Materiały źródłowe

• #1 Ovarian hyperstimulation syndrome: pathophysiology and prevention

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2842872/

  To review and discuss the pathophysiology and prevention strategies for ovarian hyperstimulation syndrome (OHSS), which is a condition that may occur in up to 20% of the high risk women submitted to assisted reproductive technology cycles. […] In addition we consider the prevention strategies, including coasting, administration of albumin, renin-angiotensin system blockage, dopamine agonist administration, non-steroidal anti-inflammatory administration, GnRH antagonist protocols, reducing hCG dosage, replacement of hCG and in vitro maturation of oocytes (IVM). […] Among the many prevention strategies that have been discussed, the current evidence points to the replacement of hCG by GnRH agonists in antagonist cycles and the performance of IVM procedures as the safest approaches. […] The most important aspects of OHSS prevention are sound clinical judgment with ovulation induction and acknowledgment of the risk factors.

• #2 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  Cabergoline is a dopamine antagonist which prevents the excessive increase in VEGF mediated vascular permeability encountered with OHSS through its antiangiogenic properties. […] OHSS is a complication associated with COS which clinicians have no complete way of preventing at present. Through the various prevention strategies reviewed in this paper, there are avenues by which its incidence can be greatly reduced.

• #3 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence that factors associated with a robust response to ovarian stimulation predispose to OHSS. This includes baseline characteristics such as younger age and the diagnosis of PCOS, in addition to elevated ovarian reserve markers, including AFC (24) and AMH levels (3.4 ng/mL). (Grade A) […] There is strong evidence associating OHSS with stimulation-related factors such as a heightened number of mature range follicles at the trigger (1719), elevated estradiol at the trigger (3,5005,000 pg/mL), and an increased number of oocytes retrieved (1518). (Grade A) […] There is moderate evidence that lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) may decrease the risk of OHSS. (Grade B)

• #4 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  Being aware of the risk factors for OHSS will allow clinicians to preempt its occurrence and thereby reduce its incidence during ovulation induction with gonadotrophins. […] In women who are identified as being at a high risk of OHSS, treatment regimens need to be modified in view of curtailing an overexcessive ovarian response. […] The best evidence suggests that the minimum gonadotrophin dose should be used for OI given its lower risk of OHSS. This favours a step-up regimen over a step-down regimen. […] There is consensus on the fact that reducing the duration of gonadotrophin exposure reduces the risk of OHSS. […] Metformin is theorized to exert its influence in preventing OHSS by inhibiting the secretion of vasoactive molecules, such as VEGF, during OI and thereby modulates vascular permeability.

• #5 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  Ovarian hyperstimulation syndrome is a relatively common complication of ovarian stimulation and can be life-threatening. […] The combined use of a gonadotrophin-releasing hormone antagonist protocol with gonadotrophin-releasing hormone agonist triggering and oocyte and embryo freezing has considerable promise in preventing ovarian hyperstimulation syndrome. […] The inhibition of vascular permeability seems to be a novel therapeutic approach to preventing and treating ovarian hyperstimulation syndrome. […] The prevention of OHSS includes three main strategies: identification of women at risk, using different ovulation-induction strategies before stimulation, and preventive therapy modalities during stimulation. […] Recognising risk factors of OHSS is the key to prevention. […] Women at higher risk of developing OHSS include young age, low body weight, polycystic ovary syndrome (PCOS), use of GnRH agonists, higher doses of exogenous gonadotrophins, high absolute or rapidly rising serum oestradiol levels, development of multiple follicles during treatment, exposure to hCG, and previous episodes of OHSS.

• #6 Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment | Reproductive Biology and Endocrinology | Full Text

  https://rbej.biomedcentral.com/articles/10.1186/1477-7827-10-32

  Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian stimulation (COS) as part of assisted reproductive technologies (ART). […] Physicians should always be aware of the risk of OHSS in patients undergoing COS, as it can be fatal. […] Risk factors and predictive factors for OHSS will be presented, as recognizing these risk factors and individualizing the COS protocol appropriately is the key to the primary prevention of OHSS, as the benefits and risks of each COS strategy vary among individuals. Individualized COS (iCOS) could effectively eradicate OHSS, and the identification of hormonal, functional and genetic markers of ovarian response will facilitate iCOS. […] However, if iCOS is not properly applied, various preventive measures can be instituted once COS has begun, including cancelling the cycle, coasting, individualizing the human chorionic gonadotropin trigger dose or using a gonadotropin-releasing hormone (GnRH) agonist (for those using a GnRH antagonist protocol), the use of intravenous fluids at the time of oocyte retrieval, and cryopreserving/vitrifying all embryos for subsequent transfer in an unstimulated cycle.

• #7 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence that factors associated with a robust response to ovarian stimulation predispose to OHSS. This includes baseline characteristics such as younger age and the diagnosis of PCOS, in addition to elevated ovarian reserve markers, including AFC (24) and AMH levels (3.4 ng/mL). (Grade A) […] There is strong evidence associating OHSS with stimulation-related factors such as a heightened number of mature range follicles at the trigger (1719), elevated estradiol at the trigger (3,5005,000 pg/mL), and an increased number of oocytes retrieved (1518). (Grade A) […] There is moderate evidence that lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) may decrease the risk of OHSS. (Grade B)

• #8 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence that factors associated with a robust response to ovarian stimulation predispose to OHSS. This includes baseline characteristics such as younger age and the diagnosis of PCOS, in addition to elevated ovarian reserve markers, including AFC (24) and AMH levels (3.4 ng/mL). (Grade A) […] There is strong evidence associating OHSS with stimulation-related factors such as a heightened number of mature range follicles at the trigger (1719), elevated estradiol at the trigger (3,5005,000 pg/mL), and an increased number of oocytes retrieved (1518). (Grade A) […] There is moderate evidence that lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) may decrease the risk of OHSS. (Grade B)

• #9 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to counsel patients with elevated antimullerian hormone levels, polycystic ovary syndrome (PCOS), and anticipated high oocyte yields that they are at increased risk for ovarian hyperstimulation syndrome (OHSS). Interventions to reduce OHSS risk should be focused on this patient population. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to employ ovarian stimulation protocols using gonadotropin-releasing hormone (GnRH) antagonists over protocols using GnRH agonists when there is a concern for OHSS. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to dose gonadotropins based on individualized ovarian reserve testing to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate)

• #10 Ovarian Hyperstimulation Syndrome Treatment & Management: Approach Considerations, Treatment Based on Degree of Hyperstimulation, Resolution

  https://emedicine.medscape.com/article/1343572-treatment

  The best preventive method is to adapt the treatment and closely monitor patients at risk. Remember that women at risk are those with high levels of estrogen and many follicles at the assumed time of ovulation. Patients with polycystic ovarian syndrome should be closely monitored as well. […] Laboratory findings of a serum estradiol concentration of greater than 2000 pg/mL and a progesterone concentration of greater than 30 ng/mL in the early part of the luteal phase are warning signs of developing OHSS. […] Vaginal intercourse is restricted in women with any grade of OHSS because of the risk of rupturing a cyst. Patients should also avoid impact-type activities or strenuous exertion. […] A clinical practice guideline from the American Society for Reproductive Medicine includes the following recommendations for the prevention of moderate and severe OHSS: Counsel patients with elevated antimullerian hormone levels, polycystic ovary syndrome (PCOS), and anticipated high oocyte yields about their increased risk for OHSS.

• #11 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  Being aware of the risk factors for OHSS will allow clinicians to preempt its occurrence and thereby reduce its incidence during ovulation induction with gonadotrophins. […] In women who are identified as being at a high risk of OHSS, treatment regimens need to be modified in view of curtailing an overexcessive ovarian response. […] The best evidence suggests that the minimum gonadotrophin dose should be used for OI given its lower risk of OHSS. This favours a step-up regimen over a step-down regimen. […] There is consensus on the fact that reducing the duration of gonadotrophin exposure reduces the risk of OHSS. […] Metformin is theorized to exert its influence in preventing OHSS by inhibiting the secretion of vasoactive molecules, such as VEGF, during OI and thereby modulates vascular permeability.

• #12 Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment | Reproductive Biology and Endocrinology | Full Text

  https://rbej.biomedcentral.com/articles/10.1186/1477-7827-10-32

  The key to the primary prevention of OHSS during COS is recognizing risk factors and individualizing the ovarian stimulation protocol appropriately using iCOS. […] If iCOS is not correctly applied then patients are more likely to experience OHSS. To minimize the risk of severe complications, secondary preventative measures are normally applied. Various preventative protocols have been proposed to reduce or minimize the risk of developing OHSS during COS, including in vitro oocyte maturation, coasting, decreasing the hCG trigger dose, and using a gonadotropin-releasing hormone agonist (GnRHa) trigger. […] The use of AMH, as a biomarker to individualize COS protocols, has been evaluated in a retrospective study of women undergoing ART. […] Cryopreservation is considered a traditional approach for the prevention of OHSS in COS. […] The pregnancy rates achieved with frozen oocytes and embryos are now similar to those achieved in fresh cycles. […] Cryopreservation appears to reduce, but not eliminate, OHSS without adversely affecting pregnancy rates.

• #13 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence to support the use of GnRH antagonist cycles over GnRH agonist cycles in controlled ovarian stimulation protocols to decrease the risk of OHSS. (Grade A) […] There is moderate evidence to support individualized gonadotropin dosing on the basis of ORT compared with standardized dosing to decrease the risk of OHSS. (Grade B) […] There is weak evidence to recommend coasting for the prevention of OHSS. (Grade C) […] It is not recommended to administer a luteal GnRH antagonist alone to reduce rates of moderate-to-severe OHSS. Most studies report no reduction in rates of moderate-to-severe OHSS or in signs or symptoms associated with OHSS. Some low-quality evidence suggests modest symptomatic improvement in women with OHSS who received a GnRH antagonist after the hCG trigger. (Strength of evidence: C; strength of recommendation: weak)

• #14 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  The use of GnRH antagonist protocol resulted in a more physiological approach to ovarian stimulation, leading to fewer side-effects and complications than the long-agonist protocol. […] A Cochrane review concluded that the use of antagonist compared with long GnRH agonist protocols was associated with a large reduction in OHSS. […] Although hCG has been the gold standard for ovulation triggering, it is responsible for an increased incidence of OHSS. […] Gonadotrophin-releasing hormone agonist triggering is now a valid alternative to hCG triggering. […] Luteal support with hCG is associated with a higher risk for OHSS and should be avoided. […] Administration of hCG to trigger ovulation followed by oocyte retrieval and elective freezing of all embryos will not avoid early OHSS but will prevent the development of the late form of OHSS.

• #15 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  The use of GnRH antagonist protocol resulted in a more physiological approach to ovarian stimulation, leading to fewer side-effects and complications than the long-agonist protocol. […] A Cochrane review concluded that the use of antagonist compared with long GnRH agonist protocols was associated with a large reduction in OHSS. […] Although hCG has been the gold standard for ovulation triggering, it is responsible for an increased incidence of OHSS. […] Gonadotrophin-releasing hormone agonist triggering is now a valid alternative to hCG triggering. […] Luteal support with hCG is associated with a higher risk for OHSS and should be avoided. […] Administration of hCG to trigger ovulation followed by oocyte retrieval and elective freezing of all embryos will not avoid early OHSS but will prevent the development of the late form of OHSS.

• #16 Ovarian Hyperstimulation Syndrome Prevention Guidelines: Update from ASRM – Endocrinology Advisor

  https://www.endocrinologyadvisor.com/features/ovarian-hyperstimulation-syndrome-prevention-guidelines-update-from-asmr/

  The American Society for Reproductive Medicine (ASRM) updated its clinical practice guidelines for the prevention of moderate and severe ovarian hyperstimulation syndrome (OHSS) and for the identification of individuals at high risk for OHSS. […] The committee strongly recommended controlled ovarian stimulation protocols with the use of gonadotropin-releasing hormone (GnRH) antagonists rather than GnRH agonists among patients with increased risk for OHSS. […] However, GnRH agonists should be used as a first-line strategy to trigger oocyte maturation before retrieval to reduce risk for moderate and severe OHSS. […] Other recommendations to reduce risk for OHSS included: Conducting ovarian reserve testing before dosing with gonadotropins; Reducing the initial dose of gonadotropins and/or using oral ovulation-inducing medications, such as clomiphene citrate and letrozole; Coasting, or withholding gonadotropins until appropriate levels of estrogen and number of follicles are reached, as an adjunct to other therapies, including cabergoline and a freeze-only strategy; Using freeze-only vs fresh embryo transfer cycles for patients with a high ovarian response or elevated estradiol levels; and, Not using a lower dose of the human chorionic gonadotropin (hCG)-only trigger as a means to reduce OHSS risk.

• #17 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence to support the use of GnRH antagonist cycles over GnRH agonist cycles in controlled ovarian stimulation protocols to decrease the risk of OHSS. (Grade A) […] There is moderate evidence to support individualized gonadotropin dosing on the basis of ORT compared with standardized dosing to decrease the risk of OHSS. (Grade B) […] There is weak evidence to recommend coasting for the prevention of OHSS. (Grade C) […] It is not recommended to administer a luteal GnRH antagonist alone to reduce rates of moderate-to-severe OHSS. Most studies report no reduction in rates of moderate-to-severe OHSS or in signs or symptoms associated with OHSS. Some low-quality evidence suggests modest symptomatic improvement in women with OHSS who received a GnRH antagonist after the hCG trigger. (Strength of evidence: C; strength of recommendation: weak)

• #18 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to employ ovarian stimulation protocols using GnRH antagonists over protocols using GnRH agonists when there is concern for OHSS. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to dose gonadotropins on the basis of individualized ORT to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is recommended to consider lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] Coasting is generally not recommended as a primary strategy to reduce the risk of moderate-to-severe OHSS. However, when other more effective strategies are not available to reduce the risk of OHSS, coasting in combination with cabergoline and a freeze-only strategy may mitigate the risk. (Strength of evidence: C; strength of recommendation: weak)

• #19 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to employ ovarian stimulation protocols using GnRH antagonists over protocols using GnRH agonists when there is concern for OHSS. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to dose gonadotropins on the basis of individualized ORT to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is recommended to consider lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] Coasting is generally not recommended as a primary strategy to reduce the risk of moderate-to-severe OHSS. However, when other more effective strategies are not available to reduce the risk of OHSS, coasting in combination with cabergoline and a freeze-only strategy may mitigate the risk. (Strength of evidence: C; strength of recommendation: weak)

• #20 Ovarian hyperstimulation syndrome – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/ovarian-hyperstimulation-syndrome-ohss/symptoms-causes/syc-20354697

  To decrease your chances of developing ovarian hyperstimulation syndrome, you’ll need an individualized plan for your fertility medications. Expect your health care provider to carefully monitor each treatment cycle, including frequent ultrasounds to check the development of follicles and blood tests to check your hormone levels. […] Strategies to help prevent OHSS include: […] Adjusting medication. Your provider uses the lowest possible dose of gonadotropins to stimulate your ovaries and trigger ovulation. […] Adding medication. Some medications seem to reduce the risk of OHSS without affecting the odds of pregnancy. These include low-dose aspirin; dopamine agonists such as carbergoline or quinogloide; and calcium infusions. Giving women who have polycystic ovary syndrome the drug metformin (Glumetza) during ovarian stimulation may help prevent hyperstimulation.

• #21 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  Being aware of the risk factors for OHSS will allow clinicians to preempt its occurrence and thereby reduce its incidence during ovulation induction with gonadotrophins. […] In women who are identified as being at a high risk of OHSS, treatment regimens need to be modified in view of curtailing an overexcessive ovarian response. […] The best evidence suggests that the minimum gonadotrophin dose should be used for OI given its lower risk of OHSS. This favours a step-up regimen over a step-down regimen. […] There is consensus on the fact that reducing the duration of gonadotrophin exposure reduces the risk of OHSS. […] Metformin is theorized to exert its influence in preventing OHSS by inhibiting the secretion of vasoactive molecules, such as VEGF, during OI and thereby modulates vascular permeability.

• #22 Prevention and Management of Ovarian Hyperstimulation Syndrome

  https://www.ijifm.com/abstractArticleContentBrowse/IJIFM/21671/JPJ/fullText

  Ovarian hyperstimulation syndrome (OHSS) is a potential iatrogenic life-threatening situation. Complete prevention of OHSS is never possible, but endocrine profile and ultrasonographic follicular monitoring are the mainstay of its prediction. Withholding hCG, continuation of gonadotropin-releasing hormone analogs, coasting, agonist trigger, intravenous albumin, dopamine agonists, and cryopreservation of embryos are cornerstones of OHSS prevention. […] Prevention of OHSS sets its first milestone by tailoring stimulation protocol of a particular patient according to their own risk profile, i.e., individualized controlled ovarian stimulation. […] Young, thin women with polycystic ovaries on ultrasound (12 antral follicles in each ovary) are at higher risk for OHSS, and thus lower starting dose of gonadotropin should be used. Careful monitoring is prudent and robust monitoring is required to detect early hyperresponse and thus taper the dose.

• #23 Prevention and Management of Ovarian Hyperstimulation Syndrome

  https://www.ijifm.com/abstractArticleContentBrowse/IJIFM/21671/JPJ/fullText

  Women identified with risk factors should have modified treatment according to their history and clinical profile so as to curtail an overexcessive response. […] Aim unifollicular ovulation: In PCOS women, risk of OHSS increases. Goal is unifollicular growth preventing OHSS progression. This can be done by reducing gonadotropin dose by following step-up regimen over a step-down regimen with 75 IU FSH low dose. […] Cycle cancelation before trigger can prevent OHSS, but the emotional and financial burden it imposes on patients should be considered before the cycle is canceled. […] Coasting involves temporarily stopping gonadotropin administration and postponing the hCG trigger until the estradiol level is lower causing decreased luteinization with lower LH levels. […] Administration of intravenous albumin and HES: Colloid infusion at time of opu are useful. It binds to vasoactive mediators and prevent OHSS.

• #24 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  The agent of choice for triggering ovulation should be picked based on the risk of the woman for developing OHSS. No agent, however, completely eliminates the risk of OHSS. […] Secondary prevention is extended to women who have undergone COS and subsequently mounted an exaggerated response. The aim of interventions in these circumstances is to prevent progression to OHSS. […] Coasting is a preventative strategy by which gonadotrophins are withdrawn when a certain E2 concentration and/or a critical number of follicles are reached. […] During cryopreservation, COS and subsequent oocyte retrieval is performed followed by the cryopreservation of embryos. […] Cycle cancellation and withholding of hCG are the only definite methods of preventing OHSS. […] Colloid infusions are administered around the time of oocyte retrieval as they are theorized to prevent OHSS by binding to and deactivating the vasoactive mediators of OHSS.

• #25 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to consider lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is recommended to use a GnRH agonist to trigger oocyte maturation as a first-line strategy to reduce the risk of moderate-to-severe OHSS. (Strength of evidence: A; strength of recommendation: strong) […] In patients at risk for moderate-to-severe OHSS, it is recommended to start a dopamine agonist such as cabergoline on the day of the hCG trigger or soon thereafter and continue for several days. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to consider a freeze-only cycle and subsequent frozen embryo transfer in patients at risk for OHSS on the basis of a high ovarian response or elevated serum estradiol levels. Multiple high-quality studies have reported a significant reduction in rates of moderate or severe OHSS when this strategy is employed. (Strength of evidence: A; strength of recommendation: strong)

• #26 Ovarian Hyperstimulation Syndrome Treatment & Management: Approach Considerations, Treatment Based on Degree of Hyperstimulation, Resolution

  https://emedicine.medscape.com/article/1343572-treatment

  Use ovarian stimulation protocols that employ gonadotropin-releasing hormone (GnRH) antagonists rather than protocols that employ GnRH agonists. […] Base the gonadotropin dose on individualized ovarian reserve testing, and consider lower starting doses of gonadotropins, as well as the use of oral ovulation-inducing medications. […] Coasting should generally not be used as a primary strategy but can be considered in combination with cabergoline and a freeze-only strategy when other options are not available. […] Using a GnRH agonist to trigger oocyte maturation, and not planning a fresh embryo transfer are recommended strategies. […] Starting a dopamine agonist such as cabergoline on the day of the human chorionic gonadotropin (hCG) trigger or soon after is also advised for patients at risk for moderate to severe OHSS. […] Consider a freeze-only cycle and subsequent frozen embryo transfer in patients who have a high ovarian response or elevated serum estradiol levels. This strategy can significantly reduce rates of moderate and severe OHSS.

• #27 Ovarian Hyperstimulation Syndrome Prevention | GLOWM

  https://www.glowm.com/section-view/heading/Ovarian%20Hyperstimulation%20Syndrome%20Prevention/item/671

  The most important benefit emerging from the use of GnRHa, rather than hCG, for ovulation induction is the ability of this regimen to completely eliminate the threat of clinically significant OHSS. […] In summary, to secure a good clinical pregnancy rate post agonist trigger, luteal support must be patient-tailored. In OHSS high risk situations intensive estradiol and progesterone support will eliminate any threat of OHSS and will yield a good pregnancy rate.

• #28 Ovarian Hyperstimulation Syndrome (OHSS): A Narrative Review and Legal Implications

  https://www.mdpi.com/2075-4426/14/9/915

  The complexities inherent in OHSS require absolute compliance with guidelines and evidence-based recommendations, both for the sake of patient welfare and the medicolegal tenability of all procedures. […] After gaining experience and knowledge over the years, it has been found that using the GnRHa trigger with modified luteal phase support yields reproductive outcomes comparable to those achieved with the hCG trigger in fresh cycles. Additionally, the results with frozen embryos derived from the GnRHa trigger are similar to those from the hCG trigger. […] One significant advantage of using GnRHa trigger is the significant reduction in or complete elimination of OHSS in high responders. […] An endogenous hCG rise related to a fresh transfer cycle, which can potentially worsen late-onset OHSS symptoms and duration, can be prevented through the elective cryopreservation of all embryos and their subsequent transfer in non-stimulated cycles. […] There is no one-size-fits-all method for preventing OHSS, but the chances of developing the syndrome can be reduced by individualizing treatment and categorizing women based on their risk of OHSS.

• #29 Ovarian hyperstimulation syndrome – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/ovarian-hyperstimulation-syndrome-ohss/symptoms-causes/syc-20354697

  Coasting. If your estrogen level is high or you have a large number of developed follicles, your provider may have you stop injectable medications and wait a few days before giving HCG, which triggers ovulation. This is known as coasting. […] Avoiding use of an HCG trigger shot. Because OHSS often develops after an HCG trigger shot is given, alternatives to HCG for triggering have been developed using gonadotropin-releasing hormone (Gn-RH) agonists, such as leuprolide (Lupron), as a way to prevent or limit OHSS. […] Freezing embryos. If you’re undergoing in vitro fertilization (IVF), all the follicles (mature and immature) may be removed from your ovaries to reduce the chance of OHSS. Mature follicles are fertilized and frozen, and your ovaries are allowed to rest. You can resume the IVF process at a later date, when your body is ready.

• #30 Top 10 steps to prevent ovarian hyperstimulation syndrome

  https://www.inviafertility.com/blog/ivf/drvkarande/top-10-steps-to-prevent-ovarian-hyperstimulation-syndrome/

  Identify patients at risk by an accurate antral follicle count and/or measurement of anti-mullerian hormone (AMH) levels. Patients with polycystic appearing ovaries ( 12 antral follicles per ovary) and those with an AMH level 3.5 ng/mL are at higher risk for OHSS. […] Use a lower starting dose of fertility drugs (gonadotropins) in patients at high-risk for OHSS. An initial dose of 150 iu may be sufficient. By limiting the dose, fewer small follicles, which are the driving force of OHSS, are launched. In patients with a robust response, the dose of medications can be tapered down. […] Decreasing the trigger dose of hCG. hCG is the prime stimulator of VEGF. Instead of the standard dose of 10,000 units, one may lower the dose to 5,000 or even 3,300. This may reduce the number of mature eggs retrieved, but will also reduce the incidence of OHSS.

• #31 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  The agent of choice for triggering ovulation should be picked based on the risk of the woman for developing OHSS. No agent, however, completely eliminates the risk of OHSS. […] Secondary prevention is extended to women who have undergone COS and subsequently mounted an exaggerated response. The aim of interventions in these circumstances is to prevent progression to OHSS. […] Coasting is a preventative strategy by which gonadotrophins are withdrawn when a certain E2 concentration and/or a critical number of follicles are reached. […] During cryopreservation, COS and subsequent oocyte retrieval is performed followed by the cryopreservation of embryos. […] Cycle cancellation and withholding of hCG are the only definite methods of preventing OHSS. […] Colloid infusions are administered around the time of oocyte retrieval as they are theorized to prevent OHSS by binding to and deactivating the vasoactive mediators of OHSS.

• #32 Ovarian hyperstimulation syndrome: pathophysiology and prevention

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2842872/

  In the face of a high risk for OHSS situation, many strategies have been reported to decrease the risk of OHSS. […] Coasting clearly decreases estradiol levels. […] Evidence is still insufficient to determine whether or not coasting is an effective strategy for preventing OHSS and OHSS can occur in up to 9.4% of patients even with coasting. […] The best currently available evidence shows that albumin administration does not decrease the incidence of OHSS. […] Drugs have potential harmful effects to the fetuses and may worsen an OHSS associated renal failure. […] Even using cabergoline, the OHSS incidence may be as high as 10.8%. […] A large RCT demonstrated that low dose aspirin was associated with reduction in the OHSS incidence (0.25% vs. 8.4%) in a high-risk group with similar pregnancy rates.

• #33 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to employ ovarian stimulation protocols using GnRH antagonists over protocols using GnRH agonists when there is concern for OHSS. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to dose gonadotropins on the basis of individualized ORT to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is recommended to consider lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] Coasting is generally not recommended as a primary strategy to reduce the risk of moderate-to-severe OHSS. However, when other more effective strategies are not available to reduce the risk of OHSS, coasting in combination with cabergoline and a freeze-only strategy may mitigate the risk. (Strength of evidence: C; strength of recommendation: weak)

• #34 Ovarian Hyperstimulation Syndrome Treatment & Management: Approach Considerations, Treatment Based on Degree of Hyperstimulation, Resolution

  https://emedicine.medscape.com/article/1343572-treatment

  Use ovarian stimulation protocols that employ gonadotropin-releasing hormone (GnRH) antagonists rather than protocols that employ GnRH agonists. […] Base the gonadotropin dose on individualized ovarian reserve testing, and consider lower starting doses of gonadotropins, as well as the use of oral ovulation-inducing medications. […] Coasting should generally not be used as a primary strategy but can be considered in combination with cabergoline and a freeze-only strategy when other options are not available. […] Using a GnRH agonist to trigger oocyte maturation, and not planning a fresh embryo transfer are recommended strategies. […] Starting a dopamine agonist such as cabergoline on the day of the human chorionic gonadotropin (hCG) trigger or soon after is also advised for patients at risk for moderate to severe OHSS. […] Consider a freeze-only cycle and subsequent frozen embryo transfer in patients who have a high ovarian response or elevated serum estradiol levels. This strategy can significantly reduce rates of moderate and severe OHSS.

• #35 Top 10 steps to prevent ovarian hyperstimulation syndrome

  https://www.inviafertility.com/blog/ivf/drvkarande/top-10-steps-to-prevent-ovarian-hyperstimulation-syndrome/

  Coasting. In patients with a robust response (high estrogen levels with the follicles still being small (14 mm)), it may be possible to stop the fertility drugs for 2 3 days till the estrogen levels drop to a more acceptable level (generally 3000 pg/mL) when the hCG trigger can be given. In the meanwhile, the larger follicles will continue to grow and the smaller follicles (which contribute to OHSS) do not. […] Antagonist coast. In patients who are down regulated with Lupron, one can stop the Lupron and give a GnRH antagonist (Ganirelix, Cetrotide) for a couple of days while continuing the fertility drugs at a low dose (75 units hMG daily s.c.). This results in a prompt drop in the estrogen levels (probably due to direct action of the GnRH antagonist on the granulosa cells) and VEGF production.

• #36 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to consider lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is recommended to use a GnRH agonist to trigger oocyte maturation as a first-line strategy to reduce the risk of moderate-to-severe OHSS. (Strength of evidence: A; strength of recommendation: strong) […] In patients at risk for moderate-to-severe OHSS, it is recommended to start a dopamine agonist such as cabergoline on the day of the hCG trigger or soon thereafter and continue for several days. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to consider a freeze-only cycle and subsequent frozen embryo transfer in patients at risk for OHSS on the basis of a high ovarian response or elevated serum estradiol levels. Multiple high-quality studies have reported a significant reduction in rates of moderate or severe OHSS when this strategy is employed. (Strength of evidence: A; strength of recommendation: strong)

• #37 Ovarian Hyperstimulation Syndrome Treatment & Management: Approach Considerations, Treatment Based on Degree of Hyperstimulation, Resolution

  https://emedicine.medscape.com/article/1343572-treatment

  Use ovarian stimulation protocols that employ gonadotropin-releasing hormone (GnRH) antagonists rather than protocols that employ GnRH agonists. […] Base the gonadotropin dose on individualized ovarian reserve testing, and consider lower starting doses of gonadotropins, as well as the use of oral ovulation-inducing medications. […] Coasting should generally not be used as a primary strategy but can be considered in combination with cabergoline and a freeze-only strategy when other options are not available. […] Using a GnRH agonist to trigger oocyte maturation, and not planning a fresh embryo transfer are recommended strategies. […] Starting a dopamine agonist such as cabergoline on the day of the human chorionic gonadotropin (hCG) trigger or soon after is also advised for patients at risk for moderate to severe OHSS. […] Consider a freeze-only cycle and subsequent frozen embryo transfer in patients who have a high ovarian response or elevated serum estradiol levels. This strategy can significantly reduce rates of moderate and severe OHSS.

• #38 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  The agent of choice for triggering ovulation should be picked based on the risk of the woman for developing OHSS. No agent, however, completely eliminates the risk of OHSS. […] Secondary prevention is extended to women who have undergone COS and subsequently mounted an exaggerated response. The aim of interventions in these circumstances is to prevent progression to OHSS. […] Coasting is a preventative strategy by which gonadotrophins are withdrawn when a certain E2 concentration and/or a critical number of follicles are reached. […] During cryopreservation, COS and subsequent oocyte retrieval is performed followed by the cryopreservation of embryos. […] Cycle cancellation and withholding of hCG are the only definite methods of preventing OHSS. […] Colloid infusions are administered around the time of oocyte retrieval as they are theorized to prevent OHSS by binding to and deactivating the vasoactive mediators of OHSS.

• #39 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  The use of GnRH antagonist protocol resulted in a more physiological approach to ovarian stimulation, leading to fewer side-effects and complications than the long-agonist protocol. […] A Cochrane review concluded that the use of antagonist compared with long GnRH agonist protocols was associated with a large reduction in OHSS. […] Although hCG has been the gold standard for ovulation triggering, it is responsible for an increased incidence of OHSS. […] Gonadotrophin-releasing hormone agonist triggering is now a valid alternative to hCG triggering. […] Luteal support with hCG is associated with a higher risk for OHSS and should be avoided. […] Administration of hCG to trigger ovulation followed by oocyte retrieval and elective freezing of all embryos will not avoid early OHSS but will prevent the development of the late form of OHSS.

• #40

  https://journals.lww.com/fsar/fulltext/2014/01020/prevention_of_ovarian_hyperstimulation_syndrome.3.aspx

  The risk of OHSS in GnRH antagonist cycles may be further reduced by using GnRH agonist for final follicular maturation in place of hCG. […] If hCG is withheld in cycles at risk of OHSS and an endogenous LH surge is avoided, OHSS should not develop. Treatment can then restart using a modified regime with a lower risk of OHSS. […] Avoiding fresh embryo transfer eliminates exposure to endogenous hCG and should thereby eliminate the possibility of pregnancy-associated „late” OHSS. […] A systematic review of randomized trials shows that metformin reduces the risk of OHSS in women with PCOS undergoing IVF. […] Dopamine agonists have a role as a preventative measure for OHSS, based on the action of dopamine in antagonizing the vascular permeability-enhancing effect of VEGF through the dopamine receptor type 2. […] The role of hCG in precipitating OHSS is well-established. It is known that progesterone is as effective as hCG for luteal support and is associated with a lower risk of OHSS.

• #41 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  The agent of choice for triggering ovulation should be picked based on the risk of the woman for developing OHSS. No agent, however, completely eliminates the risk of OHSS. […] Secondary prevention is extended to women who have undergone COS and subsequently mounted an exaggerated response. The aim of interventions in these circumstances is to prevent progression to OHSS. […] Coasting is a preventative strategy by which gonadotrophins are withdrawn when a certain E2 concentration and/or a critical number of follicles are reached. […] During cryopreservation, COS and subsequent oocyte retrieval is performed followed by the cryopreservation of embryos. […] Cycle cancellation and withholding of hCG are the only definite methods of preventing OHSS. […] Colloid infusions are administered around the time of oocyte retrieval as they are theorized to prevent OHSS by binding to and deactivating the vasoactive mediators of OHSS.

• #42 Ovarian Hyperstimulation Syndrome Prevention | GLOWM

  https://www.glowm.com/section-view/heading/Ovarian%20Hyperstimulation%20Syndrome%20Prevention/item/671

  Ovarian hyperstimulation syndrome (OHSS) is the price we occasionally pay for our attempt to override natures delicate balances that were created to ensure a single oocyte ovulation in the human. […] The aim of this chapter is to review the available methods used for OHSS prevention, and to focus on the one approach that totally prevents this iatrogenic complication. […] Therefore, there is more than ever an urgent need for alternative final oocyte maturation-triggering medication. This alternative is available, as detailed below and completely eliminates OHSS. […] The safest way to prevent OHSS is to abort the cycle, e.g. stop ovarian stimulation and let all growing follicles undergo demise by atresia. […] Ovarian stimulation per se does not cause OHSS, unless it is followed by ovulation. In ART cycles the ovulatory agent most commonly used is hCG, therefore, withholding it prevents OHSS.

• #43 Prevention and Management of Ovarian Hyperstimulation Syndrome

  https://www.ijifm.com/abstractArticleContentBrowse/IJIFM/21671/JPJ/fullText

  Women identified with risk factors should have modified treatment according to their history and clinical profile so as to curtail an overexcessive response. […] Aim unifollicular ovulation: In PCOS women, risk of OHSS increases. Goal is unifollicular growth preventing OHSS progression. This can be done by reducing gonadotropin dose by following step-up regimen over a step-down regimen with 75 IU FSH low dose. […] Cycle cancelation before trigger can prevent OHSS, but the emotional and financial burden it imposes on patients should be considered before the cycle is canceled. […] Coasting involves temporarily stopping gonadotropin administration and postponing the hCG trigger until the estradiol level is lower causing decreased luteinization with lower LH levels. […] Administration of intravenous albumin and HES: Colloid infusion at time of opu are useful. It binds to vasoactive mediators and prevent OHSS.

• #44 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is recommended to consider lowering the starting dose of gonadotropins and/or supplementing with oral ovulation-inducing medications (clomiphene citrate and/or letrozole) to decrease the risk of OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is recommended to use a GnRH agonist to trigger oocyte maturation as a first-line strategy to reduce the risk of moderate-to-severe OHSS. (Strength of evidence: A; strength of recommendation: strong) […] In patients at risk for moderate-to-severe OHSS, it is recommended to start a dopamine agonist such as cabergoline on the day of the hCG trigger or soon thereafter and continue for several days. (Strength of evidence: A; strength of recommendation: strong) […] It is recommended to consider a freeze-only cycle and subsequent frozen embryo transfer in patients at risk for OHSS on the basis of a high ovarian response or elevated serum estradiol levels. Multiple high-quality studies have reported a significant reduction in rates of moderate or severe OHSS when this strategy is employed. (Strength of evidence: A; strength of recommendation: strong)

• #45 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence that dopamine agonist administration near the time of the hCG trigger reduces the incidence of moderate-to-severe OHSS. (Grade A) […] It is recommended to start a dopamine agonist such as cabergoline on the day of the hCG trigger or soon thereafter and continue for several days. (Strength of evidence: A; strength of recommendation: strong) […] There is weak evidence that the use of an aromatase inhibitor such as letrozole does not prevent OHSS on the basis of a few studies with contradictory findings. The studies with an appropriate control group report no reduction in the incidence of moderate-to-severe OHSS after letrozole administration. (Grade C) […] There is insufficient evidence to determine whether additional strategies such as administration of mifepristone, myoinositol, D-chiro-inositol, or glucocorticoids reduce the incidence of moderate-to-severe OHSS. (Grade C) […] There is strong evidence that avoiding a fresh embryo transfer and cryopreserving embryos (freeze-only cycle) significantly reduces the risk of moderate-to-severe OHSS compared with fresh embryo transfer cycles. (Grade A)

• #46 Ovarian Hyperstimulation Syndrome Treatment & Management: Approach Considerations, Treatment Based on Degree of Hyperstimulation, Resolution

  https://emedicine.medscape.com/article/1343572-treatment

  Ovarian hyperstimulation syndrome (OHSS) is a self-limiting disease of the luteal phase. Without luteinizing hormone (LH) or its imitator, human chorionic gonadotropin (hCG), ovulation or the luteal phase does not occur. Avoidance of hCG during ovarian stimulation offers an opportunity to prevent OHSS in high-risk patients. However, those patients do not conceive. Other options are delaying hCG (coasting) for 1-3 days until estradiol levels plateau or decline (2500 pg/mL), using a gonadotropin-releasing hormone (GnRH) agonist to induce ovulation, or lowering doses of hCG. […] A Cochrane review that included 22 trials involving 3171 women at high risk for OHSS evaluated the safety and efficacy of three dopamine agonists (cabergoline, bromocriptine, and quinagolide) for prevention. The dopamine agonists seem to reduce the incidence of moderate or severe OHSS in women at risk, compared with placebo or no treatment, with no influence on pregnancy outcome.

• #47 Ovarian Hyperstimulation Syndrome Prevention | GLOWM

  https://www.glowm.com/section-view/heading/Ovarian%20Hyperstimulation%20Syndrome%20Prevention/item/671

  Although frequently used, the efficacy of coasting in OHSS prevention is not well established. […] Not surprisingly, two independent meta-analyses, with more than 1000 patients in each, reached the conclusion that intravenous albumin administration in high-risk patients does not appear to reduce the occurrence of severe OHSS. […] A formal meta-analysis concluded that there is insufficient evidence to support routine cryopreservation. […] The pathophysiological hallmark of OHSS is increased vascular permeability. […] Its use in the context of OHSS prevention was tested in humans (egg donors). It was found that cabergoline (0.5 mg daily, from the day of hCG trigger, for 8 days) can significantly reduce the incidence of moderate OHSS, as well as pelvic fluid accumulation and hemoconcentration, when compared with placebo in oocyte donors at risk of OHSS.

• #48 Prevention and Management of Ovarian Hyperstimulation Syndrome

  https://www.ijifm.com/abstractArticleContentBrowse/IJIFM/21671/JPJ/fullText

  Dopamine agonist therapy: Recent evidence shows that administration of cabergoline or quinagolide can decrease incidence of OHSS by targeting nonphosphorylation of VEGFR-2. […] Metformin should be started 8 weeks before stimulation and continue till egg retrieval. […] Elective single embryo transfer is advised in patients at risk for OHSS. This may decrease the risk of multiple pregnancy, in turn decreasing severe form of OHSS.

• #49 Top 10 steps to prevent ovarian hyperstimulation syndrome

  https://www.inviafertility.com/blog/ivf/drvkarande/top-10-steps-to-prevent-ovarian-hyperstimulation-syndrome/

  Agonist trigger. In patients using a protocol with a GnRH antagonist, it is possible to substitute the hCG trigger with an agonist trigger. The use of 40 units of Lupron has been suggested as being adequate. The details of this approach will be discussed in a subsequent blog. The agonist trigger can be combined with the freezing of all the eggs. It can also be combined with a low-dose hCG trigger (1,000 1,500 units) given at the same time or just after egg retrieval. […] Use of dopamine agonists. Cabergoline is a drug that has been used for treatment of elevated prolactin levels for many years. It has an indirect action of acting against the VEGF receptor and preventing OHSS. Cabergoline (0.5 mg orally once daily) is generally started on day of hCG and continued for 8 21 days. […] Freezing all the eggs or embryos. Since pregnancy will increase the severity of OHSS, it is often prudent to postpone embryo transfer to a subsequent cycle in patients that are at high risk for OHSS.

• #50 Prevention and Management of Ovarian Hyperstimulation Syndrome

  https://www.ijifm.com/abstractArticleContentBrowse/IJIFM/21671/JPJ/fullText

  Dopamine agonist therapy: Recent evidence shows that administration of cabergoline or quinagolide can decrease incidence of OHSS by targeting nonphosphorylation of VEGFR-2. […] Metformin should be started 8 weeks before stimulation and continue till egg retrieval. […] Elective single embryo transfer is advised in patients at risk for OHSS. This may decrease the risk of multiple pregnancy, in turn decreasing severe form of OHSS.

• #51 Prevention of Ovarian Hyperstimulation Syndrome: A Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4446511/

  Being aware of the risk factors for OHSS will allow clinicians to preempt its occurrence and thereby reduce its incidence during ovulation induction with gonadotrophins. […] In women who are identified as being at a high risk of OHSS, treatment regimens need to be modified in view of curtailing an overexcessive ovarian response. […] The best evidence suggests that the minimum gonadotrophin dose should be used for OI given its lower risk of OHSS. This favours a step-up regimen over a step-down regimen. […] There is consensus on the fact that reducing the duration of gonadotrophin exposure reduces the risk of OHSS. […] Metformin is theorized to exert its influence in preventing OHSS by inhibiting the secretion of vasoactive molecules, such as VEGF, during OI and thereby modulates vascular permeability.

• #52

  https://journals.lww.com/fsar/fulltext/2014/01020/prevention_of_ovarian_hyperstimulation_syndrome.3.aspx

  The risk of OHSS in GnRH antagonist cycles may be further reduced by using GnRH agonist for final follicular maturation in place of hCG. […] If hCG is withheld in cycles at risk of OHSS and an endogenous LH surge is avoided, OHSS should not develop. Treatment can then restart using a modified regime with a lower risk of OHSS. […] Avoiding fresh embryo transfer eliminates exposure to endogenous hCG and should thereby eliminate the possibility of pregnancy-associated „late” OHSS. […] A systematic review of randomized trials shows that metformin reduces the risk of OHSS in women with PCOS undergoing IVF. […] Dopamine agonists have a role as a preventative measure for OHSS, based on the action of dopamine in antagonizing the vascular permeability-enhancing effect of VEGF through the dopamine receptor type 2. […] The role of hCG in precipitating OHSS is well-established. It is known that progesterone is as effective as hCG for luteal support and is associated with a lower risk of OHSS.

• #53 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is not recommended to administer letrozole as an intervention to reduce rates of moderate-to-severe OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is not recommended to administer medications such as mifepristone, myoinositol, D-chiro-inositol, or glucocorticoids to reduce rates of OHSS because studies have shown these interventions to be ineffective. (Strength of evidence: C; strength of recommendation: weak) […] It is not recommended to use volume expanders such as albumin, hydroxyethyl starch, or mannitol in patients who are at high risk of developing moderate or severe OHSS. (Strength of evidence: C; strength of recommendation: weak) […] It is not recommended to administer metformin for the sole purpose of reducing the incidence of OHSS in GnRH antagonist cycles because most studies do not report a significant reduction in rates of OHSS in women with PCOS who were given metformin. Metformin may, however, be considered for OHSS risk reduction among women with PCOS using a GnRH-agonist protocol. (Strength of evidence: B; strength of recommendation: moderate)

• #54 Ovarian Hyperstimulation Syndrome Prevention Guidelines: Update from ASRM – Endocrinology Advisor

  https://www.endocrinologyadvisor.com/features/ovarian-hyperstimulation-syndrome-prevention-guidelines-update-from-asmr/

  To reduce the incidence of OHSS, the committee supported the initiation of a dopamine agonist, such as cabergoline, alone or in combination with other strategies after triggering oocyte maturation with hCG. […] On the other hand, the committee recommended against the administration of: Aromatase inhibitors (such as letrozole); Luteal GnRH antagonists alone; Aspirin as a primary OHSS prevention strategy; Mifepristone, myoinositol, D-chiro-inositol, or glucocorticoids; and, Volume expanders, including albumin, hydroxyethyl starch, and mannitol among patients at high risk of developing OHSS. […] Although the committee recommended against the use of metformin in GnRH antagonist cycles, clinicians may consider metformin for OHSS risk reduction among patients with PCOS in GnRH agonist protocols.

• #55 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is not recommended to administer letrozole as an intervention to reduce rates of moderate-to-severe OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is not recommended to administer medications such as mifepristone, myoinositol, D-chiro-inositol, or glucocorticoids to reduce rates of OHSS because studies have shown these interventions to be ineffective. (Strength of evidence: C; strength of recommendation: weak) […] It is not recommended to use volume expanders such as albumin, hydroxyethyl starch, or mannitol in patients who are at high risk of developing moderate or severe OHSS. (Strength of evidence: C; strength of recommendation: weak) […] It is not recommended to administer metformin for the sole purpose of reducing the incidence of OHSS in GnRH antagonist cycles because most studies do not report a significant reduction in rates of OHSS in women with PCOS who were given metformin. Metformin may, however, be considered for OHSS risk reduction among women with PCOS using a GnRH-agonist protocol. (Strength of evidence: B; strength of recommendation: moderate)

• #56 Ovarian hyperstimulation syndrome: pathophysiology and prevention

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2842872/

  In the face of a high risk for OHSS situation, many strategies have been reported to decrease the risk of OHSS. […] Coasting clearly decreases estradiol levels. […] Evidence is still insufficient to determine whether or not coasting is an effective strategy for preventing OHSS and OHSS can occur in up to 9.4% of patients even with coasting. […] The best currently available evidence shows that albumin administration does not decrease the incidence of OHSS. […] Drugs have potential harmful effects to the fetuses and may worsen an OHSS associated renal failure. […] Even using cabergoline, the OHSS incidence may be as high as 10.8%. […] A large RCT demonstrated that low dose aspirin was associated with reduction in the OHSS incidence (0.25% vs. 8.4%) in a high-risk group with similar pregnancy rates.

• #57 Ovarian Hyperstimulation Syndrome Prevention | GLOWM

  https://www.glowm.com/section-view/heading/Ovarian%20Hyperstimulation%20Syndrome%20Prevention/item/671

  Although frequently used, the efficacy of coasting in OHSS prevention is not well established. […] Not surprisingly, two independent meta-analyses, with more than 1000 patients in each, reached the conclusion that intravenous albumin administration in high-risk patients does not appear to reduce the occurrence of severe OHSS. […] A formal meta-analysis concluded that there is insufficient evidence to support routine cryopreservation. […] The pathophysiological hallmark of OHSS is increased vascular permeability. […] Its use in the context of OHSS prevention was tested in humans (egg donors). It was found that cabergoline (0.5 mg daily, from the day of hCG trigger, for 8 days) can significantly reduce the incidence of moderate OHSS, as well as pelvic fluid accumulation and hemoconcentration, when compared with placebo in oocyte donors at risk of OHSS.

• #58 Ovarian hyperstimulation syndrome: pathophysiology and prevention

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2842872/

  In the face of a high risk for OHSS situation, many strategies have been reported to decrease the risk of OHSS. […] Coasting clearly decreases estradiol levels. […] Evidence is still insufficient to determine whether or not coasting is an effective strategy for preventing OHSS and OHSS can occur in up to 9.4% of patients even with coasting. […] The best currently available evidence shows that albumin administration does not decrease the incidence of OHSS. […] Drugs have potential harmful effects to the fetuses and may worsen an OHSS associated renal failure. […] Even using cabergoline, the OHSS incidence may be as high as 10.8%. […] A large RCT demonstrated that low dose aspirin was associated with reduction in the OHSS incidence (0.25% vs. 8.4%) in a high-risk group with similar pregnancy rates.

• #59 Beyond the Umbrella: A Systematic Review of the Interventions for the Prevention of and Reduction in the Incidence and Severity of Ovarian Hyperstimulation Syndrome in Patients Who Undergo In Vitro Fertilization Treatments

  https://www.mdpi.com/1422-0067/24/18/14185

  The risk and severity of OHSS are closely related to luteal hCG levels, which are significantly higher in multiple implantation pregnancies. However, direct data supporting the e-SET as a strategy to reduce OHSS risk are not available. […] Aspirin inhibits the activity of the cyclooxygenase-1 enzyme, which results in a decrease in platelet activity and a reduction in the risk of blood clotting, altering the pathological cascade caused by VEGF. […] Ketoconazole is an inhibitor of the steroidogenic enzyme P450 in the adrenal cortex and gonads and is a potential modulator of the ovarian response to gonadotropin. […] The administration of GnRH-ant during the luteal phase was studied as a potential intervention to prevent early OHSS and reduce the severity of OHSS. […] The present systematic review identified several treatments/strategies that are potentially effective in reducing the incidence and severity of OHSS, even if not supported by the highest clinical evidence.

• #60 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  Administration of a dopamine or dopamine receptor 2 agonist, inactivates VEGFR-2 and prevents the increase in vascular permeability. […] Recently, the low-dose aspirin treatment (100 mg daily, beginning on the first day of ovarian stimulation) was shown to reduce the risk of severe OHSS in a large randomised clinical trial.

• #61 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  It is not recommended to administer letrozole as an intervention to reduce rates of moderate-to-severe OHSS. (Strength of evidence: B; strength of recommendation: moderate) […] It is not recommended to administer medications such as mifepristone, myoinositol, D-chiro-inositol, or glucocorticoids to reduce rates of OHSS because studies have shown these interventions to be ineffective. (Strength of evidence: C; strength of recommendation: weak) […] It is not recommended to use volume expanders such as albumin, hydroxyethyl starch, or mannitol in patients who are at high risk of developing moderate or severe OHSS. (Strength of evidence: C; strength of recommendation: weak) […] It is not recommended to administer metformin for the sole purpose of reducing the incidence of OHSS in GnRH antagonist cycles because most studies do not report a significant reduction in rates of OHSS in women with PCOS who were given metformin. Metformin may, however, be considered for OHSS risk reduction among women with PCOS using a GnRH-agonist protocol. (Strength of evidence: B; strength of recommendation: moderate)

• #62 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence that dopamine agonist administration near the time of the hCG trigger reduces the incidence of moderate-to-severe OHSS. (Grade A) […] It is recommended to start a dopamine agonist such as cabergoline on the day of the hCG trigger or soon thereafter and continue for several days. (Strength of evidence: A; strength of recommendation: strong) […] There is weak evidence that the use of an aromatase inhibitor such as letrozole does not prevent OHSS on the basis of a few studies with contradictory findings. The studies with an appropriate control group report no reduction in the incidence of moderate-to-severe OHSS after letrozole administration. (Grade C) […] There is insufficient evidence to determine whether additional strategies such as administration of mifepristone, myoinositol, D-chiro-inositol, or glucocorticoids reduce the incidence of moderate-to-severe OHSS. (Grade C) […] There is strong evidence that avoiding a fresh embryo transfer and cryopreserving embryos (freeze-only cycle) significantly reduces the risk of moderate-to-severe OHSS compared with fresh embryo transfer cycles. (Grade A)

• #63 Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline (2023) – practice guidance | American Society for Reproductive Medicine | ASRM

  https://www.asrm.org/practice-guidance/practice-committee-documents/prevention-and-treatment-of-moderate-and-severe-ovarian-hyperstimulation-syndrome-a-guideline/

  There is strong evidence to support the use of GnRH antagonist cycles over GnRH agonist cycles in controlled ovarian stimulation protocols to decrease the risk of OHSS. (Grade A) […] There is moderate evidence to support individualized gonadotropin dosing on the basis of ORT compared with standardized dosing to decrease the risk of OHSS. (Grade B) […] There is weak evidence to recommend coasting for the prevention of OHSS. (Grade C) […] It is not recommended to administer a luteal GnRH antagonist alone to reduce rates of moderate-to-severe OHSS. Most studies report no reduction in rates of moderate-to-severe OHSS or in signs or symptoms associated with OHSS. Some low-quality evidence suggests modest symptomatic improvement in women with OHSS who received a GnRH antagonist after the hCG trigger. (Strength of evidence: C; strength of recommendation: weak)

• #64 Prevention and Management of Ovarian Hyperstimulation Syndrome

  https://www.ijifm.com/abstractArticleContentBrowse/IJIFM/21671/JPJ/fullText

  Dopamine agonist therapy: Recent evidence shows that administration of cabergoline or quinagolide can decrease incidence of OHSS by targeting nonphosphorylation of VEGFR-2. […] Metformin should be started 8 weeks before stimulation and continue till egg retrieval. […] Elective single embryo transfer is advised in patients at risk for OHSS. This may decrease the risk of multiple pregnancy, in turn decreasing severe form of OHSS.

• #65 Beyond the Umbrella: A Systematic Review of the Interventions for the Prevention of and Reduction in the Incidence and Severity of Ovarian Hyperstimulation Syndrome in Patients Who Undergo In Vitro Fertilization Treatments

  https://www.mdpi.com/1422-0067/24/18/14185

  The risk and severity of OHSS are closely related to luteal hCG levels, which are significantly higher in multiple implantation pregnancies. However, direct data supporting the e-SET as a strategy to reduce OHSS risk are not available. […] Aspirin inhibits the activity of the cyclooxygenase-1 enzyme, which results in a decrease in platelet activity and a reduction in the risk of blood clotting, altering the pathological cascade caused by VEGF. […] Ketoconazole is an inhibitor of the steroidogenic enzyme P450 in the adrenal cortex and gonads and is a potential modulator of the ovarian response to gonadotropin. […] The administration of GnRH-ant during the luteal phase was studied as a potential intervention to prevent early OHSS and reduce the severity of OHSS. […] The present systematic review identified several treatments/strategies that are potentially effective in reducing the incidence and severity of OHSS, even if not supported by the highest clinical evidence.

• #66 Ovarian hyperstimulation syndrome: pathophysiology and prevention

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2842872/

  To review and discuss the pathophysiology and prevention strategies for ovarian hyperstimulation syndrome (OHSS), which is a condition that may occur in up to 20% of the high risk women submitted to assisted reproductive technology cycles. […] In addition we consider the prevention strategies, including coasting, administration of albumin, renin-angiotensin system blockage, dopamine agonist administration, non-steroidal anti-inflammatory administration, GnRH antagonist protocols, reducing hCG dosage, replacement of hCG and in vitro maturation of oocytes (IVM). […] Among the many prevention strategies that have been discussed, the current evidence points to the replacement of hCG by GnRH agonists in antagonist cycles and the performance of IVM procedures as the safest approaches. […] The most important aspects of OHSS prevention are sound clinical judgment with ovulation induction and acknowledgment of the risk factors.

• #67

  https://link.springer.com/article/10.1007/s10815-010-9387-6

  To review and discuss the pathophysiology and prevention strategies for ovarian hyperstimulation syndrome (OHSS), which is a condition that may occur in up to 20% of the high risk women submitted to assisted reproductive technology cycles. […] In addition we consider the prevention strategies, including coasting, administration of albumin, renin-angiotensin system blockage, dopamine agonist administration, non-steroidal anti-inflammatory administration, GnRH antagonist protocols, reducing hCG dosage, replacement of hCG and in vitro maturation of oocytes (IVM). […] Among the many prevention strategies that have been discussed, the current evidence points to the replacement of hCG by GnRH agonists in antagonist cycles and the performance of IVM procedures as the safest approaches. […] Many strategies have been suggested to prevent OHSS. Based on current evidence, replacement of hCG by GnRH agonists in antagonist cycles and IVM are the safest approaches.

• #68 Ovarian hyperstimulation syndrome: pathophysiology and prevention

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2842872/

  This regimen is associated with a significant reduction in OHSS (Odds Ratio=0.60) as well as with fewer interventions to prevent OHSS (OR=0.43). […] The dosage of 15,000-30,000 IU is still too expensive. […] The risk of OHSS is entirely avoided. […] The occurrence of OHSS may be considered the most serious complication related to assisted reproduction techniques. […] We believe that to eliminate the occurrence of OHSS while maintaining acceptable costs; we should put effort into the study and the elaboration of feasible protocols with the administration of GnRH antagonists and agonists and the realization of IVM procedures in women at high risk. […] Many strategies have been suggested to prevent OHSS. Based on current evidence, replacement of hCG by GnRH agonists in antagonist cycles and IVM are the safest approaches.

• #69 Ovarian Hyperstimulation Syndrome | Doctor

  https://patient.info/doctor/ovarian-hyperstimulation-syndrome

  Ovarian hyperstimulation syndrome prevention […] OHSS is an iatrogenic condition and large numbers of strategies have been investigated to try to reduce the incidence. Techniques which may reduce risk include: […] Individualised stimulation regimes dependent on risk stratification. Step-up regimens of gonadotrophin. Avoiding aggressive ovarian stimulation. […] Use of gonadotrophin-releasing hormone (GnRH) agonists rather than hCG as an ovulation trigger. This has been shown to reduce OHSS but also reduces live birth rates. […] Freezing embryos and implanting in another cycle. In itself this does not reduce the risk significantly but in combination with the use of GnRH agonists virtually eliminates it. […] Avoid endogenous and exogenous hCG for luteal phase support. This significantly lowers the risk.

• #70

  https://journals.lww.com/fsar/fulltext/2014/01020/prevention_of_ovarian_hyperstimulation_syndrome.3.aspx

  The risk of OHSS in GnRH antagonist cycles may be further reduced by using GnRH agonist for final follicular maturation in place of hCG. […] If hCG is withheld in cycles at risk of OHSS and an endogenous LH surge is avoided, OHSS should not develop. Treatment can then restart using a modified regime with a lower risk of OHSS. […] Avoiding fresh embryo transfer eliminates exposure to endogenous hCG and should thereby eliminate the possibility of pregnancy-associated „late” OHSS. […] A systematic review of randomized trials shows that metformin reduces the risk of OHSS in women with PCOS undergoing IVF. […] Dopamine agonists have a role as a preventative measure for OHSS, based on the action of dopamine in antagonizing the vascular permeability-enhancing effect of VEGF through the dopamine receptor type 2. […] The role of hCG in precipitating OHSS is well-established. It is known that progesterone is as effective as hCG for luteal support and is associated with a lower risk of OHSS.

• #71 How to Prevent OHSS (Ovarian Hyper Stimulation Syndrome)

  https://www.santamonicafertility.com/blog/how-to-prevent-ohss-ovarian-hyper-stimulation-syndrome/

  Another helpful thing to do to prevent OHSS after egg retrieval is to stay hydrated, preferably with electrolyte rich solutions such as sports drinks or coconut water. You can also choose to make your own by adding a pinch of salt and orange and lemon slices into your glass. […] You have tips on how to prevent OHSS, including careful monitoring, regular acupuncture and staying hydrated.

• #72 Ovarian hyperstimulation syndrome – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/ovarian-hyperstimulation-syndrome-ohss/symptoms-causes/syc-20354697

  To decrease your chances of developing ovarian hyperstimulation syndrome, you’ll need an individualized plan for your fertility medications. Expect your health care provider to carefully monitor each treatment cycle, including frequent ultrasounds to check the development of follicles and blood tests to check your hormone levels. […] Strategies to help prevent OHSS include: […] Adjusting medication. Your provider uses the lowest possible dose of gonadotropins to stimulate your ovaries and trigger ovulation. […] Adding medication. Some medications seem to reduce the risk of OHSS without affecting the odds of pregnancy. These include low-dose aspirin; dopamine agonists such as carbergoline or quinogloide; and calcium infusions. Giving women who have polycystic ovary syndrome the drug metformin (Glumetza) during ovarian stimulation may help prevent hyperstimulation.

• #73 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  Ovarian hyperstimulation syndrome is a relatively common complication of ovarian stimulation and can be life-threatening. […] The combined use of a gonadotrophin-releasing hormone antagonist protocol with gonadotrophin-releasing hormone agonist triggering and oocyte and embryo freezing has considerable promise in preventing ovarian hyperstimulation syndrome. […] The inhibition of vascular permeability seems to be a novel therapeutic approach to preventing and treating ovarian hyperstimulation syndrome. […] The prevention of OHSS includes three main strategies: identification of women at risk, using different ovulation-induction strategies before stimulation, and preventive therapy modalities during stimulation. […] Recognising risk factors of OHSS is the key to prevention. […] Women at higher risk of developing OHSS include young age, low body weight, polycystic ovary syndrome (PCOS), use of GnRH agonists, higher doses of exogenous gonadotrophins, high absolute or rapidly rising serum oestradiol levels, development of multiple follicles during treatment, exposure to hCG, and previous episodes of OHSS.

• #74 Prevention and management of ovarian hyperstimulation syndrome | Obgyn Key

  https://obgynkey.com/prevention-and-management-of-ovarian-hyperstimulation-syndrome/

  Ovarian hyperstimulation syndrome is a relatively common complication of ovarian stimulation and can be life-threatening. […] The combined use of a gonadotrophin-releasing hormone antagonist protocol with gonadotrophin-releasing hormone agonist triggering and oocyte and embryo freezing has considerable promise in preventing ovarian hyperstimulation syndrome. […] The inhibition of vascular permeability seems to be a novel therapeutic approach to preventing and treating ovarian hyperstimulation syndrome. […] The prevention of OHSS includes three main strategies: identification of women at risk, using different ovulation-induction strategies before stimulation, and preventive therapy modalities during stimulation. […] Recognising risk factors of OHSS is the key to prevention. […] Women at higher risk of developing OHSS include young age, low body weight, polycystic ovary syndrome (PCOS), use of GnRH agonists, higher doses of exogenous gonadotrophins, high absolute or rapidly rising serum oestradiol levels, development of multiple follicles during treatment, exposure to hCG, and previous episodes of OHSS.

• #75 New algorithm for OHSS prevention | Reproductive Biology and Endocrinology | Full Text

  https://rbej.biomedcentral.com/articles/10.1186/1477-7827-9-147

  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. […] 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. […] The protocol of choice for potential high-responder patients prone to develop OHSS should be the GnRH antagonist protocol, as it has been shown to decrease the incidence of OHSS significantly.

• #76 Preventing Ovarian Hyperstimulation Syndrome

  https://www.rmany.com/blog/preventing-ovarian-hyperstimulation-syndrome

  Patient education about the risks and drivers of OHSS are an integral part of any treatment program because patient participation in the treatment plan can help to avoid the occurrence of OHSS. […] Advancements in understanding the causes of OHSS, the availability of techniques to modify the risk of its occurrence, and experienced practitioners trained in the proper management of patients undergoing ovarian stimulation procedures have thankfully made the likelihood of the severest forms of OHSS rare and have made fertility treatments very safe.

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