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A 30-year-old primigravid (G1P000) female with infertility secondary to her partner's oligospermia and her chronic anovulation presented 13 days after an oocyte retrieval for in vitro fertilization (IVF) with a positive home pregnancy test, abdominal distention, a 5-pound weight gain, nausea, shortness of breath, and reduced urinary frequency. Her IVF cycle included the usual cocktail for gonadotropin stimulation and was uncomplicated, except for excessively stimulated ovaries that led to a peak estradiol level of 6,000 pg/ml and the retrieval of 30 oocytes. Her past history was relevant only for anovulation due to polycystic ovarian syndrome (PCOS), though her preprocedure body mass index was normal at 21 kg/m^sup 2^. Pelvic ultrasound revealed abundant ascites and enlarged ovaries, at 8 cm average diameter. Serum human chorionic gonadotropin (hCG) concentration was 200 mIU/ml; she was hemoconcentrated (hemoglobin 16 g/dl), with normal liver function and coagulation testing. An ultrasound guided, transvaginal paracentesis removed 4 liters of straw-colored fluid, resulting in significant short-term symptom relief.
The patient described above has moderate to severe ovarian hyperstimulation syn- drome (OHSS), the most serious maternal complication of gonadotropin therapy. OHSS poses a significant risk of maternal morbidity and mortality as well as preg- nancy loss. The patient's risk factors for having OHSS include youth, excessive ovarian stimulation, PCOS, and a likely twin gestation. Signs and symptoms of severe OHSS include abdominal disten- tion, compromised renal function (includ- ing renal failure) due to decreased renal perfusion secondary to pressure from tense ascites and decreased intravascular volume, respiratory compromise due to pleural effusion and pulmonary edema, thromboembolism (including stroke) due to hemoconcentration and high estrogen levels, ovarian rupture, electrolyte abnor- malities, and liver dysfunction. Although most cases are mild and self limited, severe cases can result in acute respira- tory distress syndrome (ARDS) or stroke and can require intensive care unit (ICU) admission to prevent death.
Current knowledge
Older literature suggests that significant ovarian hyperstimulation occurs in excess of 3% of gonadotropin stimulation cycles, but more recent data suggest a rate of less than 1% per cycle (1). The reduction in OHSS cases likely reflects better recogni- tion of risk factors...