Clinical Review ABC of subfertility

Assisted conception. III–Problems with assisted conception

BMJ 2003; 327 doi: (Published 16 October 2003) Cite this as: BMJ 2003;327:920
  1. Peter Braude,
  2. Paula Rowell, senior embryologist
  1. Guy's and St Thomas's assisted conception unit, London


    Problems associated with assisted conception can be clinical, ethical, or psychological. This article covers medical problems (such as ovarian hyperstimulation syndrome (OHSS) and ectopic pregnancy), ethical questions that arise from situations such as the creation of surplus embryos, and difficult decisions that have to be made, such as when to advise a couple to stop treatment.

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    Presentation of OHSS

    Ovarian hyperstimulation syndrome

    OHSS is arguably the most serious risk of treatment with gonadotrophins. It is not clear why OHSS occurs, although it is particularly severe with the use of gonadotrophin releasing hormone analogues and polycystic ovary syndrome. It generally develops if the patient has had an excessive response to gonadotrophins and has produced a large number (20 or more) follicles with its associatedexcessive rise in oestrogen production. OHSS occurs after exogenous human chorionic gonadotrophin has been administered, or when human chorionic gonadotrophin rises endogenously after a treatment cycle has been successful and an embryo has implanted.

    OHSS presents with substantial enlargement of the ovaries, which are filled with enlarging follicles (despite drainage at the time of egg collection) causing abdominal pain, distension, and extravascular fluid extravasation, which results in ascites and haemoconcentration. In the severest OHSS pleural effusions may develop and arterial or venous thromboses can occur because of hypercoagulability.

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    Management of OHSS

    Embedded Image

    Ultrasound scan showing an enlarged ovary (10 cm x 6 cm) and fluid in the pouch of Douglas and the uterovesical pouch

    Superovulation regimens should be designed and monitored to minimise OHSS. However, because of its idiosyncratic nature, the syndrome cannot be avoided completely. Indeed, it can occur simply by using clomifene to induce ovulation in sensitive patients, such as those with polycystic ovary syndrome. OHSS should be managed in a specialist hospital, preferably one with an in vitro fertilisation unit, where there will be the appropriate expertise to deal …

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