Saturday, February 20, 2010

OHSS: Ovarian Hyperstimulation Syndrome and the PCOS Patient

On Wednesday, February 24th, at 6pm EST, I will be interviewed by Sasha Ottey on her radio show. The subject: "The Real Deal about PCOS and Your Fertility" Join us at
Prior to my blog radio interview, I would like to publish a question from last year regarding OHSS, ovarian hyperstimulation syndrome, in a PCOS patient. In this year's January cycle I had a patient with PCOS at my clinic who had undergone IVF last year at another clinic in the Bay Area. There she developed severe, life-threatening OHSS, was admitted to the hospital and stayed there for seven days. Needless to say, that cycle failed. She returned to the same clinic to do a frozen embryo transfer, which also failed. She then came to me. I put her on my standard protocol for PCO patients, low dose stimulation (Lupron/Ganerelix) and carefully monitored her. I'm proud to report that this patient had no adverse reactions and is now pregnant after only her first cycle with us.

Typically, signs and symptoms of OHSS appear within the first 10 days after a gonadotropin injection, when the ovarian blood vessels have an abnormal reaction to the hormone and begin to leak fluid. This fluid fills the follicles, swells the ovaries and sometimes moves into the abdomen in large amounts. Fewer than 2% of women develop the most severe form of OHSS.

Here is a link to the Mayo Clinic's informative website regarding OHSS, definition and symptoms .


Dear Dr. Ramirez,
First I would like to give you some background information. I have PCOS and have been undergoing infertility treatment for apx. 2 years. First, I tried using drugs like Clomid and Follistem. After about 1 1/2 yrs of it not working, we decided to go the route of IVF.

On June 23 I had my egg retrieval. They retrieved 15. After the retrieval they recommended not doing the transfer due to the risk of over stimulation (OHSS). I ended up being admitted to the hospital on June 29 with severe OHSS and on July 1, they drained a little over a liter of fluid. I was sent home on July 2. I had my period on July 5. I went back on July 7 and still had a little fluid around my lungs and my left ovary was still swollen. They were able to freeze 7 fertilized eggs. How long should I wait to do the transfer and can I develop OHSS again with the transfer?

Thanks! I am from Missouri.



It is unfortunate that you developed OHSS with this cycle. It should have been expected and could have been prevented. There are measures/protocols an RE can take to reduce the chances of developing OHSS such as "coasting" using "antagonist + Lupron to trigger" and lowering the dosage of stimulation.

The Lupron trigger has been used extensively and written about extensively in Europe. It is better than HCG with hyperstimulation because it has a shorter duration, reducing the chances of developing OHSS. I use it with my PCO patients who have a tendency to hyperstimulate and are at higher risk of OHSS. I only given one injection, not two. Lupron used daily or in the higher doses can certainly suppress the ovary. It works indirectly but has the same effect as the Ganerelix. In low doses, it mimics HCG and triggers ovulation. I love the Ganerelix-Lupron protocol.

I have not had a case of OHSS in over 10 years by taking these precautions. In any case, you should not do the transfer until your ovaries have returned to normal. Pregnancy can exacerbate the OHSS. Once this resolves then you can go through the frozen embryo transfer cycle. You will not undergo ovarian stimulation with an FET. Only the uterine lining needs to be prepared. For that reason, you are not at risk of OHSS.

Good luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program


  1. Dear Doctor,

    I am a 31 yr old patient about to go through my first IVF. I am terrified of OHSS risk involved. What can I do to minimize this risk? I have heard that with the Lupron trigger the lining of the uterus does not seem to be prepared as well as with the HCG? Is progesterone support doing anything to prevent OHSS? Do you think methylprednisolone could prevent OHSS?
    Thank you

  2. Hi,

    You should not be worried about OHSS because (1) the incidence is not that high (0.6-14%) and (2) it does not occur in everyone. There are certain patients that are at higher risk, namely PCOS patients. So in those patients, a competent IVF doc will take appropriate precautions to prevent this complication. (3)Now there are protocols that can be used to prevent the OHSS from occurring or worsening, such as the Antagonist/Lupron protocol. Lupron can only be used as a trigger if the antagonist is used to suppress the ovaries. It cannot be used with the long (Lupron) protocol. Progesterone and Medrol do nothing to prevent or treat OHSS.

    The bottom line is that you should not worry about OHSS and this should not be cause to prevent you from doing IVF. It is not that much of a risk (for instance, I have not had a case of OHSS for 7 years now since adopting the antagonist/lupron protocol).

  3. Hi there. I've been diagnosed with PCOS and i had a severe case of OHSS when i went through the IVF process a few years ago. Currently, we are going to proceed through IUI with donor sperm and my doctor suggests 100mg of clomid/serophene for 5 days. i'm concerned about hyperstimulating again. should i worry with this dosage?

    1. Hello. Clomid cannot cause OHSS because it is a very weak ovarian stimulation medication. In fact the most likely outcome is that your ovaries won't respond to this medication at all (in light of the fact that you are at a very low dose of medication.) One worry I have in reading your story is a worry that your doctor does not know what he/she is doing. Maybe you should see someone more competent.



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