To the Editor:
I read the recent publication on ovarian hyperstimulation syndrome (OHSS) with great interest (1). The dopamine agonist bromocriptine and gonadotropin-releasing hormone agonist for the prevention of OHSS were mentioned (1,2). Indeed, there are many recent studies on how to prevent OHSS. Apart from using an agonist, there are also other concerns for management. The classification of the risk before the procedure (3) and the individualized adjustment of drug dosage (4) seem to be the two additional means for prevention of OHSS.
Viroj Wiwanitkit, M.D.
1. Spitzer D, Wogatzky J, Murtinger M, Zech MH, Haidbauer R, Zech NH. Dopamine agonist bromocriptine for the prevention of ovarian hyperstimulation syndrome. Fertil Steril. 2011 Mar 14. [Epub ahead of print]
2. Griesinger G, Schultz L, Bauer T, Broessner A, Frambach T, Kissler S. Ovarian hyperstimulation syndrome prevention by gonadotropin-releasing hormone agonist triggering of final oocyte maturation in a gonadotropin-releasing hormone antagonist protocol in combination with a “freeze-all” strategy: a prospective multicentric study. Fertil Steril. 2011 Mar 1. [Epub ahead of print]
3. Papanikolaou EG, Humaidan P, Polyzos NP, Tarlatzis B. Identification of the high-risk patient for ovarian hyperstimulation syndrome. Semin Reprod Med. 2010 Nov;28(6):458-62.
4. Olivennes F. Ovarian hyperstimulation syndrome prevention strategies: individualizing gonadotropin dose. Semin Reprod Med. 2010 Nov;28(6):463-7.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.04.017
The Authors Respond:
We very much appreciate Prof. Wiwanitkit’s comments.
Despite taking known risk factors into account when treating patients at risk for OHSS, it is still not always possible to prevent the occurrence of OHSS (1). In our study, the age of the women, body mass index, basal hormone status, and the antral follicle count were taken into consideration when assessing the risk for OHSS. On the basis of this information, we prepared individualized treatment plans comprising a dosage of gonadotropins necessary for the development of approximately 10 follicles. Our decision to use bromocriptine (Parlodel®, Pravidel®) was a result of the increased secondary risk of OHSS on the day of follicular puncture. We defined indications for its use as follows: ≥ 20 oocytes, or 4500 pg/ml, or symptoms of OHSS on the day of aspiration, grade 1-2 according to our modified OHSS staging (2).
There are several studies showing that cabergoline (Dostinex®, Cabersil®) or quinagolide (Norprolac®) reduces the incidence of OHSS (3-6). In our study, we tried to demonstrate, however, the efficacy of bromocriptine (Parlodel®, Pravidel®), whose advantages are its lower half-life and the greater clinical experience with it in pregnancy.
It is clear that, in addition to dopamine agonists, we could have discussed a number of other effective strategies for the prevention of OHSS (1). The focus of our work was, however, the comparison with other dopamine agonists. Admittedly, a limiting factor of our study is the additional use of other treatments, such as coasting and infusion therapy with NaCl or glucose in a subset of patients. Coasting or fluid infusions do not seem, however, to reduce the incidence of OHSS (1,7,8). Notably, in our study, 50% of patients at high risk did not develop OHSS. This initial series of treatments appears to show that bromocriptine is as effective as cabergoline.
Dietmar Spitzer, M.D.a
Nicolas H. Zech, M.D.b,c
aIVF Centers Prof. Zech, Salzburg, Austria
bIVF Centers Prof. Zech, Bregenz, Austria
cDepartment for Obstetrics and Gynecology
Unit of Gynecological Endocrinology and Reproductive Medicine
University of Graz
1. Humaidan P, Quartarolo J, Papanikolaou G. Preventing ovarian hyperstimulation syndrome: guidance for the clinician. Fertil Steril 2010;94:389-400.
2. Spitzer D, Wogatzky J, Murtinger M, Zech M, Haidbauer R, Zech NH. Dopamine agonist bromocriptine for the prevention of ovarian hyperstimulation syndrome. Fertil Steril 2011 Mar 14 [Epub ahead of print].
3. Busso C. Symposium: Update on prediction and management of OHSS. Prevention of OHSS – dopamine agonists. RBM Online 2009;19:43-51.
4. Soares S, Gomez R, Simon C, Garcia-Velasco J, Pellicer A. Targeting the vascular endothelial growth factor system to prevent ovarian hyperstimulation syndrome. Hum Reprod Update 2008;14:321-33.
5. Carizza C, Abdelmassih V, Abdelmassih S, Ravizzini P, Salgueiro L, Salgueiro TP, et al. Cabergoline reduces the early onset of ovarian hyperstimulaton syndrome: a prospective randomized study. RBM Online 2008;17:751-5.
6. Youssef M, van Wely M, Hassan MA, Al-Inany HG, Mochtar M, Khattab S, et al. Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A systematic review and meta-analysis. Hum Reprod Update 2010;16:459-66.
7. Kovács P, Mátyás S, Kaali SG. Effect of coasting on cycle outcome during in vitro fertilization/intracytoplasmic sperm injection cycles in hyper-responders. Fertil Steril 2006 5,4,913-7.
8. Venetis CA, Kolibianakis EM, Toulis KA, Goulis DG, Papadimas I, Tarlatzis BC. Intravenous albumin administration for the prevention of severe ovarian hyperstimulation syndrome: a systematic review and metaanalysis. Fertil Steril 2011, 95,1,188-96.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.04.018