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It comprises marked ovarian enlargement, high serum sex steroids, and an increase in vascular permeability, pleural and rarely in pericardial cavities. The following symptoms may be observed in severe cases of OHSS: abdominal pain, abdominal distensions, severe ovarian enlargement, weight gain, dyspnoea, oliguria and gastrointestinal symptoms including nausea, vomiting and diarrhoea, dbol legal in us. Clinical examination may reveal hypovolaemia, haemoconcentation, electrolyte imbalances, ascites, haemoperitoneum, pleural effusions, hydrothorax, acute pulmonary distress and thromboembolic events. Excessive ovarian response to gonadotrophin treatment seldom gives rise to OHSS unless hCG is administered to trigger ovulation. Therefore in cases of OHSS it is prudent to withhold hCG and to advise the patient to refrain from coitus or to use barrier methods for at least four days. OHSS may progress rapidly (within 24 hours to several days) to become a serious medical event, therefore patients should be followed for at least two weeks after hCG administration. To minimize the risk of OHSS or of multiple pregnancy, ultrasound scans as well as oestradiol measurements are recommended. In anovulation the risk of OHSS and multiple pregnancy is increased by a serum oestradiol >900 pg/ml (3300pmol/L) and more than 3 follicles of 14 mm or more in diameter. In ART there is an increased risk of OHSS with a serum oestradiol > 3000 pg/ml (11000 pmol/L) and 20 or more follicles of 12 mm or more in diameter. When the oestradiol level is > 5500 pg/ml (20200 pmol/L) and where there are 40 or more follicles in total, it may be necessary to withhold hCG administration. Adherence to recommended Merional dosage, regimen of administration and careful monitoring of therapy will minimise the incidence of ovarian hyperstimulation and multiple pregnancy (see sections 4. In ART, aspiration of all follicles prior to ovulation may reduce the occurrence of hyperstimulation. OHSS may be more severe and more protracted if pregnancy occurs. Most often OHSS occurs after hormonal treatment has been discontinued and reaches its maximum at about 7-10 days following treatment. Usually, OHSS resolves spontaneously with the onset of menses. If severe OHSS occurs, gonadotrophin treatment should be stopped if still ongoing, the patient hospitalised and specific therapy for OHSS started. This syndrome occurs with higher incidence in patients with polycystic ovarian disease. Multiple pregnancy, especially high order, carries an increased risk of adverse maternal and perinatal outcomes. In patients undergoing ovulation induction with Merional the incidence of multiple pregnancies is increased as compared with natural conception. To minimize the risk of multiple pregnancy, careful monitoring of ovarian response is recommended. In patients undergoing ART procedures the risk of multiple pregnancy is related mainly to the number of embryos replaced, their quality and the patient’s age. The patient should be advised of the potential risk of multiple births before starting treatment. The incidence of pregnancy wastage by miscarriage or abortion is higher in patients undergoing stimulation of follicular growth for ovulation induction or ART than in the normal population. Women with a history of tubal disease are at risk of ectopic pregnancy, whether the pregnancy is obtained by spontaneous conception or with fertility treatments. The prevalence of ectopic pregnancy after IVF is reported to 2-5% as compared to 1-1.
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