卵巢过度刺激综合征B超引导下经阴道腹水抽吸与腹部腹膜穿刺引流的效果对比

目的 探讨卵巢过度刺激综合征(OHSS)患者B超引导下经阴道腹水抽吸与腹部腹膜穿刺引流的效果.方法 选取146例OHSS患者,采用随机数字表法分为对照组与研究组,各73例.对照组采用B超引导下经阴道腹水抽吸治疗,研究组采用腹部腹膜穿刺引流治疗.比较两组24 h尿量、腹围、红细胞比容(HCT)、引流量、引流次数、病情恢复...     

辅助生殖技术后妊娠合并卵巢过度刺激综合征的诊治

卵巢过度刺激综合征(ovarian hyperstimulation syndrome,OHSS)是辅助生殖技术最常见的并发症之一,妊娠可使病情加重,严重者甚至危及性命。因此,对妊娠合并卵巢过度刺激综合征需积极预防、严密监测、及时处理,避免其产生的严重后果。     

Recent advances of laparoscopic approach in adnexal torsion of premenarcheal girls

The adnexal torsion is an uncommon gynaecological emergency; however, it must be excluded in young girls in order to conserve their future ovarian function and fertility. The diagnosis of adnexal torsion is particularly difficult in girls before the menarche during which time the clinical examination is very delicate. We review the recent literature and laparoscopic advances in this domain and propose a management algorithm.     

Thrombosis following ovarian hyperstimulation syndrome

The aim of this review is to analyse the pathophysiology and complications of thrombosis in conjuction with ovarian hyperstimulation syndrome (OHSS) following ovulation induction and to suggest practical guidelines usefull for the prevention and treatment. Although the incidence of thrombosis varies from 0.2% among in vitro fertilization (IVF) cycles and up to 10% for severe cases of the syndrome, it represents the most dangerous complication of OHSS. Different changes in haemostatic markers have been found to create a state of hypercoagulability, but no single standard test is available to estimate the state of thrombosis. The role of markers for thrombophilia is controversial. Thromboses are mostly venous (67–75%) involving upper limbs and neck, then arterial (25–33%) which are mainly intracerebral. The predominant sites of venous thromboembolism in the upper part of the body may be explained by higher concentrations of estrogens drained through lymphatic ducts from ascites and by compression of rudimentary branchyal cysts. Once early diagnosis is established, it is crucial to use an anticoagulant treatment with heparin proceeded with thromboprophylaxis. However, identification of patients at risk and preventive measures of OHSS are the best means in reducing the risk of thrombosis after ovarian stimulation.     

Unilateral follicular aspiration and in-vitro maturation before contralateral oocyte retrieval: a method to prevent ovarian hyperstimulation syndrome

Background: Five women undergoing intracytoplasmatic sperm injection (ICSI) considered to be at high risk of developing an ovarian hyperstimulation syndrome (OHSS) from March to July 2002 underwent unilateral follicular aspiration. Methods: When ≥15 follicles of 12–15 mm diameter in each ovary and a serum estrodial level ≥2500 pg/ml was present, follicular aspiration was performed unilaterally without hCG administration. Ovarian stimulation was continued for 1–3 days in four women before human chorionic gonadotrophin (hCG) was given. In one woman hCG injection was administered at the evening after unilateral follicular aspiration. The oocyte retrieval from the contralateral ovary was performed 36 h after hCG injection. By unilateral follicular aspiration two to six germinal vesicle (GV) oocytes could be retrieved. After in-vitro maturation of those oocytes ICSI was performed. Results: In four women one to two oocytes were fertilized and cryopreserved. In one case only one triploid pronucleus (3PN) was observed. At the contralateral ovum-pick up after hCG injection a median of 10 could be retrieved. After transfer of a median of 3 embryos, no pregnancy was achieved. Four of five patients developed a severe OHSS and were hospitalized for a median of 3 days. Conclusion: Unilateral follicular aspiration and continuation of stimulation therefore can not be recommended for the prevention of OHSS.     

48例卵巢囊肿蒂扭转的手术治疗分析

目的:探讨不同卵巢囊肿蒂扭转手术方式治疗的安全性及有效性。方法:选取2009年1月至2013年6月于山东省阳谷县人民医院行手术治疗的48例卵巢囊肿蒂扭转患者,其中26例行保留附件的囊肿剥除术(A组)和22例行患侧附件切除术(B组)。比较两组患者的发病时间、卵巢囊肿扭转周数、手术时间、术中平均出血量、术后住院时间、雌激素及孕激素水平。结果:A组的发病时间、囊肿扭转周数小于B组(P0.05),手术时间长于B组(P0.05),雌、孕激素水平恢复情况优于B组(P0.05);而两组的术中平均出血量、术后住院时间无统计学差异(P0.05)。结论:卵巢囊肿蒂扭转手术治疗中卵巢的去留由多因素决定,保留卵巢的保守性手术具有一定的安全性及有效性。     

Early timed follicular aspiration prevents severe ovarian hyperstimulation syndrome

Purpose: Early timed follicular aspiration (ETFA) of one ovary 10–12 hr after administration of chorionic gonadotropin (hCG) is an attempt to prevent severe ovarian hyperstimulation syndrome (OHSS). After the introduction of early timed follicular aspiration ETFA of one ovary in IVF/ET cycles at high risk for severe OHSS, no cases of severe OHSS were registered in the Ljubljana IVF/ET program. In the period before preventive ETFA (1984–1992) there were 16 cases of severe OHSS of 4798 IVF/ET cycles followed by 577 clinical pregnancies. After the introduction of ETFA (1992–1993) there were no cases of severe OHSS of 2289 IVF/ET cycles followed by 364 clinical pregnancies. Methods: We attempted to evaluate the significance of this observation by comparing two groups of female infertility IVF/ET cycles at high risk for severe OHSS. The occurrence of severe OHSS and clinical parameters in the two groups of IVF/ET cycles at high risk for severe OHSS were compared. Results: In the group of 106 IVF/ET female infertility cycles at high risk of severe OHSS with preventive ETFA, there were no cases of severe OHSS. In the control group of 92 IVF/ET female infertility cycles at high risk for severe OHSS with normally timed follicular aspiration (NTFA) of both ovaries, severe OHSS occurred in 16 cases. The difference in the occurrence of severe OHSS between the two groups is highly significant (P<0.005), both in hMG/hCG- and in GnRHa/hMG/hCG-induced IVF/ET cycles. No difference in live birth rate (16 vs. 16%) between the two groups was noted. Conclusions: Considering these results we conclude that ETFA is another successful option to decrease the incidence of severe OHSS in assisted reproduction. The preventive effect of follicular aspiration seems to depend on its timing.     

Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence

Objective

To report our clinical experience in adnexal torsion.

Study design

A retrospective case review of surgically proven adnexal torsion.

Results

216 cases were identified. Mean age was 29 ± 12. Twenty-two were premenarchal, 59 had ovarian stimulation, 48 were pregnant (with a median gestational age of 7 weeks) and 14 were post-menopausal. The most common risk factor was a previous history of adnexal torsion. The main clinical features were sudden, intermittent pain. Forty-five percent of Doppler examinations demonstrated normal flow: premenarchal and postmenopausal patients had higher rates of abnormal flow, compared to pregnant patients or after ovarian stimulation. Median time from admission to diagnosis was 6 h. Laparoscopy was conducted in 81.0% of the cases, and laparotomy in the rest. Twenty-three cases of recurrent torsion were documented. The majority of these events occurred following detorsion only. An enlarged ovary was found in 77 cases, dermoid cyst in 8 cases, and one case was malignant. Sixty eight-cases underwent detorsion, in 82 cases a combined detorsion and cystectomy or fenestration were performed and 43 patients underwent partial or total adnexectomy. Adnexal fixation was conducted in 21 cases. Cyst drainage or cystectomy significantly reduced the chance of retorsion by 50% and 75%, respectively, compared to detorsion only.

Conclusion

Ovarian stimulation and early pregnancy are predisposing factors for ovarian torsion. Doppler flow studies may be a helpful diagnostic tool among premenarchal and post-menopausal women. Cystectomy should be considered in order to reduce the risk of retorsion.     

Follicular aspiration does not protect against the development of ovarian hyperstimulation syndrome

Objective The purpose of this study was to determine the effect of follicular aspiration on the incidence of ovarian hyperstimulation syndrome (OHSS).Design A retrospective study was done on 219 IVF cycles that proceeded to follicular aspiration (group A) and they were compared with 189 cycles of ovulation induction for non-IVF cycles (group B). We compared the incidence of OHSS in regularly ovulating patients (subgroups A1 and B1) and anovulatory patients (subgroups A2 and B2) in both groups.Settings The study took place at The Egyptian IVF-ET Center.Participants Participants were 319 infertility patients.Intervention Ovulation was induced and follicles were aspirated.Main Outcome Measures The incidences of moderate and severe OHSS were the main outcome measures.Results The incidence of OHSS in group B was significantly higher than that in group A (P =0.016). There was no significant difference in the incidence of OHSS between subgroup A1 and subgroup B1 or between subgroup A2 and subgroup B2. Conclusions Follicular aspiration had no effect on the incidence of OHSS. In contrast, the higher incidence of OHSS in group B was related to the higher incidence of anovulatory infertility.     

重度卵巢过度刺激综合征38例晚期妊娠结局分析

目的:探讨重度卵巢过度刺激综合征(OHSS)患者的晚期妊娠结局。方法:回顾分析我院行体外受精-胚胎移植(IVF-ET)而发生重度OHSS的晚期妊娠患者的临床资料,与同期未发生OHSS的IVF晚期妊娠患者的妊娠结局比较。结果:38例重度OHSS患者中单胎18例、双胎20例;IVF组232例中相应为119例、113例。OHSS组单胎早产率为5.56%、双胎早产率45%,IVF组相应为5.04%、43.36%。OHSS组与IVF组的单胎与双胎分娩比率、早产比率差异均无统计学意义(P>0.05)。OHSS组单胎妊娠期糖尿病(GDM)发病率为5.56%,双胎为5%;IVF组分别为5.04%、5.31%。OHSS组单胎妊娠期高血压疾病(PIH)发病率为11.11%,双胎为10%;IVF组分别为9.24%、9.73%。OHSS组GDM及PIH的发生率与IVF组比较,差异无统计学意义(P>0.05)。结论:重度OHSS的发生未对晚期妊娠结局产生明显不良影响。     

132例中、重度卵巢过度刺激综合征妊娠结局分析

目的探讨中、重度卵巢过度刺激综合征（ovarian hyperstimulation syndrome，OHSS）对患者妊娠结局有无影响。方法对于2004年至2005年在我院行体外受精-胚胎移植而发生中、重度OHSS的132例患者（妊娠患者72例）临床资料进行回顾性分析，并与同期未发生中、重度OHSS的妊娠患者861例就妊娠结局进行对比性分析。结果（1）132例中、重度OHSS患者，其中87例移植，临床妊娠率为82．8％（72／87），妊娠结局为：单胎分娩53．5％，双胎分娩25．4％，流产16．9％，胎死宫内1．4％，宫外孕1．4％，因胎儿畸形引产1．4％，其中出生缺陷共1．4％。同期非OHSS患者上述比率分别为：55．0％、19．5％、18．7％、0．6％、6．1％、0．1％，其中出生缺陷共2．4％。（2）OHSS患者与未发生OHSS的患者在单胎与双胎分娩比率，妊娠丢失（流产＋死胎）与分娩（早产＋足月产）比率上均无显著性差异（P〉O．05）；但OHSS患者早期流产率（7．0％）低于晚期流产率（9．9％），而非OHSS患者早期流产率（13．3％）高于晚期流产率（5．4％）（P=0．075）。（3）OHSS患者与未发生OHSS的患者在早产与低体重儿比率，妊娠期并发症（妊娠期高血压疾病、妊娠期糖尿病与前置胎盘等）比率上均无统计学意义（P〉O．05）。结论OHSS的发生对妊娠结局未产生明显不良影响。     

Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound-guided aspiration and single-dose methotrexate

OBJECTIVE: To present a case of cervical ectopic pregnancy successfully treated with ultrasound-guided aspiration and single-dose methotrexate administered systemically. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old nulliparous woman with a cervical ectopic pregnancy. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical ectopic pregnancy followed by single-dose methotrexate administered systemically. MAIN OUTCOME MEASURE(S): Recovery of the patient, successful conservative treatment of the cervical ectopic pregnancy, with preservation of the uterus. RESULT(S): The cervical ectopic pregnancy was successfully aborted, and the reproductive capability of the patient was preserved. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with single-dose methotrexate administered systemically can be safely used to treat cervical ectopic pregnancies.     

Combined modalities for the prevention of ovarian hyperstimulation syndrome following an excessive response to stimulation

Although the classification and management of ovarian hyperstimulation syndrome (OHSS) are well described in the literature, little attention has been given to modalities that aim to prevent its occurrence. In this retrospective study, we sought to investigate whether a combination of modalities in addition to GnRH agonist triggering in GnRH antagonist cycles could result in better prevention of OHSS. The study included 170 hyperresponder patients who were stimulated with GnRH antagonist protocol and were triggered with GnRH agonist for final oocyte maturation. Freeze all embryos was performed in all patients. The intervention group included treatment with dopamine agonist and restarting the GnRH antagonist. Of the 170 patients included, 63 were included in the intervention group. Compared to no intervention, women in the intervention group were more likely to have: menses within 7?days of the oocyte retrieval, smaller ovarian diameter, the absence of free pelvic fluid, less hemoconcentration and higher serum sodium levels. It can be concluded that combining other modalities in addition to triggering with GnRH agonist in GnRH antagonist cycles, results in targeting several pathways that lead to OHSS and result in rapid resolution of signs of ovarian hyperstimulation.     

Unilateral pleural effusion as the main presentation of "early onset" severe ovarian hyperstimulation syndrome

OBJECTIVE: To report a case of severe early onset ovarian hyperstimulation syndrome with unilateral pleural effusion and little ascites as the main presenting clinical signs. DESIGN: Case report. SETTING: University affiliated teaching hospital and in vitro fertilization (IVF) clinic. PATIENT(S): A 33-year-old woman known to have bilateral polycystic ovaries underwent IVF and became pregnant. INTERVENTION(S): Pleuracentesis. MAIN OUTCOME MEASURE(S): Resolution of symptoms, pregnancy outcome. RESULT(S): A total of 4,200 mL of pleural fluid was drained from the right hemithorax. Complete resolution of symptoms did not occur until 16 weeks' gestation. The pregnancy progressed normally until 27 weeks when spontaneous preterm labor resulted in a vaginal delivery of a live female infant weighing 880 grams. CONCLUSION(S): This case described is unusual in that the patient presented with significant right-sided pleural effusions on day 2 after embryo transfer and continued to be symptomatic until 16 weeks' gestation. This is much earlier than any previously described case report of isolated unilateral pleural effusion associated with ovarian hyperstimulation syndrome.     

Aggressive outpatient treatment of ovarian hyperstimulation syndrome with ascites using transvaginal culdocentesis and intravenous albumin minimizes hospitalization

Purpose: To assess the effectiveness of outpatient treatment of Ovarian Hyperstimulation Syndrome associated with ascites. Methods: Forty-eight patients diagnosed with ovarian hyperstimulation and ascites from 2246 consecutive in vitro fertilization cycles were retrospectively studied. Patients were treated with outpatient transvaginal culdocentesis and rehydration with intravenous crystalloids and albumin every 1–3 days until resolution of symptoms or hospitalization was required. Outcomes measured included incidences of hospitalization, pregnancy outcomes, cycle characteristics, and oocyte donors versus nondonors comparisons. Results: No complications occurred from outpatient treatments, and 91.6% of patients avoided hospitalization. The pregnancy rate in patients undergoing transfer was 84.7%, and the spontaneous loss rate was 16%. Overall, the estradiol on day of hCG was 4331 pg/mL (range 2211–8167), ascites removed was 1910 cm³ (122–4000), and number of outpatient treatments was 3.4 (1–14). Nondonors averaged more outpatient treatments than donors (3.97 vs. 1.85), but similar rates of hospitalization (3/35 vs. 1/13). Conclusions: Outpatient treatment consisting of culdocentesis, intravenous rehydration, and albumin minimized the need for hospitalization in hyperstimulated patients.