Ob/Gyn Case Challenge: A 33-Year-Old Woman Trying to Conceive Has Dyspnea, Pain

Ziad R. Hubayter, MD, MPH


May 19, 2022


The clinical presentation of this patient was strongly suggestive of ovarian hyperstimulation syndrome (OHSS), a known complication of IVF. In this case, the severity of the symptoms, including the respiratory status, marked ascites (Figure 1), hyponatremia, and the large ovarian volume (Figure 2) indicated that this patient had severe OHSS.

Figure 1.

Figure 2.

Because 1 of every 6 couples face infertility issues and the demand for IVF may be on the rise owing to delayed childbearing (resulting from later age at marriage, divorce and remarriage, professional careers, and economic hardship), healthcare providers need to be familiar with this condition.

During a cycle of IVF, a woman receives gonadotropin stimulation for around 2 weeks until several follicles achieve a diameter larger than 18 mm. Once appropriately sized follicles develop, a dose of human chorionic gonadotropin (hCG) is administered to cause maturation of the oocytes before transvaginal oocyte retrieval. The hCG leads to luteinization of the large number of follicles.

In OHSS, the enlarged and luteinized ovaries produce a large amount of vascular endothelial growth factor (VEGF). VEGF is a vasoactive substance that may cause leaky capillary membranes. Subsequently, fluid shifts out of the intravascular space and into the lungs and peritoneum, causing pleural effusions, pulmonary edema, or ascites.[1,2]

The clinical symptoms of OHSS include bloating, nausea, vomiting, fatigue, shortness of breath, rapid weight gain, and decreased urine output. Third spacing may cause fluid to accumulate in the pleural and peritoneal spaces. The resulting decreased intravascular volume may cause hypotension, tachycardia, hemoconcentration, and decreased renal blood flow, resulting in renal failure, hyponatremia, and hyperkalemia.

Pelvic ultrasonography usually demonstrates ascites and bilaterally enlarged ovaries with multiple cysts. Ovarian torsion or rupture with internal bleeding may also occur. Other severe complications include hypovolemic shock, thromboembolic episode, acute respiratory distress syndrome, and, very rarely, death.[1,3]

Risk factors for OHSS include young age, low body weight, high serum estradiol concentrations, polycystic ovaries, higher doses of gonadotropins during ovarian stimulation, and a greater number of oocytes retrieved. The disease is self-limited and usually resolves within 1 week; however, if a patient becomes pregnant in the future, the endogenous production of hCG may lead to a recurrence of OHSS, which is then typically more severe than the previous incidence.[1,4]


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