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I feel bloated—ovarian hyperstimulation syndromes (OHSS)

Ms. Helen started appointments with me since last year. She has been married for two years without preventing pregnancy, but still no good news released. By several examinations, I found that she has some features of polycystic ovarian syndromes.

Compared to the average age of entire IVF cases, Helen was still young, and she would not like to jump into the assisted reproduction technology too fast. Hence she tried clomiphene citrate several times in timed sexual intercourse (TSI) program. Unfortunately, it did not work. For some cases, clomiphene citrate could have adverse effect on the endometrial thickness, and thus the embryo implantation may fail. Concerning this point, we discussed about the mild stimulation injections (recombinant rFSH) in intrauterine insemination program.

As expected, the response of Helen's ovaries to the injections was good. With lower dosage, both the size of follicles and blood estrodial level were steadily increased. Since higher risk of ovarian hyperstimulation syndromes (OHSS) in the IUI cases was well known, I used the GnRH agonist to trigger and gave a complete consultation to Helen and her husband before the insemination. 

Three days after insemination, Helen came back to the clinic and felt very uncomfortable. Her belly seemed obviously bloated. Through abdominal ultrasound observation, the image showed that around 2000ml of ascites accumulated there. I arranged the laparocentesis to drainage the fluid and appropriate albumin/electrolyte supplements through intravenous infusion. Sooner after, her bloating symptom was relieved. Another three days later, I saw Helen's belly accumulated 2000ml of ascites again, and she underwent the similar treatment. In the last three weeks, repeated bloated and laparocenteses filled in Helen's daily life. And also, we found that Helen got twins in her uterus. 

Helen is a typical type of OHSS.
The actual mechanism of OHSS remains unclear. Generally, it was believed to the consequence of interactions among progesterone, estrodial, beta-HCG, and vascular endothelial growth factor (VEGF). Increased concentration of the above hormones induces elevated vascular permeability. Both the fluid and related contents (albumin, electrolytes) flow out of the vessels, and then accumulate at the chest, abdomen, or lymphatic system. Thus a serial of symptoms is derived.

Common signs of OHSS include abdominal bloating, nausea, decreased urine output, and so on. According to the size of enlarged ovaries and the volume of ascites, it can be categorized as follows,

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