Knowledge of the mechanisms of single dominant follicle selection has led to the development of a novel and effective ovulation induction regimen for anovulatory women; the step down protocol. This commences with a fixed high gonadotropin dose followed by several decremental steps. For some patients the initial dose is too high, risking ovarian hyperstimulation syndrome. A major improvement to this approach would, therefore, be the ability to use initial screening characteristics to assess the individual FSH threshold beforehand. For IVF treatment, interfering in the process of single dominant follicle selection in ovulatory women by late follicular phase administration of low doses of FSH may result in a significantly reduced duration of stimulation and amounts of exogenous FSH preparations used. Less monitoring would be required and chances for short-term complications or long term risks may be reduced.
"Moreover, it occurs in a serious life-threatening form in 0.1–2% of assisted reproductive treatment cycles (Wheelan and Vlahos, 2000). We have tried several methods for the prevention of OHSS (Aboulghar and Mansour, 2003) such as minimizing the dose of HMG (Golan et al., 1988; Macklon and Fauser, 2000; El-Sheikh et al., 2001), reducing the dose of HCG for triggering ovulation (Abdalla et al., 1987) and giving intravenous albumin (Asch et al., 1993); however, complete prevention was never achieved. In 1995, we adopted the protocol of coasting (Sher et al., 1993, 1995) in our assisted reproductive technology programme and achieved a considerable reduction in the incidence of OHSS (Aboulghar et al., 2000). "
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to report a large series of patients (n = 1223) at risk of developing ovarian hyperstimulation syndrome (OHSS) who underwent coasting.
Coasting started when the leading follicle reached 16 mm and continued until the estradiol (E2) level fell to 3000 pg/ml.
The E2 level at the start of coasting was (mean +/ SD) 6408 +/- 446 and it fell to 2755 +/- 650 on the day of HCG injection, after (mean +/- SD) 2.89 +/- 0.94 days. The results were analysed according to the duration of coasting (< or = 3 days, group I: n = 983; >3 days, group II: n = 240). The number of oocytes retrieved was (mean SD) 16.45 +/- 6.25 and 14.93 +/- 6.01 in groups I and II respectively (P < 0.05). The fertilization rates were 63 and 65% in groups I and II respectively (P > 0.05). The implantation and clinical pregnancy rates were 26 and 52% in group I compared to 18 and 36% in group II respectively (P < 0.05). Severe OHSS occurred in 16 cases, which represented 0.13% of all stimulated cycles, and 1.3% of patients who were at risk of developing OHSS.
Our protocol of coasting was an effective measure in the prevention of OHSS, without jeopardizing the ICSI outcome. Coasting for >3 days is associated with a moderate decrease in the pregnancy rate.
Human Reproduction 12/2005; 20(11):3167-72. DOI:10.1093/humrep/dei180 · 4.57 Impact Factor
"However, even after increasing the gonadotrophin dose a total lack of ovarian response may occur (particularly in obese women) as the threshold for ovarian follicular development is not exceeded, and in these cases the starting dose in future cycles could be increased (Homburg and Insler, 2002). The step-down protocol is also associated with a low risk of OHSS (Macklon and Fauser, 2000). "
[Show abstract][Hide abstract] ABSTRACT: The aim of this review was to summarize previously published classifications for ovarian hyperstimulation syndrome (OHSS), as well as to analyse the available methods for preventing OHSS. Withholding hCG and cycle cancellation--once the main methods of preventing OHSS--are now seldom used. There is a growing body of evidence to support the use of coasting to prevent OHSS, without cycle cancellation. However, most studies on coasting are retrospective, and well-designed prospective randomized studies are lacking. There is no current consensus as to how coasting should be carried out. A serum estradiol level of 3000 pg/ml is generally considered optimum for administration of hCG. It appears that intravenous albumin or hydroxyethyl starch at the time of oocyte retrieval is beneficial in preventing OHSS, but does not offer complete protection. There is insufficient evidence to support routine cryopreservation of all embryos for the later transfer of frozen-thawed embryos in high-risk patients. Several uncontrolled studies have reported the protective effect of GnRH agonist to trigger ovulation in preventing OHSS, though the method is applicable solely for gonadotrophin-only or GnRH antagonist cycles. A single dose of recombinant LH to trigger ovulation significantly reduced OHSS as compared with hCG. The possible role of GnRH antagonist protocols in reducing the incidence of OHSS is debatable. The above measures to prevent OHSS were successful in reducing the incidence of the syndrome, but complete prevention is not as yet possible.
Human Reproduction Update 05/2003; 9(3):275-89. DOI:10.1093/humupd/dmg018 · 10.17 Impact Factor
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