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به نام خدا. Ovarian hyperstimulation syndrome (OHSS) Dr Marzieh Agha Hosseini,Infertility Department,Shariati Hospital , Tehran University Of Medical Sciences. OHSS is a iatrogenic complication of controlled ovarian stimulation.
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به نام خدا • Ovarian hyperstimulation syndrome • (OHSS) • Dr Marzieh Agha Hosseini,Infertility Department,Shariati Hospital , Tehran University Of Medical Sciences
OHSS is a iatrogenic complication of controlled ovarian stimulation
OHSS is a exaggerated response to this process with use of gonadotropin
Incidence – severe • Moderate to severe 3.1- 8 /20
pathophysiology • Released of vasoactive mediator from hyper stimulated ovaries increase permeability of capillary • Extra vasation of fluid into third space – hemoconcentration- hypercoagulability • Reduced organ perfusion • HCG is critical mediator • Early OH.SS • Late OH.SS
HCG play a role in pathophysiology of OHSS • Release VEGFA increase angiogenesis hyper permeability • VEGFA is increase after HCG administration
Another pathophysiology • Intra ovarian renin angiotensin system (RAS) • RAS – regulating vascular permeability angiogenesis endothelial proliferation prostaglandin released • H.CG – strong activation of RAS RAS + increasing VEGF level = OHSS
Prevention of OHSS • No perfect strategy completely eliminate OHSS • But can reduce the incidence
Primary risk factor • Identifying at risk women young age low body weight PCOs previous history of OHSS
Hormonal marker • AMH = best predictor than … estradiol
Ultra sonographic marker • Antra follicle count (AFC) ≥ 24 • AFC = AMH
Secondary risk factor • During COS ultrasound , serum E2 are vital component • ≥ 18 follicle 11mm on ultrasound • E2 ≥ 5000 ng/L
Risk stratification • Prevention : 1- primary 2-secondary
Primary prevention • Treatment regimen modified in high risk reduce gonadotropin dose avoiding GNRH agonist protocol reducing gonadotropin duration (antagonist protocol) metformin therapy
Individualising IVF treatment regimen • OHSS cancellation • Age – AFC – FSH- calculation starting FSH dose
Alternative for triggering ovulation • No agent completely eliminate risk OHSS HCG long half life – luteotropic effect dose HCG ?? • GNRH agonist shorter midcycle surge(24-36 h) • Dual trigger 2000 IUHCG + GNRHa
Recombinant LH (RLH) • Half life (10 h) • OHSS not reduced • Lower pregnancy not recommended
Secondary prevention • coasting • cryopreservation of embryo GNRHa trigger+ freeze all • Cancellation with holding HCG
Alternative method of prevention • Colloid infusion • Albumin not recommended • Hydroxy starch ( HES ) • Cabergoline dopamine agonist VEGF vascular permeability OHSS moderate pregnancy not changed recommended HCG trigger
Vasopressin induced VEGF • Secretion blockade • Vasopressin VIa receptor antagonist(relcovapton)
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