Gonadotrophin-releasing hormone agonist trigger and freeze-all strategy does not prevent severe ovarian hyperstimulation syndrome: a report of three cases

Ovarian hyperstimulation syndrome after gonadotropin-releasing hormone agonist triggering and “freeze-all”: in-depth analysis of genetic predisposition

“…Since 2014, an increasing amount of clinicians have reported on cases of severe (grade 4 or 5) early-onset OHSS following a Bfreeze-all^protocol. These cases have come from all over the globe, including India, the United Arab Emirates [19], Singapore [17], Turkey [18], and now Belgium. In all instances, the patients were administered total doses of exogenous FSH within the normal ranges that one could expect for ovarian stimulation during a conventional IVF treatment (between 775 and 2025 IU).…”

“…In a GnRH antagonist co-treated cycle, the GnRH agonist causes the displacement of the GnRH antagonist from the pituitary receptors, resulting in a LH flare-up/Bsurget hat lasts for approximately 24-36 h [7]. This approach, combined with the elective cryopreservation of all oocytes/embryos, referred to by some as the BOHSS-free clinic^ [14], had effectively abolished the incidence of severe early OHSS [14,15,10] until recently, when the first cases of OHSS requiring hospitalization were reported [16][17][18][19]. These cases include both patients with either grade 4 (3 cases) and grade 5 (4 patients) severe early-onset OHSS according to the OHSS classification proposed by Golan et al [adopted by the European Society of Human Reproduction and Embryology (ESHRE)] [20].…”

Does freeze all policy eliminate OHSS??? “It ain’t necessarily so…”

“…The main problem with the policy of using this approach is an incorrect sense of security, believing that indeed this policy has completely eliminated the risk of severe OHSS. However, it has not, as suggested by the five recent publications, including the present [1,[3][4][5][6], of OHSS necessitating hospitalization, despite GnRH agonist triggering instead of hCG. Retrospective evaluation of the patient's characteristics could have led to an appreciation of very high risk of OHSS due to PCOS, very high AMH of 18.28 ng/mL, and an antral follicle count of 40.…”

Current Medical Strategies in the Prevention of Ovarian Hyperstimulation Syndrome

“…GnRH agonist triggering is a valid alternative to hCG triggering, resulting in elimination of OHSS and no other pre vention strategy comes close to this result 25 . However, several anecdotal cases of severe OHSS, even after GnRH agonist triggering combined with freezing all embryos in GnRH antagonist cycles have been published and in these cases of extreme hyper-responders other prevention strategies should be considered 26,27 . Th erefore, clinicians should be aware that severe early OHSS could rarely occur even after GnRH agonist trigger instead of hCG, despite the fact that induction of fi nal oocyte maturation with GnRH agonist signifi cantly reduces the risk of OHSS.…”