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به نام خدا

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

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  1. به نام خدا • Ovarian hyperstimulation syndrome • (OHSS) • Dr Marzieh Agha Hosseini,Infertility Department,Shariati Hospital , Tehran University Of Medical Sciences

  2. OHSS is a iatrogenic complication of controlled ovarian stimulation

  3. OHSS is a exaggerated response to this process with use of gonadotropin

  4. Incidence – severe • Moderate to severe 3.1- 8 /20

  5. 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

  6. HCG play a role in pathophysiology of OHSS • Release VEGFA increase angiogenesis hyper permeability • VEGFA is increase after HCG administration

  7. 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

  8. Prevention of OHSS • No perfect strategy completely eliminate OHSS • But can reduce the incidence

  9. Primary risk factor • Identifying at risk women young age low body weight PCOs previous history of OHSS

  10. Hormonal marker • AMH = best predictor than … estradiol

  11. Ultra sonographic marker • Antra follicle count (AFC) ≥ 24 • AFC = AMH

  12. Secondary risk factor • During COS ultrasound , serum E2 are vital component • ≥ 18 follicle 11mm on ultrasound • E2 ≥ 5000 ng/L

  13. Risk stratification • Prevention : 1- primary 2-secondary

  14. Primary prevention • Treatment regimen modified in high risk reduce gonadotropin dose avoiding GNRH agonist protocol reducing gonadotropin duration (antagonist protocol) metformin therapy

  15. Individualising IVF treatment regimen • OHSS cancellation • Age – AFC – FSH- calculation starting FSH dose

  16. Avoiding HCG luteal phase support

  17. 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

  18. Recombinant LH (RLH) • Half life (10 h) • OHSS not reduced • Lower pregnancy not recommended

  19. Secondary prevention • coasting • cryopreservation of embryo GNRHa trigger+ freeze all • Cancellation with holding HCG

  20. 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

  21. Vasopressin induced VEGF • Secretion blockade • Vasopressin VIa receptor antagonist(relcovapton)

  22. END OF PRESENTATION THANK YOU

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