Dex- tran has been associated with development of adult  abdominal circumference (at the navel, recorded daily) respiratory distress syndrome (ARDS) and is best  monitoring of fluid intake and output (daily, or more of-  Treatment with diuretics (e.g., furosemide, 20 mg IV)  ultrasound examination (ascites, ovarian size), repeated may be considered after an adequate intravascular vol- as necessary to guide management or paracentesis (see ume has been restored (hematocrit <38%). Premature or overzealous use of diuretics will aggravate hypovole-  chest X-ray and echocardiogram (when pleural or peri- mia, and hemoconcentration, thereby increasing risk of cardial effusion is suspected), repeated as necessary  pulse oximetry (for patients with symptoms of pulmo-  Intravenous fluid administration should be sharply curtailed and oral fluid intake increased when there is  complete blood count (daily, or more often as needed to evidence that the syndrome is resolving, generally her- guide fluid management) alded by improving symptoms and onset of a brisk  electrolytes (daily)  serum creatinine or creatinine clearance, urine specific  Hyperkalemia is associated with risk of cardiac dys- gravity, repeated as necessary rhythmias. Acute management involves treatments that  liver enzymes, repeated as necessary move potassium into the intracellular space (insulin Careful and frequent re-evaluation of the hospitalized and glucose, sodium bicarbonate, albuterol) or protect patient with severe OHSS is essential. Complaints of increas- the heart from the effects of elevated potassium levels ing abdominal pain and distension demand immediate atten- (calcium gluconate). Electrocardiographic manifesta- tion, remaining mindful that pain and ascites can easily mask tions of hyperkalemia (prolonged PR and QRS intervals, ovarian rupture and acute intra-abdominal hemorrhage. Serial ST segment depression, tall peaked T waves) indicate clinical and laboratory evaluations provide the means to mon- the need for immediate treatment with calcium gluco- itor progression of illness, to judge the response to treatment, nate. Kayexelate is a cation exchange resin that removes and to recognize evidence of resolution.
potassium from the body but works more slowly (onsetof action 1–2 hours); it may be administered orally orrectally as a retention enema.
Hospitalized patients require IV fluid management to addressthe acute need for volume expansion while also considering the marked increase in vascular permeability that accom- Ultrasound-guided paracentesis may be indicated for patients panies severe OHSS. Renal and pulmonary function must with ascites that causes pain, compromised pulmonary func- be carefully monitored. Guidelines for fluid management tion (e.g., tachypnea, hypoxia, hydrothorax) (or oliguria/ for patients hospitalized with severe illness relating to anuria that does not improve with appropriate fluid manage- OHSS include the following ( ment. A transvaginal or transabdominal approach may be  Strict monitoring of fluid intake and urine output is used, under gentle ultrasound guidance (The optimal essential until symptoms improve or diuresis begins.
volume of fluid that should be removed on any one occasion,  Oral fluid intake should be carefully recorded and lim- and over what interval of time, is not well established.
ited to those amounts necessary to maintain the patient's Whereas rapid removal of large volumes of ascitic fluid has been observed to trigger dangerous compensatory fluid shifts  Rapid initial hydration may be accomplished with a bo- in elderly patients with malignant ascites, the risk of such lus of IV fluid (500–1,000 mL). Thereafter, fluids should complications in young, otherwise healthy women with be administered judiciously, in the volumes necessary to OHSS is generally small. Nevertheless, it is prudent to re- maintain adequate urine output (>20–30 mL/h) and move fluid at a deliberate pace until the desired effect is reverse hemoconcentration. Five percent dextrose in achieved, while carefully monitoring the patient's response.
normal saline is preferable to lactated Ringer's solution, Serial paracentesis may be required to maintain adequate re- given the tendency to hyponatremia. Correction of hy- nal and pulmonary function. Severe ascites may be associated povolemia, hypotension, and oliguria has highest prior- with hydrothorax, most commonly on the right, resulting ity, accepting that fluid administration may contribute to from transfer of abdominal fluid to the chest via the thoracic the accumulation of ascites.
duct. Paracentesis will generally be effective in resolving ASRM Practice Committee Ovarian hyperstimulation syndrome Vol. 90, Suppl 3, November 2008 hydrothorax and thoracentesis may be reserved for those with LH surge to promote final oocyte maturation and induce bilateral or severe pleural effusions that persist ().
ovulation ). This approach would be useful only in cyclesnot involving previous down-regulation with longer term ag- Thromboembolism is a life-threatening complication of onist treatment or use of a GnRH antagonist (e.g., ganirelix, severe OHSS, and prophylactic measures are warranted.
Full-length venous support stockings are recommended, andprophylactic heparin therapy (5,000 U SC, every 12 hours) Regardless whether hCG or a GnRH agonist is adminis- should be seriously considered. The use of an intermittent tered at midcycle, the use of exogenous P (e.g., 50 mg P in pneumatic compression device is prudent when symptoms oil IM, 100 mg P vaginal suppositories, or 8% P vaginal prevent ambulation and confine the patient to bed. Signs gel, daily) for luteal phase support rather than supplemental and symptoms suggesting thromboembolism demand prompt doses of hCG, may further reduce risks of OHSS ( additional diagnostic measures (arterial blood gas measure- When symptoms of OHSS emerge even before administra- ments, ventilation/perfusion scan) and therapeutic anticoagu- tion of hCG, cycle cancellation and less aggressive stimula- lation when the diagnosis is confirmed or strongly suspected.
tion in a subsequent cycle should be seriously considered.
Intensive care may be required for management of Although evidence indicates that meticulous follicle aspi- thromboembolic complications, renal failure, or pulmonary ration will reduce corpus luteum P production, it cannot be compromise that does not respond to supportive care and relied on to prevent development or progression of OHSS paracentesis. Renal failure will often respond to low-dose do- in ART cycles ).
pamine therapy (0.18 mg/kg/h) that will dilate renal vessels Prophylactic IV administration of 25% albumin (20–50 g) and increase renal blood flow ). Invasive monitoring of at time of oocyte retrieval has been suggested as a means to central venous pressure or pulmonary capillary wedge pres- reduce risk of OHSS when E sure and even short-term dialysis may be required. Pulmo- 2 levels are markedly elevated or there is history of a previous episode of OHSS nary intensive care may involve oxygen supplementation, Studies of its efficacy have had mixed results, and albumin thoracentesis, and assisted ventilation when more conserva- treatment risks exacerbation of ascites, allergic reactions, tive measures fail. Patients with severe OHSS who may re- and virus/prion transmission (However, a recent quire surgery for a ruptured ovarian cyst with hemorrhage, meta-analysis of five randomized controlled trials demon- torsion, or an ectopic pregnancy present a unique challenge strated that prophylactic albumin administration significantly for the anesthesiologist who is unlikely to be familiar with reduced risk of developing OHSS (odds ratio [OR] 0.28, 95% the pathophysiology of the syndrome and must be quickly ed- confidence interval [CI] 0.11, 0.73); albumin infusion may be ucated to minimize the additional risks involved ).
expected to prevent one case of severe OHSS for every 18women at risk who are treated ).
The keys to preventing OHSS are experience with ovulationinduction therapy and recognition of risk factors for OHSS.
Ovulation induction regimens should be highly individual-  Experience with ovulation induction therapy and knowl- ized, carefully monitored, and use the minimum dose and du- edge of OHSS pathophysiology, risk factors, and clini- ration of gonadotropin therapy necessary to achieve the cal features are key to preventing and managing OHSS.
therapeutic goal.
 Mild manifestations of OHSS are fairly common, occur- ring in up to a third of exogenous gonadotropin-induced Caution is indicated when any of the following indicators for increasing risk of OHSS are present:  Worsening symptoms of OHSS can still usually be man-  rapidly rising serum E2 levels aged on an outpatient basis, but frequent monitoring and  an E2 concentration in excess of 2,500 pg/mL evaluation are essential.
 the emergence of a large number of intermediate sized  Serious illness resulting from OHSS is much less com- follicles (10–14 mm) mon, but it can be life-threatening.
 Hospitalization may be necessary for patients with seri- Withholding further gonadotropin stimulation and delaying ous illness resulting from OHSS.
hCG administration until E2 levels plateau or decrease signif-icantly can reduce risks of OHSS Available evidencesuggests that such ‘‘coasting'' does not adversely affect out-come in IVF cycles unless it is prolonged (>3 days) ).
1. Blankstein J, Shalev J, Saadon T, Kukia EE, Rabinovici J, Pariente C, Given the evidence suggesting that hCG may play a pivotal et al. Ovarian hyperstimulation syndrome: prediction by number and role in the development of OHSS, a lower dose of hCG (e.g., size of preovulatory ovarian follicles. Fertil Steril 1987;47:597–602.
5,000 IU vs. the standard 10,000 IU dosage) may be prudent 2. McArdle C, Siebel M, Hann LE, Weinstein F, Taymor M. The diagnosis of ovarian hyperstimulation (OHS): the impact of ultrasound. Fertil Steril for patients judged to be at high risk for OHSS ). Alterna- tively, a GnRH agonist (e.g., leuprolide 0.5–1.0 mg SC) 3. Pride SM, James CSJ, Yuen BH. The ovarian hyperstimulation rather than hCG might be used to stimulate an endogenous syndrome. Semin Reprod Endocrinol 1990;8:247–60.
Fertility and Sterility 4. Tollan A, Holst N, Forsdahl F, Fadnes HO, Oian P, Maltau JM. Transca- hormone for in vitro fertilization: a European series and a proposal for pillary fluid dynamics during ovarian stimulation for in vitro fertilization.
prevention. Fertil Steril 1990;53:502–9.
Am J Obstet Gynecol 1990;162:554–8.
26. Mizunuma H, Andoh K, Yamada K, Takagi T, Kamijo T, Ibuki Y. Predic- 5. Goldsman MP, Pedram A, Dominguez CE, Ciuffardi I, Levin E, tion and prevention of ovarian hyperstimulation by monitoring endoge- Asch RH. Increased capillary permeability induced by human follicular nous luteinizing hormone release during purified follicle-stimulating fluid: a hypothesis for an ovarian origin of the hyperstimulation syn- hormone therapy. Fertil Steril 1992;58:46–50.
drome. Fertil Steril 1995;63:268–72.
27. Mordel N, Schenker JG. Gonadotrophin-releasing hormone agonist and 6. Bergh PA, Navot D. Ovarian hyperstimulation syndrome: a review of ovarian hyperstimulation syndrome in assisted reproduction. Hum pathophysiology. J Assist Reprod Genet 1992;9:429–38.
7. Koninckx PR, Heyns W, Verhoeven G, Van Baelen H, Lissens WD, et al.
28. Haning RV Jr, Austin CW, Carlson IH, Kuzma DL, Shapiro SS, Biochemical characterization of peritoneal fluid in women during the Zweibel WJ. Plasma estradiol is superior to ultrasound and urinary menstrual cycle. J Clin Endocrinol Metab 1980;51:1239–44.
estriol glucuronide as a predictor of ovarian hyperstimulation during 8. Koninckx PR, Renaer M, Brosens IA. Origin of peritoneal fluid in induction of ovulation with menotropins. Fertil Steril 1983;40:31–6.
women: an ovarian exudation product. Br J Obstet Gynaecol 1980;87: 29. Enskog A, Henriksson M, Unander M, Nilsson L, Brannstrom M. Prospec- tive study of the clinical and laboratory parameters of patients in whom 9. Donnez J, Langerock S, Thomas K. Peritoneal fluid volume and 17b- ovarian hyperstimulation syndrome developed during controlled ovarian estradiol and progesterone concentrations in ovulatory, anovulatory hyperstimulation for in vitro fertilization. Fertil Steril 1999;71:808–14.
and postmenopausal women. Obstet Gynecol 1982;59:687–92.
30. Golan A, Ron-el R, Herman A, Soffer Y, Weinraub Z, Caspi E. Ovarian 10. Sealey JE, Atlas SA, Glorioso N, Manapat H, Laragh JH. Cyclical secre- hyperstimulation syndrome: an update review. Obstet Gynecol Surv tion of prorenin during the menstrual cycle: synchronization with lutei- nizing hormone and progesterone. Proc Natl Acad Sci USA 1985;82: 31. Zosmer A, Katz Z, Lancet M, Konichezky S, Schwartz-Shoham Z. Adult respiratory distress syndrome complicating ovarian hyperstimulation 11. Derkx FH, Alberda AT, Zeilmaker GH, Schalekamp MA. High concen- syndrome. Fertil Steril 1987;47:524–6.
trations of immunoreactive renin, prorenin and enzymatically-active 32. Abramov Y, Elchalal U, Schenker JG. Pulmonary manifestations of renin in human ovarian follicular fluid. Br J Obstet Gynaecol 1987;94: severe ovarian hyperstimulation syndrome: a multicenter study. Fertil 12. Lightman A, Tarlatzis BC, Rzasa PJ, Culler MD, Caride VJ, 33. Pattinson HA, Hignett M, Dunphy BC, Fleetham JA. Outcome of thaw NegroVilar AF, et al. The ovarian renin-angiotensin system: renin-like embryo transfer after cryopreservation of all embryos in patients at activity and angiotensin II/III immunoreactivity in gonadotropin-stimu- risk of ovarian hyperstimulation syndrome. Fertil Steril 1994;62:1192–6.
lated and unstimulated human follicular fluid. Am J Obstet Gynecol 34. Shaker AG, Zosmer A, Dean N, Bekir JS, Jacobs HS, Tan SL. Compar- ison of intravenous albumin and transfer of fresh embryos with cryopres- 13. Geva E, Jaffe RB. Role of vascular endothelial growth factor in ovarian ervation of all embryos for subsequent transfer in prevention of ovarian physiology and pathology. Fertil Steril 2000;74:429–38.
hyperstimulation syndrome [see comments, Fertil Steril 1997;67:587– 14. Levin ER, Rosen GF, Cassidenti DL, Yee B, Meldrum D, Wisot A, et al.
9.]. Fertil Steril 1996;65:992–6.
Role of vascular endothelial cell growth factor in ovarian hyperstimula- 35. Ferraretti AP, Gianaroli L, Magli C, Fortini D, Selman HA, Feliciani E.
tion syndrome. J Clin Invest 1998;102:1978–85.
Elective cryopreservation of all pronucleate embryos in women at risk of 15. McClure N, Healy DL, Rogers PA, Sullivan J, Beaton L, Haning RV, ovarian hyperstimulation syndrome: efficiency and safety. Hum Reprod et al. Vascular endothelial growth factor as capillary permeability agent in ovarian hyperstimulation syndrome. Lancet 1994;344:235–6.
36. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in 16. Neulen J, Yan Z, Raczek S, Weindel K, Keek C, Weich HA, et al. Human novel reproductive technologies: prevention and treatment. Fertil Steril chorionic gonadotropin-dependent expression of vascular endothelial growth factor/vascular permeability factor in human granulosa cells: im- 37. Borenstein R, Elhalah U, Lunenfeld B, Schwartz ZS. Severe ovarian portance in ovarian hyperstimulation syndrome. J Clin Endocrinol Metab hyperstimulation syndrome: a reevaluated therapeutic approach. Fertil 17. Pellicer A, Albert C, Mercader A, Bonilla-Musoles F, Remohi J, 38. Aboulghar MA, Mansour RT, Serour GI, Amin Y. Ultrasonically guided Simon C. The pathogenesis of ovarian hyperstimulation syndrome: in vaginal aspiration of ascites in the treatment of severe ovarian hyperstim- vivo studies investigating the role of interleukin-1b, interleukin-6, and ulation syndrome [erratum appears in Fertil Steril 1990;54:957.]. Fertil vascular endothelial growth factor. Fertil Steril 1999;71:482–9.
18. Whelan JG 3rd, Vlahos NF. The ovarian hyperstimulation syndrome.
39. Rizk B, Aboulghar M. Modern management of ovarian hyperstimulation Fertil Steril 2000;73:883–96.
syndrome. Hum Reprod 1991;6:1082–7.
19. Warren RS, Yuan H, Matli MR, Ferrara N, Donner DB. Induction of vas- 40. Rinaldi ML, Spirtos NJ. Chest tube drainage of pleural effusion correct- cular endothelial growth factor by insulin-like growth factor I in colorec- ing abdominal ascites in a patient with severe ovarian hyperstimulation tal carcinoma. J Biol Chem 1996;271:483–8.
syndrome: a case report [comment Fertil Steril 1995;64:1228–9.]. Fertil 20. Ferrara N, Davis-Smyth T. The biology of vascular endothelial growth factor. Endocrinol Rev 1997;18:4–25.
41. Ferraretti AP, Gianaroli L, Diotallevi L, Festi C, Trounson A. Dopamine 21. Navot D, Relou A, Birkenfeld A, Rabinowitz R, Brzezinski A, treatment for severe ovarian hyperstimulation syndrome [comments Margalioth EJ. Risk factors and prognostic variables in the ovarian hy- Hum Reprod 1992;7:1181.]. Hum Reprod 1992;7:180–3.
perstimulation syndrome. Am J Obstet Gynecol 1988;159:210–5.
42. Reed AP, Tausk H, Reynolds H. Anesthetic considerations for severe 22. Delvigne A, Demoulin A, Smitz J, Donnez J, Koinckx P, Dhont M, et al.
ovarian hyperstimulation syndrome. Anesthesiology 1990;73:1275–7.
The ovarian hyperstimulation syndrome in in-vitro fertilization: a Bel- 43. Grochowski D, Wolczynski S, Kuczynski W, Domitrz J, Szamatowicz J, gian multicentric study. I. Clinical and biological features. Hum Reprod Szamatowicz M. Correctly timed coasting reduces the risk of ovarian hyperstimulation syndrome and gives good cycle outcome in an in vitro 23. MacDougall MJ, Tan SL, Jacobs HS. In-vitro fertilization and the ovar- fertilization program. Gynecol Endocrinol 2001;15:234–8.
ian hyperstimulation syndrome. Hum Reprod 1992;7:597–600.
44. Al-Shawaf T, Zosmer A, Hussain S, Tozer A, Panay N, Wilson C, et al.
24. Buyalos RP, Lee CT. Polycystic ovary syndrome: pathophysiology and Prevention of severe ovarian hyperstimulation syndrome in IVF with or outcome with in vitro fertilization. Fertil Steril 1996;65:1–10.
without ICSI and embryo transfer: a modified ‘‘coasting'' strategy based 25. Forman RG, Frydman R, Egan D, Ross C, Barlow DH. Severe ovarian on ultrasound for identification of high-risk patients. Hum Reprod hyperstimulation syndrome using agonists of gonadotropin-releasing ASRM Practice Committee Ovarian hyperstimulation syndrome Vol. 90, Suppl 3, November 2008 45. Ulug U, Bahceci M, Erden HF, Shalev E, Ben-Shlomo I. The signicance tion syndrome in an in vitro fertilization program: a prospective, random- of coasting duration during ovarian stimulation for conception in assisted ized, placebo-controlled study. Fertil Steril 1994;62:137–42.
fertilization cycles. Hum Reprod 2002;17:310–3.
50. Shalev E, Giladi Y, Matilsky M, Ben-Ami M. Decreased incidence of se- 46. Lewitt N, Kol S, Manor D, Itskovitz-Eldor J. Comparison of vere ovarian hyperstimulation syndrome in high risk in-vitro fertilization gonadotrophin-releasing hormone analogues and human chorionic patients receiving intravenous albumin: a prospective study. Hum Re- gonadotrophin for the induction of ovulation and prevention of ovarian hy- perstimulation syndrome: a case-control study. Hum Reprod 1996;11: 51. Ng E, Leader A, Claman P, Domingo M, Spence JE. Intravenous albumin does not prevent the development of severe ovarian hyperstimulation 47. Friedman CI, Schmidt GE, Chang FE, Kim MH. Severe ovarian hyper- syndrome in an in-vitro fertilization programme [comments Hum Re- stimulation following follicular aspiration. Am J Obstet Gynecol prod 1996;11:460–1.]. Hum Reprod 1995;10:807–10.
52. Ben-Chetrit A, Eldar-Geva T, Gal M, Huerta M, Mimom T, Algur N, 48. Asch RH, Ivery G, Goldsman M, Frederick JL, Stone SC, Balmaceda JP.
et al. The questionable use of albumin for the prevention of ovarian hy- The use of intravenous albumin in patients at high risk for severe ovarian perstimulation syndrome in an IVF programme: a randomized placebo- hyperstimulation syndrome [comments Hum Reprod 1994;9:753–4 and controlled trial. Hum Reprod 2001;16:1880–4.
Hum Reprod 1995;10:2750–2.]. Hum Reprod 1993;8:1015–20.
53. Aboulghar M, Evers JH, Al-Inany H. Intra-venous albumin for prevent- 49. Shoham Z, Weissman A, Barash A, Borenstein R, Schachter M, Insler V.
ing severe ovarian hyperstimulation syndrome. Cochrane Database Syst Intravenous albumin for the prevention of severe ovarian hyperstimula- Fertility and Sterility


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