IVF & OHSS Explained: Risks, Symptoms, and Treatments

Idea of IVF  

It is to retrieve 6–15 eggs through aspiration.

• Controlled ovarian hyperstimulation means trying to get many eggs in one cycle to improve the chances of conception with IVF.
• Understand with example:
• Each egg makes 150-200 pg estradiol.
• 200 x 15 eggs = 3000 pg of Estradiol: Controlled ovarian hyperstimulation, 200 x 40 eggs = 8000 pg of Estradiol: Ovarian hyperstimulation >20 eggs or >3500 pg of estradiol leads to an increase.

Vascular endothelial growth factor, renin, pro-rennin, and angiotensin increase vascular permeability. HCG is given to trigger ovulation and is also known as the final trigger for OHSS.

The size of the ovary increases in OHSS as it is filled with multiple follicles, and it can undergo:

• Torsion, Rupture of ovary,  Hemorrhage, Death

Also read: Pre Conception and Prenatal Diagnostic Techniques (PCPNDT)

Types of OHSS 

Early OHSS

• Occurs 3 to 7 days flowing hCG trigger (due to exogenous hCG)

Late OHSS

• Late-onset disease occurs 12–17 days after the hCG trigger.
• Result of endogenous hCG from pregnancy.
• More severe.

Predisposing Factors 

1. Polycystic ovarian syndrome (PCOS)
2. Hypogonadotropic hypogonadism
3. Young age
4. Low body mass index
5. Increased ovarian volume and high antral follicle count on baseline scan.
6. Elevated baseline measurements of  AMH (AMH-2 to 6 ng/ml is normal)
7. High treatment doses of FSH
8. Large number of oocytes collected (>17), · MC common cause of OHSS
   • Mild OHSS: Clomiphene citrate
   • Severe OHSS: Injection Recombinant FSH
   • Critical OHSS: injection of human menopausal gonadotropin. HCG along with these 3 leads to COH 

USG

Also read: Perineal Tears : Types, Risk Factors 

Classification

Treatment of OHSS 

• Daily examination of vitals, input and output charting (30-40 ml/hr)
• CBC, electrolytes, and LFT
• Thromboprophylaxis, TED stocking
  • Enoxaparin
  • Frequent Mobility of the patient
• Antiemetics, Analgesics

Fluid management

Give fluids to maintain perfusion. The best is to give normal saline. Colloids like injection albumin (20% albumin 100 ml over 30 mins), Dextran or FFP can be given as well  Remove fluids, Paracentesis, No limit ascitic tap; diuretics are not given.

Also read: Fetal Surveillance: Antepartum Surveillance 

Tests of Ovulation

Tests of ovulation: Tests the effects of progesterone, After ovulation: Luteal phase (14 days) is constant

• Basal body temperature
  • Progesterone is a thermogenic hormone (catabolic action)
  • Ovulation: Basal body temperature increased by 0.5°F to 1°F for 3 days.
• Serum progesterone: On day 21, if > 3 ng/mL suggestive of ovulation
• Serum LH
  • Onset of LH surge: Takes 36 hours to ovulate
  • Peak of LH surge: Take 12 hours to ovulate
  • > 15 IU suggestive of ovulation
  • After 2 hours of serum LH peak, LH can appear in urine. Serum LH should be 35 to 50 mIU/mL. Urine LH testing should be done twice a day.

Serial Follicular Monitoring 

• By transvaginal sonography (TVS) > transabdominal sonography (TAS)
• Started on day 9—indicates ovulation when: Follicular size is increasing serially (size of mature follicle: 15 to 20 mm) and then the follicle shrinks

Premenstrual Endometrial Biopsy

1. Performed around day 20 to 24 under general or local anesthesia
2. Intercourse should be avoided the whole month in which the premenstrual endometrial biopsy is scheduled to avoid the risk of accidental abortion. It is done to check secretory changes. If the secretory changes are present, then we know that ovulation occurred.
   • Check adequate secretory changes: For every day of the month, endometrial changes are different. Luteal phase defect (reason for infertility): When the difference between expected and observed changes is ≥ 2 days, a premenstrual endometrial biopsy can also be used to detect TB.

Serial Cervical Mucus Studies 

In the preovulatory phase:

• High estrogen-tin cervical mucus, Maximum stretchability at day 14 Spinnbarkeit and ferning are due to estrogen.
• After Ovulation: Serum progesterone increases, cervical mucus thickens, and loss of spinnbarkeit and ferning is due to progesterone. Loss of spinnbarkeit and ferning is suggestive of ovulation.

Diagnostic Laparoscopy 

1. It is not usually done for diagnosing ovulation.
2. Best direct evidence of ovulation.
3. Corpus luteum present (yellow punctum on the ovary): Signifies that ovulation has occurred.

Also read: 30-Day Strategy for INI-CET Exam: From Here to the Top Rank 

FAQ’S

Q. Which medicines are used for ovary stimulation?

Ans. Clomiphene citrate

Q. What is OHSS?

Ans. It is a complication that occurred during fertility treatment, mainly IVF.

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