Prevention of severe ovarian hyperstimulation syndrome in IVF with or without ICSI and embryo transfer: a modified `coasting' strategy based on ultrasound for identification of high-risk patients

Abstract

Ovarian hyperstimulation syndrome (OHSS) can be a severe and potentially life-threatening complication of ovarian stimulation for IVF. Coasting or withholding gonadotrophin stimulation relies on frequent estimation of serum oestradiol to identify patients at risk. A modified coasting protocol was developed in which identification of patients at risk of severe OHSS was based on ultrasound monitoring. Serum oestradiol concentrations were measured only in patients with >20 follicles on ultrasound (high risk). If serum oestradiol concentrations were <3000 pmol/l, the gonadotrophin dose was maintained; if concentrations were ≥3000 pmol/l but <13200 pmol/l and ≥25% of the follicles had a diameter of ≥13 mm, the gonadotrophin dose was halved; and if serum oestradiol concentrations were ≥13 200 pmol/l and ≥25% of the follicles had a diameter of ≥15 mm, patients were coasted. In the latter group, human chorionic gonadotrophin (HCG) 10000 IU was administered when at least three follicles had a diameter of ≥18 mm and serum oestradiol concentrations were <10000 pmol/l. Over a 10 month period, serum oestradiol concentrations were measured in 123 out of 580 cycles (24%) and in 50 cycles, gonadotrophins were withheld. Overall, moderate OHSS occurred in three patients (0.7%) and severe OHSS in one patient (0.2%). The pregnancy rates in the cycles where the gonadotrophin dose was reduced or withheld were 39.6 and 40% per cycle respectively; corresponding implantation rates were 30.7 and 25.6%. It is concluded that the modified coasting strategy is associated with a low risk of moderate and severe OHSS to a minimum without compromising pregnancy rates. Identification of patients at risk by ultrasound reduces the number of serum oestradiol measurements and thus inconvenience to patients as well as costs and workload.

Short coasting of 1 or 2 days by withholding both gonadotropins and gonadotropin-releasing hormone agonist prevents ovarian hyperstimulation syndrome without compromising the outcome

“…Usually, the mean coasting duration has been reported to be 3.7 AE 0.1 days (6); some reports have shown prolonged coasting for more than 4 days (8,10,11). Although prolonged coasting periods influence oocyte quality and endometrial receptivity, resulting in decreased pregnancy and implantation rates (6,12,(13)(14)(15), we have seen short coasting for 1 or 2 days that resulted from a rapid decline of serum estradiol (E 2 ) levels by withdrawing both gonadotropins and GnRH agonist.…”

VEGF antagonist for the prevention of ovarian hyperstimulation syndrome: Current status

“…Pro inflammatory cytokines: interleukin-1b, IL-6, IL8 and tumor necrosis factor a have been implicated to mediate the acute phase response which leads to capillary leakage and the third space loss of OHSS. 15 Elevated serum levels of these cytokines have been found in OHSS.…”

Gonadotropin-releasing hormone agonist to induce final oocyte maturation prevents the development of ovarian hyperstimulation syndrome in high-risk patients and leads to improved clinical outcomes compared with coasting

“…Coasting is a valuable strategy for OHSS prevention but has recognized limitations, because it does not eliminate OHSS and may result in compromised cycle outcomes (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(41)(42)(43). Because OHSS may lead to dangerous and potentially fatal sequelae, complete prevention of this complication would be ideal.…”