An ohss – free clinic
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Director :-
Sec General : Delhi Gynae Forum
Chairperson : WOW India
Founder chairman : Global Institute of Gynae at Pushpanjali Crosslay
Hospital
Former : National Commission for Women (2004-2007) Advisor Health
Chairperson : Women Wing , IMA (2004-2007) Member : Resources Committee NACO (2008-2011)Former Chairperson: Adolescent Health comm., Safe Motherhood Comm. AOGD
Member : State Sup. Board , PNDT Board : Female Feticide Resources Group, NCPC
Dr. Sharda jain
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Dr. Sharda Jain
Director :
An OHSS – Free Clinic : to Manage ERROR – TERROR
International conference on Reproduction fertility &surrogacy AIIMS, New Delhi 24-25 may 2014
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An OHSS – Free Clinic to Manage
ERROR – TERROR
Review this Lecture at:Slideshare.net :
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Goals of Ovulation induction
in IUI / IVF
Minimize Complications & Risk
AIM
Ideal Outcome
Singleton live
Birth at term Cycle
Cancellation
Multiple
Pregnancy OHSS
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OHSS – Risk is a reality
OHSS - Mortality is also a reality - Grossly Underestimated (Bewley et al 2011)
DEVROEY 2011
OHSS is ↑ in numbers with
↑ in IVF /ICSI cycles all over the globe
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Mortality due to critical OHSS
in IVF is Unacceptable
DEVROEY 2011
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OHSS IVF Cycles Most Serious Complications of OI
PRIOR TO 2000 – ↑ OHSSAFTER 2000
of OHSS is almost always present with OI in good & high responders
(Delvigne -2009)
(Dreadful – Hospitalisation & ? Death) (Papanikolaou et al.2005)
Severe OHSS - 2%
Moderate OHSS - 5%
Mild form
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MATERNAL MORTALITY RATES
Due to OHSS
Netherland & UK – 2007
MORTALITY : 3 / 1,00,000 CYCLES
1 Aboulghar. Fertil Steril. 2012;97:523-6; 2 Confidential Enquiry into Maternal and Child Health, 2007;
1-5 million IVF cycles / year500 death (last 10 years)
Grossly Underreported
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Aetiopathogenesis
Exact Pathogenesis is not clear
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IMPORTANCE of OHSSWHAT IT means to ME & to You ?
• Totally IATROGENIC problem of OI
Induced by clinician • without Long Protocol & HCG Trigger OHSS is
extremely rare.• 100% PREVENTION IMPOSSIBLE
• Profound Economical impact
• Profound Psychological Impact
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3 Facts
• Long protocol of Down regulation
With GnRH agonist in IVF is associated
↑ OHSS• HCG Trigger for ovulation creates HAVOC
– Compels IVF experts to use long protocol
Supposedly ↑ PRWith long protocol
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HCG
Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod. 2000;15:1037; Gómez et al. Endocrinology. 2002;143:4339
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Classification (Clinical Forms)
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ClassificationMathur et al - 2005.
• THE EARLY FORM (<10 days after the HCG trigger.
• THE LATE FORM (>- 10 days after HCG).
• COMBINATION of the early form , followed
by pregnancy is SERIOUS AND LONG LASTING (Papnikolaou et al., 2004)
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Mild
Mild abdominal pain
Abdominal bloating
Ovarian size usually <8 cm
Moderate
Moderate abdominal pain
Nausea +/- Vomiting
Ultrasound Evidence of ascites
Ovarian size 8-12 cm
Grading
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Mild
Mild abdominal pain
Abdominal bloating
Ovarian size usually <8 cm
Moderate
Moderate abdominal pain
Nausea +/- Vomiting
Ultrasound Evidence of ascites
Ovarian size 8-12 cm
Grading
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Severe
Clinical ascites (rarely hydrothrorax)
Oliguria
heamoconcentration - HEAMATOCRIT >45%
Hypoproteinaemia
Critical
Ovarian size > 12 cmTENSE ASCITES + HYDROTHORAX
WHITE CELL COUNT > 25 000/ ML
OLIGURIA / ANURIA
Thromboembolism
Acute respiratory distress syndrome
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Severe / Critical Cases are dreadful !!
Life Threatening
Massive Ascites
• Hemoconcentration
PCV > 45%, Hb > 15gm %• Venous thrombosis • Electrolyte imbalance
Renal• Hepatic failure
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The Truth is that
OHSS MUST
BE PREVENTED RATHER than treated
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Dale Carnegi Said
“The successful man profits from his mistake
and tries again in a different way”.
“That’s true for errors of OHSS events in IVF – a dangerous emergency
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HOW TO PREVENT IT ?
• Steps Before stimulation
• Step During Stimulation
• Step on Impending Severe OHSS
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Young patients Lean womenPolycystic Ovarian PCOSPrevious OHSS
• High number of follicle in both ovaries at the quiescent state before Stimulation
(>- 10 follicle of 4-10mm in each ovary)
• Raised AMH
EasilyRecognized
WHO are AT HIGH RISK BEFORE OI – IUI & IVF
PRIMARY RISK FACTORS
SENSITIVE OVARIES
25.0 pmol/l for a high response
(Delhi AMH H >7 ng/ml
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OHSS Monitoring should be
• Easy
• Reliable
• Patient friendly
• Not Expensive
• Can be done by IVF Team
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IDEA
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Welcome Protocol to manage Error Terror
Paul Devrory et al -2011
Human Reproduction
An OHSS-Free Clinic by segmentation of IVF Treatment
OHSS
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Proposed Protocol of Zero% OHSS
• The use of the GnRH antagonist protocol for OI instead of long protocol
• Ovulation Triggering with GnRH agonist Instead of HCG trigger
• Cryopreservation of all oocytes and embryos
↓ET in frozen – thawed cycle
3 Steps
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STEP - 1
Use of GnRH antagonist
Protocol for OI
• Patients friendly
- Fewer injection of OI
- Short duration of stimulation
- Absence of side effects
Uses • ↓↓ OHSS rate• No difference in Term LB Rates
Between antagonist & agonist Al- Inany et al 2006- 20011, Kolibisnskis et al 2006
Devroey et al 2009 2011
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STEP - II
Ovulation Triggering - ↓↓↓↓ OHSS Rate- but can’t eliminate it all
together
GOLD STANDARD as ovulation triggering agent because of long half life with levels remaining elevated even after six days of administrations
HCG
Antagonist protocol
GnRH Agonisttrigger
For triggering final Oocyte maturation• Effective in preventing OHSS
(Segal and Casper ,1992
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ZERO % OHSS (Severe / Critical)is achieved
• Incidence of Severe OHSS is GnRH antagonist cycles is 0% when triggered with a GnRH agonist.
• This was tested in OOCYTE DONORS (Melo et al ,2009)
Major Disadvantages
↑ Luteal phase defect &
significant ↓ Pregnancy Rate
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It is EASIER Said Than Doneto cancel a cycle !!
↓
GnRH AGONIST as a triggering agent
Luteal phase defect - ↓ PRNegative effect on corpus luteum function
Negative effect on function of endometrium
BY GIVING HCG 1500 units on O.P.U.
day – P.R. ↑ (NORMALISED)
↑
Cryo Preservation
↑
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Step III
CRYO PRESERVATION of oocytes & embryoA valuable modality…But Skill - is the key
Oocyte / embryo vitrification –
↑ P.R. (40% - 80%)
↓ Severe OHSS to 0% Results better than COASTING
Ethical Issue of freezing embryo
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CDC Report 2008
Pregnancy Rate same
in FRESH / FROZEN – thawed cycles
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Endometrum Preparation in frozen – thawed cycles
(A) Natural Cycle
(B) GnRH agonists (Day 21)
+ E2
+ progesterone from OPU Day
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Key : Take Home messages
• SAFETY OF PATIENT in IVF is public
& doctors TOP PRIORITY
Concept ofhas to be accepted sooner than later FOGSI / ICMR
OHSS FREE CLINIC
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Replace Long protocol of GnRH agonist with short antagonist protocol
+ Agonist ovulation trigger
+ Oocyte & embryo freezing
+ET in
Natural cycle Or Artificially prepared Endometrium
Key Take Home messages
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OHSS : an IATROGENIC problem must never hold you back if you face it.
Instead - these problems can help you shine brighter in the next take off –
of your PROFESSIONAL MATURITY & support OHSS Free Clinic
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Future Strategy for Safe IVF Practice
• 100% antagonist cycle
• 100% freezing of embryos
• 100% frozen-thawed
IVF cycles
Zero % OHSS Free Clinic
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Thank You
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ADDRESS 35 , Defence Enclave, Opp. Preet
Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092
CONTACT US 011-22414049, 42401339
WEBSITE : www.lifecarecentre.in
www.drshardajain.com www.lifecareivf.com
E-MAIL ID
[email protected]@gmail.com
&