Last updated December 18, 2021

Prevention And Treatment Of Moderate And Severe Ovarian Hyperstimulation Syndrome

Summary

There is fair evidence that PCOS, elevated AMH values, peak estradiol levels, multifollicular development, and a high number of oocytes retrieved increase the risk of OHSS. (II-2, B)
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While cut points require validation, AMH values >3.4 ng/mL, AFC >24, development of ≥25 follicles, estradiol values >3,500 pg/mL, or ≥24 oocytes retrieved are particularly associated with an increased risk of OHSS. (, B)
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There is good evidence to support the use of ovarian stimulation protocols using GnRH antagonists in order to reduce the risk of OHSS. (, A)
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There is insufficient evidence that clomiphene independently reduces OHSS risk. (, C)
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There is fair evidence that aspirin reduces the incidence of OHSS based on a single, randomized trial comparing aspirin alone with no treatment and another study comparing combined acetylsalicylic acid and steroid treatment with no treatment. (, B)
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There is good evidence that metformin decreases the risk of OHSS risk in PCOS patients. (, A)
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There is insufficient evidence to recommend coasting for the prevention of OHSS. (, C)
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There is insufficint evidence to recommend a lower dose of hCG to trigger oocyte maturation for reduction in OHSS risk based on one underpowered randomized trial. (, C)
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There is good evidence to recommend the use of a GnRH agonist to trigger oocyte maturation prior to oocyte retrieval in order to reduce the risk of OHSS. (, A)
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There is good evidence that live-birth rates are lower in fresh autologous cycles after GnRH trigger, but not donor-recipient cycles. (, A)
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There is fair evidence that reproductive outcomes are improved when a low dose of hCG is co-administered at the time of GnRH agonist trigger for luteal support. (, B)
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There is good evidence that dopamine agonist administration starting at the time of hCG trigger for several days reduces the incidence of OHSS. (, A)
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There is insufficient evidence to conclusively state that albumin lowers OHSS risk. (, C)
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There is fair evidence that calcium lowers OHSS risk. (, B)
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There is fair evidence that cryopreservation prevents OHSS, based on the results of two small RCTs. (, B)
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There is fair evidence to recommend paracentesis or culdocentesis for the management of OHSS in an outpatient setting. (, B)
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There is insufficient evidence to support the use of volume expanders alone in treatment of OHSS. (, C)
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Recommendations

Women with PCOS, elevated AMH values, and elevated AFC may benefit from ovarian stimulation protocols that reduce the risk of OHSS. (, B)
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Ovarian stimulation protocols using GnRH antagonists are preferable in women at high risk of OHSS. (, A)
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The use of a GnRH agonist to trigger oocyte maturation prior to oocyte retrieval is recommended to reduce the risk of OHSS if peak estradiol levels are high or multifollicular development occurs during stimulation. (, A)
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Low-dose hCG co-trigger, luteal hormonal support, or cryopreservation of embryos are strategies that may improve pregnancy rates in this setting.
(, B)
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Dopamine agonist administration starting at the time of hCG trigger for several days also may be used to reduce the incidence of OHSS. (, A)
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Additional strategies to prevent OHSS which may be helpful include the use of metformin in PCOS patients, (, A)
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  • aspirin administration 
(, A)
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  • and cryopreservation of embryos.
(, B)
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The mainstay of OHSS treatment includes fluid resuscitation and prophylactic anticoagulation. Paracentesis or culdocentesis may be recommended for management of OHSS when a large amount of ascites is present. (, B)
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Recommendation Grading

Overview

Title

Prevention And Treatment Of Moderate And Severe Ovarian Hyperstimulation Syndrome

Authoring Organization

Publication Month/Year

December 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Ovarian hyperstimulation syndrome (OHSS) is an uncommon but serious complication associated with assisted reproductive technology (ART). This systematic review aims to identify who is at high risk, how to prevent OHSS, and the treatment for existing OHSS.

Target Patient Population

Woman undergoing controlled ovarian stimulation with gonadotropins

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Scope

Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D007247 - Infertility, Female, D016471 - Ovarian Hyperstimulation Syndrome, D012098 - Reproduction

Keywords

gonadotropins, infertility, Reproductive Health, ovarian stimulation