Risks of ivf

1. Risks in
IVF
AHMED ELBOHOTY
MSc, MD, MRCOG, MIGSC
Reproductive Endocrinology & Infertility consultant
Associate professor in Ain Shams University

2. ILOs
To be aware of all the potential
risks of each step in IVF/ICSI
procedure.
To counsel the patient and give
adequate information about
these risks.
To take the prophylactic
measures to decrease these risks.
To be competent to take the
needed actions to prevent OHSS
and mange it in a perfect way .

3. ILOs
• To be aware of all the potential risks of each step in IVF/ICSI
procedure.
• To counsel the patient and give adequate information about
these risks.
• To take the prophylactic measures to decrease these risks.
• To be competent to take the needed actions to prevent
OHSS and mange it in a perfect way .
4/16/20 Elbohoty 3

4. Risks in IVF
Procedu
re
Stimulatio
n
Egg collection Surgical sperm
recovery
Embryo
transfer
Pregnancy Long term
RISKS Poor
response
Anesthetic
complications
Infection Failure MP Woman
Borderline
ovarian tumour
OHSS Infection Bleeding Ectopic Children
Childhood cancer
risk Imprinting
disorders
Torsion Hemorrhage Testicular
atrophy
Miscarriage
SE of
medication
s
Visceral damage Abnormal child
Bowel Transmission of
genetic disease
Ureteral injury VTE
nerve injury Placenta
previa/adherence
4/16/20 Elbohoty 4
Emotional Psychological Financial

5. Pelvic infection
•It results from the transvaginal oocyte retrieval
(TVOR).
•It has been reported between 0.02% to 0.5
•It must be recognized and managed
appropriately to avoid serious consequences
such as an acute abdomen or pelvic abscess.
4/16/20 Elbohoty 5

6. Why
• Bacterial flora from the vagina
• Reactivation of latent pelvic inflammatory disease
• Direct colonic injury.
• Endometriotic cyst
4/16/20 Elbohoty 6

7. Type of organism
• E. coli is the most common
• Enterococcus, Bacteroides, Peptostreptococcus, and other
anaerobes)
4/16/20 Elbohoty 7

8. How to decrease:
• Using the fewest possible vaginal punctures.
• Using vaginal disinfectants (controversial).
• with 1% solution of povidone-iodine was associated with a lower
pregnancy rate secondary to the possible embryotoxic effects of
the disinfectants
• Rinsing the vagina with saline, instead, did not cause a significant
risk of infection, but it did have a much higher pregnancy rate of
30% compared to only 17% in the disinfectant group
• recent studies have shown that preparing the vagina with
povidone iodine followed by thorough saline irrigation prior to the
punctures helps prevent pelvic infection without compromising
pregnancy outcome
• Prophylactic antibiotics (controversial) and even antifungal
agents (highly controversial) may also help decrease the risk
of pelvic infection however it should be mandatory in high
risk patients such as those with history of pelvic
inflammatory disease or endomteriosis.4/16/20 Elbohoty 8

9. Dealing with endometriotic cysts
• Those patients should be handled with more stringent
protocols for prophylaxis whether that be antibiotics, and/or
vaginal preparation.
• Avoid the puncture and aspiration of an endometrioma
during TVOR, which is why a good ultrasound technique is
essential during this procedure.
4/16/20 Elbohoty 9

10. Bleeding
• Intraperitoneal bleeding may originate from the ovarian
vein, iliac or sacral vessels, or from the actual follicle
puncture.
• Other sources of bleeding can be ovarian lacerations, and
ruptured endometriomas.
• Major bleeding is reported in 0.03-0.5% of IVF cases.
4/16/20 Elbohoty 10

11. How to decrease?
• Patients with a known bleeding tendency or on
anticoagulants should be optimized preoperatively
• Limiting the number of vaginal punctures
• Ultrasound visualization of peripheral follicles in a cross
section before puncture, and using color Doppler whenever
possible (color Doppler is not commonly used and not
available in all IVF centers).
• Structures should always be visualized in the longitudinal
and transverse axis.
4/16/20 Elbohoty 11

12. Detection
• Hematomas should be suspected in patients with worsening
lower abdominal pain, falling serial hematocrits, and anemia
symptoms such as lightheadedness, weakness, shortness of
breath, and/or palpitations.
• Peritoneal signs on physicalexam may help differentiate the
location of the hematoma.
• Both intraperitoneal and extraperitoneal hematomas may
form secondary to the bleeding, and are best definitively
diagnosed with CT scans.
4/16/20 Elbohoty 12

13. Management
• Hospitalization with close monitoring and according
to the general codition of the patient and continuity
of bleeding:
• Hemodynamically stable patients without signs of
deterioration can be managed conservatively.
Many hematomas resorb without the need for
evacuation and exploratory surgery.
• Unstable patients should be explored
• Coagulation disorders should also be considered in
patients with bleeding complications after TVOR.
This is especially a concern for patients with massive
bleeding, but no significant vascular injury
4/16/20 Elbohoty 13

14. Torsion
• Superovulation protocols used in IVF lead to transiently
enlarged, multicystic ovaries that are at risk for torsion.
• This can enlarge the ovaries to two to four times the normal
size even after follicular aspiration.
• The incidence of torsion is approximately 0.1% overall.
• It rises significantly with OHSS (2%) and more rise in IVF
pregnant patients with OHSS (reprted up to 16%)
4/16/20 Elbohoty 14

15. Management
• The gold standard has shifted to a more
conservative approach which encourages
laparoscopic untwisting of the ovary, especially in
young infertile women.
• Early surgical intervention can allow for reperfusion
and preservation of the affected ovary, especially if
performed within six hours of the torsion.
• Although the current conservative surgical
management approach for adnexal torsion has been
shown to be successful, it does not mean that
adnexal necrosis can never occur.
4/16/20 Elbohoty 15

16. Ureteral and nerve injury
• Extremely rare
• Limiting the number of needle punctures is again very
important in decreasing the risk of injury to surrounding
structures whether they are bowels, vessels, ureters, or
nerves.
4/16/20 Elbohoty 16

17. Summary of surgical complications
4/16/20 Elbohoty 17

18. MP
• The more embryos that are transferred into the
uterus, the higher the risk.
4/16/20 Elbohoty 18

19. Birth defects
• Most reports on birth defects of children conceived through IVF-
ICSI show similar rates to Naturally conceived children (3%) .
• Increased incidence of rare defects (<1% of children born from
IVF-ICSI) known as
• Imprinting disorders (including Beckwith-Wiedemann, Angelman
syndromes and Wilms tumour ) (OR) (95% CI) of 3.67 (1.39–9.74)
• Hypospadias
• Sex chromosome abnormalities.
• Some genetic causes of male infertility can be transmitted (e.g.
microdeletion of Y chromosome, CF,..)
• Young men born from ICSI treatment have reduced semen
parameters favours the argument that ICSI should not be used
routinely, but only where there is a defined male factor.
4/16/20 Elbohoty 19

20. Childhood cancer
• The largest population-based study found no
association between the maternal use of fertility
drugs and the overall risk of childhood cancers,
except that exposure to maternal progesterone
markedly increased the risk of acute lymphocytic
leukaemia and sympathetic nervous system
tumours
4/16/20 Elbohoty 20

21. Miscarriage and ectopic
• Miscarriage rate is similar to that in the general population.
• Ectopic rate is at least doubled (2%) in 15 % of ectopic
pregnancy a psedosac is present in the uterus
• Heterotopic pregnancy 8:1000 ( in spontaneous pregnancy
1:30000)
4/16/20 Elbohoty 21

22. 4/16/20 Elbohoty 22
Prevalence heterotopic pregnancy
Spontaneous pregnancy1:30,000
ART pregnancy1:100-500

23. MP
Twins:
• 5.5 RR of PTD
• MBW 2350 gm
• Mean gestation 36 weeks
• LBW in 53%
4/16/20 Elbohoty 23
Triplets
• 20 x RR of PTL
• MBW 1750
• Mean gestation 32 weeks
• LBW in 90 %

24. Monozygotic twins
• Its risk following eSET (0.7–3.1%)
• in natural conceptions (0.4%).
• Blastocyst transfer and intracytoplasmic sperm
injection (ICSI) are associated with an increased
incidence of monozygotic twins following eSET
compared to cleavage stage embryo transfer (ET)
and in vitro fertilisation (IVF), respectively
4/16/20 Elbohoty 24

25. • ART is associated with a higher incidence of
placenta praevia independent of the high rate of
multiple pregnancies generated by the technique
used.
• A 2016 meta-analysis of ART singleton pregnancies
reported a RR of 3.71 (95% CI 2.67–5.16) for
placenta praevia32 that was confirmed by a 2017
meta- analysis (OR 2.67, 95% CI 2.01–3.34)
4/16/20 Elbohoty 25

26. OHSS
AHMED ELBOHOTY MD, MRCOG
Assistant professor of Obstetrics and Gynecology
Ain Shams University
4/16/20 Elbohoty 26

27. Amplitude of the problem
• In most cases OHSS is self-limiting
• Significant physical and psychosocial morbidity and
has been associated with maternal death.
4/16/20 Elbohoty 27

28. • Ovarian enlargement, increased vascular
permeability and fluid shift.
• OHSS is a dynamic condition and the level of
severity may change over time
4/16/20 Elbohoty 28

29. 4/16/20 Elbohoty 29

30. FolFol
FolFol
Fol
Fol
VESSEL
R
R
R
R
VEGF
VEGF
VEGF
VEGF
VEGF
VEGF
VEGF
Fol
Fol
Fol
High VEGF secretion
or high receptors
(Genetic predispose)
OHSS Pathophysiology
multiple
follicular
growth
FSH
hCG
luteinization
Vasoactive
mediators
­capillary
permeability
of mesothelial
surfaces
intravascular dehydration

31. 4/16/20 Elbohoty 31

32. Steps
• Ovarian stimulation by follicle-stimulating hormone (FSH)
• Exposure of ovaries to human chorionic gonadotrophin (hCG) or
luteinising hormone (LH)
• Production of proinflammatory mediators.
• Chief among these is vascular endothelial growth factor (VEGF)
• local and systemic effects of proinflammatory mediators
• Increased vascular permeability leads to loss of fluid into the third space,
manifesting as
• ascites or
• less commonly, pleural and pericardial effusions.
• a prothrombotic effect
• Hypovolemia and hyponatremia
• In severe OHSS: a typical loss of 20% of their calculated blood volume
• reduced serum osmolality and sodium.
• This paradoxical combination of hypovolaemia and hypo-osmolality has been
ascribed to a ‘reset’ of the osmotic thresholds of vasopressin and thirst to lower
osmolality and sodium levels as these women remain able to concentrate and
dilute their urine around the new, lower, level of osmolality.4/16/20 Elbohoty 32

33. in one-third of women with severe OHSS
• is rare.
• Hyperkalemia
• Hyponatremia
• VTE
• 25–40% of severe OHSS which
normalise with resolution of the disease
a rare associated with vigorous intravenous fluid
therapy.
• Death: any related death to OHSS must be reported to the Confidential Enquiries
into Maternal Deaths, irrespective of whether the woman was pregnant
4/16/20 Elbohoty 33

34. • The true incidence of OHSS remains unknown because there is
no mandatory reporting for mild and moderate cases.
• OHSS is rare following ovulation induction with clomiphene, or
monofollicular ovulation induction with gonadotropins, but it has
been reported.
• Very rarely, OHSS may occur spontaneously, in association
with pregnancy
4/16/20 Elbohoty 34

35. Incidence:
•Mild cases of OHSS: 30%
•Moderate :3-8 %
•Sever cases of OHSS: 0.1– 2%
In IVF stimulated cycles
354/16/20 Elbohoty

36. It can be fatal
• Overall mortality from IVF: 1:20000
• Mortality from OHSS: 1:500-1000
4/16/20 Elbohoty 36

37. Patients at risk of OHSS
Before stimulation During stimulation After stimulation
Previous OHSS. GnRH agonist Increased egg numbers
Young age <35 years High follicle numbers Exogenous hCG for
luteal phase support.
AFC > 16
AMH>25 pmol/L
PCOS patients.
High or Rapidly rising
serum E2
Pregnancy particularly
multiple pregnancy
Low BMI
• Third of cases of severe OHSS occur in cycles that would not be considered ‘high-
risk’
• Predictive value of these parameters is poor, especially for late OHSS with no single
parameter, or combination of parameters, that offers reliable prediction of OHSS.
4/16/20 Elbohoty 37

38. Prevention OHSS

39. • Correct the cause e.g. thyroxine in hypothyrodism, bromochriptine for
pituitary adenoma,…
• Clomiphin citrate +/- metformine
• Laparoscopic ovarian drilling in PCOS who do not conceive with clomifene.
• chronic low-dose step-up regimen aiming for monofolicular ovulation
• Cancel induction cycles for more than 2 recruited follicles
4/16/20 Elbohoty 39

40. Important factors to consider in
preventing OHSS are
• avoiding cycle cancellation
• maintaining the pregnancy rate without compromising the
outcome of ART
• reducing or preventing the risk of OHSS occurrence.
4/16/20 Elbohoty 40

41. Prevention of OHSS during IVF cycles
1. Identifying the patients at risk before ovulation induction e.g.
• previous OHSS, high AFC, AMH, …..
2. Proper ovulation induction protocol
1. Use of GnRH antagonist with proper calculation of the dose of HMG
2. Use metformin (1500mg/day) in PCOS patients.
3. Careful monitoring of ovarian response:
• US & E2
4. Patients at risk during ovulation induction:
• Step down FSH dose
• Coasting
• Use GnRH agonist in antagonist protocol
• Decrease hCG dose
• Cryopreservation of all embryo and transfer in unstimulated cycle
5. Single embryo transfer
6. Use adjuvants treatments , such as metformin, dopamine agonist, antagonists for
VEGF
7. Luteal phase support with progesterone
8. Cancel the cycle4/16/20 Elbohoty 41

42. Monitoring with US and E2
• No additional benefit of greater efficiency in combination of
adding E2 to TVUs in LB, Pregnanacy and OHSS.
• A combined monitoring protocol may need to be retained as
precauitionary good clinical practice and a confirmatory test
in a subset of women to identify those at high risk of OHSS
• Cochrane Syst Rev, 2014
4/16/20 Elbohoty 42

43. GnRH Antagonist
• The use of an antagonist protocol compared with
long GnRH agonist protocols was associated with a
large reduction in OHSS (OR .15)
• Lower live birth rate
• Higher early miscarriage rate
• Effect dependent on type of luteal phase support
• Not seen in ovum recipients
• Cochrane Syst Rev, 2014
Elbohoty 434/16/20

44. Shift from agonist to GnRH antagonist
during the stimulation
Prevention of OHSS (Continued)
Despite being pretreated with GnRH agonist and without
withholding gonadotropins, serum E2 decreased by 49.5% of
pretreatment value after initiation of ganirelix
But to trigger with agonist needs to withhold agonist for at
least 4 days
Elbohoty 444/16/20

45. Triggering ovulation and OHSS
•Gonadotrophin releasing hormone
agonist to trigger ovulation in
antagonist + freeze all (is the best
prevention)
• Reducing the hCG trigger dose (5000IU)
• The use of recombinant hCG to trigger ovulation
• Recombinant LH for triggering ovulation.
Elbohoty 454/16/20

46. Trigger with GnRha
•0.2 IU (between 0.1 to
0.4)
4/16/20 Elbohoty 46

47. Choice Of Trigger For Final Oocyte Maturation Prior
To Retrieval
Elbohoty 47
• The use of a GnRH agonist to trigger oocyte
maturation prior to oocyte reduces the risk of OHSS.
(Grade A)
• But live-birth rates are lower in fresh autologous
cycles after GnRH trigger, but not donor-recipient
cycles. (Grade A)
• The reproductive outcomes are improved when a
low dose of hCG is co-administered at the time of
GnRH agonist trigger for luteal support. (Grade B)
4/16/20

48. co-administration of low-dose hCG at the
time of GnRH agonist administration
• It supports the post- retrieval luteal phase to help mitigate
the reported reduction in pregnancy rate when GnRH
agonist is administered alone.
4/16/20 Elbohoty 48

49. It is not enough in who exhibit signs of
significant suppression of the
hypothalamic-pituitary axis
• lower follicle-stimulating hormone (FSH) and LH levels at
baseline as well as lower LH levels on the day of GnRH
agonist trigger.
• irregular menses and prolonged oral contraceptive pill use,
as well as a trend to lower body mass
4/16/20 Elbohoty 49

50. Diagnosis of insufficiency
• suboptimal LH surge (LH <15) after trigger with
GnRH agonist alone or in combination with low-
dose hCG
4/16/20 Elbohoty 50

51. Use of metformin in PCOS cases
• It increases clinical pregnancy rate with decreasing
the risk of OHSS
4/16/20 Elbohoty 51

52. Cabergoline
• It reduces the incidence, but not the severity of
OHSS, without compromising pregnancy outcomes.
• Cabergoline may work through the relation between
VEGF/VEGFr and its relation with the
neurotramitter dopamine
• 0.5 mg/day from the day of trigger (not supported by
RCOG)
Elbohoty 524/16/20

53. Can Aspirin Reduce The Risk Of
OHSS?!
Elbohoty 53
• There is fair evidence that aspirin reduces the
incidence of OHSS based on a single randomized
trial comparing aspirin alone with no treatment
and another study comparing combined
acetylsalicylic acid and steroid treatment with no
treatment.
• a daily dose of 100 mg aspirin from the first day of
stimulation until the day of the pregnancy test
4/16/20

54. Coasting
It is withholding gonadotropins for few days before
giving hCG until E2 drops to a safer level.
Available evidence suggests that such “coasting” does
not adversely affect outcome in IVF cycles unless
it is prolonged (>2 days)
> 4 days affects implantation
to stop the gonadotrophins when the leading follicles
reach 16 Till the E2 drops to < 3000 pg/ml
4/16/20 Elbohoty 54

55. Coasting
• How to monitor coasting cycles?
vDaily E2 assays.
vDaily folliculometry.
• When to give hCG?
vWhen E2 levels drop to 3000 pg/ml
Elbohoty 554/16/20

56. Problems with coasting:
vOccasionally E2 drops markedly to very low levels and
cycle is canceled.
vDifficulty in identification of oocytes in aspirated
follicular fluid after prolonged coasting.
Elbohoty 564/16/20
There is insufficient evidence to recommend
coasting for the prevention of OHSS. (Grade
C)

57. Can Albumin Prevent OHSS Risk?
•Given mixed results in the literature, there
is insufficient evidence to conclusively
state that albumin lowers the risk of
OHSS.
Elbohoty 574/16/20

58. Can Calcium Prevent OHSS Risk?
Elbohoty 58
•There is fair evidence that
calcium lowers OHSS risk.
4/16/20

59. Can Calcium Prevent OHSS Risk?
Elbohoty 59
•10 mL of 10% calcium gluconate in 200 mL
normal saline) on the day of oocyte
retrieval and days 1, 2, and 3 after oocyte
retrieval
4/16/20

60. Cryopreservation for all Prevent OHSS Risk?
Elbohoty 60
• there is fair evidence that cryopreservation prevents
OHSS (the late type) and if combined with the GnrH
trigger there is elimination of the risk
4/16/20

61. Elective Single Embryo Transfer
Elbohoty 61
•It is recommended in patients at high
risk for ovarian hyperstimulation
syndrome.
4/16/20

62. Withholding hCG and cycle
cancellation
•It is seldom used
•Cycle cancellation before the administration of
human chorionic gonadotropin is an effective
strategy for the prevention of ovarian
hyperstimulation syndrome, but the emotional
and financial burden it imposes on patients
should be considered before the cycle is
cancelled.
Elbohoty 624/16/20

63. Management
• Setting
• Team
• Fluid balance
• VTE prophylaxis
• Paracentesis
• Diuretics
• Adjuvants
4/16/20 Elbohoty 63

64. Organisation of services
• Fertility clinics should provide
• verbal and written information concerning OHSS to all women
undergoing fertility treatment
• a 24-hour contact telephone number.
• Agreed local protocols for the assessment and
management of these women
• Close liaison and coordination between fertility
centers and acute units where their patients may
present.
4/16/20 Elbohoty 64

65. Initial assessment
•Face-to-face assessment by a clinician if there
is any doubt about the diagnosis or if the
severity is likely to be greater than mild
4/16/20 Elbohoty 65

66. • Clinical
• a history of ovarian stimulation
• followed by the typical symptoms of abdominal
distension, abdominal pain, nausea and vomiting.
4/16/20 Elbohoty 66

67. Exclude other causes
• In women presenting with severe abdominal pain or
pyrexia, extra care should be taken to rule out other causes
of the patient’s symptoms.
• The input of clinicians experienced in the management of
OHSS should be obtained in such cases.
4/16/20 Elbohoty 67

68. History
• Time of onset of symptoms relative to trigger
• Medication used for trigger (hCG or GnRH agonist)
• Number of follicles on final monitoring scan
• Number of eggs collected
• Were embryos replaced and how many?
• Polycystic ovary syndrome diagnosis?
4/16/20 Elbohoty 68

69. Symptoms
• Abdominal bloating
• Abdominal discomfort/pain, need for analgesia
• Nausea and vomiting
• Breathlessness, inability to lie flat or talk in full sentences
• Reduced urine output
• Leg swelling
• Vulval swelling
• Associated comorbidities such as thrombosis
4/16/20 Elbohoty 69

70. Examination
• General:
• assess for dehydration,
• oedema (pedal, vulval and sacral);
• record heart rate,
• respiratory rate,
• blood pressure,
• body weight
4/16/20 Elbohoty 70

71. Abdominal:
• assess for ascites,
• palpable mass,
• peritonism;
• measure girth
4/16/20 Elbohoty 71

72. Respiratory:
• assess for pleural effusion,
• pneumonia
• pulmonary oedema
4/16/20 Elbohoty 72

73. Investigations
• Full blood count
• Haematocrit (haemoconcentration)
• C-reactive protein (severity)
• Urea and electrolytes (hyponatraemia and hyperkalaemia)
• Serum osmolality (hypo-osmolality)
• Liver function tests (elevated enzymes and reduced albumin)
• Coagulation profile (elevated fibrinogen and reduced
antithrombin)
• hCG (to determine outcome of treatment cycle) if appropriate
• Ultrasound scan: ovarian size, pelvic and abdominal free fluid.
• Consider ovarian Doppler if torsion suspected
4/16/20 Elbohoty 73

74. Other tests
• Arterial blood gases
• D-dimers
• Electrocardiogram (ECG)/echocardiogram
• Chest X-ray
• Computerised tomography pulmonary angiogram (CTPA) or
ventilation/perfusion (V/Q) scan
4/16/20 Elbohoty 74

75. Early Late
Classification( 1-onset)
FSH/hMGTrigger OPU ET Pregnancy
4/16/20 Elbohoty 75

76. Classification:
Elbohoty 764/16/20

77. 4/16/20 Elbohoty 77

78. Ovarian size may not correlate with severity of OHSS in cases of assisted reproduction because
of the effect of follicular aspiration. Women demonstrating any feature of severe or critical OHSS
should be classified in that category.
4/16/20 Elbohoty 78

79. 4/16/20 Elbohoty 79
• mild or moderate OHSS
• selected cases with severe OHSS.

80. • Strenuous exercise and sexual intercourse should be avoided
for fear of injury or torsion of hyper- stimulated ovaries.
• Increasing severity of pain, increasing abdominal distension,
shortness of breath and a subjective impression of reduced
urine output are dangerous symptoms and plane of care should
be modulated
• Encourage patients to drink to thirst rather than a set amount.
• Fluid intake of at least 1 litre a day should be advised.
• Outpatient management may be aided if patients are able to
maintain fluid input–output charts.
• Urine output of less than 1000 ml per 24 hours or a positive fluid
balance of greater than 1000 ml over 24 hours should prompt
medical review to assess severity.
4/16/20 Elbohoty 80

81. How
• Apropriately counselled and provided with information
regarding fluid intake and output monitoring.
• They should be provided with contact details to access
advice.
• Nonsteroidal anti-inflammatory agents should be avoided,
as they may compromise renal function.
• thromboprophylaxis with low molecular weight heparin
(LMWH) for Women with severe OHSS being managed on an
outpatient basis
• The duration of treatment should be individualised, taking
into account risk factors and whether or not conception
occurs.
• Paracentesis of ascitic fluid may be carried out on an
outpatient basis by the abdominal or transvaginal route
under ultrasound guidance.4/16/20 Elbohoty 81

82. Monitoring
• Routine review every 2–3 days is likely to be adequate
• Women should be reviewed urgently if they develop
symptoms or signs of worsening OHSS..
• Baseline laboratory investigations should be repeated if the
severity of OHSS is thought to be worsening.
• Haematocrit is a useful guide to the degree of intravascular
volume depletion.
• Laboratory haemoglobin, haematocrit, serum creatinine ,
electrolytes and liver function tests.
• pelvic ultrasound ovarian size and ascites.
4/16/20 Elbohoty 82

83. Promising treatments ?
• An observational study has suggested that GnRH antagonist
administration in women with established severe early
OHSS may result in quicker regression of the syndrome.
• Small observational studies also suggest that dopamine
agonists may have a beneficial role in the treatment of
established OHSS.
• Further research is required to evaluate these interventions.
4/16/20 Elbohoty 83

84. Principles to manage severe cases
• Phase 1: treat hemoconcentration: Normal saline & Albumin
• Phase 2: Fluid restriction
• Phase 3: Paracentesis & Diuretics
4/16/20 Elbohoty 84

85. Inpatient
4/16/20 Elbohoty 85

86. Hospital admission should be considered
for women who:
• are unable to achieve satisfactory pain control
• are unable to maintain adequate fluid intake due to nausea
• show signs of worsening OHSS despite outpatient
intervention
• are unable to attend for regular outpatient follow-up
• have critical OHSS
4/16/20 Elbohoty 86

87. Care providence
• Multidisciplinary assistance should be sought for the care of
women with critical OHSS and severe OHSS who have
persistent haemoconcentration and dehydration.
• Features of critical OHSS should prompt consideration of the
need for intensive care.
• A clinician experienced in the management of OHSS should
remain in overall charge of the woman’s care.
4/16/20 Elbohoty 87

88. Women should be assessed at least once
daily.
• increasing abdominal distension and pain
• shortness of breath
• tachycardia or hypotension
• reduced urine output (less than 1000 ml/24 hours) or
• positive fluid balance (more than 1000 ml/24 hours)
• weight gain and increased abdominal girth
• increasing haematocrit (greater than 0.45).
4/16/20 Elbohoty 88

89. •More frequent assessment is appropriate
for women with critical OHSS and those
with complications.
•Analgesia (with paracetamol and opiates)
and antiemetics may be used in women
with OHSS, avoiding nonsteroidal agents
and medicines contraindicated in
pregnancy.
4/16/20 Elbohoty 89

90. Avoid dehydration or hypervolemia
• Fluid replacement by the oral route, guided by thirst, is the
most physiological approach to correcting intravascular
dehydration.
• Women with persistent haemoconcentration despite
volume replacement with intravenous colloids (normal
saline) may need invasive monitoring and this should be
managed with anaesthetic input.
• Diuretics should be avoided as they further deplete
intravascular volume, but they may have a role in a
multidisciplinary setting if
• oliguria persists despite adequate fluid replacement and drainage of
ascites.
4/16/20 Elbohoty 90

91. Fluid replacement
• Acutely dehydrated women may need intravenous fluid
therapy to correct fluid balance, followed by oral fluids to
maintain hydration.
• Crystalloids are useful for the initial correction of
dehydration in women who are unable to maintain
adequate oral intake.
• Human albumin can been used for correction of
dehydration in women with severe OHSS.
• Human albumin solution 25% may be used as a plasma
volume expander in doses of 50–100 g infused over 4 hours
and repeated 4- to 12-hourly.
• Strict fluid balance recording should be followed for these
patients.
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92. Paracentesis
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93. Indications
• severe abdominal distension and abdominal pain
secondary to ascites
• shortness of breath and respiratory compromise
secondary to ascites and increased intra-abdominal
pressure
• oliguria despite adequate volume replacement,
secondary to increased abdominal pressure causing
reduced renal perfusion.
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94. Technique
• It is carried out under ultrasound guidance to avoid trauma
to the enlarged, vascular ovaries.
• Route:
• Both abdominal and transvaginal routes are well described.
• Abdominal paracentesis allows the insertion of an indwelling
catheter and this may minimise the need for repeat paracentesis.
• Amount:
• There is little evidence to guide clinical practice regarding the
optimal amount of ascitic fluid to be removed on any one
occasion, the time over which ascites should be drained or the
route of drainage.
• Intravenous colloid therapy should be considered for
women who have large volumes of fluid removed by
paracentesis.4/16/20 Elbohoty 94

95. Benefits
• Early drainage of ascites to lower the intra-abdominal
pressure in patients with moderate to severe OHSS may
prevent disease progression and lower the risk of severe
complications associated with this condition.
• Drainage of 2000 ml of ascitic fluid in women with severe
OHSS produced significant reductions in intra-abdominal
pressure and renal vascular resistance
• This is different to elderly patients with malignant ascites
who may experience significant fluid shifts in such situations
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96. Use of diuretics
• Diuretics should be avoided as they further deplete
intravascular volume with worsening of hypovolemia
• Careful use of diuretics may be appropriate in women who
continue to exhibit oliguria despite adequate fluid
replacement, particularly if any tense ascites that may have
been contributing to oliguria has been drained
• Only with normal haematocrite and poor urinary output:
40 mls Lasix
4/16/20 Elbohoty 96

97. VTE prophylaxis
•Full-length venous support stockings or
intermittent pneumatic compression device:
immobile women with OHSS .
•LMWH prophylaxis: Women with severe or
critical OHSS and those admitted with OHSS
•The duration of LMWH prophylaxis:
individualised according to patient risk factors
and outcome of treatment.
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98. • Continuing prophylactic heparin at least until the
end of the first trimester of pregnancy. .
• Women with moderate OHSS should be evaluated
for predisposing risk factors for thrombosis and
prescribed either antiembolism stockings or LMWH
if indicated.
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99. Atypical presentation of VTE
•Thromboembolism should be suspected
in women with OHSS who present with
unusual neurological symptoms, even if
they present several weeks after apparent
improvement in OHSS.
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100. Worsening pelvic pain in OHSS:
• Ovarian Haemorrhagae: sudden drop of
Heamatocrit/Hb
• Torsion: unilateral visceral pain with stable Hb
• Infection: Pyrexic, excessive leucocytosis
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101. Role of surgery
• Surgery is only indicated in patients with OHSS if there is a
coincident problem such as
• adnexal torsion
• ovarian rupture
• ectopic pregnancy
• It should be performed by an experienced surgeon.
• Hyperstimulated ovaries are very friable and vascular; hence
any surgery if required should only be undertaken by an
experienced surgeon.
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102. Pregnancy complications
• Clinicians should be aware, and women informed, that
pregnancies complicated by OHSS may be at increased risk
of pre-eclampsia and preterm delivery.
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103. 4/16/20
ELBOHOTY 103
Thank you