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• W1970190316 abstract "The incidence of ovarian hyperstimulation syndrome (OHSS) did not decrease during the 5 years in which single-embryo transfer was introduced; OHSS is not more frequent in twin than in singleton pregnancies. The incidence of ovarian hyperstimulation syndrome (OHSS) did not decrease during the 5 years in which single-embryo transfer was introduced; OHSS is not more frequent in twin than in singleton pregnancies. The most important adverse effect of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment is multiple pregnancies owing to the scale of the problem and the seriousness of the related obstetric and neonatal complications. Ovarian hyperstimulation syndrome (OHSS) is a less frequent but potentially life-threatening condition for a young woman undergoing assisted reproduction. The pathophysiology of the disease is poorly understood but the condition and disease are related to estrogens and vascular endothelial growth factor (VEGF), and to the luteal phase induced by LH or hCG. It has been suggested that late onset OHSS is induced by the rising serum hCG concentration produced by early pregnancy and that it could be associated with multiple gestation (1Lyons CA, Wheeler CA, Frishman GN, Hackett RJ, Seifer DB, Haning RV Jr. Early and late presentation of ovarian hyperstimulation syndrome. Hum Reprod 1994;9:792–9.Google Scholar). We investigated whether the introduction of single-embryo transfer (SET) with its subsequent decline in twin pregnancies would result in a lower incidence of OHSS. The population at risk remains the same: young women with a good or even exaggerated ovarian response who previously had received double-embryo transfer and conceived with a high chance of twin pregnancy and who now are advised to have SET. We analyzed the incidence of OHSS over a 5-year period (January 1998 to December 2002), during which time we gradually introduced SET into our IVF/ICSI program. The percentage of SET increased from 13% to 46%; coincidently, the mean number of embryos per transfer declined from 2.26 to 1.67. The overall pregnancy rate remained stable at 31.3% while the multiple pregnancy rate declined from 33.6% to 11.7% (2De Neubourg D. Gerris J. SET—state of the ART.RBMonline. 2003; 7: 615-622Google Scholar, 3Gerris J. De Neubourg D. Mangelschots K. Van Royen E. Vercruyssen M. Barudy-Vasquez J. et al.Elective single day-3 embryo transfer halves the twinning rate without decrease in the ongoing pregnancy rate of an IVF/ICSI programme.Hum Reprod. 2002; 17: 2621-2626Crossref PubMed Scopus (177) Google Scholar). Patients were treated with the long gonadotropin-releasing hormone agonist (GnRH-a) desensitization protocol, starting in the midluteal phase with 6 × 100 μg of intranasal buserelin (Suprefact; Hoechst AG, Frankfurt am Main, Germany) for a period of 3 weeks. Ovarian stimulation was initiated using 150 IU of Metrodin HP (Serono; Geneva, Switzerland) or Gonal-F (Serono) SC except in patients with known poor response, where the dose was augmented to 225 IU. The criterion for hCG administration was the presence of at least three mature follicles with a diameter of 18 mm. Exactly 37 hours before oocyte pick-up, 10,000 IU of hCG (Profasi; Serono) IM was administered. The IVF/ICSI procedure, embryo quality assessment, and embryo-transfer technique were performed as previously described elsewhere (4De Neubourg D. Mangelschots K. Van Royen E. Vercryussen M. Ryckaert G. Valkenburg M. et al.Impact of patients' choice for single embryo transfer of a top quality embryo versus double embryo transfer in the first IVF/ICSI cycle.Hum Reprod. 2002; 17: 1621-1625Crossref Google Scholar). The oocyte pick-up was performed vaginally under ultrasound guidance. Approximately 16 to 19 hours after insemination/injection, normal fertilization was checked. On day 2, every embryo was scored for the total number of cells and the presence of anuclear fragments as well as multinucleated blastomeres. On day 3, embryo quality was again evaluated. Selection for embryo replacement was made according to the embryo characteristics, as elaborated previously by our team (5Van Royen E. Mangelschots K. De Neubourg D. Laureys I. Ryckaert G. Gerris J. Characterization of a top quality embryo, a step towards single-embryo transfer.Hum Reprod. 1999; 14: 2345-2349Crossref PubMed Scopus (434) Google Scholar). All transfers were performed on an outpatient basis using a Wallace embryo transfer catheter (Sims Portex Ltd., Hythe, Kent, United Kingdom), consisting of an inner catheter and an outer catheter. In all cycles, the luteal phase was supported by vaginally administered micronized natural progesterone (200 mg, three times daily, Utrogestan; Besins International Belgium, Drogenbos, Belgium ). When the patient was pregnant, the treatment continued until her first ultrasound. When a patient was identified as being at risk for OHSS, in general two types of preventive measures were taken. When her estradiol levels were ≥4,000 pg/mL on the day of hCG administration, a reduced amount of 5,000 IU of hCG was administered instead of the usual 10,000 IU. On the other hand, coasting was performed when estradiol levels were found to be rapidly increasing to a level of ≥5,000 pg/mL before a sufficient number of dominant follicles (≥18 mm) were present. Gonadotropin injections were withdrawn until the estradiol levels dropped to ≤3,000 pg/mL and follicles with a diameter ≥18 mm were present (6Urman B. Pride S.M. Ho Yuen B. Management of overstimulated gonadotrophin cycles with a controlled drift period.Hum Reprod. 1992; 7: 213-217PubMed Google Scholar, 7Waldenstrom U. Kahn J. Marsk L. Nilsson S. High pregnancy rates and successful prevention of severe ovarian hyperstimulation syndrome by “prolonged coasting” of very hyperstimulated patients: a multicentre study.Hum Reprod. 1999; 14: 294-297Crossref PubMed Scopus (69) Google Scholar). We used the criteria of Golan (8Golan A. Ron-El R. Herman A. Soffer Y. Weinraub Z. Caspi E. Ovarian hyperstimulation syndrome: an update review.Obstet Gynecol Surv. 1989; 44: 430-440Crossref PubMed Scopus (730) Google Scholar) to classify the stage of OHSS. Patients with moderate to severe OHSS, according to these criteria, who required bedrest or admission to a hospital, were entered into our database. Student's t-test was used to evaluate the statistically significant differences between continuous variables. A P value ≤.05 was considered statistically significant. Confidence interval analysis was performed to compare the incidence of OHSS. Over this 5-year period, 27 cases of OHSS occurred in 2,007 cycles. The incidence of OHSS was fairly stable over this period, varying between 0.5% and 2.4% with an average of 1.3% per cycle. Of the 27 cases of OHSS, 6 cases occurred in a nonconception cycle during the first week after oocyte retrieval. Twenty-one cases of OHSS occurred during conception cycles: 16 cases in 482 singleton conception cycles (3.32%) and 5 cases in 134 twin pregnancy cycles (3.73%) (odds ratio [OR] = 0.88; 95% confidence interval [CI], 0.31–2.46) (Fig. 1) . Analysis of cycle-related variables in singleton and twin pregnancies showed no statistically significant differences between the rank of the cycle, the number of oocytes retrieved, or the level of estradiol on the day of hCG administration. However, the level of hCG on day 12 after a day-3 embryo transfer was statistically significantly higher in conception cycles leading to twin pregnancy (266 ± 48 IU/L) compared with cycles resulting in a singleton pregnancy (154 ± 73 IU/L) (P=.002). As it is clear that the late form of OHSS is induced by the presence of hCG originating from the early pregnancy, it appears that merely the presence of hCG rather than its level is responsible for the occurrence of late OHSS (1Lyons CA, Wheeler CA, Frishman GN, Hackett RJ, Seifer DB, Haning RV Jr. Early and late presentation of ovarian hyperstimulation syndrome. Hum Reprod 1994;9:792–9.Google Scholar). Therefore, to reduce the incidence of OHSS, measures other than those mentioned herein should be considered. Embryo transfer can be postponed until the blastocyst stage to evaluate the symptoms in a patient with early presentation of OHSS (9Trout S.W. Bohrer M.K. Seifer D.B. Single blastocyst transfer in woman at risk of ovarian hyperstimulation syndrome.Fertil Steril. 2001; 76: 1066-1067Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar). Another possibility is to proceed with hCG administration and oocyte retrieval but to cancel the embryo transfer and freeze all the embryos (10Wada I. Matson P.L. Troup S.A. Morroll D.R. Hunt L. Lieberman B.A. Does elective cryo-preservation of all embryos of women at risk of ovarian hyperstimulation syndrome reduce the incidence of the condition?.Br J Obstet Gynecol. 1993; 10: 265-269Google Scholar). The success of this policy largely depends on the results of a center's cryopreservation program (11Queenan Jr, J.T. Veek L.L. Toner J.P. Oehninger S. Muasher S.J. Cryo-preservation of all prezygotes in patients at risk of severe hyperstimulation syndrome does not eliminate the syndrome, but chances of pregnancy are excellent with subsequent frozen-thaw transfers.Hum Reprod. 1997; 12: 573-576Google Scholar). Recently, the introduction of GnRH antagonists has seemed to offer a good perspective for prevention of OHSS (12Olivennes F. GnRH antagonists: do they open new pathways to safer treatment in assisted reproductive techniques?.Reprod Biomed Online. 2002; 5: 20-25Abstract Full Text PDF PubMed Scopus (12) Google Scholar). An important advantage of the use of GnRH antagonists is the possibility of using GnRH agonists for ovulation induction in the prevention of OHSS (13Itskovic J. Kol S. Mannaerts B. Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report.Hum Reprod. 2000; 15: 1965-1968Crossref PubMed Scopus (169) Google Scholar). This inevitably brings us to the consideration of “friendly IVF” (14Olivennes F. Patient-friendly ovarian stimulation.Reprod Biomed Online. 2003; 7: 30-34Abstract Full Text PDF PubMed Scopus (11) Google Scholar), provided that a lower number of oocytes and embryos does not decrease the chance to present an embryo with a high implantation potential, thus maintaining the high pregnancy rates for SET. Some of the investigated protocols appear to be very hopeful (15Hohmann F.P. Macklon N.S. Fauser B.C. A randomized comparison of two ovarian stimulation protocols with gonadotropin-releasing hormone (GnRH) antagonist cotreatment for in vitro fertilization commencing recombinant follicle-stimulating hormone on cycle day 2 or 5 with the standard long GnRH agonist protocol.J Clin Endocrinol Metab. 2003; 88: 166-173Crossref PubMed Scopus (223) Google Scholar) (Fig. 1)." @default.
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• W1970190316 title "Singleton pregnancies are as affected by ovarian hyperstimulation syndrome as twin pregnancies" @default.
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