INTRODUCTION

2. INTRODUCTION �Why is it a concern?� Marked increase in patient population in infertility clinics Changing lifestyle Advances in the field of ART - �Double edged sword� ART technology - patient friendly - economy - less complication

3. What is OHSS? Life Threatening Complication A medical complication completely iatrogenic and unique to the treatment of infertility Is an acute, reversible condition Essential characteristics -cystic enlargement of ovaries -fluid shift from intravascular compartment to third space with it�s attendant sequelae

4. INCIDENCE World registry of ART � 100 � 200 / lakh stimulated cycles per year Mild � 8 � 23% Moderate � 0.005 � 7% Severe � 0.008 � 1.8% After COH 7.3% (mild or moderate) 4.2% (severe disease)

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6. ETIO-PATHOGENESIS Enigma Very complex Poorly understood

8. COMPLICATIONS Vascular - Thrombo Embolism, DIC Abnormal Liver Function Respiratory � ARDS due to pleural effusion or massive ascites Renal � prerenal failure, hydroureter GIT � ascites, intraperitoneal hemorrhage Ovarian � Torsion, rupture

10. Golan et al, 1989Daniel Navot et al, 1992 Severe OHSS Clinical ascites, hydrothorax Hemoconcentration � PCV > 45%, TC � 15000/ml Oliguria with normal serum creatinine Liver dysfunction Anasarca, Ovarian size > 12 cms Critical OHSS Tense ascites Worsening hemoconcentration � PCV > 55%, TC > 25000/ml Oliguria with elevated serum creatinine Thromboembolic phenomena, ovarian size > 12 cm

11. CLINICAL PICTURE Most frequent symptoms and signs are � Distention of lower abdomen Nausea and vomiting Dyspnea and respiratory distress Diarrhea Quick weight gain Ovaries enlarged up to >12 cm

14. Hypotension Pleural effusion (more, and more frequently on the right side) Adult form of respiratory distress syndrome (ARDS) Pericardial effusion Ascites Oliguria and anuria Multiple organ failure Death (1/500,000 cycles)

15. BIOCHEMICAL FINDINGS Hypovolemia Hemoconcentration (hematocrit > 45%) Leukocytosis > 15,000/mm3 Electrolyte disorders (hyponatremia < 136 mEq/L; hyperkalemia > 5.0 mEq/L) Elevated liver enzymes Hypoproteinemia and hypoalbuminemia (< 30g/L) Creatinine clearance < 50 mL minute; serum creatinine >1.2 mg/dL Hypercoagulability

16. MANAGEMENT OF OHSS Principles Monitoring Supportive therapy Maintenance of intravascular volume Prevention/treatment of complication Counselling - Signs and symptoms of OHSS Evaluate the baseline status with - complete history - complete general and systemic examination (pelvic examination contraindicated as ovaries are fragile,can rupture or undergo torsion)

17. OUTPATIENT CARE: Limit activity Weigh daily Monitor intake(1liter/day) and output Daily follow up Report if symptoms worsen or weight gain > 2lb/day

18. INPATIENT CARE: Meticulous monitoring of - vitals every 4 hours - fluid intake and output - daily weight and abdominal girth - daily hematocrit,TC,DC,Serum electrolytes, RFT - LFT,PT, APTT on admission and repeated if necessary ICU-Renal failure,ARDS,coagulation failure

19. SUPPORTIVE CARE: FLUID MANAGEMENT Hypotention and oliguria-bolus 1 litre NS over 1 hr,then DNS at 150ml/hr Oliguria persists � bolus 250 to 500 ml of NS, 25% albumin, 10 mg furosemide Oral intake � 1 liter/day ANTI COAGULANTS Heparin � abnormal clotting profile IONOTROPES Dopamine � Renal hypoperfusion

20. DIURETICS Pulmonary edema, persistent oliguria HYPERKELEMIA Corrected with insulin and glucose, calcium gluconate PARACENTESIS Large volume of ascites Persistent oliguria or hypotension ANALGESICS & ANTIEMETICS

21. SURGERY Rarely done Ovarian torsion, rupture Intraperitoneal hemorrhage Ectopic pregnancy

22. PREDICTING OHSS Young age, Low body mass index Polycystic ovary syndrome (PCOS) Higher doses of exogenous gonadotropins Absolute serum E2 level > 2500 pg/ml Day 9 E2 > 800 pg/ml Rise in E2 by 50% or more in 24 hours Previous episodes of OHSS Multiple developing follicles(20-25) Exogenous hCG for superovulation/ luteal support Multiple Pregnancy Serum VEGF, cytokines

23. PREVENTION OF OHSS Primary prevention Secondary prevention Cycle cancellation Coasting or controlled drift Drugs � GnRH analogs GnRH antagonists Recombinant LH Insulin sensitizers - Metformin IV albumin 20% ACE inhibitors + Angiotensin II receptor blocker Glucocorticoids

24. USG Guided Follicular Aspiration Elective Embryo Cryo Preservation and Transfer in subsequent cycle In vitro maturation of oocytes (IVM) A Cochrane review (2002) Coasting effective as IV albumin No difference with IV albumin & elective cryopreservation Large scale RCTs are necessary � to prove efficacy and safety

25. CONCLUSION Incidence �underestimated Traumatising event Limit gonadotropin for ovulation induction Replace hCG by rLH ,GnRH agonist Counselling Early diagnosis and hospitalisation Proper case selection,adequate technique and training ,counselling- TAKES US A LONG WAY

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