Severe ovarian hyperstimulation syndrome with GnRH agonist trigger during the COVID pandemic: lessons learned from an unusual case

Bradley S Hurst, Evan A. Schrader, Tanner Hurley, Lariena Welch, Y. Ying, A. Eskew
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Abstract

Background: Injectable gonadotropins stimulate multi-follicular recruitment and allows retrieval of multiple oocytes for assisted reproduction. The widespread utilization of gonadotropin releasing hormone agonist (GnRHa) to induce oocyte maturation for oocyte retrieval has nearly eliminated the risk of severe ovarian hyperstimulation syndrome (OHSS), and only a few cases have been reported in the literature. The rarity of severe OHSS may lead to the mistaken conclusion that gonadotropin stimulation can be safely administered with limited monitoring, even in high-risk patients. We present an unusual case of a woman with limited monitoring due to the COVID pandemic who developed severe OHSS before GnRH agonist trigger and oocyte. Case Presentation: A 29-year-old nulliparous woman with polycystic ovarian syndrome (PCOS) initiated ovarian stimulation for oocyte retrieval. She had a robust initial response, and developed worsening abdominal pain, bloating, nausea, vomiting, and decreased appetite before retrieval. GnRH agonist was given to “trigger ovulation and retrieval scheduled due to the low reported incidence of severe OHSS. Symptoms progressed, and on the morning of retrieval, ultrasound demonstrated bilaterally enlarged ovaries >10cm and 48 oocytes were retrieved for a planned cryo-all cycle. She was hospitalized on the day of retrieval for severe OHSS and had two large-volume paracenteses. She was stable and discharged home by day 5, and symptoms markedly improved with the onset of menses. She has an ongoing pregnancy from her first frozen embryo transfer. Conclusion: We add a rare case of severe OHSS with a GnRHa trigger and cryo-all protocol with the onset of symptoms before GnRH agonist administration. Although rare, severe OHSS may still occur with a GnRHa trigger, and caution is needed when an initial robust response is identified. Here we also provide an opportunity to review the important patient risk factors for the development of OHSS and measures to reduce the risk in excessive responders.
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COVID大流行期间GnRH激动剂引发的严重卵巢过度刺激综合征:从一个不寻常病例中吸取的教训
背景:可注射的促性腺激素刺激多卵泡募集,并允许多个卵母细胞用于辅助生殖。广泛应用促性腺激素释放激素激动剂(GnRHa)诱导卵母细胞成熟以获取卵母细胞,几乎消除了严重卵巢过度刺激综合征(OHSS)的风险,文献中仅有少数病例报道。严重卵巢过度刺激症的罕见性可能导致一个错误的结论,即即使在高风险患者中,也可以在有限的监测下安全地给予促性腺激素刺激。我们提出了一个不寻常的病例,一名妇女由于COVID大流行而监测有限,在GnRH激动剂触发和卵母细胞之前发生了严重的OHSS。病例介绍:一名29岁的未生育女性,患有多囊卵巢综合征(PCOS),开始卵巢刺激以获取卵母细胞。患者最初反应强烈,但在取药前腹痛、腹胀、恶心、呕吐和食欲下降加剧。由于严重OHSS的发生率较低,GnRH激动剂被用于“触发排卵和恢复计划”。症状逐渐加重,在取卵的早晨,超声显示双侧卵巢增大>10cm,取卵48个卵母细胞进行计划的全冷冻周期。她因严重OHSS入院,并有两个大容量的输卵管。患者病情稳定,第5天出院,症状随月经开始明显改善。第一次冷冻胚胎移植后,她一直在怀孕。结论:我们增加了一例罕见的GnRH触发和cro -all方案的严重OHSS,在GnRH激动剂使用前出现症状。虽然罕见,但严重的OHSS仍可能在GnRHa触发下发生,当确定最初的强烈反应时,需要谨慎。在这里,我们也提供了一个机会来回顾OHSS发展的重要患者风险因素和减少过度反应者风险的措施。
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