Table 3.
The consensus statements. IVF, in vitro fertilization; OHSS, ovarian hyperstimulation syndrome; PCOS, polycystic ovarian syndrome; GnRH, gonadotropin-releasing hormone; hCG, human chorionic gonadotropin; FET, frozen embryo transfer. No consensus was reached regarding the preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder, weighing above 80 kg. No consensus was reached regarding hospitalizing vs. management as an outpatient in the cases of a patient with significant ascites
| Stimulation goals in a hyper-responder | |
| 1. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15–19. | |
| 2. For a potential hyper-responder, I would rather achieve a hyper-response and freeze all than aim for a fresh transfer | |
| Treatment protocol in an anticipated hyper-responder | |
| 3. GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF. | |
| 4. I do not use any specific algorithm to estimate the starting dose for an IVF cycle | |
| 5. The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day. | |
| 6. Body weight should be considered to determine the daily gonadotropin dosage for an anticipated hyper-responder undergoing IVF. | |
| 7. Increasing the starting gonadotropin dose in the first IVF cycle of an anticipated hyper-responder is recommended if her weight is above 80 kg | |
| Cycle modifications in response to a hyper-response | |
| 8. I decrease gonadotropin dosage in the middle of an IVF cycle if the patient seems to hyper-respond based on serum estradiol levels and/or number of growing follicles > 10mm. | |
| 9. Under the risk of hyper-response during stimulation, I would not trigger one to two days before the patient reaches my usual trigger criteria. | |
| 10. I do not use coasting to decrease the risk of OHSS. | |
| Use of adjuvants during the stimulation of a hyper-responder | |
| 11. I add metformin before/during ovarian stimulation to anticipated hyper-responders only if the woman has PCOS and is insulin resistant. | |
| 12. I do not add any adjuvants from the first day of stimulation to a potential hyper-responder. | |
| 13. During ovarian stimulation, I do not add any adjuvant if the patient seems to hyper-respond based on serum estradiol levels and/or number of growing follicles > 10 mm. | |
| Choice of trigger in a hyper-responder | |
| 14. On the day of ovulation trigger, if the number of follicles > 10 mm and the estradiol levels are discordant, I would decide to use a GnRH agonist trigger alone based on the number of follicles > 10 mm. | |
| 15. There is no minimal estradiol level on the day of trigger that would require agonist trigger alone | |
| 16. On the day of ovulation trigger, the minimal number of follicles > 10 mm that would require agonist trigger alone (in an antagonist cycle) is 18 | |
| OHSS prevention and the use of dopaminergic agent | |
| 17. In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer. | |
| 18. For maximal effectiveness, cabergoline 0.5 mg for OHSS prevention should be started on the day of trigger. | |
| 19. For maximal effectiveness in OHSS prevention, cabergoline 0.5 mg should be continued for 7 days. | |
| 20. In a woman with a hyper-response, triggered with hCG, the only interventions I would add to prevent OHSS are freeze all and the use of cabergoline. | |
| 21. In a woman with a hyper-response, triggered with GnRH agonist the only interventions I would add to prevent OHSS is freeze all. | |
| 22. If a hyper-response occurred after a trigger that included hCG I would always freeze all | |
| 23. After using a GnRH agonist trigger due to a perceived risk of OHSS, I would not consider a luteal phase rescue with hCG and attempt a fresh transfer regardless of the number of oocytes collected. | |
| FET protocol in a hyper-responder | |
| 24. My choice of FET protocol is not influenced by the fact that the patient is a hyper-responder. | |
| 25. In cases of freeze all due to an OHSS risk, I perform an FET cycle in the immediate first menstrual cycle. | |
| OHSS management | |
| 26. I would recommend admission following a hyper-response after the diagnosis of severe OHSS. |