Poor response
Sometimes despite our best efforts the ovaries respond very poorly or not at all to the FSH injections and a difficult decision has to be made about stopping the treatment cycle.
Often this is not unexpected as you may have been warned that your ovarian reserve was low and that we were concerned that you would not respond to the injections.
Sometimes however we are surprised when even with a predicted good response the ovaries do not behave as expected. We know that this is difficult and upsetting news to receive.
Some women will have the opportunity to try again with an increased dose of FSH injections but for those women already on the maximum dose there is nothing more we can do to make the ovaries respond in a better way. If this happens to you we will explain the scan results in detail and talk about your options.
We may ask you to go away and think about the advice we are giving then return to the outpatient clinic at a later date to discuss things further.
Ovarian hyperstimulation syndrome
A small number of women who are having treatment to stimulate the ovaries will develop a problem called “Ovarian Hyperstimulation Syndrome” (OHSS).
Overall it affects only about 2% of women, but we will tell you if you are at higher risk. Detailed below are some specific answers to the questions you might ask.
What is ovarian hyperstimulation syndrome?
It is a combination of symptoms including enlargement of the ovaries, swelling and discomfort in the abdomen. Often it is associated with nausea and vomiting. Although we know that it is caused by the drugs we give you to simulate the ovaries, we do not know why only a small number of women develop these problems.
When will I start getting symptoms?
The usual time to start getting problems is a few days after the trigger injection and commonly after egg collection.
When will I get better?
If you are not pregnant, the symptoms will usually resolve when you have your period. If you are pregnant, you may continue having problems until about the second month of the pregnancy. It will then resolve completely. Occassionally, it can last longer than that.
Does it affect my chances of pregnancy?
This problem will have no effect on your chances of pregnancy. In fact some studies suggest that women who have this problem have a higher chance of pregnancy.
What treatment is given?
If the problem becomes severe, you may need to come into hospital. Often we simply need to give you rest and mild painkillers. Specific treatment depends on your symptoms and may include daily blood tests, an intravenous drip to stop you becoming dehydrated and injections to thin your blood and prevent blood clots.
If you collect a lot of fluid in your abdomen, it may cause you to feel very uncomfortable and under these circumstances we may drain the fluid away using a fine needle.
What do I do if I feel unwell?
You will most likely develop some of the symptoms described above and it may be difficult for you to know whether to be worried. Please ensure you keep yourself well hydrated by drinking to thirst and are passing good amount of urine. We need to know if you are concerned about abdominal discomfort, start vomiting or are unable to drink anything.
Where can I get further information regarding OHSS?
Please visit the following reliable web resources from the HFEA, RCOG and BFS .
Some women may be at higher risk of developing OHSS as they have a high ovarian reserve or have had OHSS before and it is for this reason that they are placed on the antagonist protocol.
Why use the antagonist protocol?
The antagonist protocol has been shown to reduce ovarian hyper stimulation syndrome (OHSS), but it doesn’t remove the risk altogether. One advantage of the antagonist protocol is the option of using an agonist trigger.
Agonist trigger
Normally, in an IVF cycle, we use a hormone called HCG to trigger egg maturation before egg collection. However, HCG has been shown to be the main driver of OHSS.
Using an agonist trigger further reduces the risk of OHSS, but, pregnancy rates are lower with the agonist trigger compared with HCG.
If you are considered to be at very high risk of developing severe OHSS, the doctor may advise you to use an agonist trigger for egg maturation. To give the highest chance of success, all good quality embryos would be frozen. A frozen embryo transfer cycle has no risk of OHSS.
Plans for women who have an agonist trigger.
- Freeze all good quality embryos and not have a fresh transfer.
- To reduce the risk of OHSS
- Improve overall pregnancy rates compared to a fresh transfer.
- Replace embryos if none are suitable for freezing.
- If no embryos are suitable for freezing, they could still be transferred, although lower pregnancy rates.
- Accept some risk of developing OHSS.
Women who have an agonist trigger will still start Cyclogest pessaries, to enable an embryo transfer if embryos are not suitable for freezing. Nonetheless, Plan A is to freeze all embryos and replace them in a future frozen embryo transfer treatment cycle. This decision will be guided by how well your embryos develop over the days after egg collection.
Will the baby be normal?
This is a question that all parents ask during a pregnancy.
If you conceive naturally there will be a 3-5% chance of having a baby with congenital abnormality. This increases to 4-7% if you have a baby after IVF/ICSI but the absolute risk still remains low.
Many babies have now been born after being conceived by ICSI and there is no conclusive evidence that they have a higher rate of abnormality than IVF children. The oldest individuals conceived by IVF or ICSI are not yet into middle age so there will still be ongoing studies that you may hear about in the future.
