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

It is dangerous to become pregnant with overstimulated ovaries. If conception does occur, then the threat to the fetus remains throughout the entire gestational period.

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

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

• ascites – accumulation of aqueous 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 resulting from the effect of fluid on the diaphragm in the pleural area;
• nausea accompanied by vomiting and diarrhea (appears due to irritation of the digestive tract);
• anasarca – accumulation of fluid in the lower part of the body, manifested severe swelling hands, fingers, feet and peritoneum;
• decrease in pressure indicators;
• impaired diuresis (less urine is produced).

After puncture, hyperstimulation may worsen, as a corpus luteum forms in place of the former follicles. Transfer 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 pathological process in isolated cases, the protocol ends with 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 individual characteristics of the female body to prevent a condition such as hyperstimulation.

Risk factors for developing OHSS

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

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

Ovarian hyperstimulation syndrome can be prevented by addressing risk factors. Based on the available information about the patient, the doctor will select the best dose of hormonal drugs. Thanks to the knowledge, qualifications and ability of reproductive specialists to evaluate prognoses, ovarian hyperstimulation during IVF occurs only in exceptional cases. Doctors usually manage to avoid such a complication.

What are the dangers of ovarian hyperstimulation?

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 enlarged gonads will death. With active fluid intake, cardiac and renal failure occurs, as well as acute thromboembolism. The mechanism of development of pathology is as follows:

1. Under the influence medicines the work of the gonads is activated, as a result of which massive growth of follicles begins;
2. plasma and proteins leak from blood vessels glands into the peritoneal cavity;
3. the blood thickens greatly, increasing the risk of blood clots;
4. due to an increase in blood viscosity and a decrease in its volume, acute failure of some organs occurs (the heart and kidneys are at risk).

After embryo transfer (if the manipulation was considered acceptable and carried out), symptoms of hyperstimulation may persist for several months. During this period, a serious threat to the fetus arises. The likelihood of miscarriage with OHSS is many times higher than without it. Pregnancy and ovarian hyperstimulation together can seriously complicate the patient’s condition. Throughout the entire gestation period, the risk of fetoplacental insufficiency remains, the threat premature birth, hormonal imbalance, circulatory disorders and hypoxia for the child. 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, ovarian depletion may occur against the background of OHSS. The culmination of this complication is early menopause.

Stages of ovarian hyperstimulation

Symptoms of ovarian hyperstimulation have different intensities, which characterize the stages of enlargement of the gonad: mild, moderate, severe. Pathology is also divided into two forms:

• early - signs of hyperstimulation appear immediately after the follicle matures and go away on their own with the onset of a new one menstrual cycle(if pregnancy occurs, then OHSS requires mandatory therapy, since it risks going into a late form);
• late - symptoms appear from 4-5 weeks of pregnancy and persist for several months, are severe and require mandatory treatment.

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

Mild degree

Early hyperstimulation syndrome occurs in almost all women undergoing IVF. At the same time, the size of the ovaries increases by one and a half to two times. Multiple follicles and cysts are visualized in the ovaries on ultrasound. Woman feels insignificant nagging pain, bloating. During ultrasound examination a small accumulation of fluid may be detected in abdominal cavity. This condition can be considered normal 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 are enlarged to 12 cm. A characteristic difference medium degree from mild is the inclusion of the digestive tract in the process, which is manifested by nausea, vomiting and diarrhea.

Severe degree

One of characteristic features syndrome - swelling of the legs.

To characterize the severe form of OHSS, the main symptoms can be noted: significant enlargement of the abdomen due to fluid accumulation, pain and discomfort, swelling lower limbs. There are also disturbances in the functioning of the heart, which causes tachycardia and shortness of breath. The woman is forced to adhere to bed rest. Breathing becomes easier when you take a semi-sitting position with your torso elevated.

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. Additionally, body temperature may increase.

Critical degree

The most severe degree of OHSS is critical. The total volume of urine excreted is reduced to 1 liter. The pulse is rapid, breathing is difficult. Blood pressure is reduced. The abdomen swells greatly (up to 6 liters of fluid accumulates there). There are symptoms of thrombosis and thromboembolism. This condition requires urgent medical intervention.

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 peace. The diet for ovarian hyperstimulation is protein. It is necessary to limit the consumption of salt, bran and completely eliminate alcohol. You should drink as needed, mainly mineral water.

In the case of a moderate condition, therapy is carried out in a hospital due to the likelihood of rapid progression of the pathology. Continuous monitoring allows the patient’s well-being to be assessed: indicators of water and electrolyte balance, hematocrit, vital function important organs. Constant supervision of medical personnel specializing in such pathologies is necessary.

• Treatment of ovarian hyperstimulation involves the use of medications aimed at replenishing the volume of circulating blood. They help 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, the drugs Fraxiparin or Dalteparin are administered.
• If necessary, the patient is provided with anti-inflammatory, painkillers and antipyretic medications. If possible, Paracetamol, Ortofen, Nurofen are taken orally. IN in case of emergency analgesics are administered intramuscularly.
• Antibacterial therapy is prescribed in some cases to prevent infection of the abdominal and pelvic organs. Preference is given to drugs wide range actions.

If ovarian hyperstimulation syndrome develops during pregnancy, then to the expectant mother Maintenance hormonal therapy with progesterone-based agents is mandatory. It is also recommended to take antispasmodics, sedatives, vitamin complexes. Sexual contact should be avoided for the entire period of treatment.

How to avoid ovarian hyperstimulation during IVF

Prevention of ovarian hyperstimulation syndrome begins even before the prescription of stimulant medications. Today there is no specialized unified method for preventing pathology. It is important at all stages of planning to assess the likelihood of early or late risks and calculate the prospects in advance. You can prevent OHSS by the following methods:

• use gonadotropins hormonal agents in the minimum effective dosage for the procedure;
• refuse administration human chorionic gonadotropin in an ovulatory dose or completely eliminate it;
• take type 2 dopamine receptor agonists from the day of using the medication that triggers the ovulation process;
• reduce stimulation time;
• carry out aspiration of all accessible follicles;
• use progesterone preparations to maintain the second phase instead of drugs based on human chorionic gonadotropin.

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

It is important that the doctor knows all the characteristics of the patient’s body. If the woman has already had stimulation or had problems with functioning reproductive system, for example, PCOS - you should tell your doctor about all the nuances. While taking hormones, you need to carefully monitor your well-being, and if unusual signs appear, notify your fertility specialist.

Clinical manifestations of this syndrome develop after the administration of hCG, an ovulation trigger.

Ovarian hyperstimulation during IVF is a consequence dangerous to health. A mild form of complication occurs in up to 91% of cases, a severe form – in up to 9-15%.

Mild OHSS, the symptoms of which arise gradually, is not particularly life-threatening if medical care is provided in a timely manner.

The goal of treatment is to prevent the transition of a mild form of hyperstimulation during IVF to a severe one. In the absence of literate medical care Possible death due to complications (heart attack, kidney failure, liver failure, other).

The onset of pregnancy after embryo transfer during IVF can intensify the manifestation of the symptom complex.

Symptoms of hyperstimulation during IVF

Before the procedure, the woman is notified of all possible complications and symptoms during the development of the syndrome. The information provided will allow violations to be detected in a timely manner in order to take preventive measures. The patient is required to scrupulously follow medical recommendations and immediately report to the leading doctor about any changes in well-being.

The main signs of OHSS are:

• Vomiting, nausea.
• Excessive urination.
• Reduced blood pressure.
• Abdominal pain, bloating.
• Difficulty breathing.

Symptoms are not always pronounced; sometimes women exhibit only some of the signs listed above. Therefore it is required Special attention and control so as not to miss the development of complications.

Severity

There are four degrees of severity of ovarian hyperstimulation syndrome:

1. Mild degree - there is slight discomfort in the abdominal area, the ovaries increase to 8 cm.
2. Moderate – the ovaries increase to 12 cm, fluid accumulates in the abdominal cavity (ascites). Dyspeptic disorders and mild pain in the lower abdomen are possible.
3. Severe - the ovaries enlarge by more than 12 cm, ascites is characteristic, a decrease in the daily volume of urine, and the hematocrit value (the volume of red blood cells) increases.
4. Critical degree - accumulation of fluid in the cavities (abdominal and thoracic), increased content of red blood cells in the plasma due to a decrease in the amount of plasma (hemoconcentration), possible formation of emboli and blood clots.

The forms of development of the syndrome (early and late) depend on the period of appearance of symptoms after the procedure. Manifestations early form Follicle punctures are observed within 1-6 days. Manifestations of the late form – after seven days or more. In most cases, the cause of the late form is the production of hCG by the embryo.

Risks

Threat factors for the appearance of ovarian hyperstimulation syndrome:

• Asthenic build.
• Body mass deficiency (body mass index< 18,5), возраст до 35 лет.
• High total doses of drugs (gonadotropins) in an IVF cycle.
• Increased concentration of estradiol in the blood.
• History of OHSS.
• PCOS (polycystic ovary syndrome).
• Use of GnRH agonists during IVF.
• A large number of follicles that develop in an IVF cycle.

By what mechanisms and reasons OHSS develops is not specifically known. There is an assumption that ovarian hormones influence the production of factor X, which stimulates the growth of blood vessels in the corpus luteum and their development, increasing the permeability of the vascular wall. As a result of this mechanism, a large number of HCG, under the influence of which characteristic symptoms appear.

Another factor that plays a major role in the occurrence of ovarian hyperstimulation syndrome is the vasoendothelial factor, which complicates the course of the pathological process. Among possible reasons OHSS studied in this moment, highlight increased sensitivity receptors for gonadotropins. But so far there are no proven causes of the syndrome. The number of follicles does not determine whether ovarian hyperstimulation syndrome will develop during IVF or not. IN medical practice There have been cases when a severe degree of the syndrome developed during ovulation of one follicle.

Examination for hyperstimulation

When the syndrome appears, it is carried out additional diagnostics. With OHSS, the blood contains high concentration protein, the electrolyte balance is disturbed, the amount of immunoglobulins IgA and IgG decreases, and an increased concentration of fibrinogen is noted.

To detect ascites in the peritoneum, chest cavity, and pericardium, an ultrasound examination method is used. Patients undergo an electrocardiogram, and in severe cases, a chest x-ray is taken.

Preventive measures with hyperstimulation

Stimulation during in vitro fertilization does not always lead to the development of OHSS. To reduce the risk of developing the syndrome, prevention is carried out. Preventive actions must be comprehensive.

Prevention includes the following:

• Cancellation of embryo transfer, embryos undergo cryopreservation. The next transfer occurs in a natural cycle.
• Discontinuation of hormone-containing drugs or reduction of dosage.
• Temporary refusal to undergo IVF.
• Control of estrogen levels in the artificial insemination cycle.
• Regular monitoring of the patient's health status.

When signs of ovarian hyperstimulation do not appear clearly, you still need to immediately inform your doctor about a change in your health so that timely and adequate measures can be taken. This is the main way to prevent the development of the syndrome.

Treatment of hyperstimulation

A mild form of the syndrome does not require specific therapy. It is recommended to follow a drinking regime; you can drink still mineral water, compotes without sugar, and a decoction of dried fruits. You need to consume enough protein, which is found in low-fat varieties meat, fish and dairy products. The diet should be rich in vegetables and fruits. It is better to bake, boil, stew, rather than fry foods. You should follow a daily routine, rest more often, do not overwork, it is advisable not to be nervous, and avoid psycho-emotional overload.

In moderate to severe OHSS, the main goal of treatment is to correct electrolyte balance and plasma protein. Medicines are prescribed and administered under medical supervision.

Consequences

The lack of competent therapy for ovarian hyperstimulation syndrome leads to increased vascular permeability and the spread of this process due to the formation of many yellow bodies. The result is that the plasma volume decreases, it accumulates in the peritoneum, pleural cavity, and pericardial cavity. A large amount of albumin is released with plasma, which further increases vascular permeability.

Other dangerous consequences of ovarian hyperstimulation syndrome:

• Significant reduction in circulating blood volume.
• Blood clot formation.
• Violation of the functions of internal organs due to deterioration of their blood supply.
• Ischemia.
• Brain disorders, stroke.
• Kidney and liver failure, which can be fatal.

Timely treatment measures lead to recovery, eliminating all symptoms.

To prevent the development of hyperstimulation, an individual stimulation scheme is selected for each patient. It is important to follow the specialist’s instructions during stimulation and, when the first signs of OHSS appear, to report everything to the doctor.

Ovarian hyperstimulation: symptoms, consequences of OHSS after puncture and pregnancy

Ovarian hyperstimulation syndrome (OHSS) is one of the most dangerous and unpleasant consequences stimulation of the ovaries during the cycle. Only those who have already had unsuccessful attempts, but have repeated protocols ahead, need to know about the existence of OHSS. Any intervention in the body does not remain without consequences. But when the birth of a child is in the balance, in most cases, the instinct to become a mother wins.

• Ovarian hyperstimulation - what is it?
• Early and late OHSS
• Signs of hyperstimulation after puncture
• Consequences
• How to avoid OHSS
• Who is at risk
• Symptoms of hyperstimulation
• What should you be concerned about?
• Treatment

What is ovarian hyperstimulation

Ovarian hyperstimulation is a severe complication of ovarian stimulation, which is based on an uncontrolled ovarian response to the administration of gonadotropins (drugs that are administered to induce ovulation).

Without the presence of hCG, hyperstimulation will not develop. The hormone is trigger mechanism in the appearance of symptoms and manifestations. Therefore, it is very important to monitor how the follicles grow, how many there are, and carefully choose the drug before. The drugs that are prescribed before puncture of the follicles are prescribed to “ripen” the eggs. They contain human chorionic gonadotropin (hCG).

Ovarian hyperstimulation during IVF and pregnancy

If symptoms of hyperstimulation appear at the “after puncture” stage, it is recommended to delay the transfer and transfer it in a natural cycle or in). In the current situation it is good way out. The woman will experience hyperstimulation in mild form, the body will recover and the effectiveness of IVF protocols with cryopreservation is much higher - 65-70%, versus 30-35%.

Signs of hyperstimulation after ovarian puncture:

• temperature rise to 38 °C;
• bloating;
• the appearance of edema, including ascites - accumulation of fluid in the abdominal cavity;
• difficulty urinating;
• nausea and vomiting.

Consequences of hyperstimulation

The consequences of an excessive ovarian response to stimulation include:

• Ascites is an accumulation of fluid in the peritoneal space, hydrothorax is an accumulation of fluid in pleural cavities. This complication occurs as a result of the launch of atypical physiological state processes as a result of which blood plasma sweats through the mucous membranes and accumulates in the cavities.
• Torsion (complete and partial) of the ovaries is a rare consequence, but if it occurs, it requires surgical treatment.
• Gap.
• Follicular cysts.
• Kidney failure.
• Liver failure.

How to avoid overstimulation during IVF

It is almost impossible to completely avoid OHSS during IVF. During in vitro fertilization, doctors' actions and observation are aimed at preventing the development severe conditions. It is very important to notice in time the development of an uncontrolled reaction of the body and take measures to prevent severe forms OHSS.

1. Identification of risk factors. For this purpose it is controlled hormonal background, great attention given to the hormone. Ultrasound and folliculometry are performed already during stimulation.
2. Very mild stimulation schemes with low doses of drugs are used ().

The body of young girls with good ovarian reserve, normal level AMH - can respond to mild induction of ovulation by growing a large number of follicles. Overstimulation can also be prevented at this stage.

Prevention at the stage of ovarian stimulation:

• selection of drugs for egg maturation that do not contain hCG;
• delayed introduction of an ovulation trigger:
• cancel ;
• use, if necessary, special drugs Dostinex or Cabergoline, low molecular weight heparins - Fraxiparine, Clexane.

Who is at risk for developing OHSS

Risk factors for the development of hyperstimulation are:

• young age;
• low body mass index (small, thin, delicate girls);
• or multifollicular ovaries;
• high concentration of anti-Mullerian hormone (if the concentration is higher than 3.7 ng/ml, the higher the risk of developing an excessive ovarian response if stimulation is performed incorrectly);
• a large number of antral follicles determined by ultrasound (more than 10 follicles from 4 to 10 in each ovary;
• history of hyperstimulation (in previous IVF attempts);
• complicated allergic history.

Symptoms of ovarian hyperstimulation and classification

Mild manifestations of hyperstimulation occur in many patients at reproductive clinics.

Signs of ovarian hyperstimulation that should alert you

• You should definitely tell your doctor if the following signs of hyperstimulation appear:
• weakness, dizziness, decreased blood pressure;
• shortness of breath, respiratory disorders;
• distension in the abdomen, bloating, pain in the hypochondrium and in the abdomen (spread);
• rare and scanty urination;
• increased body temperature;
• swelling of the external genitalia and lower extremities.

How is hyperstimulation syndrome determined?

Attention! When examining for the presence of ovarian hyperstimulation syndrome, a gynecological examination is prohibited.

• blood pressure, respiratory rate, daily diuresis, abdominal circumference are measured
• Conducted laboratory research: general analysis blood with hematocrit (total protein, albumin, liver transaminases), hemostasiogram (D-dimer).
• Ultrasound of the pelvis, abdominal cavity, pleural cavities.

Treatment of ovarian hyperstimulation

There is no pathogenetic treatment for ovarian hyperstimulation syndrome; all therapeutic measures are aimed at eliminating the symptoms of dysfunction of internal organs. Ovarian hyperstimulation is treated until clinical and laboratory parameters stabilize and symptoms resolve. Treatment of mild and moderate OHSS is carried out on an outpatient basis, while severe cases require hospitalization.

For moderate hyperstimulation, the following simple corrective measures are necessary:

• Normalization of water metabolism - you need to drink up to 2 liters of liquid;
• Appointed protein diet. The goal is to limit products fermentative in the intestines and bloating. Limit vegetables, fruits, carbohydrates in large quantities. Preference is given to protein foods: boiled chicken, fish, cottage cheese.
• To monitor the development of OHSS, body weight, abdominal circumference, and daily volume of urine excreted are measured.

According to indications, low molecular weight heparins are prescribed, under the control of D-dimer, and infusion therapy under the control of diuresis.

For severe hyperstimulation, antispasmodics may be prescribed. In case of severe and progressive ascites, laparocentesis is performed - a manipulation in which a puncture of the abdominal cavity is performed and the accumulated fluid is removed. Surgical treatment is performed only in urgent cases in the presence of acute gynecological complications.

To avoid severe manifestations of ovarian hyperstimulation and its consequences, you must strictly follow your doctor’s instructions and monitor your condition. If your health suddenly deteriorates, you must contact your doctor or the doctor on duty at the clinic where ovarian stimulation was performed.

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Symptoms and consequences of ovarian hyperstimulation

Induction of ovulation, or artificial stimulation of follicle maturation through hormonal drugs, the indications for which are constantly expanding, is one of the achievements of modern reproductology.

Ovarian hyperstimulation is used as a main component of a number of reproductive technologies during IVF, when artificial insemination, with luteal phase deficiency, transfer of zygotes or gametes to the fallopian tubes etc. However, possible Negative consequences this procedure (for their prevention, timely diagnosis and provision of qualified assistance) require the knowledge and experience of doctors.

What is the danger of ovarian hyperstimulation and what is it?

Its rather serious, although not common, complication is ovarian hyperstimulation syndrome (OHSS). It can occur with varying degrees of severity and sometimes be fatal.

Definition of pathology and its statistics

The disease is currently considered systemic inflammatory process endothelial layer of blood vessels, representing an excessive systemic reaction of the body. OHSS is manifested by a complex of clinical symptoms, syndromes and laboratory parameters. It develops, as a rule, in response to the sequential administration of gonadotropic hormones (follicle-stimulating hormone in the first phase of the menstrual cycle and human chorionic hormone in an ovulatory dose) in accordance with classical programs or stimulation of superovulation.

Due to the lack of a single, generally accepted classification, statistical assessment is difficult and is based mainly only on cases of moderate and severe severity that required assistance to women in a hospital setting. On average, the frequency of the syndrome is 0.5-33% (with various schemes stimulation), and the frequency of its severe forms is 0.2-10%.

There are isolated cases of self-occurring hyperstimulation syndrome in the first trimester of spontaneous pregnancy, as well as rare cases of spontaneously occurring recurring familial episodes of the syndrome that are not associated with ovulation stimulation and reproductive technologies. It is believed that they may be the result of mutations in the follicle-stimulating hormone receptors, resulting in significantly increased sensitivity to human chorionic gonadotropin.

In most cases, this complication is a consequence of the use of gonadotropins in the form of injections in IVF programs; sometimes it occurs as a result of the use of Clomiphene citrate.

Pathogenesis and predisposing factors of the disease

The final mechanism of development of the pathology remains unclear, however, a prerequisite for adequate intensive treatment is taking into account the main features of the pathogenesis of the disease.

Physiological for the female body is the maturation of, as a rule, one, less often two oocytes at the same time, which are at the preovulation stage. The menstrual cycle is associated with the production of fluid into the abdominal cavity by the ovaries and peritoneum. Its volume, insignificant during the follicular phase, increases towards the period of ovulation, reaches its maximum value after it, then gradually decreases by the first day of menstruation.

This is explained by cyclic changes in the permeability of ovarian vessels during the growth of the dominant follicle, its formation and corpus luteum. All processes are associated with changes in the levels of sex hormones, in particular estradiol and progesterone, as well as prostaglandins, cytokines, vascular epithelial growth factor, histamine and other biological factors. active substances, contributing to increased permeability vascular wall and, accordingly, a change in the volume of fluid in the abdominal cavity.

The meaning of the mechanism of development of ovarian hyperstimulation syndrome comes down to the fact that artificial superovulation in assisted reproductive technology programs is a deliberate violation of the physiological principle aimed at the simultaneous maturation of 10-20 or more follicles in order to select the best egg. As a result of this, multiple cysts form in the ovaries and the first ones increase in volume.

It is assumed that the introduction of an ovulatory dose of human chorionic gonadotropin and the formation of a large number of follicles with the formation of a correspondingly increased total volume of intrafollicular fluid, in which there are large quantities of macrophages and cytokines involved in immune reactions, is a trigger factor for the development of the disease.

Under its influence, abnormally high amounts of sex steroids and biologically active substances enter the blood. Activation of the body's renin-angiotensin-aldosterone system occurs, which is one of the links in the development of the pathological process. Of particular importance is the excessive secretion of vascular endothelial growth factor by the ovaries, leading to damage to endothelial cells inner shell vessels.

As a result of these mechanisms, the permeability of the walls of the capillary network of tissues of many organs for proteins that carry water with them increases. A massive varying degrees severity of sweating and redistribution of a significant volume of the liquid part of the blood from the bloodstream into the organ cavities. These are the pleural, pericardial, abdominal (from the vessels of the omentum and peritoneum) cavities. Hydrothorax, hydropericardium, ascites and, less commonly, anasarca are formed.

A decrease in intravascular blood volume leads to hypovolemia, a decrease in blood pressure, a compensatory increase in the number of heart contractions, a decrease in renal blood supply and a decrease in renal filtration, disturbances in the water-electrolyte balance and the acid-base state of the blood, as well as thickening of the blood and an increase in its coagulability. Blood thickening and increased coagulability are the cause of the formation of blood clots and associated complications.

Thus, secondary consequences mechanisms of ovarian hyperstimulation syndrome are dysfunction of the heart, liver and kidneys, development respiratory distress syndrome adults, hypovolemic shock, disseminated intravascular coagulation syndrome with the formation of thrombosis and thromboembolism. In addition, less dangerous complications are possible, such as intra-abdominal bleeding, torsion of the uterine appendages, and exacerbation of long-term chronic diseases.

There are two types of hyperstimulation syndrome depending on the time of its development:

1. Early.
2. Late.

Early syndrome extremely rarely begins against the background of direct stimulation of hyperovulation. This usually occurs immediately after follicular puncture or during the first 7-10 days before transfer of the embryo into the uterine cavity. It is associated with the introduction of an ovulatory dose of drugs (mainly human chorionic gonadotropin), which have a stimulating effect on the growth and maturation of follicles. The early development of pathology is the cause of a high frequency of spontaneous miscarriages.

Late syndrome is explained by a significant increase in the level of human chorionic gonadotropin during implantation and early dates pregnancy. If, after transfer of the embryo into the uterine cavity, implantation of a fertilized egg occurs, then in most cases there is a deterioration general condition women, which lasts until approximately 12 weeks of pregnancy. The earlier the symptoms of the syndrome appear, the more severe its course.

If pregnancy does not occur after ovarian hyperstimulation, then (most often) the symptoms of the pathology that arise disappear at the onset of menstruation. Only in rare cases, in the absence of pregnancy, signs of OHSS may persist or even increase for some time.

The planning of hyperovulation induction by a fertility specialist takes into account the initial risk factors. These include:

• The woman's age is less than 36 years.
• Cases of ovarian hyperstimulation syndrome in the past.
• Body type of asthenic type and very low body weight (BMI less than 18.5).
• Availability .
• High levels of total estradiol in the blood - more than 4,000 pg/ml.
• Anti-Mullerian hormone concentration more than 3.6 ng/ml
• The number of follicles after stimulation is more than 35.
• Use (for induction purposes) of urinary gonadotropins - Menogon, Humegon, etc.
• Stimulation with GnRH agonists such as human menopausal gonadotropin or Clomiphene citrate.
• Supporting the second phase of the menstrual cycle and/or stimulating hyperovulation using human chorionic gonadotropin preparations such as Pregnil, Ovitrel, etc.
• High dosages of gonadotropic hormones, although developmental dependence pathological condition depending on the dose is questionable.
• Support through progesterone of the luteal phase.
• Development of an infertile pregnancy cycle.

The least danger of the disease is observed when:

• woman's age is less than 36 years;
• overweight;
• weak ovarian response to stimulation;
• the formation of single mature follicles in response to the induction of superovulation.

Symptoms of ovarian hyperstimulation

Depending on the severity clinical picture and the nature of laboratory changes, there are 4 degrees of severity of the disease:

1. Easy.
2. Average.
3. Heavy.
4. Critical.

Mild severity

Almost always accompanies ovulation induction procedures. The general condition of the woman is usually satisfactory. The main sensations during ovarian hyperstimulation are discomfort and heaviness in the abdomen, moderate thirst. A slight nagging pain appears in the abdomen. Its swelling and slight tension are noted, and upon palpation lower sections ovaries can be identified.

When performing an ultrasound, multiple follicles and luteal cysts are determined in the ovaries; the diameter of the ovaries is less than 8 cm. In addition, a small amount of fluid may sometimes be present in the pelvis. Hematocrit values ​​are normal.

Average degree

The general condition sometimes remains relatively satisfactory, but is more often regarded as moderate. The intensity of abdominal pain increases, which is associated with increasing irritation of the peritoneum by enlarged ovaries and an increase in the volume of exudate in the abdominal cavity. The subjective symptoms mentioned above are more pronounced compared to mild severity. These are accompanied by symptoms of gastrointestinal disorders - nausea, vomiting, and sometimes diarrhea. There is a moderate increase in abdominal circumference and body weight due to increased fluid consumption and its redistribution into free cavities.

The pulse rate and number of respirations increase slightly. The size of the abdominal circumference and body weight increase even more. Ultrasound reveals the presence of ascitic (exudate) fluid in the abdominal cavity and an increase in the diameter of the ovaries to 12 cm. Hematocrit values ​​do not exceed 45%. Signs of moderate pathology in most women persist for 10 days after administration of hCG in an ovulatory dose.

Severe degree

Most often, the criteria for distinguishing it from the moderate severity of hyperstimulation syndrome are ambiguous. The general condition is assessed as serious. Subjective symptoms may include a feeling of fear, dizziness and headache, a feeling of “floaters” before the eyes. Due to the development of respiratory and heart failure, the woman’s position in bed is forced - sitting or with the head end of the bed significantly raised. There is shortness of breath, rapid pulse and a decrease in blood pressure, an increase in body temperature (in 80% of women) against the background of development respiratory infection, infections urinary tract, abscesses at injection sites, etc.

The abdomen is dense on palpation and significantly increased in volume due to ascites. When performing radiography or ultrasound, fluid is sometimes detected in the pleural and pericardial cavities, the diameter of the ovaries exceeds 12 cm - up to 25 cm. With echocardiography - reduced cardiac output and venous return of blood, end-diastolic volume is reduced, and fluid is sometimes detected in the pericardial cavity. Sometimes swelling of the face and lower extremities is possible, and in rare cases, anasarca. Due to poor circulation in the pelvic organs, swelling of the external genitalia may appear.

Laboratory tests - a decrease in daily diuresis (the amount of urine per day), blood tests indicate an increase in hematocrit of more than 45%, the number of leukocytes more than 15x10 9 / l, an increase in hepatic aminotransferases and a decrease in indicators total protein blood, an increase in the specific density of urine and an increase in protein in it.

Critical degree

Characterized by severe or extremely severe general condition. Complaints and subjective sensations are the same as in severe cases. The amount of urine excreted is significantly reduced. Daily diuresis is less than 1,000 ml.

On external examination of the patient - shortness of breath, rapid pulse, low arterial pressure, symptoms of peritoneal irritation, enlarged liver size, tense and even more enlarged abdomen due to significant accumulation of ascitic fluid (up to 5-6 l), enlarged ovaries are easily palpated in its lower parts. X-ray or echography often reveals a large amount of fluid in the pleural cavities. Symptoms of respiratory and heart failure are expressed.

In blood tests, the hematocrit exceeds 55%, the number of leukocytes exceeds 25x10 9 g/l, electrolyte imbalance and hemocoagulation disorders are determined. Symptoms of respiratory distress syndrome and acute renal failure, thrombosis and thromboembolism appear, severe multiple organ failure develops with corresponding indicators of laboratory and instrumental studies.

Treatment of ovarian hyperstimulation syndrome

At mild degree OHSS observation and treatment are carried out in outpatient setting. It is recommended to limit sexual contact and physical activity, a diet high in protein and limited in fiber-rich foods, fluid intake is allowed depending on need. The liquid should be mainly in the form of mineralized water - to prevent disturbances in water-electrolyte balance.

Considering the possibility of a rapid increase in the severity of a woman’s condition, treatment of moderate and severe disease is carried out only in specialized specialized hospitals with departments or wards intensive care and resuscitation. This allows for a thorough examination and monitoring of body weight, functions of vital organs, acid-base status, water and electrolyte balance, as well as hematocrit indicators, which are one of the most important criteria assessing the severity of the disease. Observation and treatment should be carried out by doctors who have experience in managing patients with this pathology.

Basic medications for ovarian hyperstimulation syndrome - these are means that help restore the volume of circulating blood (circulating blood volume). They are necessary to reduce blood clotting and maintain renal filtration. They are administered intravenously. Therapy begins with balanced crystalloid solutions in the form of Ringer's solution, isotonic sterofundin, Trisol, ionosteril. In some cases (hyperkalemia), an isotonic sodium chloride solution is used.

The choice of crystalloid solutions is carried out in accordance with the indicators of the balance of electrolytes in the blood. At the same time, the clinical guideline for their sufficiency is monitoring of hematocrit, central venous pressure and laboratory data of renal function.

After infusion of crystalloids for severe ovarian hyperstimulation, colloidal plasma-substituting solutions based on hydroxyethyl starch (HES) are prescribed: Infucol, Volutenz, Voluven, Volucam, Refortan. They remain in the bloodstream for a long time, improve the rheological properties of the blood, help normalize central and peripheral circulation, microcirculation, vascular wall permeability, oxygen delivery to tissues, reduce the inflammatory response, activate the immune system, etc.

In addition, unfractionated and low molecular weight types of heparin (Fraxiparin, Dalteparin, etc.) are prescribed to prevent the formation of blood clots, immunoglobulins and antibacterial drugs- for the prevention of secondary infection, antispasmodics and paracetamol to reduce abdominal pain, etc.

In the presence of progressive tense ascites and associated disorders of the general condition, breathing, and cardiac activity, fluid is evacuated from the abdominal cavity through an abdominal or transvaginal puncture. A critical degree of pathology is an indication for artificial termination of pregnancy.

How to avoid the development of a pathological condition

Currently, a unified approach to preventing the development of complications has not yet been developed. The first and important condition for prevention is the individual determination of early and late risk factors in a particular patient. The main prevention of ovarian hyperstimulation syndrome is:

• reducing the dosage of gonadotropic hormones, especially when introducing a starting dose;
• refusal to use an ovulatory dose of human chorionic gonadotropin;
• the use of carbegoline (Dostinex) as a powerful agonist of type 2 dopamine receptors on the day of use of the drug that triggers ovulation and/or after transfer of the embryo into the uterine cavity;
• more late start use of gonadotropic hormones or early introduction human chorionic gonadotropin, which helps reduce stimulation time;
• performing aspiration of accessible follicles;
• the use of progesterone instead of human chorionic gonadotropin to maintain the luteal phase.

This pathology, associated mainly with the development of assisted reproduction technologies, is relatively new. It can lead to severe complications, which poses a danger not only to the health, but also to the life of a woman. Treatment methods are mainly syndromic and symptomatic. In this regard, their use requires the presence of experienced reproductive specialists, anesthesiologists and resuscitation specialists and careful development of the principles of preventive measures.

) involves several successive stages. The first stage is the stimulation of superovulation, so that the woman’s follicles produce many more eggs than usual. The maturation of several follicles in the ovary is achieved by taking special medications. Typically, after taking them, 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 follicle puncture and egg collection. During the third stage, the doctor fertilizes them with sperm “in vitro”. If everything goes well, on about 3-5 days, one (maximum two) is selected from the already formed embryos, 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 can’t get pregnant, she’ll do IVF and that’s it! In most cases, this is true. But, as with any issue, there is another side to the coin. Unfortunately, not very pleasant.

What is hyperstimulation during IVF?

It turns out that in some women, drugs that are used to stimulate superovulation provoke hyperstimulation syndrome. Each woman experiences this condition differently. There are also very difficult cases. They are especially often recorded 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 does become pregnant as a result of IVF, then the condition of the pregnant woman, due to physiological hormonal changes, gets even worse. In some cases, symptoms of hyperstimulation persist for 10 or even 12 weeks. By the way, it has been established that the earlier hyperstimulation manifests itself, the more difficult it will be.

Who may experience hyperstimulation during IVF?

Although hyperstimulation syndrome is a disease that is caused by medical intervention, no doctor can answer a patient with 100% accuracy whether she is at risk of hyperstimulation syndrome. However, there are certain factors that can contribute to the occurrence of ovarian hyperstimulation. Among them: genetic predisposition of women under 35 years of age (fair-haired and not prone to obesity), polycystic ovary syndrome, increased amount estradiol in the blood, allergic reactions, use of GnRH a-for the purpose of superstimulation, 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.

Mild degree: slight swelling, increased abdominal volume, feeling of heaviness, pain, as during menstruation, frequent urination. The diameter of the ovaries increases to 5-10 cm.

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

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

Complications of ovarian hyperstimulation include: 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 poor circulation followed by necrosis (the ovary dies). When a woman is torsioned, she feels a sharp pain that does not subside, but on the contrary, intensifies. In this case, the woman needs urgent surgery. If irreversible processes have already occurred, the entire ovary or part of it has to be removed.

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 fluid from the bloodstream is not removed through the kidneys or through 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 during in vitro fertilization

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

To date, the mechanism of development of hyperstimulation is unknown, so it is especially specific treatment does not exist. Only the right way cured - eliminate pregnancy. But this is hardly the right solution, since it was precisely for the sake of pregnancy that the in vitro fertilization, which provoked ovarian hyperstimulation syndrome. Therefore, in a hospital setting, all actions come down to alleviating the woman’s condition and maintaining the pregnancy.

Do not use in mild forms of hyperstimulation syndrome medications. The woman is prescribed rest and proper nutrition, which includes drinking plenty of fluids, complete and balanced nutrition. A woman should monitor her weight and daily urine output.

In the case of moderate and severe forms of ovarian hyperstimulation syndrome, home treatment will not work. The woman is admitted to the hospital. The hospital is monitoring her breathing and work. of cardio-vascular system, liver, kidneys. Electrolyte balance is monitored (abdominal size, weight, diuresis,). To treat OHSS, drugs are used that reduce capillary permeability, as well as those used to prevent thromboembolism.

IN severe cases, with ruptures of cysts and internal bleeding, the woman will undergo an abdominal puncture and surgery.

After last stage IVF - embryo transfer - requires very careful monitoring of the woman's condition. She is prescribed rest and sexual relations with her husband are prohibited. 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 their dream, experiences strong emotional stress. In case there are observed serious complications, psychological stress is possible. Some women fear, for example, that using stimulant drugs will cause ovarian cancer. But, in fact, studies have proven that there is no connection between taking such drugs and ovarian cancer (as well as other organs).

Especially for Olga Rizak