From the Guidelines
The risk of Ovarian Hyperstimulation Syndrome (OHSS) is extremely high with an estrogen level of 23,000 and 20 follicles retrieved, necessitating immediate preventive measures to mitigate this risk. These values significantly exceed the typical risk thresholds for OHSS, which include estradiol levels above 3,500-4,000 pg/mL and more than 15-20 follicles 1. According to the evidence, preventive measures such as withholding IUI when more than two dominant follicles >15 mm or more than five follicles >10 mm at the time of HCG injection or LH surge are present can help prevent high rates of multiple gestation pregnancies and OHSS in IUI-OS cycles 2.
Key considerations for management include:
- Using a GnRH agonist trigger instead of hCG if not already administered
- Considering "freeze-all" of embryos to avoid pregnancy-related hormonal stimulation
- Initiating cabergoline 0.5mg daily for 8 days to reduce vascular permeability
- Aggressive hydration with electrolyte-balanced fluids rather than plain water
- Daily weight monitoring and abdominal girth measurement
- Close monitoring for symptoms like severe bloating, weight gain, decreased urination, and difficulty breathing over the next 7-10 days.
It is crucial to prioritize these preventive measures given the high risk of OHSS, as indicated by the elevated estrogen level and the large number of follicles retrieved, to minimize the risk of serious complications including blood clots, respiratory difficulties, and kidney problems.
From the Research
Ovarian Hyperstimulation Syndrome (OHSS) Risk
- The risk of OHSS is a concern in patients undergoing assisted reproductive technology (ART) treatment, particularly those with high estrogen levels and multiple follicles at retrieval 3, 4, 5, 6, 7.
- A study published in 2013 found that cabergoline and coasting are both effective in reducing the risk of OHSS, with no cases of OHSS reported in the cabergoline group 3.
- Another study from 2009 reported a case of moderate OHSS that was treated with high-dose cabergoline, resulting in rapid resolution of OHSS and a healthy live birth 4.
- The use of cabergoline has been shown to reduce the incidence of OHSS, particularly moderate OHSS, in high-risk women undergoing ART treatment 5, 6, 7.
Estrogen Level and Follicle Count
- An estrogen level of 23000 on trigger day and 20 follicles at retrieval indicate a high risk of OHSS 3, 5, 6, 7.
- Studies have shown that high estrogen levels and multiple follicles at retrieval are associated with an increased risk of OHSS 3, 5, 6, 7.
Cabergoline as a Preventive Measure
- Cabergoline has been shown to be effective in reducing the risk of OHSS, particularly when used as a preventive measure in high-risk women 3, 4, 5, 6, 7.
- A study published in 2012 found that prophylactic oral low-dose cabergoline was more effective and less costly than intravenous human albumin in preventing OHSS in high-risk patients 7.
- The use of cabergoline does not appear to affect pregnancy outcomes, such as clinical pregnancy rate and miscarriage rate 6.