What day is easier after hyperstimulation. Ovarian hyperstimulation syndrome: symptoms and treatment

Ovarian hyperstimulation is a pathological reaction of a woman's body to a specific hormonal treatment before or after IVF. Statistical data on the occurrence of this pathology vary from 0.5 to 30%. This difference is due to different treatment regimens in clinics and some other factors.

Ovarian hyperstimulation syndrome (OHSS) poses a real threat to a woman's life, especially when unskilled care is provided. Why and for whom does the condition arise, what can it lead to and how to deal with it correctly?

Read in this article

Causes of Ovarian Hyperstimulation Syndrome

The hyperstimulation syndrome can occur both during the maturation and ovulation of one egg, and several, single cases of the appearance of OHSS in their own cycle without any external influences are described.

Normally, after the release of the egg from the ovary, a corpus luteum. The process is accompanied by an expansion blood vessels, activation various substances(interleukins, tumor necrosis factor, "X" and others). At the same time, capillary permeability increases, a certain amount of plasma enters the abdominal cavity. Normally, this does not bring a woman any discomfort pain or something like that.

With artificial stimulation, maturation of not one, but two or three, and sometimes even more than ten eggs, often occurs. It is also impossible to predict how sensitive a woman is to all the drugs used. As a result, almost the same thing happens as in the norm, but in a different volume. This leads to more fluid leaking into the abdominal cavity, up to several liters.

These mechanisms do not go unnoticed in the body, other processes are activated. The result is a bright clinical picture sometimes with life-threatening complications.

The mechanism of occurrence of OHSS can be described as follows:

• From the blood vessels, plasma, along with proteins, enters the abdominal cavity. This leads to the appearance of pain, symptoms of irritation of the peritoneum (" acute abdomen”), nausea, vomiting, etc.
• Since there is less plasma in the vessels, the blood thickens greatly. And this directly provokes the formation of blood clots, pulmonary embolism, etc.
• The blood supply to the kidneys is impaired due to a decrease in blood volume. This leads to kidney failure. Other organs may react in the same way. Therefore, often a woman needs resuscitation.

Risk factors for developing OHSS

It is impossible to predict the likelihood of developing ovarian hyperstimulation syndrome. But they distinguish a certain risk group among all girls planning a pregnancy using. These include:

• With a large supply of eggs. At the same time, several follicles respond during stimulation, which subsequently leads to the launch of an extensive mechanism. The number of presumed active eggs in practice is checked using an anti-Mullerian hormone test, the value of which correlates with a woman's fertility.
• Young age of girls: the younger the patient, the more eggs she still has.
• Deficiency in body weight. This is due to the lack of compensatory capabilities of the body. With a small weight, even a relatively small plasma effusion will lead to serious consequences.
• Use as a stimulation of hCG or gonadotropic hormones under a long protocol.
• Multiple pregnancy.
• If a girl has ever had OHSS, then the severity of symptoms during the next IVF in most cases is greater.
• If a girl suffers from various kinds of allergic reactions.
• In polycystic ovary syndrome, OHSS is also much more common.

Symptoms of ovarian hyperstimulation syndrome

The severity of symptoms in OHSS depends on the severity of the pathology.

At mild form the woman is practically not bothered by anything, as the condition progresses, the symptoms worsen.

The clinical picture does not depend on whether OHSS developed immediately after the puncture, already during pregnancy or after embryo transfer. Symptoms may include the following:

• . The intensity varies from the severity of ascites. At the same time, the circumference of the abdomen will increase in parallel.
• Difficulty breathing due to accumulation of fluid in pleural cavity and pressurizing the diaphragm. Shortness of breath appears.
• Nausea, vomiting, stool disturbance due to intestinal irritation.
• The appearance of swelling of the hands, feet, abdominal wall and the whole body - anasarca.
• In severe form, rhythm disturbances, a sharp decrease in pressure, etc. may appear.

If the pregnancy is fixed, then a mild degree of OHSS must be differentiated from the threat of termination. Nausea, vomiting, weakness, pulling pains in the lower abdomen will be common to all these conditions.

Types of OHSS

Classification of OHSS is carried out taking into account the severity and severity of symptoms. The following stages are distinguished:

• 1 and 2 count mild manifestations OHSS. In this case, the ovaries increase to no more than 6 cm in diameter. A woman is worried about minor fights in the lower abdomen, she may not even apply for medical care.
• Stages 3 and 4 are considered moderate. The ovaries can grow up to 12 cm, and ascites (fluid in abdominal cavity), vomiting and nausea, less often - diarrhea.
• Stages 5 and 6 are considered severe manifestations of OHSS. Against the background of sharply enlarged ovaries (more than 12 cm), there are signs of hypovolemia (decrease in blood volume): low blood pressure, confusion, impaired kidney function, and others. Ascites is pronounced, as well as hydrothorax (fluid in the pleural cavity), hydropericardium (near the heart), etc.

Thrombosis may occur kidney failure, disruption of the liver, swelling of the whole body (anasarca) and other symptoms. With this degree of OHSS, treatment is carried out only in the intensive care unit.

According to the time of occurrence, the following types are distinguished: early and late. In the first case, all symptoms of hyperstimulation occur within 5 to 6 days after ovarian puncture for egg collection. With late OHSS - on the 7th day and beyond, even on early dates pregnancy.

The severity of symptoms does not depend on the time of occurrence.

Watch the video about ovarian hyperstimulation syndrome:

Diagnosis of ovarian hyperstimulation syndrome

In most cases, ovarian hyperstimulation syndrome occurs after a woman leaves an IVF center. Therefore, the diagnosis and treatment have to deal with general practitioners. When making a diagnosis, the following is done:

• An anamnesis is collected, in which it becomes known when IVF was performed, what drugs were stimulated, what kind of attempt it was, etc.
• A general examination and a special (gynecological) examination are carried out. As a result, the doctor prescribes an additional examination and determines the severity of OHSS.
• Ultrasound of the small pelvis and abdominal cavity is performed, and signs of ascites, etc. can be detected.
• Ultrasound of the heart, pleural cavity, and X-ray of the lungs can detect the accumulation of fluid in these places.
• If necessary, an ECG and some other research methods are performed.
• Mandatory execution general analyzes blood and urine, biochemical profile and others.

Treatment of ovarian hyperstimulation syndrome

Treatment can be carried out both on an outpatient basis (with a mild degree), and in a gynecological hospital and even in intensive care (with a severe degree). Rarely, but if complications occur (rupture or torsion of the ovary), emergency surgical care. The main directions of therapy are as follows:

• Bed rest.
• Sufficient intake of fluid in the body - plentiful drink or intravenous infusion solutions. And mostly not the usual "water" - physiological solution, but special ones, for example, HES (hydroxyethylene starch), etc. The latter do not so quickly sweat again in the body cavity.
• Drugs to reduce the permeability of the vascular wall. It also avoids blood clotting and all subsequent disorders (acute renal failure, pulmonary embolism, etc.).
• If necessary, fluid is evacuated from the cavities where it has accumulated (puncture of the abdominal cavity, pleural cavity, etc.). But this is more of a "desperate move" to relieve the pressure on internal organs and somehow temporarily reduce the severity of the process. After the evacuation of the fluid, it immediately begins to re-penetrate there, if adequate basic symptomatic treatment is not carried out.
• If acute renal failure occurs, hemodialysis may be temporarily used.
• Antibacterial drugs are prescribed to prevent infection in moderate and severe OHSS.
• If OHSS develops already against the background of pregnancy, additionally, preservation therapy (antispasmodics, hormonal, and others) is prescribed.

In any case, treatment should be comprehensive, competent and timely. Therefore, after IVF or ovarian puncture, it is necessary to seek medical help if even the slightest unpleasant symptoms appear.

Complications that can occur with OHSS

Mild to moderate OHSS resolves without sequelae in most cases. But they can turn into severe forms, and also have an unpredictable course. The most common complications encountered are:

• Ascites, the volume of accumulating fluid can reach 15 - 20 or more liters.
• Acute cardiac, pulmonary and renal insufficiency. All of these conditions require emergency medical attention.
• Rupture and torsion of the ovary, violation of its nutrition. These conditions require surgical treatment.
• As a long-term consequence, ovarian exhaustion syndrome may occur due to their constant stimulation with drugs. This can develop 3-5 years after IVF and manifests itself as premature menopause.

Prevention of ovarian hyperstimulation

Prevention of development is as follows:

• It is necessary to plan pregnancy and undergo a thorough examination the day before.
• When choosing drugs for stimulation, one should take into account all previous IVF attempts, the reaction of the woman's body to the drugs.
• At the time of planning, the girl needs to observe mental and physical peace, eat right and balanced, drink enough fluids.

Ovarian hyperstimulation syndrome is a serious condition that requires a competent approach and individual treatment. Today it is not so common, but it can still pose a threat to life. In order to avoid this, one should carefully approach the schemes and methods of stimulation, observe the woman's reaction.

) involves several successive stages. The first stage is the stimulation of superovulation so that many more eggs are produced in the woman's follicles than usual. The maturation of several follicles in the ovary is achieved by taking special preparations. Usually, after taking them, from 10 to 12 follicles are formed. Naturally, an increased number of simultaneously mature follicles significantly increases the chances of conception, but also increases production, which leads to certain consequences. The next stage is the puncture of the follicles, the taking of eggs. During the third stage, the doctor fertilizes them with "in vitro" spermatozoa. If everything goes well, on about 3-5 days, one (maximum two) of the already formed embryos is selected, which are transplanted into the woman's uterus. Those embryos that remain are frozen to be used if pregnancy does not occur this time.

It seems that the mechanism is clear and, at first glance, not so complicated. It seems, well, a woman cannot get pregnant, she will do IVF and that's it! In most cases, it is. But, as in any matter, there is another side to the coin. Unfortunately not very pleasant.

What is hyperstimulation in IVF?

It turns out that in some women, drugs that are used to stimulate superovulation provoke hyperstimulation syndrome. Every woman experiences this condition in her own way. There are also very difficult cases. They are especially common in women diagnosed with polycystic ovary syndrome (PCOS). If a woman is diagnosed with PCOS, she needs to reduce the dose of the drug.

Ovarian hyperstimulation syndrome is the most serious and very dangerous complication that can occur during in vitro fertilization. Hyperstimulation develops already at the stage of superovulation, but, as a rule, it manifests itself a little later - after it enters the woman's uterine cavity.

If a woman with ovarian hyperstimulation still becomes pregnant as a result of IVF, then the condition of the pregnant woman, due to physiological hormonal changes, is even more aggravated. In some cases, the symptoms of hyperstimulation persist for 10 or even 12 weeks. By the way, it has been established that the earlier hyperstimulation has manifested itself, the more difficult it will be to proceed.

Who can experience hyperstimulation during IVF?

Although hyperstimulation syndrome is a disease that is caused by medical intervention, no doctor can answer the patient with absolute accuracy whether hyperstimulation syndrome threatens her. However, there are certain factors that can contribute to the occurrence of ovarian hyperstimulation. Among them: the genetic predisposition of women under the age of 35 (fair-haired and not prone to fullness), polycystic ovary syndrome, increased amount estradiol in the blood allergic reactions, the use of a-GnRH for the purpose of superstimulation, the support of the luteal phase with drugs.

Symptoms of ovarian hyperstimulation during IVF

The development of hyperstimulation may be indicated by several symptoms, which depend on the severity of the disease.

Light degree: slight swelling, an increase in the volume of the abdomen, a feeling of heaviness, pain, as during menstruation, frequent urination. The diameter of the ovaries increases to 5-10 cm.

Average degree: added nausea, vomiting, loss of appetite, diarrhea, bloating, weight gain. The ovaries increase to 8-12 cm.

Severe degree: shortness of breath, heart rhythm disturbances, high blood pressure, a very strong increase in the volume of the abdomen. The ovaries become more than 12 cm in diameter. In some cases, they reach 20-25 cm in diameter.

Complications of ovarian hyperstimulation are ectopic pregnancy, rupture of ovarian cysts, torsion of the uterine appendages. Ovarian torsion can happen because the enlarged ovaries become very mobile. Torsion leads to impaired circulation, followed by necrosis (the ovary dies). A woman with torsion feels sharp pain, which does not subside in any way, but, on the contrary, intensifies. In this case, the woman needs urgent surgery. If irreversible processes have already occurred, it is necessary to remove the entire ovary or part of it.

The most common complications of ovarian hyperstimulation are ascites (fluid accumulation in the abdomen) and hydrothorax (fluid accumulation in the abdomen). chest). This happens because the fluid from the bloodstream is not excreted through the kidneys or with breathing, but sweats into the cavity. There are other complications: the formation of blood clots (up to thromboembolism), impaired liver and (or) kidney function.

Treatment of ovarian hyperstimulation in in vitro fertilization

Most doctors are familiar with this problem only in practice. Sometimes a doctor in his entire practice never encounters something like this.

To date, the mechanism for the development of hyperstimulation is unknown, so there is no special specific treatment. Only the right way cured - eliminate the pregnancy. But this is hardly the right way out, since it was for the sake of pregnancy that in vitro fertilization was carried out, which provoked ovarian hyperstimulation syndrome. Therefore, in a hospital, all actions are reduced to alleviating the condition of the woman and maintaining the pregnancy.

With a mild form of hyperstimulation syndrome, do not use medications. The woman is prescribed peace and proper nutrition, which provides for abundant drinking, a complete and balanced diet. A woman should monitor her weight and daily amount of urine.

In the case of moderate and severe forms of ovarian hyperstimulation syndrome home treatment will not work. The woman is admitted to the hospital. In the hospital, they monitor her breathing, the work of the heart vascular system, liver, kidneys. Monitor electrolyte balance (abdominal size, weight, diuresis,). For the treatment of OHSS, drugs are used that reduce capillary permeability, as well as those used to prevent thromboembolism.

In severe cases, with ruptured cysts and internal bleeding, the woman will undergo a puncture of the abdominal cavity and surgery.

After the last stage of IVF - embryo transfer - it is necessary to carefully monitor the condition of the woman. She is prescribed peace and forbidden sexual relations with her husband. Sometimes, after embryo transfer, a woman may develop an inflammatory process.

Any married couple who dreams of a child, but encounters various difficulties on the way to a dream, experiences strong emotional stress. If serious complications are observed, psychological stress is possible. Some women are afraid, for example, that the use of stimulant drugs will provoke ovarian cancer. But, in fact, studies have shown that there is no connection between taking such drugs and ovarian cancer (however, like other organs) does not exist.

Especially for Olga Rizak

Ovarian hyperstimulation syndrome (OHSS) is considered one of the most dangerous and formidable complications of such a procedure as in vitro fertilization. This syndrome is an iatrogenic condition that occurs in response to the administration of an excessive amount of hormonal drugs necessary to stimulate the ovaries. The first mention of ovarian hyperstimulation syndrome appeared more than sixty years ago. And in 1951, the first fatal outcome was recorded, which became a consequence of OHSS.

Mild OHSS is recorded in the majority of patients who decide to resort to infertility treatments such as IVF. As a rule, mild manifestations of OHSS do not pose a serious danger to a woman's health. It is important to prevent this phase from turning into a more difficult one.
Since assisted reproductive technologies have been developing more and more actively in recent years, the risk of ovarian hyperstimulation syndrome is constantly increasing. As a rule, the main symptoms of this complication do not appear immediately, but during the luteal phase of the cycle, in the early stages of pregnancy, that is, when the patients are already returning home after the IVF procedure. And only if the diagnosis of pregnancy is positive. Timely gynecological examination makes it possible to reduce the risk of complications to a minimum.

Severe forms of OHSS are recorded on average in 9-15% of cases. Deaths are rare, most often caused by hepatic-renal failure, cerebral infarction or ARDS (adult respiratory distress syndrome).

Symptoms of ovarian hyperstimulation syndrome

One of the first signs of ovarian hyperstimulation syndrome is a feeling of discomfort in the lower abdomen, which may be accompanied by a feeling of heaviness, fullness, mild soreness, which is the result of a significant increase in the ovaries. As a result, fluid accumulates in the abdomen, and circulatory disorders are possible. A woman who underwent an in vitro fertilization procedure the day before notices that her waist circumference slightly increases, 2-3 extra pounds are added. Mild forms of OHSS, as a rule, disappear without a trace within two to three weeks, and do not require special treatment, but a woman needs to appear on time for a gynecological examination.

Table 1. Classification of stages of OHSS

Degree of OHSS	Ovarian diameter, cm	Stage of OHSS	E 2 level, pg/ml	Symptoms
				There are no clear signs
				Abdominal tension, feeling of discomfort
				Same as mild + signs of ascites on ultrasound
				Same as mild + nausea, vomiting, diarrhea
				The same as with the average degree + clinical symptoms ascites, liver dysfunction, accumulation of fluid in the pleural cavity.
				Same as moderate + symptoms of intense ascites, increased blood viscosity, hemoconcentration (hematocrit > 45%), oliguria, decreased renal perfusion, ARDS, thromboembolism, hypovolemic shock

In the event that the ovarian hyperstimulation syndrome after IVF goes into a more severe stage, fluid accumulation can be observed not only in the lower abdomen, but also in the lung region, which causes shortness of breath. In addition, symptoms such as flatulence, nausea, liquid stool sometimes vomiting. In severe ovarian hyperstimulation syndrome, the ovaries increase dramatically in size, reaching 12 or more cm in diameter. A woman who has been treated for infertility with the help of IVF, in this case, must be urgently hospitalized in a hospital, where she will undergo a comprehensive examination and treatment.

Table 2. Classification of severe and critical stages of OHSS

Severe stage of OHSS	Critical stage of OHSS
Ovarian enlargement	Ovarian enlargement
Massive ascites ± hydrothorax	Tension ascites ± hydrothorax
Leukocytes > 15? 10 9 /l	Leukocytes > 35? 10 9 /l
Hematocrit > 45%	Hematocrit > 55%
Pronounced oliguria	Pronounced oliguria
Creatinine 1–1.5 mg% (88–132 µmol/l)	Creatinine 1.6 mg% (141.3 µmol/l)
Anasarka	ARDS, thromboembolism
liver dysfunction	kidney failure

Treatment of ovarian hyperstimulation syndrome

Assisted reproductive technologies do not exclude the emergence adverse effects. Therefore, at the time of admission of the patient to the hospital, where the pregnancy is being managed in parallel, her thorough examination is carried out with the establishment of the stage of OHSS. In order to provide effective infusion therapy, the necessary measures should be taken to ensure full access to the veins. In addition, catheterization Bladder, which allows you to evaluate hourly diuresis, as well as control intra-abdominal pressure (IAP). As a rule, it is IAP that most often provokes an unfavorable outcome of the disease that occurs after IVF.

In the middle and severe stages of OHSS, treatment is carried out with antiemetics (metoclopramide) parenterally, solutions of hydroxyethyl starch (HES) together with solutions of crystalloids. In severe cases, when Ht exceeds 45%, the use of human albumin is recommended, which is necessary to maintain diuresis and reduce edema. With a pronounced pain syndrome shows parenteral administration of opioids.

In the case of the development of intense ascites, paracentesis should be performed - pumping out the fluid that has accumulated in the abdominal cavity. Paracentesis in a patient undergoing in vitro fertilization is carried out under ultrasound control, which avoids injury to the ovaries. To avoid puncture of the abdominal wall allows a spiral catheter that provides continuous drainage.

Surgical intervention should only be carried out by an experienced surgeon, since enlarged ovaries are easily damaged.

Risk Factors for Developing Ovarian Hyperstimulation Syndrome

The young age of the patient who is undergoing treatment for infertility (up to 35 years);

Low body mass index of a woman suffering from female infertility(asthenic physique);

Allergic reactions in the past;

polycystic ovary syndrome;

High activity of estradiol in the blood serum;

Many developing follicles;

OHSS, which is a consequence of in vitro fertilization, in history;

Superovulation stimulation protocols using GnRH agonists;

The introduction of high or repeated doses of exogenous chorionic gonadotropin;

Pregnancy.

Prevention of ovarian hyperstimulation syndrome

The main measures to prevent OHSS include:

Reducing the dose of gonadotropic drugs or refusing to stimulate ovulation, if the patient has a pronounced tendency to develop OHSS;

Cancellation of injections of ovulatory or maintenance doses of human chorionic gonadotropin;

Aspiration maximum number cyst and follicle;

Cancellation of embryo transfer followed by their cryopreservation, in order to subsequently transfer them to the uterus during the natural cycle.

IVF ovarian hyperstimulation (OHSS for short) is one of the serious complications after the procedure. Each specialist, during a discussion with the patient of all, must necessarily inform her about the risk of OHSS.

Ovarian hyperstimulation syndrome occurs as a response to hormonal preparations(prescribed at). Their use contributes to the development of too much. As a result, blood begins to thicken, capillaries and blood vessels weaken, and fluid begins to accumulate in the body, filling tissues and causing swelling. The reaction of the ovaries is manifested in their increase.

Women with a genetic predisposition to this disease or with long-term infertility treatment are more often at risk. Most often, the syndrome begins to develop before pregnancy (during the period of stimulation). Able to form until the moment when the embryo is transferred to the uterus. But the symptoms appear only after the embryo moves into the body of the uterus.

In cases of successful fertilization, the patient undergoes a natural restructuring of the hormonal background of the body and the state of health worsens. Early manifestations of OHSS threaten a large number of complications later and long-term treatment. The pain that the syndrome causes can persist throughout the first trimester.

How does the syndrome develop?

The female body is naturally capable of producing only one mature egg per monthly cycle. For some patients, this is not enough for fertilization to occur. modern medicine reproductive technology offers a method of stimulating the body with hormones. As a result, several eggs mature in the follicles at the same time (up to 20 pcs.). Then the chances of successful fertilization increase significantly.

The other side of reproductive technology with the help of hormone stimulation is that the level begins to increase in the body. This affects the walls of the vessels, which become too permeable. Liquid plasma freely begins to leave the bloodstream. This affects other organs of the body, which begin to swell. In a toga, a woman is threatened with the development of the following diseases:

• development of ascites - fluid accumulates in the abdominal cavity;
• development of the hydropericardium - the pericardial sac (the space that is around the heart muscle) begins to fill with fluid;
• the development of hydrothorax - the cavity in the chest is filled with fluid.

Complications in the form of ovarian hyperstimulation are accompanied by a strong increase in them. From this, their protective shell begins to suffer. As it stretches, the woman begins to experience pain of varying intensity in the lower abdomen.

3 stages of hyperstimulation

The ovaries can increase in size up to 20 cm.

1. At initial stage an increase in the ovary is observed in the range of 5.5–10 cm in diameter. A woman may experience slight discomfort in the lower abdomen.
2. In the middle stage, the increase can reach 12.5 cm. general state- the intensity of pain increases, nausea, gag reflex and diarrhea may occur. Specialists at this stage determine the pronounced edema (ascites begins to develop).
3. The severe stage is determined by the size of the ovaries up to 20 cm. A large accumulation of fluid provokes in a woman: shortness of breath, repeated vomiting, low blood pressure. At this stage, hydrothorax begins to develop, accompanied by disturbances in the work of the heart.

Important: The sooner ovarian hyperstimulation syndrome begins to appear, the more difficult it will be to undergo treatment. The prognosis of this syndrome is unpromising.

For women whose body is predisposed to this pathology, the chances of conceiving a child are halved. In cases where the fertilized egg could not take root in the uterus, the symptoms of the disease disappear on their own immediately after the start of the menstrual cycle. When fertilization is successful and the pregnancy begins to develop, the symptoms increase, and the woman's well-being worsens.

Which women are at risk?

When in vitro fertilization was chosen for conception, it becomes impossible to predict which of the patients may develop ovarian hyperstimulation syndrome.

• women whose body (and individually the ovaries) are too sensitive to the effects of hormonal drugs that stimulate ovulation;
• women with low weight and asthenic body shape;
• the age of the patient has not reached 35 years;
• the patient already had an increased level of estradiol in the blood, and stimulation provoked an even greater increase;
• a woman's body is prone to frequent allergic reactions;
• the presence of a woman with polycystic ovaries;
• when a woman has already been stimulated with hormonal drugs and there has already been a case of developing OHSS;
• the risk of the syndrome also increases when a woman is supported with hCG preparations during the luteal phase.

Interesting: It was also noticed that the syndrome develops more precisely in fair-haired women with low body weight.

OHSS can develop due to a doctor's error. The specialist incorrectly determined the individual dosage of hormonal drugs.

Symptoms of OHSS depending on the stage of development

The symptoms of OHSS can vary. They will depend on the intensity of the manifestation of the syndrome, as well as on its degree. In the first degree, a woman feels the following signs that should alert:

• the general state of health worsens (may feel nauseated, diarrhea sometimes appears, the temperature rises slightly);
• slight discomfort in the lower abdomen, which increases after physical activity;
• constant sensations of fullness and petrification in the abdominal cavity.

With an average degree of the syndrome, the following symptoms intensify and join the above symptoms:

• pains in the lower abdomen become more distinguishable, aggravated by sudden movements and spreading to the groin and sacrum;
• the external genitalia may swell;
• swelling also appears on the limbs (arms and legs);
• weight may increase
• sensations of constant bloating and a feeling of fullness;
• the daily volume of urine and the frequency of urges decrease;
• the presence of dysbacteriosis;
• the patient complains of constant dizziness;
• visual disturbances can be observed, which are manifested by the presence of "flies" in front of the gaze.

The third degree of the syndrome is considered the most dangerous for a woman's health. Accompanied by the following symptoms:

• ascites develops, accompanied by severe swelling;
• significantly reduced daily rate urine;
• a woman complains of constant fatigue, visual disturbances and headaches;
• pronounced excruciating pain in the abdomen (in the form of bursting from the inside), which does not go away after changing the position of the body, but only spreads more intensively to the sacrum, groin and coccyx;
• frequent vomiting;
• the presence of hypotension (low blood pressure);
• a significant increase in body temperature;
• swelling that spreads from the limbs throughout the body;
• accumulation of fluid (hydrothorax);
• violated heartbeat accompanied by difficulty in inhaling and exhaling.

Symptoms of hyperstimulation syndrome in most cases begin to appear from 3-4 days after the first intake of hormonal drugs that are prescribed for women.

How is OHSS diagnosed?

If a woman was prescribed hormonal drugs in order to stimulate ovulation and she had the first signs of poor health, there is no need to wait and hope that everything will go away on her own. OHSS develops very quickly, causing serious complications.

First of all, the doctor analyzes the complaints: the presence pain, bad feeling, existing swelling and nausea. The specialist should be informed:

• about the history of previous diseases;
• about the presence of bad habits;
• possible hereditary factors in the patient;
• the presence of similar cases in the past (whether there were already attempts to stimulate ovulation that ended unsuccessfully).

This disease does not forgive errors in diagnosis. The neglect of the case and improper treatment threatens a woman with serious health complications. Therefore, for accurate diagnosis of OHSS, several methods are used simultaneously.

The general condition of the patient is examined to establish the severity of the case. being looked around skin which turn pale with OHSS. This condition is caused by disturbances in blood circulation. The limbs suffer the most (due to their remoteness from the heart muscle). During examinations of the cardiovascular system, tachycardia is determined, and the tones of the heart muscle are muffled.

Many patients with OHSS develop edema of the vulva, extremities, and anterior abdominal wall.

Investigated respiratory system. Tachypnea is detected - rapid breathing, which does not depend on physical exertion. Hydrothorax may also occur - respiratory sounds are not heard, or auscultation - respiratory sounds are weakened.

When examining the abdominal cavity and its organs: due to the formation of ascites, the patient's abdomen is swollen, when pressed, a reaction to pain is manifested, which is present in all its departments (especially in the ovarian region). The abdomen may lag behind a little in the act of breathing. On palpation of the abdominal cavity, enlarged ovaries are felt, as well as the liver, which begins to protrude under the costal arch.

Research of the urinary system. With OHSS, there are delays in urination, the excreted urine is normal<1000 мл.

CNS studies: consciousness, adequacy and contact of the patient. With the appearance of neurological symptoms, there may be a suspicion of thrombosis, which has formed in the vessels of the brain.

A high risk of intrauterine bleeding and (ovarian rupture) are a contraindication to a bimanual examination - a gynecological examination with the fingers. Ultrasound is recommended to assess the condition of the appendages and uterus.

Blood and urine tests

According to laboratory blood tests, determine:

• the rate of sex hormones present in the blood;
• blood clotting (in the presence of OHSS);
• how much the volume of the liquid part of the blood has decreased;
• biochemical analysis will help identify signs of disorders in the functioning of the kidneys and liver.

Urine analysis will help determine its density, the concentration of protein present, as well as the rate of urine discharge.

Ultrasound will help to correctly assess the situation on the part of the ovaries (the size of their increase), detect the existing excess fluid in the abdominal cavity, and also refute or confirm the presence of pregnancy.

To determine the correct functioning of the heart, echocardiography and electrocardiography procedures are prescribed. And the x-ray procedure will help determine the presence of accumulated fluid in the chest and cavities in the region of the heart.

Since ovarian hyperstimulation occurs as a result of ovulation stimulation, in addition, you will need to consult a reproductive specialist.

Consultation of other specialists

Due to the fact that ovarian hyperstimulation gives impetus to the development of pathologies associated with many body systems, a therapist's consultation will be required.

In cases of suspected development of thrombotic complications, it is recommended to consult a vascular surgeon. In critical and severe OHSS - consultation of an anesthesiologist-resuscitator. In the presence of severe hydrothorax - the advice of a thoracic surgeon. Whether or not to perform a puncture of the pleural cavity will depend on his decision.

Features of the treatment of ovarian hyperstimulation

Treatment for OHSS depends on the severity of the case. The doctor and patient will have the choice of continuing or interrupting the in vitro fertilization method.

In the case of a severe development of the pathology, the intake of drugs that are prescribed to stimulate ovulation is canceled. This means that fertility treatment will also be interrupted. It will be possible to repeat the ovulation stimulation procedure only from the next menstrual cycle, but the risk of re-development of OHSS increases significantly. In cases where fertilization has been successful, and the pathology is in the first stage, the specialist may advise you to continue infertility treatment, which is carried out at home. To do this, a woman must follow some rules:

• avoid physical activity;
• properly balance the diet (the doctor will tell you);
• drink enough liquid;
• wearing elastic underwear;
• adhere to bed rest;
• exclude sexual activity (sex can provoke ovarian injury).

In addition to following these rules, painkillers are prescribed to a woman, as well as medicines that will help in the fight against nausea.

Severe and moderate stages of OHSS require urgent hospitalization. The patient should be under the constant supervision of specialists. In stationary conditions, a variety of solutions are administered intravenously:

• drugs that reduce vascular permeability;
• drugs that reduce the occurrence of blood clots;
• antibiotics that reduce the risk of joining infectious processes;
• protein nutritional supplements.

You may also need to remove the ascitic fluid. For this procedure, a puncture is performed in the abdominal wall, which makes it possible to create an outflow of fluid. If fluid collects in the chest cavity, the puncture is made in the chest wall. In cases where the pathology has given severe complications to the kidneys, the patient is prescribed hemodialysis (a method of extrarenal blood purification using special equipment).

Consequences of OHSS

Any stage of the development of the syndrome can give complications in the form of: the development of ascites, renal or heart failure, as well as hydrothorax. If control over the course of the disease is not started in time, ovarian hyperstimulation leads to the following complications (some of them threaten the patient's life):

• with uncontrolled development of ascites, the fluid in the abdominal cavity can reach volumes of 25 liters;
• uncontrolled accumulation of fluid in the chest and abdominal cavity - acute heart failure;
• accumulation of fluid in the chest and abdominal cavity - violations of the pulmonary function, provoking acute respiratory failure;
• development ;
• necrosis or clamping of the vessels that feed the ovaries - torsion of the ovary;
• thickening of the blood or a decrease in its volume - acute renal failure, provoked by impaired renal function;
• apoplexy of one or both ovaries (their rupture with the risk of bleeding);
• premature exhaustion of the ovaries, which threatens with final violations of hormonal and ovular function.

In cases of severe stage of ovarian hyperstimulation syndrome, the specialist reconsiders the strategy of infertility treatment.

How to avoid ovarian hyperstimulation during IVF

When ovarian hyperstimulation syndrome appears at the beginning of treatment, the woman refuses treatment, thinking to keep the pregnancy. But the most effective treatment for OHSS is to avoid drugs that cause the syndrome. In order not to face the choice of preventing or maintaining pregnancy in the future, a woman needs to follow some recommendations of fertility doctors in order to prevent the disease. These recommendations include the following rules:

1. Before the ovulation stimulation procedure, you need to prepare in advance by passing a full examination of the whole body.
2. Compliance with a properly composed diet (foods rich in protein, as well as a sufficient daily intake of fluids drunk). It is worth giving up fatty, spicy and salty foods.
3. When planning a pregnancy, a woman needs to minimize stress factors and excessive physical activity.

The success of IVF will also depend on the specialist. Only he can choose the right regimen and dosage for taking hormonal drugs that are prescribed to stimulate ovulation. Age, weight and previous gynecological diseases are taken into account.

Ovarian hyperstimulation is an artificially induced dangerous condition, accompanied by a woman's physical and moral discomfort. Occurs, as a rule, when using methods of assisted reproductive technologies (IVF). Pathology has different forms and can be characterized by signs differing in intensity.

With hyperstimulated ovaries, it is dangerous to become pregnant. If conception nevertheless occurred, then during the entire gestational period there is a threat to the fetus.

What is hyperstimulation

Ovarian hyperstimulation syndrome is a condition in which there is a multiple increase in the sex glands due to the growth of several follicles. Depending on the severity of the pathology, these organs of the small pelvis from 3-4 cm increase several times. The sex glands can grow up to 20 cm.

Hyperstimulated ovaries appear in women using assisted reproductive technologies. Isolated cases of OHSS in the natural cycle, without the use of hormonal agents, have also been recorded. Hyperstimulation during IVF occurs most often, since the protocol necessarily uses drugs that stimulate the growth of follicles. This condition can be determined by a characteristic clinical picture:

• ascites - accumulation of water substance in the peritoneal cavity (the abdomen "swells");
• pain in the lower abdomen (the severity of the symptom depends on the severity of the pathology);
• difficulty breathing due to fluid exposure to the diaphragm in the pleural region;
• nausea, accompanied by vomiting, and diarrhea (appears due to irritation of the digestive tract);
• anasarca - accumulation of fluid in the lower body, manifested by severe swelling of the hands, fingers, legs and peritoneum;
• decrease in pressure indicators;
• violation of diuresis (less urine is released).

After the puncture, hyperstimulation may worsen, as a corpus luteum forms in place of the former follicles. Replantation of fertilized eggs in such situations is not recommended. However, medical practice shows that at the discretion of the doctor and after assessing the stage of the pathological process in isolated cases, the protocol ends with the planned implantation.

With a pronounced stage of hyperstimulation, the prognosis is usually unfavorable, since the production of hCG aggravates ovarian hyperstimulation during IVF, and pregnancy is complicated.

In vitro fertilization must be approached taking into account the individual characteristics of the female body in order to prevent such a condition as hyperstimulation.

Risk factors for developing OHSS

For some women, it is possible to assume in advance the likelihood of a multiple increase in the gonads. The following groups of patients are prone to pathology:

• fair-haired under the age of 35;
• with a diagnosis of polycystic and frequent formation of functional cysts on the ovaries;
• with an increase in the amount of secreted estradiol;
• prone to allergic reactions;
• with prior intake of gonadotropin-releasing hormone agonists;
• with the support of the second phase with hCG preparations.

Ovarian hyperstimulation syndrome can be prevented if risk factors are considered. Based on the available information about the patient, the doctor will select the best dose of hormonal agents. Thanks to the knowledge, qualifications and ability of reproductologists to evaluate forecasts, ovarian hyperstimulation during IVF occurs only in exceptional cases. Doctors usually manage to avoid such complications.

Why is ovarian hyperstimulation dangerous?

The consequences of ovarian hyperstimulation can be very different. Much depends on the stage and form of the pathological process, as well as the timeliness of the assistance provided. The main and most dangerous complication of enlarged gonads will be fatal. With the active intake of fluid, heart and kidney failure occurs, as well as acute thromboembolism. The mechanism for the development of pathology is as follows:

1. under the influence of drugs, the work of the sex glands is activated, as a result of which the massive growth of follicles begins;
2. plasma and proteins penetrate from the blood vessels of the gland into the peritoneal cavity;
3. the blood thickens strongly, the risk of blood clots increases;
4. due to an increase in blood viscosity and a decrease in its volume, acute insufficiency of some organs occurs (the heart and kidneys are at risk).

After embryo transfer (if the manipulation was considered acceptable and carried out), the symptoms of hyperstimulation may persist for several months. During this period, there is a serious threat to the fetus. The chance of miscarriage with OHSS is many times higher than without it. Pregnancy and ovarian hyperstimulation together can seriously complicate the patient's condition. During the entire gestation period, the risk of fetoplacental insufficiency, the threat of premature birth, hormonal failure, circulatory disorders and hypoxia for the child remains. According to statistics, a baby born after OHSS is more likely to have health problems in the first days of life.

During pregnancy, after IVF, and even several years after childbirth, OHSS can cause ovarian failure. This complication culminates in early menopause.

Stages of ovarian hyperstimulation

Symptoms of ovarian hyperstimulation have different intensity, which characterizes the stages of gonadal enlargement: mild, moderate, severe. Also, pathology is divided into two forms:

• early - signs of hyperstimulation occur immediately after the maturation of the follicle and disappear on their own with the start of a new menstrual cycle (if pregnancy occurs, then OHSS requires mandatory therapy, as it risks going into a late form);
• late - symptoms appear from 4-5 weeks of pregnancy and persist for several months, it is difficult and requires mandatory treatment.

The severity of the symptoms gives the doctor the opportunity to understand how serious the pathological process is and whether it requires intervention.

Light degree

Early hyperstimulation syndrome occurs in almost all women in the IVF protocol. At the same time, the size of the ovaries increases by one and a half to two times. In the ovaries on ultrasound, multiple follicles and cysts are visualized. The woman feels a slight pulling pain, bloating. During an ultrasound examination, a small accumulation of fluid in the abdominal cavity may be detected. This condition can be considered the norm in the IVF protocol.

Average degree

Moderate ovarian hyperstimulation is characterized by pain in the lower abdomen and a slight increase in its volume. Ultrasound data show the presence of fluid in the abdominal cavity, and the gonads increase to 12 cm. A characteristic difference between moderate and mild is the inclusion in the process of the digestive tract, which is manifested by nausea, vomiting and diarrhea.

Severe degree

One of the characteristic signs of the syndrome is swelling of the legs.

To characterize the severe form of OHSS, the main symptoms can be noted: a significant increase in the abdomen due to fluid accumulation, pain and discomfort, swelling of the lower extremities. There are also disturbances in the work of the heart, which causes tachycardia, shortness of breath. The woman is forced to adhere to bed rest. Relief of breathing occurs when taking a semi-sitting posture with an elevation of the torso.

Diagnostic measures show that the ovaries are enlarged in volume up to 25 cm, the number of leukocytes in the blood is increased, the density of blood and urine is increased. The total amount of urine excreted decreases. In addition, body temperature may rise.

critical degree

The most severe degree of OHSS is critical. The total volume of excreted urine is reduced to 1 liter. The pulse is frequent, breathing is difficult. BP is reduced. The abdomen is very swollen (up to 6 liters of fluid accumulate there). There are symptoms of thrombosis and thromboembolism. This condition requires urgent medical attention.

Treatment of ovarian hyperstimulation syndrome

In the mild stage of hyperstimulated ovaries, outpatient treatment is carried out, which does not involve the use of drugs. The patient is recommended bed rest and psycho-emotional rest. Diet for ovarian hyperstimulation - protein. It is necessary to limit the intake of salt, bran and completely eliminate alcohol. You should drink as needed, mainly mineral water.

In the case of the development of a moderate condition, therapy is carried out in a hospital due to the likelihood of rapid progression of the pathology. Continuous monitoring allows assessing the patient's well-being: indicators of water and electrolyte balance, hematocrit, functionality of vital organs. It is necessary to constantly monitor medical personnel specializing in such pathologies.

• Treatment of ovarian hyperstimulation involves the use of medications aimed at replenishing the volume of circulating blood. They help to improve kidney filtration and reduce blood density. Physiological solutions are administered intravenously or drip.
• An important aspect in the treatment of OHSS is the prevention of thrombosis. For this purpose, drugs Fraxiparine or Dalteparin are introduced.
• If necessary, the patient is supplied with anti-inflammatory, analgesic and antipyretic drugs. If possible, Paracetamol, Ortofen, Nurofen are taken orally. In emergency cases, analgesics are administered intramuscularly.
• Antibacterial therapy is prescribed in some cases in order to prevent infection of the abdominal cavity and small pelvis. Preference is given to broad-spectrum drugs.

If ovarian hyperstimulation syndrome develops during pregnancy, then the expectant mother must be prescribed maintenance hormone therapy with progesterone-based agents. It is also recommended to take antispasmodics, sedatives, vitamin complexes. For the entire period of treatment, sexual intercourse should be excluded.

How to avoid ovarian hyperstimulation during IVF

Prevention of ovarian hyperstimulation syndrome begins even before the appointment of stimulant drugs. To date, there is no specialized single way to prevent pathology. It is important at all stages of planning to assess the likelihood of early or late risks and calculate prospects in advance. OHSS can be prevented by the following methods:

• use gonadotropic hormonal agents in the minimum effective dosage for the procedure;
• refuse to administer chorionic gonadotropin in an ovulatory dose or completely exclude it;
• to take dopamine receptor agonists of the second type from the day of using the medication that triggers the process of ovulation;
• reduce stimulation time;
• aspirate all available follicles;
• use progesterone preparations to maintain the second phase instead of agents based on human chorionic gonadotropin.

It is possible to avoid ovarian hyperstimulation syndrome during IVF in most of the protocols. OHSS is becoming the exception rather than the rule in assisted reproductive technology.

It is important that the doctor knows all the features of the patient's body. If a woman has already undergone stimulation or had problems with the functioning of the reproductive system, for example, PCOS, all the nuances should be told to the doctor. While taking hormones, you need to carefully monitor your well-being, and if unusual signs appear, inform your reproductologist.