Director :-

Sec General : Delhi Gynae Forum

Chairperson : WOW India

Founder chairman : Global Institute of Gynae at Pushpanjali Crosslay

Hospital

Former : National Commission for Women (2004-2007) Advisor Health

Chairperson : Women Wing , IMA (2004-2007) Member : Resources Committee NACO (2008-2011)Former Chairperson: Adolescent Health comm., Safe Motherhood Comm. AOGD

Member : State Sup. Board , PNDT Board : Female Feticide Resources Group, NCPC

Dr. Sharda jain

Dr. Sharda Jain

Director :

An OHSS – Free Clinic : to Manage ERROR – TERROR

International conference on Reproduction fertility &surrogacy AIIMS, New Delhi 24-25 may 2014

An OHSS – Free Clinic to Manage

ERROR – TERROR

Review this Lecture at:Slideshare.net :

Goals of Ovulation induction

in IUI / IVF

Minimize Complications & Risk

AIM

Ideal Outcome

Singleton live

Birth at term Cycle

Cancellation

Multiple

Pregnancy OHSS

OHSS – Risk is a reality

OHSS - Mortality is also a reality - Grossly Underestimated (Bewley et al 2011)

DEVROEY 2011

OHSS is ↑ in numbers with

↑ in IVF /ICSI cycles all over the globe

Mortality due to critical OHSS

in IVF is Unacceptable

DEVROEY 2011

OHSS IVF Cycles Most Serious Complications of OI

PRIOR TO 2000 – ↑ OHSSAFTER 2000

of OHSS is almost always present with OI in good & high responders

(Delvigne -2009)

(Dreadful – Hospitalisation & ? Death) (Papanikolaou et al.2005)

Severe OHSS - 2%

Moderate OHSS - 5%

Mild form

MATERNAL MORTALITY RATES

Due to OHSS

Netherland & UK – 2007

MORTALITY : 3 / 1,00,000 CYCLES

1 Aboulghar. Fertil Steril. 2012;97:523-6; 2 Confidential Enquiry into Maternal and Child Health, 2007;

1-5 million IVF cycles / year500 death (last 10 years)

Grossly Underreported

Aetiopathogenesis

Exact Pathogenesis is not clear

IMPORTANCE of OHSSWHAT IT means to ME & to You ?

• Totally IATROGENIC problem of OI

Induced by clinician • without Long Protocol & HCG Trigger OHSS is

extremely rare.• 100% PREVENTION IMPOSSIBLE

• Profound Economical impact

• Profound Psychological Impact

3 Facts

• Long protocol of Down regulation

With GnRH agonist in IVF is associated

↑ OHSS• HCG Trigger for ovulation creates HAVOC

– Compels IVF experts to use long protocol

Supposedly ↑ PRWith long protocol

HCG

Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod. 2000;15:1037; Gómez et al. Endocrinology. 2002;143:4339

Classification (Clinical Forms)

ClassificationMathur et al - 2005.

• THE EARLY FORM (<10 days after the HCG trigger.

• THE LATE FORM (>- 10 days after HCG).

• COMBINATION of the early form , followed

by pregnancy is SERIOUS AND LONG LASTING (Papnikolaou et al., 2004)

Mild

Mild abdominal pain

Abdominal bloating

Ovarian size usually <8 cm

Moderate

Moderate abdominal pain

Nausea +/- Vomiting

Ultrasound Evidence of ascites

Ovarian size 8-12 cm

Grading

Mild

Mild abdominal pain

Abdominal bloating

Ovarian size usually <8 cm

Moderate

Moderate abdominal pain

Nausea +/- Vomiting

Ultrasound Evidence of ascites

Ovarian size 8-12 cm

Grading

Severe

Clinical ascites (rarely hydrothrorax)

Oliguria

heamoconcentration - HEAMATOCRIT >45%

Hypoproteinaemia

Critical

Ovarian size > 12 cmTENSE ASCITES + HYDROTHORAX

WHITE CELL COUNT > 25 000/ ML

OLIGURIA / ANURIA

Thromboembolism

Acute respiratory distress syndrome

Severe / Critical Cases are dreadful !!

Life Threatening

Massive Ascites

• Hemoconcentration

PCV > 45%, Hb > 15gm %• Venous thrombosis • Electrolyte imbalance

Renal• Hepatic failure

The Truth is that

OHSS MUST

BE PREVENTED RATHER than treated

Dale Carnegi Said

“The successful man profits from his mistake

and tries again in a different way”.

“That’s true for errors of OHSS events in IVF – a dangerous emergency

HOW TO PREVENT IT ?

• Steps Before stimulation

• Step During Stimulation

• Step on Impending Severe OHSS

Young patients Lean womenPolycystic Ovarian PCOSPrevious OHSS

• High number of follicle in both ovaries at the quiescent state before Stimulation

(>- 10 follicle of 4-10mm in each ovary)

• Raised AMH

EasilyRecognized

WHO are AT HIGH RISK BEFORE OI – IUI & IVF

PRIMARY RISK FACTORS

SENSITIVE OVARIES

25.0 pmol/l for a high response

(Delhi AMH H >7 ng/ml

OHSS Monitoring should be

• Easy

• Reliable

• Patient friendly

• Not Expensive

• Can be done by IVF Team

IDEA

Welcome Protocol to manage Error Terror

Paul Devrory et al -2011

Human Reproduction

An OHSS-Free Clinic by segmentation of IVF Treatment

OHSS

Proposed Protocol of Zero% OHSS

• The use of the GnRH antagonist protocol for OI instead of long protocol

• Ovulation Triggering with GnRH agonist Instead of HCG trigger

• Cryopreservation of all oocytes and embryos

↓ET in frozen – thawed cycle

3 Steps

STEP - 1

Use of GnRH antagonist

Protocol for OI

• Patients friendly

- Fewer injection of OI

- Short duration of stimulation

- Absence of side effects

Uses • ↓↓ OHSS rate• No difference in Term LB Rates

Between antagonist & agonist Al- Inany et al 2006- 20011, Kolibisnskis et al 2006

Devroey et al 2009 2011

STEP - II

Ovulation Triggering - ↓↓↓↓ OHSS Rate- but can’t eliminate it all

together

GOLD STANDARD as ovulation triggering agent because of long half life with levels remaining elevated even after six days of administrations

HCG

Antagonist protocol

GnRH Agonisttrigger

For triggering final Oocyte maturation• Effective in preventing OHSS

(Segal and Casper ,1992

ZERO % OHSS (Severe / Critical)is achieved

• Incidence of Severe OHSS is GnRH antagonist cycles is 0% when triggered with a GnRH agonist.

• This was tested in OOCYTE DONORS (Melo et al ,2009)

Major Disadvantages

↑ Luteal phase defect &

significant ↓ Pregnancy Rate

It is EASIER Said Than Doneto cancel a cycle !!

↓

GnRH AGONIST as a triggering agent

Luteal phase defect - ↓ PRNegative effect on corpus luteum function

Negative effect on function of endometrium

BY GIVING HCG 1500 units on O.P.U.

day – P.R. ↑ (NORMALISED)

↑

Cryo Preservation

↑

Step III

CRYO PRESERVATION of oocytes & embryoA valuable modality…But Skill - is the key

Oocyte / embryo vitrification –

↑ P.R. (40% - 80%)

↓ Severe OHSS to 0% Results better than COASTING

Ethical Issue of freezing embryo

CDC Report 2008

Pregnancy Rate same

in FRESH / FROZEN – thawed cycles

Endometrum Preparation in frozen – thawed cycles

(A) Natural Cycle

(B) GnRH agonists (Day 21)

+ E2

+ progesterone from OPU Day

Key : Take Home messages

• SAFETY OF PATIENT in IVF is public

& doctors TOP PRIORITY

Concept ofhas to be accepted sooner than later FOGSI / ICMR

OHSS FREE CLINIC

Replace Long protocol of GnRH agonist with short antagonist protocol

+ Agonist ovulation trigger

+ Oocyte & embryo freezing

+ET in

Natural cycle Or Artificially prepared Endometrium

Key Take Home messages

OHSS : an IATROGENIC problem must never hold you back if you face it.

Instead - these problems can help you shine brighter in the next take off –

of your PROFESSIONAL MATURITY & support OHSS Free Clinic

Future Strategy for Safe IVF Practice

• 100% antagonist cycle

• 100% freezing of embryos

• 100% frozen-thawed

IVF cycles

Zero % OHSS Free Clinic

Thank You

ADDRESS 35 , Defence Enclave, Opp. Preet

Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092

CONTACT US 011-22414049, 42401339

WEBSITE : www.lifecarecentre.in

www.drshardajain.com www.lifecareivf.com

E-MAIL ID

Sharda.lifecare@gmail.comLifecarecentre21@gmail.com

info@lifecareivf.com

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