Ep 311: What Is Ovarian Hyperstimulation Syndrome: Exploring OHSS

  Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. What is ovarian hyperstimulation syndrome (OHSS)? OHSS is a condition that can occur after ovarian stimulation, most often during IVF cycles, when the ovaries respond excessively to fertility medications. Who is at highest risk for OHSS? Patients at increased risk include women with a high egg count, younger patients, and patients with PCOS (polycystic ovary syndrome). Does pregnancy increase the risk of OHSS? Yes; a fresh embryo transfer can increase the risk because the pregnancy hormone (hCG) may worsen or prolong OHSS symptoms. How has the risk of OHSS decreased in modern IVF treatment? The use of GnRH agonist (Lupron) trigger shots has dramatically reduced the risk by quickly lowering estrogen levels and preventing severe symptoms. How is OHSS treated? Treatment focuses on symptom management; medications such as cabergoline (Dostinex) and letrozole may be used to lower estrogen levels and shorten symptom duration. When should patients call their doctor about OHSS symptoms? Patients should call immediately if they experience low urine output, an inability to drink fluids, severe abdominal pain, shortness of breath, or pain or swelling in the arms or legs. Why is it important to call your doctor if you are concerned? OHSS can be serious, and early evaluation and treatment are critical. Patients should always contact their doctor if they are worried about symptoms. This podcast was sponsored by U.S. Fertility. 

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Carrie Bedient MD (00:22)

Hello and welcome to another episode of Fertility Docs Uncensored. I am joined by my two fantastically gorgeous, hilarious, and insightful co-hosts Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center. How are you girls doing?

Abby  Eblen, MD (00:36)

Hi everybody.

Susan Hudson MD (00:40)

Hello, everyone.

Abby  Eblen, MD (00:43)

What are you been up to?

Carrie Bedient MD (00:47)

We have had house guests recently.

And so There is about 10 of us at our house, 10 of us that were all staying in our house. And so There's a whole spread of ages and demographics and things like that. And I tend to be kind of the primary cook for various reasons, which is generally just fine because I'm overall well suited to that when I plan for it.

Once upon a time in another life, I would do a lot more hosting than I do currently. We have to do all these big dinners and feeding 10 people at the same time is not necessarily super easy. And so I'm like, okay, I'm going to do chicken parm one night, I'm going to do pork roast one night, and I'm going to do prime rib for the big night when we're all together. And so The chicken parm was fine, the pork roast was fine.

We get to the prime rib and I'm following the instructions that one of my friends has given me of this tried and true recipe that he has had forever and ever amen. He sends it to me and so I read it and I research it and I go to the butcher counter at the grocery store to go pick it up and they're like, no, we don't have that at all. And what did you say your name was and can you spell that? And so we went through that and fortunately, even though they had given mine away, chopped it up and sold it that morning.

They had another one available and so they just did whatever it is you have to do to a roast to be able to wrap it up and tie it off and give it to somebody. So We did that and so my blood pressure went up and went down and then we got to the next day and so I prepped it with a ton of butter and herbs and tied it up and had it pre-marinating, don't know, whatever it's called, dry rub, whatever it is,

the night before and I go to put it in the oven and it said two hours at this temperature for this weight and I'm like great. So I put it in like two and a half hours ahead of time so that we're gonna be able to eat right at six and then at nine o'clock we sat down for dinner. ⁓ Nothing or actually nothing rapidly. Things happen very, very slowly.

Abby  Eblen, MD (02:37)

Ooh, what happened?

Carrie Bedient MD (02:45)

And so I did absolutely everything that the recipe said. I actually called my friend and he very thankfully came over and was like, no, no, you need to do, because I was supposed to baste it every half an hour. And I'm like, there is nothing in the bottom of this for me to baste, but little brown crunchy bits. And there should not be brown crunchy bits here. And so he came over and he's like, okay, we're going to add a pound, read that a pound four sticks of butter.

And that made everything better because clearly what is made worse by four sticks of butter, mean, besides your coronary arteries. So we added that. And so I kept basting and I just kept following the temperature. It, took five hours to get this roast instead of the advertised, uh, two or, two and a half, two 45 that I kind of plan for to build an extra wiggle room, but it tasted delicious. It's,

Abby  Eblen, MD (03:23)

Well good, that's the important part. It tasted good at the end, even though it took a little extra time. I hope you had a lot of hors d'oeuvres ahead of time. 

Carrie Bedient MD (03:35)

I mean, everyone was starving. So really did it taste good or was it just that I starved them enough so that I could have fed them shoe leather and it would have been fine?

Abby  Eblen, MD (03:44)

Hey, I need to think about doing that sometime.

Susan Hudson MD (03:46)

So could you ever figure out what happened? Was it a different thickness or gas versus electric oven or?

Abby  Eblen, MD (03:56)

Convection versus regular oven?

Carrie Bedient MD (03:59)

So the gas versus electric is what we think might have happened. I still don't really know, because I was using the same, we're going to have somebody come out and actually look at the oven and make sure that the temperature is what it says it is, because not that long ago, the whole oven had failed and we had to replace the motherboard, whatever it is. And so I'm wondering if that did something, but ⁓ yeah, not my favorite.

Susan Hudson MD (04:21)

I want a new oven but I don't want to pay for one just because I want something new.

Abby  Eblen, MD (04:28)

We have a new ish oven. It's about a year and a half old and it cooks a lot hotter than my other oven. And I recently trying to make some fudge and I'm always careful to try and turn it down a little bit since it, and particularly for candy, the temperature is so critical. I followed everything to the letter of the law, poured out my fudge and it was great for caramel, but it was not the texture of fudge.

So I think sometimes just different ovens cook different ways.

Susan Hudson MD (04:56)

We have double ovens and the top oven is the one that we use the most. ⁓ I think it works a little bit better than the bottom oven does, but that's the one that it's the one that you look at. It's like the logical one for you to use first. I don't know why, but the people in my house are relatively tall. I mean, I'm five seven and I'm the shortest person in my house now.

Abby  Eblen, MD (05:22)

Yeah, your family's tall.

Susan Hudson MD (05:24)

We have tall people and literally when you open the door, because it's out, and then you're going to put something in, you're just stretching just enough that you're like, ooh, this is not, it definitely is not ergonomic and there may be safety issues periodically involved. We recently had a ⁓ splash of some greasy hot liquid that I think potentially ruined a pair of my shoes.

Carrie Bedient MD (05:36)

No! Sorry.

Susan Hudson MD (05:50)

And so I know, I know it's really sad, but I'm going to take them to the shoe doctor and see if they can fix them. I'm hoping that they can.

Abby  Eblen, MD (05:58)

Just as a side note, Susan, for those watching on YouTube, they can experience this, but I felt like I was in the oven looking at you. You're like reaching up and pulling the door down.

Susan Hudson MD (06:07)

And so, but they have these new doors where instead of pulling down towards you, one, either you pull down and they slide in, which at first I was intrigued about, but that seems like a lot of engineering things and gizmos that could go bad and misbehave, particularly when you need them not to misbehave.

On the logical side, have new ones that open sideways, like an actual door. And I'm like, this is brilliant. This is exactly what I need. It's gonna, I mean, if I didn't have a door in front of me that I'm like reaching over trying not to burn my elbows, it would be perfect. that's what I'm hoping for, but I'm hoping it dies a meaningful death.

Carrie Bedient MD (06:55)

I like the idea of having a door that opens in another direction. Although when I think about the reason why that's actually not going to help, because in the same process of making this roast, there was a small human being who has no regard for her own personal safety in the house. And you know the scene in Hansel and Gretel where the witch looks in and then they push her in? Imagine that scenario with the lower oven that's nice and close to the ground. I had that flash before my eyes of ⁓ I'm going to cook a small child and come out with a gingerbread person. And so...I was thinking yeah, having a different type of door would help that. And no, it's having the lower oven that somebody who does not have better judgment tried to run into. Hmm.

Susan Hudson (07:44)

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Susan Hudson MD (08:51)

Alright, our question today. I am a 40 year old with a history of four chemical pregnancies in 14 months. After the third chemical, I was referred to a fertility clinic. AMH 0.9, 14 follicles initially. Saline ultrasound took two attempts with different providers as they had to pop through my cervix and also notice fluid leaking out into the upper right cavity. MRI shows no adenomyosis but endometrioma. HSG no issue.

Had hysteroscopy to have endometrial biopsy taken and it took MD 40 minutes to enter my uterus due to my now diagnosed cervical stenosis. For reference, I get a monthly period every 28 days and have a history of four to five cervical biopsies due to HPV. Egg retrieval last month, three fertilized, one PGT-euploid. How would you go about best success for upcoming embryo transfer?

I think you need to have a hysteroscopy with a cervical dilation done before anybody's trying to put anything into your uterus.

Carrie Bedient MD (09:53)

Yeah. Another way to go about that would be to do a mock transfer at your baseline along with that cervical dilation to make sure that the transfer catheter can get through. And I would probably go all the way and do that with an ultrasound, with a full bladder, all of those things. Because sometimes that transfer catheter is really small. And sometimes it's a lot harder to do the hysteroscopy than it is to actually do the transfer. But you want that mapped out ideally by the person who's going to be doing the transfer because if there's a component of twistiness in that cervix, you want them to know the roadmap of, into down, up to the patient's left, whatever it may be, you want them to know that roadmap and do a dilation at the same time, plus or minus putting a little stitch in the cervix so that they've got some counter-traction already present. Those would all be things that I would think about.

Abby  Eblen, MD (10:44)

Yeah, exactly what you said, Carrie. I think hysteroscopies can sometimes work great to dilate the cervix, but sometimes it's more the twisty, curvy part that's the hard part. And so I do think there's a lot of benefit to your own physician and the person that's going to do the trial transfer being the one to do it because practice makes perfect. I know if the cervix, I'm worried about stenosis, But I know that with what I did, I got through it pretty easily. It always makes me feel so much better and so much more relaxed when I'm going into that transfer.

Susan Hudson MD (11:11)

What did you take from the part of the question that's talking about they're doing the saline ultrasound and Yeah, and then notice fluid leaking out into the right upper cavity.

Abby  Eblen, MD (11:17)

And fluid came out somewhere.

I wonder if they're trying to basically say that her right tube is open. They saw fluid go through. It sounds like they were trying to demonstrate tubal patency and they had trouble, but they saw fluid leak out, so they thought one side was open. Because then she went on to say, I think that she had an HSG. Yeah, so that's why she probably had the HSG.

Carrie Bedient MD (11:41)

So what I can't tell is does that mean that the tube is open, which is what I lean towards? Or the other question is, was, did they...

Abby  Eblen, MD (11:46)

Yeah, that's what I think.

Carrie Bedient MD (11:52)

Well, or was it something where when they were putting the catheter in, went in further. So when they infused the fluid, went into the actual intrauterine muscle as opposed to just the cavity itself. But I don't, without seeing images, that would be unusual.

Susan Hudson MD (11:58)

Yeah.

Abby  Eblen, MD (12:06)

I would bet it was an SIS and they couldn't demonstrate patency on one side. So therefore they said, let's go ahead and do an HSG and she had an HSG and it was normal. That's what would be my guess.

Susan Hudson MD (12:15)

Yeah.

And I would, I would definitely considering you had a saline ultrasound and it took two providers, which means I'm assuming you had two REIs that had difficulty threading the catheter for a saline ultrasound. When we talk about a cervical dilation, realize what we're talking about is essentially we're putting little metal rods, ideally while you're asleep.

Through your cervix and it helps stretch, it opens. We want to get it open enough that when it contracts back down and it heals, it's still going to be open and it's going to be open more than that little catheter. But so it's less eventful because no one wants to be in a situation where, you you had that whole thing. I mean, 40 minutes to do an endometrial biopsy. We've all been there. We've all had people that that happens.

But we really don't want that to be the situation on the day of embryo transfer.

Susan Hudson MD (13:13)

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Carrie Bedient MD (13:52)

Absolutely. All right. So our topic of today is OHSS. And so first things first, what is the alphabet soup of OHSS?

Susan Hudson MD (14:03)

Ovarian hyperstimulation syndrome.

Carrie Bedient MD (14:05)

Okay, what is that?

Abby  Eblen, MD (14:07)

So That's a condition where the ovaries get big, they get full of follicles, and then sometimes, depending on how severe it is, and there's different stages, and we'll talk about this, sometimes patients can even have fluid in their abdomen that leaks out. Sometimes they can be nauseated and vomit. And sometimes it can just be just fluid and they just feel bloated. There's different stages and different levels of it.

Carrie Bedient MD (14:31)

Can someone who is just randomly being seen in your infertility clinic and it's her first visit and she's just walking in and says, hi, I've been trying to get pregnant for six months or 12 months, do they get diagnosed with OHSS? Is this any fertility patient, any random patient anywhere?

Susan Hudson MD (14:45)

So You have to have gone through a fertility treatment. I'm sure there's some really strange situation that this may have been, a case study, but for the vast majority, like 99.9 % of people, you have to have been taking fertility medications for it to happen. Now, back in the day when more of us use Clomid, I think there was a reasonable amount of hyperstimulation that would sometimes occur. I personally don't use Clomid hardly at all anymore. I use Letrazole and I don't think I've ever had a true case of hyperstimulation syndrome that needed any type of treatment from Letrazole. But essentially what we expect is during an IVF cycle, because we're wanting to not only recruit maybe one to three follicles, but 10 to 20 follicles, those follicles as they get bigger, there's little cells within the follicles. So remember the follicles are the houses of the eggs. There are cells within those follicles that you can't see on ultrasound. And those are called granulosa cells. And those granulosa cells help produce estrogen. And as they get bigger, we get more and more of them. That's why you get higher and higher estrogen levels. And then that estrogen the high estrogen levels which we want to happen in everybody to a certain degree but sometimes they get higher than others and the level that we often think about is usually about 3000 but when when that happens it activates another type of chemical within your Body called VEGF that makes your blood vessels leaky Leading to the fluid in the abdomen fluid in the lungs and sometimes even putting you at risk of salt abnormalities within your blood or even getting blood clots. And that can sometimes be a very scary situation.

Carrie Bedient MD (16:44)

So what type of patient characteristics are most likely to be associated with OHSS?

Abby  Eblen, MD (16:51)

So sometimes it can be the use of oral medicine, more times than not it's the use of injectable fertility medicines. And so The characteristics specifically of the patients tend to be women who were young, women who have polycystic ovary syndrome, because a lot of times those patients tend to have more follicles or more eggs. And as Susan just said, the more follicles you have, the higher your, and the more they grow, the higher your estrogen level gets.

And we do think there's a pretty good correlation with high estrogen levels and ovarian hyperstimulation syndrome. And it doesn't necessarily mean that every woman that has an estrogen level of a certain amount or has a certain number of follicles is gonna get it. That's the thing that's tricky. You never really know for sure who's gonna get it, but just the higher the estrogen levels and the more eggs that you have and the younger the patient, the more likely a person is to get it.

Carrie Bedient MD (17:36)

What are things that you can do to mitigate your risk of OHSS, especially in an IVF cycle?

Susan Hudson MD (17:43)

One of the major things a lot of us do now is we do not tend to use as much hCG or pregnancy hormone that's found in most common brands in the US are going to be We don't use that particular medication as a trigger shot to help mature your eggs and instead use Luprolide or a Lupron trigger to make your eggs mature and that helps significantly decrease the risk. Not only do you have that surge within your brain of LH from the Lupron trigger that helps mature your eggs, it also after the egg retrieval really helps things shut down very quickly and helps those estrogen levels drop very, very expeditiously. In addition to that, doing gentler stimulations. So on somebody who we expect to have a lot of eggs, giving them smaller doses, so we get enough eggs, but not too many. That is sometimes easier said than done. We do our best to control the stimulation, but sometimes despite our best efforts, the body has its own mind.

Carrie Bedient MD (18:57)

What is the reason that hCG is so potentially ⁓ inciting for OHSS in the course of an IVF cycle? Like why, you You explain the physiology behind Lupron where it makes that LH surge. What is it about hCG that is the reason we use it and what's the reason that it is less ideal in a patient who might get OHSS?

Abby  Eblen, MD (19:21)

It attaches to the hCG receptor and hCG triggers the production of vascular endothelial growth factor or VEGF, which is a chemical that can therefore make the blood vessels leaky and kind of lead to all the cascade of events that happen with hyperstimulation syndrome.

Carrie Bedient MD (19:37)

And the hCG lives for an awful lot longer than the LH does. And it can stick around for easily 24 hours. And when you figure it's got five half-lives before it really goes down, what that means is 24 hours times five, so five days, before those levels really go down. So it means it can be having its effect for a considerably longer period of time than something that produces LH, like a Lupron trigger.

Susan Hudson MD (20:00)

And to bounce off of that when you're talking about other ways to help minimize the risk of hyperstimulation syndrome, something that we don't see nearly as much anymore is late onset OHSS, which is what happens if you do a fresh embryo transfer, you get pregnant, you have your own hCG within your body that triggers that VEGF to make your blood vessels leaky. And in some cases that could even make things even more scary because it's not just the case of, I took an injection of hCG and in a few days it's going to be out of my system. Your pregnancy is producing more and more hCG and having to manage the negative effects of the OHSS while maintaining the pregnancy can make things very difficult. And so by doing frozen embryo transfers, that's also another major way that we've helped minimize OHSS rates in the last 10 years.

Carrie Bedient MD (21:04)

What are some of the treatments that you do for OHSS? So Let's say you've taken all these precautions. You've used your Lupron trigger. You haven't stimmed as hard as you maybe otherwise would. And yet you're still in a position where a ton of follicles have grown and you're worried about hyperstimulation syndrome for that patient. What can we do in those cases?

Abby  Eblen, MD (21:25)

Sometimes we can start them on a medicine called Dostinex that may be helpful. Like you said, we trigger with Lupron. And then once they actually get hyperstimulated, sometimes we'll even make sure that they don't have high levels of clotting factors. And so Certainly if they do, we may think about starting a patient on aspirin. We may also even think about putting a patient on Lovenox. It's a pretty high-powered blood thinner.

But one of the risks that we really worry most about is if somebody has unrecognized hyperstimulation syndrome, their blood vessels get leaky, fluid leaks into their abdomen in a place it shouldn't be, and so all the little blood cells that are in the vessels get clogged together, get clotted, and there's a much higher risk of things like deep venous thrombosis and things like pulmonary emboli.

We always want to make sure that patients are on blood thinners of some sort. And usually in our practice, we always said if we ended up having to drain fluid off and do a paracentesis, that was sort of our trigger that they needed to be on Lovenox versus just something like aspirin.

Susan Hudson MD (22:25)

In addition, I often the Dostinex or cabergolene, I use that a lot, but I also use it in combination with letrazole. Letrazole is a oral medicine that we often use to help people get pregnant, but it's also really good at helping estrogen levels get low very fast.

And so I use those in combination with each other. Sometimes I even use antagonists, the injectable medications that we use to help prevent you from ovulating. I've been using that less and less and really sticking to the oral medicines because the combination of the two work really, really well.

Carrie Bedient MD (23:02)

Do you the letrozole during stim or primarily after retrieval?

Susan Hudson MD (23:06)

I usually ⁓ start it right after trigger if there's somebody I'm concerned about. I know Abby has quite a few patients. All of us have patients who live a decent distance away from us. And as hard as it is to manage anybody with hyperstimulation syndrome, managing somebody long distance with hyperstimulation syndrome is is exceptionally challenging. And so I really, really focus on the safety of those people. I have a pretty low trigger on wanting to give a little additional oral medicine to help all those levels go back down to normal. And it tends to work really well.

Abby  Eblen, MD (23:45)

And one really, really, really important thing, and this just came back recently, but this happens over and over again, reproductive endocrinologists are the only ones that deal with hyperstimulation syndrome. And ascites is a condition that people can get if they have liver failure or they're an alcoholic or for other reasons. The way we manage hyperstimulation syndrome is very, very differently than we manage somebody who has cirrhosis of the liver or renal failure or something like that.

It's the same end result, but it's because of different reasons. And so back to the clotting disorder, we give patients a lot of fluid. And even though a lot of it leaks out of the blood vessels, it's really important that a patient gets lots of fluid when they're doing this or when they're in the middle of hyperstimulation syndrome because we worry about, the clotting in the blood vessels. I would venture to say, because we have a lot of people that live far away, like Susan said, and...many times they'll be like, well, do I really have to drive an hour and half to Nashville to see you guys? And we're like, yeah, you really do because I've seen this managed not in the best way in outlying places. And it's not because the doctors are trying to do anything wrong or it's just they're not used to managing this. This is a condition that's unique to infertility and reproductive endocrinologist are you uniquely the ones that are positioned in the best place to treat it.

Carrie Bedient MD (25:00)

Absolutely. What are some of the things that can lead to it outside of an IVF cycle? These are some of the more random things, but also in the setting of fertility treatment, talked about Clomid-Letrazole and we talked about IVF, but what in between cycles that most of us don't really do a whole lot of before? What are those types of cycles that can lead to OHSS if you're not careful?

Susan Hudson MD (25:24)

I have no idea what you're trying to hint at.

Abby  Eblen, MD (25:26)

I'm missing the boat here.

Carrie Bedient MD (25:28)

So trying to use gonadotropins during an IUI cycle, which we don't tend to do very much. Usually when we're talking about injectable medications, we're thinking about IVF, but it used to be far more common that in addition to the clomid that you would get, you would get some injectable medications or in the case of people who had failed clomid a couple of times or didn't have a pituitary of their own, they would get all injectable medications to help the eggs grow and then they'd get a trigger shot and from there they would get an hyperstimulation syndrome. And so now Part of the reason why we almost exclusively rely on the oral medications is because at this point the risk of hyperstimulation is a lot higher when you're doing those medications in the same way that the risk of twins, triplets, quadruplets is a lot higher because…

Abby  Eblen, MD (26:18)

That's what I was going to say.

I would argue the biggest risk in those cycles, maybe they're a little bit hyperstimulated, but the biggest risk for hyperstimulation from gonadotrophin cycle is twins, triplets, and quadruplets, unfortunately. But yeah, certainly both can happen.

Carrie Bedient MD (26:28)

Yeah. Well, it's not just the multiple pregnancy. It's also that they're pregnant immediately after the stim because you can't do a frozen transfer scenario in that setup. And so It's something that's pretty rare, but in the setting where we're able to control for hyperstimulation a lot better, that is one of the scenarios where you just don't have as many controls. And so it's another part of the reason, in addition to multiple pregnancies with twins, triplets, and beyond, as part of the reason why we don't do them nearly as much. And then and then you've also got the rare rare things like receptor defects that I think I've seen once or twice in my career where somebody comes in and they're hyper stimulated and they've gone they have not gone through any fertility treatment or their response to meds is far out of proportion to what it should be for what they're getting. And so in those cases, you just kind of manage as best you can and then see how things go afterwards.

Abby  Eblen, MD (27:24)

And the one thing about hyperstimulation syndrome, unfortunately, there's no magic pill to treat it. You just have to treat the symptoms. And so It can be pretty uncomfortable for several days, up to really about seven days after the trigger shot that people are really uncomfortable. just, you know, most of it is just trying to mitigate your discomfort with giving you pain medicine and trying to remove some of the fluid if your abdomen's really stretched and giving you anti-nausea medicine to keep you from vomiting from all the pressure of the fluid.

Susan Hudson MD (27:51)

If you're not pregnant. Yeah, interesting story. When I started fellowship, I remember we had two inpatients, which, it's kind of unusual to have inpatient patients in reproductive endocrinology and infertility. And they were both inpatients for OHSS, severe OHSS while they were pregnant and one of them was in the ICU for a while. It can be pretty scary. It can be definitely one of those things that we need to have multiple team members helping us maintain.

Carrie Bedient MD (28:25)

Now, arguably, this is the most important question we're going to answer in this episode. How does someone who has just gone through a very successful stimulation and gotten a bunch of eggs and is uncomfortable afterwards know this is normal discomfort or hyperstimulation discomfort?

What are things that she needs to watch for or look for and of course be in communication with her team about so that they can help monitor to know, all right, what's the difference between this patient needs more serious treatment versus just supportive treatment and wait it out.

Abby  Eblen, MD (28:51)

Vomiting.

Nausea and vomiting.

Susan Hudson MD (28:52)

So if you're nauseated and vomiting, watching your belly get more more swollen instead of getting less and less swollen, watching your urine output. So if you are peeing less and less, that's a really big concern. 

Abby  Eblen, MD (29:08)

Weighing yourself can also be helpful because it gives you kind of a, you we all vary a little bit between morning and night, but if you weigh yourself the same time every day, and we usually would tell patients if you gain more than about five pounds, you need to let us know about it and we'll bring you in for evaluation.

Susan Hudson MD (29:12)

And I think this is one of those things that's so important to actually, as Abby mentioned, go in to be seen for. If your doctor says, hey, you need to come in, so much of the diagnosis is also just looking at the patient. I I bet when you walk in before you listen to their lungs, you feel their belly, any of those things, the general glance of their overall demeanor, 98 % of your diagnosis was made in those three seconds. Is that not correct?

Abby  Eblen, MD (29:55)

We always joke with the nursing team that before I even get to the room, the nursing team can tell me if this patient's really sick or not by the way she walks in. We know.

Carrie Bedient MD (30:04)

Yes, yes.

Susan Hudson MD (30:05)

If you're smiling and joking around and you're like, I think my belly is a little full. You don't have severe hyperstimulation.

Carrie Bedient MD (30:12)

Yeah. And there's a lot of overlap between a really good stim and hyper stimming. Even those high estrogen levels, having a high estrogen level by itself does not mean you're going to get hyper stim. We've all had patients whose levels have gotten really high and they're totally fine. And patients whose levels are relatively much lower who are very much feeling it when you would otherwise say, you are the lowest person on my list right now to think would get this. Communicating with your team is really important.

I would argue staying off the internet is really important for this one because just about everybody with a decent stim with a bunch of follicles is going to think she has hyperstimulation because the swelling of your abdomen as your belly gets bigger, the feeling kind of nauseated as your hormone levels go higher, all of those things are, feeling very full, not wanting to drink. That type of stuff is all part and parcel with an IVF stimulation. It's very, very common.

When people are doing a lot of their internet research and they're looking at it, they tend to think, my gosh, I have hyperstimulation. When, like Susan said, we can take a quick look at you and we're always going to cross check the other data, but we've got a pretty good sense of who's sick and who's not sick and who needs additional medications, IVs, other things versus just continued reassurance and keeping an eye on.

Abby  Eblen, MD (31:28)

Well, and then the other point to make too is, everybody that does IVF is hyperstimulated. So you do meet the criteria. You have multiple follicles, your ovaries are enlarged, but the people that we really worry about are what we mentioned before, the ones who are not urinating, not able to keep liquids down, feeling nauseated, just having tremendous abdominal pressure. Those are the patients that we're really worried about. But if you're worried, call us. We won't mind at all. And chances are, if you're worried about it, we're probably a little worried about it too if your...estrogen levels are high, so just call us if you're concerned about it.

Carrie Bedient MD (31:59)

Mm-hmm. Sometimes just draining a little bit of fluid off the abdomen is a huge help in terms of your comfort and symptoms and can help you get through those next couple of days so that your body can turn the corner and you just start usually peeing like it's your job and all that fluid starts to come out and you feel quite a bit better. So, all right. Anything else about hyper stim that we haven't talked about that we should?

Susan Hudson MD (32:27)

I think those are the big things.

Carrie Bedient MD (32:28)

Okay, cool, we'll take it. All right, well, to our audience, thank you so much for listening. Subscribe to Apple Podcast to have next Tuesday's episode pop up automatically for you. And be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Abby  Eblen, MD (32:45)

Visit us on fertility.sonscensored.com to ask questions for our Ask the Doc segment. Also check out our new book, the IVF Blueprint. You can find it on Amazon, Barnes & Nobles, and bookshop.org. We'd love for you to subscribe and leave us a review on Apple Podcasts. We'd really love to hear from you.

Susan Hudson MD (33:00)

Check out our Instagram and TikTok for quick hits of fertility tips between weekly episodes. And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye.