New algorithm for OHSS prevention

Evangelos G Papanikolaou, Peter Humaidan, Nikos Polyzos, Sofia Kalantaridou, Sahar Kol, Claudio Benadiva, Herman Tournaye, Basil Tarlatzis, Evangelos G Papanikolaou, Peter Humaidan, Nikos Polyzos, Sofia Kalantaridou, Sahar Kol, Claudio Benadiva, Herman Tournaye, Basil Tarlatzis

Abstract

Ovarian hyperstimulation syndrome (OHSS) still remains a life-threatening complication of in vitro fertilization treatment (IVF), keeping patients and especially those, who previously experienced OHSS, from attempting infertility treatment and childbearing. The recent implementation of four new modalities: the GnRH antagonist protocol, GnRH agonist (GnRHa) triggering of ovulation, blastocyst transfer and embryo/oocyte vitrification, renders feasible the elimination of OHSS in connection with ovarian hyperstimulation for IVF treatment. The proposed current algorithm is based on the number of follicles developed after ovarian stimulation, setting a cut-off level at the development of 18 or more follicles. Further, fulfilling this criterion, the algorithm is based on four decision-making points: the final day of patient work-up, the day of triggering final oocyte maturation, day-1 post oocyte pick-up (OPU) and day-5 post OPU. If the physician decides to administer hCG for final oocyte maturation regardless the type of analogue used, he has the option on day-1 to either freeze all embryos or to proceed to day-5. On this day, based on the clinical condition of the patient, a decision should be made to either transfer a single blastocyst or to vitrify all blastocysts available. However, this strategy will not guarantee an OHSS free luteal phase especially if a pregnancy occurs. If the physician decides to trigger ovulation with GnRHa, feasible only with the antagonist protocol, embryos can be cultured until day-5. On this day a transfer can be performed with no risk of OHSS and spare blastocysts may be vitrified. Alternatively, on day-1 or day-2 post OPU, all embryos could be frozen. Hopefully, in a near future, GnRHa triggering and vitrification of oocytes will become everyday practice. Only the combined use of a GnRH antagonist protocol with GnRHa triggering and subsequent single blastocyst transfer or embryo/oocyte freezing will completely abolish the risk of OHSS after ovarian hyperstimulation.

Figures

Figure 1
Figure 1
New proposed algorithm for OHSS prevention and treatment. The upper pathway (traditional) applies to both the GnRH agonist and GnRH antagonist protocol. The lower pathway (innovative) applies only to the GnRH antagonist protocol.

References

    1. Rizk B, Aboulghar MA. In: In-Vitro Fertilization and Assisted Reproduction. Brinsden P, editor. New York, NY: Parthenon Publishing Group; 1999. Classification, pathophysiology and management of ovarian hyperstimulation syndrome; pp. 131–155.
    1. Papanikolaou EG, Pozzobon C, Kolibianakis EM, Camus M, Tournaye H, Fatemi HM, Van Steirteghem A, Devroey P. Incidence and prediction of ovarian hyperstimulation syndrome in women undergoing gonadotropin-releasing hormone antagonist in vitro fertilization cycles. Fertil Steril. 2006;85:112–120. doi: 10.1016/j.fertnstert.2005.07.1292.
    1. Orvieto R. Can we eliminate severe ovarian hyperstimulation syndrome? Hum Reprod. 2005;20:320–322.
    1. Mathur RS, Akande VA, Keay SD, Hunt LP, Jenkins JM. Distinction between early and late ovarian hyperstimulation syndrome. Fertil Steril. 2000;73:901–907. doi: 10.1016/S0015-0282(00)00492-1.
    1. Kol S. Prediction of ovarian hyperstimulation syndrome: why predict if we can prevent! Hum Reprod. 2003;18:1557–1558. doi: 10.1093/humrep/deg302.
    1. Papanikolaou EG, Humaidan P, Polyzos NP, Tarlatzis B. Identification of the high-risk patient for ovarian hyperstimulation syndrome: Semin. Reprod Med. 2010;28:458–462. doi: 10.1055/s-0030-1265671.
    1. Griesinger G, Diedrich K, Tarlatzis BC, Kolibianakis EM. GnRH-antagonists in ovarian stimulation for IVF in patients with poor response to gonadotrophins, polycystic ovary syndrome, and risk of ovarian hyperstimulation: a meta-analysis. Reprod Biomed Online. 2006;13:628–638. doi: 10.1016/S1472-6483(10)60652-9.
    1. Al-Inany HG, Abou-Setta AM, Aboulghar M. Gonadotrophin-releasing hormone antagonists for assisted conception: a Cochrane review. Reprod Biomed Online. 2007;14:640–649. doi: 10.1016/S1472-6483(10)61059-0.
    1. Humaidan P, Kol S, Papanikolaou EG. on behalf of the "The Copenhagen GnRH Agonist Triggering Workshop Group. GnRH agonist for triggering of final oocyte maturation: time for a change of practice? Hum Reprod Update. 2011;17:510–524. doi: 10.1093/humupd/dmr008.
    1. Loutradi KE, Kolibianakis EM, Venetis CA, Papanikolaou EG, Pados G, Bontis I, Tarlatzis BC. Cryopreservation of human embryos by vitrification or slow freezing: a systematic review and meta-analysis. Fertil Steril. 2008;90:186–193. doi: 10.1016/j.fertnstert.2007.06.010.
    1. Lee TH, Liu CH, Huang CC, Wu YL, Shih YT, Ho HN, Yang YS, Lee MS. Serum anti-Müllerian hormone and estradiol levels as predictors of ovarian hyperstimulation syndrome in assisted reproduction technology cycles. Hum Reprod. 2008;23:160–167.
    1. La Marca A, Giulini S, Tirelli A, Bertucci E, Marsella T, Xella S, Volpe A. Anti-Müllerian hormone measurement on any day of the menstrual cycle strongly predicts ovarian response in assisted reproductive technology. Hum Reprod. 2007;22:766–770.
    1. Kwee J, Elting ME, Schats R, McDonnell J, Lambalk CB. Ovarian volume and antral follicle count for the prediction of low and hyper responders with in vitro fertilization. Reprod Biol Endocrinol. 2007;15;5:9.
    1. Papanikolaou EG, Tournaye H, Verpoest W, Camus M, Vernaeve V, Van Steirteghem A, Devroey P. Early and late ovarian hyperstimulation syndrome: early pregnancy outcome and profile. Hum Reprod. 2005;20:636–641. doi: 10.1093/humrep/deh638.
    1. Humaidan P, Quartarolo J, Papanikolaou EG. Preventing ovarian hyperstimulation syndrome: guidance for the clinician. Fertil Steril. 2010;94:389–400. doi: 10.1016/j.fertnstert.2010.03.028.
    1. Schmidt D, Maier D, Nulsen J, Benadiva CA. Reducing the dose of hCG in high responders does not affect the outcomes of in vitro fertilization. Fertil Steril. 2004;82:841–846. doi: 10.1016/j.fertnstert.2004.03.055.
    1. Kol S, Itskovitz-Eldor J. Sever OHSS; Yes there is a strategy to prevent it! Hum Reprod. 2000;15:2226–2227.
    1. Symosium Aboulghar M. Update on prediction and management of OHSS. Prevention of OHSS. Reprod Biomed Online. 2009;19:33–42. doi: 10.1016/S1472-6483(10)60043-0.
    1. Engmann L, DiLuigi A, Schmidt D, Nulsen J, Maier D, Benadiva C. The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospective randomized controlled study. Fertil Steril. 2008;89:84–91. doi: 10.1016/j.fertnstert.2007.02.002.
    1. Humaidan P, Ejdrup Bredkjaer H, Westergaard LG, Yding Andersen C. 1,500 IU human chorionic gonadotropin administered at oocyte retrieval rescues the luteal phase when gonadotropin-releasing hormone agonist is used for ovulation induction: a prospective, randomized, controlled study. Fertil Steril. 2010;93:847–854. doi: 10.1016/j.fertnstert.2008.12.042.
    1. Papanikolaou EG, Verpoest W, Fatemi H, Tarlatzis B, Devroey P, Tournaye H. A novel method of luteal supplementation with recombinant luteinizing hormone when a gonadotropin-releasing hormone agonist is used instead of human chorionic gonadotropin for ovulation triggering: a randomized prospective proof of concept study. Fertil Steril. 2011;95:1174–1177. doi: 10.1016/j.fertnstert.2010.09.023.
    1. Bodri D, Guillen JJ, Galindo A, Mataro D, Pujol A, Coll O. Triggering with human chorionic gonadotropin or a gonadotropin-releasing hormone agonist in gonadotropin-releasing hormone antagonist-treated oocyte donor cycles: findings of a large retrospective cohort study. Fertil Steril. 2009;91:365–371. doi: 10.1016/j.fertnstert.2007.11.049.
    1. Saragusty J, Arav A. Current progress in oocyte and embryo cryopreservation by slow freezing and vitrification. Reproduction. 2011;141:1–19. doi: 10.1530/REP-10-0236.
    1. Castillo JC, Dolz M, Bienvenido E, Abad L, Casan EM, Bonilla-Musoles F. Cycles triggered with GnRH agonist: exploring low-dose HCG for luteal support. Reprod Biomed Online. 2010;20:175–181. doi: 10.1016/j.rbmo.2009.11.018.
    1. Papanikolaou EG, Kolibianakis EM, Tournaye H, Venetis CA, Fatemi H, Tarlatzis B, Devroey P. Live birth rates after transfer of equal number of blastocysts or cleavage-stage embryos in IVF. A systematic review and meta-analysis. Hum Reprod. 2008;23:91–99.

Source: PubMed

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