Ovarian Hyperstimulation Syndrome

Why would you be dealing with Ovarian Hyperstimulation Syndrome (OHSS)?

Every time you undergo controlled ovarian hyperstimulation – either for IVF or IUI, there is a small degree of risk. However, your symptoms are likely to be very mild, involving only a minor degree of swelling or discomfort. OHSS usually starts a couple of days after an egg retrieval – although, like everything, this can vary and your symptoms may start earlier or later.

Factors Which Increase Your Risk (not limited to)

1. Lots of follicles and high estrogen levels. This is the biggest risk factor, and one of the reasons why more isn’t necessarily better. You may be “coasted” to reduce the number of follicles/estrogen levels.

2. hCG seems to trigger, prolong, and increase the severity of OHSS. If you are at very high risk, your retrieval may be cancelled because the hCG trigger injection will be deemed too dangerous. If you are at slightly lower risk, you will be asked to trigger and undergo retrieval, but your transfer will be cancelled to avoid pregnancy in that cycle and the embryos frozen for later use.

3. Low body mass index. Women who are thin or underweight are slightly more at risk. Professionals have yet to discover the reason for this.

4. Polycystic ovary syndrome — a common reproductive disorder that causes irregular menstrual periods, excess hair growth and unusual appearance of the ovaries on ultrasound examination

What You Can Expect

With mild to moderate OHSS symptoms may include:

• Mild to moderate abdominal pain
• Abdominal bloating or increased waist size
• Nausea
• Vomiting
• Diarrhea
• Tenderness in the area of your ovaries

Some women who use injectable fertility drugs get a mild form of OHSS. This usually goes away after about a week. But, if pregnancy occurs, symptoms of OHSS may worsen and last several days to weeks.

With severe OHSS symptoms may include:

• Rapid weight gain — more than 2.2 pounds (1 kilogram) in 24 hours
• Severe abdominal pain
• Severe, persistent nausea and vomiting
• Blood clots
• Decreased urination
• Shortness of breath
• Tight or enlarged abdomen

The average case lasts seven to ten days. Unfortunately, there is no way to make the OHSS go away. Instead, you need to support your body until the hormones settle down. Most of the time, adequate monitoring and treatment can be given at home – this is discussed in more detail under “troubleshooting”. If your symptoms become too severe for at-home treatment, you will be admitted to the hospital. Although the principles of supportive care and monitoring remain the same, both will be more aggressive for in-hospital patients.

Treating OHSS

Mild OHSS typically resolves on its own. Treatment for moderate – severe OHSS may involve:

• Increased fluid intake – You will be losing fluids into your abdominal cavity. If you can’t keep up with this loss by drinking fluids, you will be put on an IV drip.
• Blood tests to monitor for dehydration, electrolyte imbalance and other problems
• Drainage of excess abdominal fluid using a needle inserted in your abdominal cavity
• Medications to support symptoms such as nausea, diarrhea & pain
• Keep up the proteins. You will also be losing proteins into your abdominal cavity. If eating protein-rich foods and drinking protein shakes isn’t enough, you can be given albumin via a drip.
• Maintain organ function and treat specific complications. If the pressure in your abdomen is too great, an in-dwelling tube can be placed under local anaesthetic to drain some of the fluid away. As the proteins in this fluid are lost to the body forever, and cannot be resorbed, this will only be done if the benefits are thought to outweigh the risks. If you are having trouble emptying your bladder due to the enormous swelling of your ovaries, you may need an in-dwelling urinary catheter placed. Other specific complications are treated as they arise.
• Control shortness of breath. Mild shortness of breath can be treated with rest. In more severe cases, intranasal oxygen may be used.

With severe OHSS, you may need to be admitted to the hospital for monitoring and aggressive treatment, including IV fluids. Your doctor may give you a medication called cabergoline to lessen your symptoms. Sometimes, your doctor may also give you other medications, such as gonadotropin-releasing hormone (Gn-RH) antagonist or letrozole (Femara) — to help suppress ovarian activity.

Serious complications may require additional treatments, such as surgery for a ruptured ovarian cyst or intensive care for liver or lung complications. You may also need anticoagulant medications to decrease the risk of blood clots in your legs.

Monitoring OHSS

1. Daily weigh-ins and waist measurements to check for drastic changes
2. Frequent physical exams and ultrasounds
3. Daily blood tests for in-hospital patients.
4. Measurements of how much urine you produce each day
4. Monitoring vital signs for in-hospital patients (heart rate, respiratory rate, oxygenation, temperature).
5. X-rays and ultrasounds may be used for some in-hospital patients, depending on symptoms.

After OHSS

Most clinics advise taking a cycle off to allow your reproductive system to get back to normal. Opinions do vary, though – some specialists are willing to do an FET the very next cycle, and others advise a longer wait of several cycles. Most patients find their next cycle is longer than usual. It’s common to be anything from two to four weeks late in the cycle following OHSS. The cycle after that may also be prolonged.

Ways to Troubleshoot

It’s very important that you report any and all symptoms to your specialist.

Simple treatment for mild cases:
1. Drink plenty of fluids. Electrolyte drinks (sports drinks) and protein shakes (eg sustagen) are especially good. This is because your body is losing fluid, electrolytes and proteins into your abdominal cavity. High-protein foods, such as chicken, are also recommended.
2. Take pain killers. Doctors usually prescribe paracetamol/acetominophen plus or minus codeine for mild pain. If these don’t work, consult your specialist.
3. Make sure you are getting adequate amounts of rest.
4. Monitor your symptoms. Check your weight on the bathroom scales each morning. Report any sudden increases in weight. Measure your waistline. If you are putting on inches each day, talk to your clinic. Take note of your urine volume. If it’s decreasing, or if you find you are going to the toilet very frequently without passing much each time, contact your clinic. If any other symptoms arise – nausea, vomiting, shortness of breath etc – contact your clinic.

Advice

Don’t be afraid to talk to your clinic about your symptoms. If your symptoms are changing and progressing – talk to them again. Better be on the safe side.

OHSS is tough mentally and emotionally. There are an awful lot of hormones involved, and you are genuinely sick, which is frightening. The fact no-one can tell you how long it will last is frustrating – will it be a few days or will you be that rare patient whose symptoms go on for over a month? Supportive treatments, especially IV albumin, can make you feel better temporarily and lead you to think it’s all over – until they wear off. This is very different from illnesses or injuries you may have had in the past, where each day you can feel yourself getting a little bit better. With OHSS, you may be getting worse each day, or feeling up and then down again, with no clear ending in sight. Please remember almost everyone gets better in seven to ten days.

“You will get through this – hour by hour, day by day, moment by moment.”