Outpatient management of severe early OHSS by administration of GnRH antagonist in the luteal phase: an observational cohort study

Abstract

Background: Management of established severe OHSS requires prolonged hospitalization, occasionally in intensive care units, accompanied by multiple ascites punctures, correction of intravascular fluid volume and electrolyte imbalance. The aim of the present study was to evaluate whether it is feasible to manage women with severe OHSS as outpatients by treating them with GnRH antagonists in the luteal phase.

Methods: This is a single-centre, prospective, observational, cohort study. Forty patients diagnosed with severe OHSS, five days post oocyte retrieval, were managed as outpatients after administration of GnRH antagonist (0.25 mg) daily from days 5 to 8 post oocyte retrieval, combined with cryopreservation of all embryos. The primary outcome measure was the proportion of patients with severe OHSS, in whom outpatient management was not feasible.

Results: 11.3% (95% CI 8.3%-15.0%) of patients (40/353) developed severe early OHSS. None of the 40 patients required hospitalization following luteal antagonist administration and embryo cryopreservation. Ovarian volume, ascites, hematocrit, WBC, serum oestradiol and progesterone decreased significantly (P < 0.001) by the end of the monitoring period, indicating rapid resolution of severe OHSS.

Conclusions: The current study suggests, for the first time, that successful outpatient management of severe OHSS with antagonist treatment in the luteal phase is feasible and is associated with rapid regression of the syndrome, challenging the dogma of inpatient management. The proposed management is a flexible approach that minimizes unnecessary embryo transfer cancellations in the majority (88.7%) of high risk for OHSS patients.

Figure 1

Flow chart describing the management approach for patients at high risk for developing OHSS. 10 patients did not develop severe OHSS and had embryo transfer cancellation due to the following reasons: failed fertilization n = 1, oocyte cryopreservation n = 2, no blastocyst formation n = 2, embryo cryopreservation due to Rokitansky syndrome n = 1, due to poor endometrium n = 1, absence of sperm on day of oocyte retrieval and use of donor sperm n = 3. Four patients with positive hCG following ET developed pregnancy-induced late OHSS and were admitted to the hospital (1.1%, 95% CI: 0.5 to 3.3).

Figure 2

Concentrations of (a) oestradiol (b) progesterone, (c) left and (d) right ovarian volume, (e) hematocrit, and (f) white blood cells during the monitoring period. Asterisks depict statistically significant difference compared to day 5 (*P < 0.001). Oocyte retrieval was performed on day 0. GnRH antagonist was administered from day 5 until and including day 8 post oocyte retrieval, as indicated by arrows.

Figure 3

Distribution of ascites levels during the monitoring period. *At the end of the monitoring period, on day 11, “moderate-marked ascites” included 14 women (35%), of which 11 (27.5%) had moderate ascites, and only 3 (7.5%) had marked ascites. No women (0%) had “massive-tense” ascites, while the majority of women (65%) had no or low levels of ascites on day 11 of monitoring (chi-square p < 0.01).