Treatment of Ovarian Hyperstimulation Syndrome

ABSTRACT

Mild forms of ovarian hyperstimulation syndrome (OHSS) do not require treatment. Moderate OHSS should be followed up on an outpatient basis with no specific treatment. Severe OHSS requires proper evaluation. Investigations are done to evaluate hematocrit, electrolytes, and kidney and liver function. Conservative treatment with intravenous (IV) fluids and close monitoring is usually done. Intensive care admission is indicated in cases with severe respiratory distress or major electrolyte imbalance with elevated serum creatinine. Crystalloids in the form of IV saline and colloids as albumin or hydroxyethyl starch are commonly used to expand intravascular volume. Dopamine can be used to improve diuresis, and prophylactic heparin is administered to prevent venous thrombosis. Diuretics are generally contraindicated because they may further contract intravascular volume. Abdominal or vaginal aspiration of ascitic fluid results in marked improvement of symptoms, improved diuresis, and shortened hospital stay. The current trend to treat patients with IV fluids, albumin, and to perform aspiration of ascitic fluid on an outpatient basis has been found to be a more cost-effective protocol of treatment.

KEYWORDS

OHSS treatment - aspiration of ascitic fluid - IV albumin - hydroxyethyl starch

REFERENCES

• 1 Rizk B, Aboulghar M. Modern management of ovarian hyperstimulation syndrome.  Hum Reprod. 1991;  6(8) 1082-1087
• 2 Delvigne A, Rozenberg S. Review of clinical course and treatment of ovarian hyperstimulation syndrome (OHSS).  Hum Reprod Update. 2003;  9(1) 77-96
• 3 Borenstein R, Elhalah U, Lunenfeld B, Schwartz Z S. Severe ovarian hyperstimulation syndrome: a reevaluated therapeutic approach.  Fertil Steril. 1989;  51(5) 791-795
• 4 Aboulghar M A, Mansour R T, Serour G I, Sattar M A, Amin Y M, Elattar I. Management of severe ovarian hyperstimulation syndrome by ascitic fluid aspiration and intensive intravenous fluid therapy.  Obstet Gynecol. 1993;  81(1) 108-111
• 5 Aboulghar M A, Mansour R T. Ovarian hyperstimulation syndrome: classifications and critical analysis of preventive measures.  Hum Reprod Update. 2003;  9(3) 275-289
• 6 Rizk B, Aboulghar M. Classification, pathophysiology and management of ovarian hyperstimulation syndrome. In: Brinsden P In Vitro Fertilization and Assisted Reproduction. London, United Kingdom; Taylor and Francis 1995: 217-258
• 7 Navot D, Bergh P A, Laufer N et al. The ovarian hyperstimulation syndrome. In: Adashe EY, Rock JA, Rosenwaks Z Reproductive Endocrinology, Surgery, and Technology. Philadelphia, PA; Lippincott-Raven 1996: 2225-2232
• 8 Balasch J, Fábregues F, Arroyo V, Jiménez W, Creus M, Vanrell J A. Treatment of severe ovarian hyperstimulation syndrome by a conservative medical approach.  Acta Obstet Gynecol Scand. 1996;  75(7) 662-667
• 9 Abdalla HI, Rizk B Assisted Reproductive Technology. Abingdon, Oxford, United Kingdom; Health Press 2004: 37-39
• 10 Schenker J G. Prevention and treatment of ovarian hyperstimulation.  Hum Reprod. 1993;  8(5) 653-659
• 11 Fábregues F, Balasch J, Manau D et al. Haematocrit, leukocyte and platelet counts and the severity of the ovarian hyperstimulation syndrome.  Hum Reprod. 1998;  13(9) 2406-2410
• 12 Kodama H, Fukuda J, Karube H, Matsui T, Shimizu Y, Tanaka T. Characteristics of blood hemostatic markers in a patient with ovarian hyperstimulation syndrome who actually developed thromboembolism.  Fertil Steril. 1995;  64(6) 1207-1209
• 13 Shapiro A G, Thomas T, Epstein M. Management of hyperstimulation syndrome.  Fertil Steril. 1977;  28(3) 237-239
• 14 Kissler S, Neidhardt B, Siebzehnrübl E, Schmitt H, Tschaikowsky K, Wildt L. The detrimental role of colloidal volume substitutes in severe ovarian hyperstimulation syndrome: a case report.  Eur J Obstet Gynecol Reprod Biol. 2001;  99(1) 131-134
• 15 Abramov Y, Fatum M, Abrahamov D, Schenker J G. Hydroxyethyl starch versus human albumin for the treatment of severe ovarian hyperstimulation syndrome: a preliminary report.  Fertil Steril. 2001;  75(6) 1228-1230
• 16 Rabinerson D, Ben Rafael Z, Keslin J, Zolotarsky V, Dekel A. 10% hydroxyethyl starch for plasma expansion in the treatment of severe ovarian hyperstimulation syndrome. A case report.  J Reprod Med. 2001;  46(1) 68-70
• 17 Gamzu R, Almog B, Levin Y, Avni A, Lessing J B, Baram A. Efficacy of hydroxyethyl starch and Haemaccel for the treatment of severe ovarian hyperstimulation syndrome.  Fertil Steril. 2002;  77(6) 1302-1303
• 18 Aboulghar M A, Mansour R T, Serour G I, Amin Y. Ultrasonically guided vaginal aspiration of ascites in the treatment of severe ovarian hyperstimulation syndrome.  Fertil Steril. 1990;  53(5) 933-935
• 19 Ferraretti A P, Gianaroli L, Diotallevi L, Festi C, Trounson A. Dopamine treatment for severe ovarian hyperstimulation syndrome.  Hum Reprod. 1992;  7(2) 180-183
• 20 Tsunoda T, Shibahara H, Hirano Y et al. Treatment for ovarian hyperstimulation syndrome using an oral dopamine prodrug, docarpamine.  Gynecol Endocrinol. 2003;  17(4) 281-286
• 21 Rollene N L, Amols M H, Hudson S BA, Coddington C C. Treatment of ovarian hyperstimulation syndrome using a dopamine agonist and gonadotropin releasing hormone antagonist: a case series.  Fertil Steril. 2009;  92(3) 1169, e15-e17
• 22 Lainas T G, Sfontouris I A, Zorzovilis I Z, Petsas G K, Lainas G T, Kolibianakis E M. Management of severe early ovarian hyperstimulation syndrome by re-initiation of GnRH antagonist.  Reprod Biomed Online. 2007;  15(4) 408-412
• 23 Lainas T G, Sfontouris I A, Zorzovilis I Z et al. Management of severe OHSS using GnRH antagonist and blastocyst cryopreservation in PCOS patients treated with long protocol.  Reprod Biomed Online. 2009;  18(1) 15-20
• 24 Mills M S, Eddowes H A, Fox R, Wardle P G. Subclavian vein thrombosis: a late complication of ovarian hyperstimulation syndrome.  Hum Reprod. 1992;  7(3) 370-371
• 25 Hignett M, Spence J E, Claman P. Internal jugular vein thrombosis: a late complication of ovarian hyperstimulation syndrome despite mini-dose heparin prophylaxis.  Hum Reprod. 1995;  10(12) 3121-3123
• 26 Kodama H, Fukuda J, Karube H, Matsui T, Shimizu Y, Tanaka T. Status of the coagulation and fibrinolytic systems in ovarian hyperstimulation syndrome.  Fertil Steril. 1996;  66(3) 417-424
• 27 Katz Z, Lancet M, Borenstein R, Chemke J. Absence of teratogenicity of indomethacin in ovarian hyperstimulation syndrome.  Int J Fertil. 1984;  29(3) 186-188
• 28 Bar-Hava I, Orvieto R, Dicker D, Dekel A, Peley D, Ben-Rafael Z. A severe case of ovarian hyperstimulation syndrome: 65 liters of ascites aspirated in an on-going IVF-ET twin pregnancy.  Gynecol Endocrinol. 1995;  9(4) 295-298
• 29 Rabau E, David A, Serr D M, Mashiach S, Lunenfeld B. Human menopausal gonadotropins for anovulation and sterility. Results of 7 years of treatment.  Am J Obstet Gynecol. 1967;  98(1) 92-98
• 30 Thaler I, Yoffe N, Kaftory J K, Brandes J M. Treatment of ovarian hyperstimulation syndrome: the physiologic basis for a modified approach.  Fertil Steril. 1981;  36(1) 110-113
• 31 Padilla S L, Zamaria S, Baramki T A, Garcia J E. Abdominal paracentesis for the ovarian hyperstimulation syndrome with severe pulmonary compromise.  Fertil Steril. 1990;  53(2) 365-367
• 32 Al-Ramahi M, Leader A, Claman P, Spence J. A novel approach to the treatment of ascites associated with ovarian hyperstimulation syndrome.  Hum Reprod. 1997;  12(12) 2614-2616
• 33 Abuzeid M I, Nassar Z, Massaad Z, Weiss M, Ashraf M, Fakih M. Pigtail catheter for the treatment of ascites associated with ovarian hyperstimulation syndrome.  Hum Reprod. 2003;  18(2) 370-373
• 34 Grochowski D, Sola E, Kulikowski M, Kuczyński W, Wołczyński S, Szamatowicz M. Successful outcome of severe ovarian hyperstimulation syndrome (OHSS) with 27 liters of ascitic fluid removed by paracentesis.  J Assist Reprod Genet. 1995;  12(6) 394-396
• 35 Raziel A, Friedler S, Schachter M, Strassburger D, Bukovsky I, Ron-El R. Transvaginal drainage of ascites as an alternative to abdominal paracentesis in patients with severe ovarian hyperstimulation syndrome, obesity, and generalized edema.  Fertil Steril. 1998;  69(4) 780-783
• 36 Ozgun M T, Batukan C, Oner G, Uludag S, Aygen E M, Sahin Y. Removal of ascites up to 7.5 liters on one occasion and 45 liters in total may be safe in patients with severe ovarian hyperstimulation syndrome.  Gynecol Endocrinol. 2008;  24(11) 656-658
• 37 Ceyhan S T, Goktolga U, Karasahin E, Alanbay I, Duru N K. Continuous vaginal and bilateral thoracic fluid drainage for management of severe ovarian hyperstimulation syndrome.  Gynecol Endocrinol. 2008;  24(9) 505-507
• 38 Friedler S, Rachstein A, Bukovsky I, Ron-El R, Raziel A. Unilateral hydrothorax as a sole and recurrent manifestation of ovarian hyperstimulation syndrome following in-vitro fertilization.  Hum Reprod. 1998;  13(4) 859-861
• 39 Rinaldi M L, Spirtos N J. Chest tube drainage of pleural effusion correcting abdominal ascites in a patient with severe ovarian hyperstimulation syndrome: a case report.  Fertil Steril. 1995;  63(5) 1114-1117
• 40 Shrivastav P, Nadkarni P, Craft I. Day care management of severe ovarian hyperstimulation syndrome avoids hospitalization and morbidity.  Hum Reprod. 1994;  9(5) 812-814
• 41 Aboulghar M A, Mansour R T, Serour G I, Riad R, Ramzi A M. Autotransfusion of the ascitic fluid in the treatment of severe ovarian hyperstimulation syndrome.  Fertil Steril. 1992;  58(5) 1056-1059
• 42 Stein S F, Fulenwider J T, Ansley J D et al. Accelerated fibrinogen and platelet destruction after peritoneovenous shunting.  Arch Intern Med. 1981;  141(9) 1149-1151
• 43 Splendiani G, Mazzarella V, Tozzo C, Elli M, Casciani C U. Autologous protein reinfusion in severe ovary hyperstimulation syndrome.  J Am Coll Surg. 1994;  179(1) 25-28
• 44 Fukaya T, Chida S, Terada Y, Funayama Y, Yajima A. Treatment of severe ovarian hyperstimulation syndrome by ultrafiltration and reinfusion of ascitic fluid.  Fertil Steril. 1994;  61(3) 561-564
• 45 Koike T, Araki S, Minakami H et al. Clinical efficacy of peritoneovenous shunting for the treatment of severe ovarian hyperstimulation syndrome.  Hum Reprod. 2000;  15(1) 113-117
• 46 Csokmay J M, Yauger B J, Henne M B, Armstrong A Y, Queenan J T, Segars J H. Cost analysis model of outpatient management of ovarian hyperstimulation syndrome with paracentesis: “tap early and often” versus hospitalization.  Fertil Steril. 2010;  93(1) 167-173