Dear:
About OHSS:
Ovarian Hyper Stimulation Syndrome or hyperstimulation is a complication caused by the hormone treatment during fertility treatment including FSH (follicle stimulating hormone). Naturally, in women, FSH stimulates and matures the eggs in the ovary.
Treatment with FSH normally makes you feel bloated and heavy in the abdomen. These symptoms are expected and is caused by the maturation of numerous large follicles, which will take up a lot of space in the ovaries. The symptoms should wear off after one or two weeks after your egg retrieval.
If your treatment causes a stronger response than planned with maturation of more than 15-20 follicles, you may be at risk of developing OHSS. To prevent this, we always assess your current risk before we prescribe the ovulation trigger, Ovitrelle. Ovitrelle contains a copy of the natural pregnancy hormone, hCG, which is used to induce a controlled ovulation. Ovitrelle also facilitates the final maturation of the eggs before they are aspirated. However, Ovitrelle can also induce an overstimulation since the hCG makes the blood vessels more permeable to fluid than normal. If the ovaries are overstimulated, hCG can cause a strong leakage of fluid from the bloodstream. Such leakage worsens the symptoms from the ovaries and can spread to the abdominal cavity and cause symptoms from the entire abdominal region with pain, distention and breathing difficulties. In very severe and rare cases, OHSS can lead to blood clots.
Prevention of OHSS:
If we are concerned that you are at risk of developing OHSS, we will prescribe another type of ovulation trigger, namely Gonapeptyl. This ensures induction of ovulation and egg maturation, and at the same time it will circumvent/limit the overstimulation reaction from Ovitrelle. When Gonapeptyl is used, we will always freeze all the fertilized eggs. However, this is only possible in a short protocol. In the case of a long protocol, it can be necessary to cancel the cycle entirely if the risk of overstimulation is too big.
Freeze all cycles:
After egg retrieval, your eggs are fertilized and grown to the blastocyst stage, with the aim to freeze the blastocysts on day 5 or 6. This means that all qualified blastocysts are frozen for later use in a frozen embryo transfer (FET) cycle. With a FET cycle, there is no risk of overstimulation since the effect of the hormone treatment is gone and your ovaries are back to normal size and function. You can sign up for your first FET cycle after a month break.
Early onset OHSS:
The early onset overstimulation is observed from the end of your stimulation period and in the period after you have received the ovulation trigger. The symptoms will typically subside 7-10 days after the egg retrieval. If you become pregnant after your treatment, the symptoms of overstimulation may return.
The late onset OHSS:
The late onset hyperstimulation occurs as a result of a pregnancy. Late onset hyperstimulation is often more severe and lasts longer than the early one. This is due to the strong increase in hCG from the pregnancy which worsens and maintains the symptoms. If it is assessed that you have an increased risk of hyperstimulation in connection with your treatment, it is important to postpone pregnancy so that you avoid becoming seriously ill with the risk of hospitalization. In this case, we will make use of a FET cycle and thus, postpone your egg transfer.
Symptoms of OHSS:
Bloating and heaviness in the abdomen and stomach region
Weight gain
Difficulty breathing/shortness of breath
General discomfort
Fever
Nausea, vomiting and diarrhea
Pain in the stomach and abdomen
Difficulty urinating
Prevention and treatment of OHSS:
Liquid: Drink 3 liters a day (not just water).
It is important to drink 3 liters a day to avoid dehydration. You may drink whatever you want, but the liquid should preferably contain protein. This could for example be cocoa milk, ‘koldskål’, ‘skyr’, or protein drink. It may be a good idea to keep record on your liquid intake, as 3 liters is a lot.
Protein: Eat extra protein.
Protein helps to keep fluid in the bloodstream and prevent leakage to the ovaries and abdominal cavity. That is why it is important that you eat extra protein. ‘Skyr’, eggs, meat, beans, and fish are good sources of protein.
Salt: Eat a little extra salt.
Salt binds fluid in the bloodstream, so add a little extra salt in your food (e.g., add some salted nuts) in the period until your OHSS is over.
Physical activity: Avoid physical exertion.
Due to your enlarged ovaries, it is important that you do not overexert yourself physically. Avoid hard physical work and limit exercise. An enlarged ovary can make a twist and thereby cut off its own blood supply.
This is very painful and may require emergency surgery. Notice how you feel and adjust your activity level accordingly.
Weight: Weigh yourself every morning.
Hyperstimulation can cause you to gain weight due to water retention in the ovary -and abdominal region. The easiest way to measure this is to weigh yourself every morning after emptying your bladder. If you gain ½-1 kg each day, you must contact us in the department.
Abdominal girth: Measure around your stomach with a tape measure.It can be difficult to assess whether you get more bloated day by day. You can check this by measuring your abdominal girth every morning after you have emptied your bladder. If your bloating worsens, you should contact us.
Urine: Observe your urine.
When you drink 3 liters of liquid a day, you must also urinate more frequently than usual. It is important that you observe your urine, which should remain clear and bright yellow. If the urine become dark and sparse, or if you get difficulty urinating, it is a sign that you are dehydrated either because you have been drinking too little or due to an increased leakage of fluid in the stomach.
Pain:
Pain associated with OHSS is normal. If your pain is mild to moderate, you may take:
Tablet Paracetamol 1 gram max 4 times a day.
If this is not enough, you can supplement with:
Tablet Codeine 25-50 mg max. 4 times a day, when needed.
If the pain becomes worse than the above pain treatment can alleviate, you must contact the department, or 1813 if it is outside our opening hours.
Hospitalization:
In a serious OHSS case, it may be necessary to hospitalize you for observation and treatment. The treatment primarily involves balancing the fluids and prevention of blood clots.
Sick leave:
For some, a sick leave may be needed in order to stabilize and keep calm after an hyperstimulation reaction.
You are always welcome to contact us if you have any questions.
Kind regards
The Fertility Department, Rigshospitalet