N. Rollene

Treatment of ovarian hyperstimulation syndrome using a dopamine agonist and gonadotropin releasing hormone antagonist: a case series

OBJECTIVE To describe an outpatient treatment protocol for ovarian hyperstimulation syndrome (OHSS) that results in rapid normalization of symptoms with minimal side effects. DESIGN Case series. SETTING Midwestern academic reproductive endocrinology division. PATIENT(S) Four consecutive patients, diagnosed with OHSS, who presented after oocyte retrieval but before embryo transfer. INTERVENTION(S) All embryos were frozen and each patient was treated with the same dopamine agonist and GnRH antagonist protocol. MAIN OUTCOME MEASURE(S) Daily weights, days to resolution of clinical symptoms, side effects of the treatment protocol, and whether or not acute care or hospitalization was necessary. RESULT(S) The most rapid weight loss was within the first 5 days of treatment. The average time to resolution of clinical symptoms was 5.75 days. No side effects were reported and no patients required acute care or hospitalization. CONCLUSION(S) Dopamine agonists and GnRH antagonists, when given together at the time of diagnosis of OHSS, appear to work rapidly and effectively to diminish the clinical symptoms of the disease. The potential benefit of finding an outpatient treatment for OHSS with rapid onset and minimal side effects warrants further investigation into this protocol.

Recurrent ovarian torsion in a premenarchal adolescent girl: contemporary surgical management.

BACKGROUND: Recurrent ovarian torsion in a premenarchal adolescent girl is a rare event. Several methods of prevention using surgical plication have been proposed, which require varying degrees of technical expertise and can result in altered reproductive anatomy. CASE: A premenarchal adolescent girl presented with a history of salpingo-oophorectomy for torsion and recurrence treated by detorsion. She was evaluated for preventive strategies and underwent a laparoscopic oophoropexy, performed using transvaginal ultrasound guidance, to facilitate access should oocyte retrieval be indicated for future fertility. CONCLUSION: Recurrent ovarian torsion is an uncommon event, but given the possibility of permanent sterility, oophoropexy should be discussed. As assisted reproductive technology procedures become more common, oophoropexy designed to aid ovarian access should be considered before surgical intervention.

Short-Term Estradiol Supplementation Potentiates Low-Dose Ghrelin Action in the Presence of GHRH or Somatostatin in Older Women

CONTEXT Ghrelin is a potent gastric-derived GH-releasing peptide. How ghrelin interacts with sex steroids, GHRH, and somatostatin (SS) is not known. OBJECTIVE Our objective was to test the hypotheses that ghrelins interactions with GHRH (synergistic) and SS (disinhibitory) are ghrelin dose-dependent and amplified by estrogen. SUBJECTS, SETTING, AND DESIGN: Healthy postmenopausal women were treated with placebo (n=12) or 17β-estradiol (E2) (n=12) at the Center for Translational Science Activities in a randomized double-blind prospective study. METHODS Ghrelin dose-dependence was assessed by nonlinear curve fitting of the relationship between deconvolved GH secretory-burst mass and 5 randomly ordered ghrelin doses (0, 0.03, 0.135, 0.6, and 2.7 μg/kg bolus iv) during saline, GHRH, and SS infusion. RESULTS Under placebo, neither GHRH nor SS altered the ED50 of ghrelin (range 0.64-0.67 μg/kg). Under E2 (median E2 88 pg/mL), the ED50 of ghrelin declined in the presence of GHRH to 0.52 μg/kg. In contrast, the efficacy of ghrelin rose markedly during GHRH vs saline exposure with and without E2: placebo and saline 52±1.0 vs GHRH 173±3.8 μg/L; and E2 and saline 56±0.90 vs GHRH 174±3.7 μg/L. Sensitivity to ghrelin was similar under all conditions. SUMMARY Short-term E2 supplementation in postmenopausal women reduces the ED50 (increases the potency) of ghrelin when GHRH is present, without altering ghrelin efficacy (maximal effect) or hypothalamo-pituitary sensitivity (slope of dose response) to ghrelin. The data suggest possible physiological interactions among sex steroids (endogenous), ghrelin, and GHRH during E2 replacement in postmenopausal women.

Estradiol regulates GH-releasing peptide's interactions with GH-releasing hormone and somatostatin in postmenopausal women

OBJECTIVE Estrogen stimulates pulsatile secretion of GH, via mechanisms that are largely unknown. An untested hypothesis is that estradiol (E₂) drives GH secretion by amplifying interactions among GH-releasing hormone (GHRH), somatostatin (SS), and GH-releasing peptide (GHRP). DESIGN The design comprised double-blind randomized prospective administration of transdermal E₂ vs placebo to healthy postmenopausal women (n=24) followed by pulsatile GHRH or SS infusions for 13 h overnight with or without continuous GHRP2 stimulation. METHODS End points were mean concentrations, deconvolved secretion, and approximate entropy (ApEn; a regularity measure) of GH. RESULTS By generalized ANOVA models, it was observed that E₂ vs placebo supplementation: i) augmented mean (13-h) GH concentrations (P=0.023), GHRH-induced pulsatile GH secretion over the first 3 h (P=0.0085) and pulsatile GH secretion over the next 10 h (P=0.054); ii) increased GHRP-modulated (P=0.022) and SS-modulated (P<0.001) GH ApEn; and iii) did not amplify GHRH/GHRP synergy during pulsatile GH secretion. By linear regression, E₂ concentrations were found to be positively correlated with GH secretion during GHRP2 infusion (P=0.022), whereas BMI was found to be negatively correlated with GH secretion during GHRH (P=0.006) and combined GHRH/GHRP (P=0.015) stimulation. E₂ and BMI jointly determined triple (combined l-arginine, GHRH, and GHRP2) stimulation of GH secretion after saline (R²=0.44 and P=0.003) and pulsatile GHRH (R²=0.39 and P=0.013) infusions. CONCLUSION In summary, in postmenopausal women, E₂ supplementation augments the amount (mass) and alters the pattern (regularity) of GH secretion via interactions among GHRH, SS, GHRP, and BMI. These outcomes introduce a more complex model of E₂ supplementation in coordinating GH secretion in aging women.

Migraines and ovarian hyperstimulation syndrome: a dopamine connection

This case-control study shows a strong association between migraine history and development of ovarian hyperstimulation syndrome (OHSS). We hypothesize there may be a similar gene variant that predisposes women to both migraines and OHSS and identification will lead to optimal therapy, not only for OHSS, but also for women who suffer from migraines.

Gestational sac aspiration and instillation for treatment of early ectopic pregnancy.

We thank Cepni et al. for sharing their recent case series, ‘‘An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by single-dose methotrexate administration’’ (1). This was of great interest to us, as we have used a similar aspiration and instillation technique using hyperosmolar glucose to treat a heterotopic pregnancy created after IVF.