| Background and ObjectOvarian hyperstimulation syndrome is a serious iatrogenic complication of ovarian stimulation in assisted reproductive technology (ART). Its underlying etiology and pathogenesis is unclear, but vasoactive ovarian factor is likely to be involved in the vascular permeability increase and neoangiogenesis.OHSS is characterised by a cystic enlargement of the ovaries and an acute fluid shift from the intravascular to the third space, which may result in ascites, pleural infusions, pericardial infusion and even generalised oedema. The most common clinical symptoms include lower abdominal discomfort,progressive increase in umbilical circumference,nausea, vomiting, hemoconcentration, hypovolemia, oliguria,hepatic or renal dysfunction and so on, in severe cases it can cause thrombo-embolism events,acute respiratory distress syndrome,renal failure,and even life threatening. Whether the above pathophysiological process and symptomatic treatments will exert adverse impact on pregnancy outcome in IVF patients or not is unknown.The purpose of this study is to compare IVF pregnancy outcome in patients with or without OHSS, and to study the influence of OHSS on pregnancy outcome of IVF patients.MethodsThe medical charts of total190OHSS patients who underwent IVF or ICSI in Reproductive Medical Center in Peking Union Medical College Hospital between February2002and December2012were retrospectively reviewed.Pregnancy outcome were compared with197contemporaneous non-OHSS patients with matched age and number of Mature-II oocytes.All the patients are stimulated in three different schemes individually. When at least three follicles are above18mm in diameter, patients are injected with human chorionic gonadotropin (HCG) to trigger ovulation.36h after HCG injection,with no moderate or severe OHSS occurred,oocytes are achieved and then three days later, embryos are transplanted. Using progesterone for luteal support with or without HCG according to the function of the corpus luteum.When obvious recession,HCG is used to strengthen luteal support. All the moderate or severe OHSS patients are hospitalized.Intake and output volume is recorded in daily basis,monitor the weight, abdomen circumference, hematocrit (HCT), white blood cell count (WBC), liver and kidney function, necessarily ultrasound monitoring ovarian size and pleural fluid changes. All patients are given to the intravenous drip albumin or hydroxyethyl starch expansion treatment, liver protecting treatment, preventive anti-infection treatment,diuretic treatment, appropriate abdominal or chest pleural puncture drainage fluid to relieve symptoms according to their conditions.Pregnancy outcome evaluation indexes include pregnancy outcomes and delivering outcomes. Pregnancy outcomes can be further divided into clinical pregnancy, miscarriage, fetal death, one of twins early or late miscarriage or fetal intrauterine death, ectopic pregnancy, and artificial abortion or induction. Clinical pregnancy meets the standard of gestational sac under ultrasound diagnosis.Miscarriage include early abortion and late-term abortion. The delivering outcomes include birth gestational age, delivery mode, neonatal birth weight, and birth gestational age is divided into three categories,34weeks or less, premature delivery (28to37weeks), term delivery. Delivery mode includes cesarean section and vaginal delivery.Neonatal birth weight includes full-term SGA (small for gestational age infant, SGA) and premature SGA.Full-term SGA is defined as term birth and birth weight below2500g, and premature SGA is defined as birth weight lower than the tenth percentile of the same gestational age neonatal birth weight.ResultsThe prevalence of OHSS in our data is3.46%(190/5487), critical OHSS0.18%(10/5487),thromboembolism1.58%(3/190) in OHSS patients,major complications2.63%(5/190).There’s no significant difference between the two groups in age,BMI, infertility type or duration.Almost all the infertility factors are uniform except for the male factor with P<0.001. There’s also no significant difference found between the two groups in IVF materials like M-II oocytes number,embryo number,embryo number transferred.basic FSH value, peak E2value on HCG day, oocytes maturation scheme and luteal support scheme.But the hCG dosage for luteal support and Gn dosage are significantly lower in OHSS group than non-OHSS group. The clinical pregnancy rate of OHSS patients increased significantly compared with non-OHSS group[91.8%(168/183) vs45.1%(80/184),P<0.001];The multiple pregnancy rate was4.0%vs3.7%, miscarriage rate16.1%(27/168) vs17.5%(14/80),loss fetus of one twin10.1%(17/168) vs10.0%(8/80), and there was no significance between two groups in the above index (all P>0.05).The live-birth rate was82.1%(138/168) vs78.8%(63/80), preterm delivery20.9%(29/139) vs17.5%(11/63),delivery before gestational age of34weeks8.6%(12/139) vs7.9%(5/63),fetal intrauterine distress2.9%(4/139) vs3.2%(2/63), cesarean delivery rate84.9%(118/139) vs66.3%(53/63),birth gestational age37.7±2.3ws vs37.7±2.0ws,weight of newborn infants2813±620g vs2880±607g,term small for gestational age infant13.0%(25/139) vs10.6%(9/63),preterm small for gestational age infant6.3%(12/139) vs3.5%(3/63),and there was no significance between two groups in the above index (all P>0.05).ConclusionThe clinical pregnancy rate of OHSS patients increased significantly compared with non-OHSS group, however the miscarriage rate, the perinatal complications such as loss fetus, preterm delivery and small for gestational age infant did not increased significantly.We speculate that OHSS occuring during luteal phase or early pregnancy in IVF patients representing such a transient hemodynamics abnormality did not exert obvious adverse effect on the subsequent pregnancy.The application of a series of symptomatic and supportive treatment such as blood volume expanding, anti-infection,liver treatment, diuresis, thoracentesis and abdominocentesis also had no adverse effect on the pregnancy outcome. But when facing major life-threatening complications such as thromboembolism, ARDS, respiratory failure, cerebral infarction,patients had to terminate pregnancy, indirectly destroying pregnancy outcome. Management of OHSS increased cost and risk of pregnancy, brought a certain economic burden on patients,and adverse influence on patients’ mind. In ensuring clinical pregnancy rate, not affecting pregnancy outcomes, and avoiding the occurrence of OHSS, various reproductive center committed to the continuous improvement of ovarian stimulating drugs,so far, has achieved good results. Cesarean section rate, according to our data, rises significantly in IVF patients with84.7%, and no difference between OHSS group and non-OHSS group shows that the complication doesn’t lead to higher cesarean section rate. |
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