Ovarian Hyperstimulation Syndrome Prevention Strategies: Cryopreservation of All Embryos

ABSTRACT

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic potentially life-threatening condition resulting from excessive ovarian stimulation. The crucial event in the development of OHSS is the administration of human chorionic gonadotropin (hCG). The early onset of OHSS typically presents in the luteal phase as a consequence of ovulatory hCG. The late onset of OHSS presents in early gestation when endogenous hCG further stimulates the ovary. Many strategies have been proposed for OHSS prevention, but they may reduce but not eliminate the risk. This article reviews the evidence related to the elective cryopreservation of all embryos and their subsequent transfer in women at risk of OHSS. More research is needed to determine whether using elective cryopreservation of embryos can reduce the rate of severe OHSS in in vitro insemination (IVF)/intracytoplasmic sperm injection (ICSI). Results from many retrospective studies are encouraging, but prevention in terms of (1) identification of the high-risk population using new biochemical markers of ovarian response such as anti-Müllerian hormone, (2) tailoring ovarian stimulation and using less aggressive protocols (gonadotropin-releasing hormone antagonists or mild IVF), and (3) blastocyst culture to allow clinical monitoring of early-onset OHSS, with eventual blastocyst cryopreservation, might represent a multistep approach worth further investigation.

KEYWORDS

OHSS - ovarian hyperstimulation syndrome - embryo freezing - cryopreservation - prevention

REFERENCES

• 1 Forman R G, Frydman R, Egan D, Ross C, Barlow D H. Severe ovarian hyperstimulation syndrome using agonists of gonadotropin-releasing hormone for in vitro fertilization: a European series and a proposal for prevention.  Fertil Steril. 1990;  53(3) 502-509
• 2 Navot D, Bergh P A, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment.  Fertil Steril. 1992;  58(2) 249-261
• 3 Rabau E, David A, Serr D M, Mashiach S, Lunenfeld B. Human menopausal gonadotropins for anovulation and sterility. Results of 7 years of treatment.  Am J Obstet Gynecol. 1967;  98(1) 92-98
• 4 Schenker J G, Weinstein D. Ovarian hyperstimulation syndrome: a current survey.  Fertil Steril. 1978;  30(3) 255-268
• 5 Golan A, Ron-el R, Herman A, Soffer Y, Weinraub Z, Caspi E. Ovarian hyperstimulation syndrome: an update review.  Obstet Gynecol Surv. 1989;  44(6) 430-440
• 6 Lyons C A, Wheeler C A, Frishman G N, Hackett R J, Seifer D B, Haning Jr R V. Early and late presentation of the ovarian hyperstimulation syndrome: two distinct entities with different risk factors.  Hum Reprod. 1994;  9(5) 792-799
• 7 Sher G, Salem R, Feinman M, Dodge S, Zouves C, Knutzen V. Eliminating the risk of life-endangering complications following overstimulation with menotropin fertility agents: a report on women undergoing in vitro fertilization and embryo transfer.  Obstet Gynecol. 1993;  81(6) 1009-1011
• 8 Egbase P E, Sharhan M A, Grudzinskas J G. Early unilateral follicular aspiration compared with coasting for the prevention of severe ovarian hyperstimulation syndrome: a prospective randomized study.  Hum Reprod. 1999;  14(6) 1421-1425
• 9 Araujo Jr E, Bernardini L, Frederick J L, Asch R H, Balmaceda J P. Prospective randomized comparison of human chorionic gonadotropin versus intramuscular progesterone for luteal-phase support in assisted reproduction.  J Assist Reprod Genet. 1994;  11(2) 74-78
• 10 Gonen Y, Balakier H, Powell W, Casper R F. Use of gonadotropin-releasing hormone agonist to trigger follicular maturation for in vitro fertilization.  J Clin Endocrinol Metab. 1990;  71(4) 918-922
• 11 Kinget K, Nijs M, Cox A M et al. A novel approach for patients at risk for ovarian hyperstimulation syndrome: elective transfer of a single zona-free blastocyst on day 5.  Reprod Biomed Online. 2002;  4(1) 51-55
• 12 Ata B, Yakin K, Alatas C, Urman B. Dual renin-angiotensin blockage and total embryo cryopreservation is not a risk-free strategy in patients at high risk for ovarian hyperstimulation syndrome.  Fertil Steril. 2008;  90(3) 531-536
• 13 Amso N N, Ahuja K K, Morris N, Shaw R W. The management of predicted ovarian hyperstimulation involving gonadotropin-releasing hormone analog with elective cryopreservation of all pre-embryos.  Fertil Steril. 1990;  53(6) 1087-1090
• 14 Awonuga A O, Pittrof R J, Zaidi J, Dean N, Jacobs H S, Tan S L. Elective cryopreservation of all embryos in women at risk of developing ovarian hyperstimulation syndrome may not prevent the condition but reduces the live birth rate.  J Assist Reprod Genet. 1996;  13(5) 401-406
• 15 Fitzmaurice G J, Boylan C, McClure N. Are pregnancy rates compromised following embryo freezing to prevent OHSS?.  Ulster Med J. 2008;  77(3) 164-167
• 16 D'Angelo A, Amso N N. Embryo freezing for preventing ovarian hyperstimulation syndrome.  Cochrane Database Syst Rev. 2007;  (3) CD002806
• 17 Shaker A G, Zosmer A, Dean N, Bekir J S, Jacobs H S, Tan S L. Comparison of intravenous albumin and transfer of fresh embryos with cryopreservation of all embryos for subsequent transfer in prevention of ovarian hyperstimulation syndrome.  Fertil Steril. 1996;  65(5) 992-996
• 18 Ferraretti A P, Gianaroli L, Magli C, Fortini D, Selman H A, Feliciani E. Elective cryopreservation of all pronucleate embryos in women at risk of ovarian hyperstimulation syndrome: efficiency and safety.  Hum Reprod. 1999;  14(6) 1457-1460
• 19 Aboulghar M, Evers J H, Al-Inany H. Intra-venous albumin for preventing severe ovarian hyperstimulation syndrome.  Cochrane Database Syst Rev. 1999;  (4)
• 20 Granne I, Child T, Hartshorne G. Embryo cryopreservation: evidence for practice.  Hum Fertil (Camb). 2008;  11(3) 159-172
• 21 Eftekhari-Yazdi P, Valojerdi M R, Ashtiani S K, Eslaminejad M B, Karimian L. Effect of fragment removal on blastocyst formation and quality of human embryos.  Reprod Biomed Online. 2006;  13(6) 823-832
• 22 Lewis S E, West M C, Fleming R. Sperm and embryo cryopreservation practice in licensed clinics in the UK endorsed by The British Fertility Society.  Hum Fertil (Camb). 2006;  9(1) 15-26
• 23 Menezo Y. Cryopreservation of IVF embryos: which stage?.  Eur J Obstet Gynecol Reprod Biol. 2004;  113(Suppl 1) S28-S32
• 24 Hoover L, Baker A, Check J H, Lurie D, Summers D. Clinical outcome of cryopreserved human pronuclear stage embryos resulting from intracytoplasmic sperm injection.  Fertil Steril. 1997;  67(4) 621-624
• 25 Oatway C, Gunby J, Daya S. Day three versus day two embryo transfer following in vitro fertilization or intracytoplasmic sperm injection.  Cochrane Database Syst Rev. 2004;  (2) CD004378
• 26 Gardner D K. Development of serum-free media for the culture and transfer of human blastocysts.  Hum Reprod. 1998;  13(Suppl 4) 218-225
• 27 Hartshorne G M, Elder K, Crow J, Dyson H, Edwards R G. The influence of in-vitro development upon post-thaw survival and implantation of cryopreserved human blastocysts.  Hum Reprod. 1991;  6(1) 136-141
• 28 Veeck L L, Bodine R, Clarke R N et al. High pregnancy rates can be achieved after freezing and thawing human blastocysts.  Fertil Steril. 2004;  82(5) 1418-1427
• 29 Fuller B, Paynter S. Fundamentals of cryobiology in reproductive medicine.  Reprod Biomed Online. 2004;  9(6) 680-691
• 30 Blake D, Proctor M, Johnson N, Olive D. Cleavage stage versus blastocyst stage embryo transfer in assisted conception.  Cochrane Database Syst Rev. 2005;  (4) CD002118
• 31 Selman H, Brusco G F, Fiorini F, Barnocchi N, Mariani M, El-Danasouri I. Vitrification is a highly efficient method to cryopreserve human embryos in in vitro fertilization patients at high risk of developing ovarian hyperstimulation syndrome.  Fertil Steril. 2009;  91(4, Suppl) 1611-1613
• 32 Wennerholm U B, Hamberger L, Nilsson L, Wennergren M, Wikland M, Bergh C. Obstetric and perinatal outcome of children conceived from cryopreserved embryos.  Hum Reprod. 1997;  12(8) 1819-1825
• 33 Al-Inany H G, Abu-Seta A M, Aboulgher M. Gonadotrpophin-releasing hromone antoagonists for assisted conception.  Cochran Database of Systematic Review. 2006;  issue 3