3 Oct 2015
Introduction. OHSS, first described by Rabau and Polischuk,1,2 has undergone many classification and reclassification since then (Golan3 most recently updated classification). Women undergoing controlled ovarian stimulation for IVF have a 1-4% risk of developing moderate or severe OHSS4. OHSS has been subdivided into 2 distinct time related types. A; Early, occurring 3 to 7 days post HCG administration,5-8 and B; Late onset, usually at the time of pregnancy being confirmed and is divided into A; Mild, B; Moderate and C; Severe (Critical). Severe OHSS is considered a life threatening condition, stroke is a rare but serious complication occurring in severe (critical) OHSS9-14 and is often associated with intracardiac septal defects or other thrombophilic conditions. In 1968 Cross15 reemphasized the risk of strokes in Pregnancy and the puerperium. Although usually associated with Gonadotrophins used in COH for IUI or IVF cases of moderate or severe OHSS have been recorded with Clomid use,16 spontaneous pregnancy without any fertility medication,17-19 with ectopics,20 molar pregnancy21 and in a recurrent familial basis22-25 (association with FSH receptor polymorphism). Sauer reported the rarity of OHSS in egg donors.26 The objective here is to report the first known case of arterial ischemic stroke in a young woman after ovarian stimulation for oocyte donation with early mild OHSS.
Materials and Methods. A 23-year-old woman, G0P0, with no previous history of ovarian stimulation or medical conditions, had a negative family history for any condition, denied smoking or previous drug use. Gonal-F at the usual dose was used for ovarian stimulation with step down, after 4 days of stimulation, Ganirelix Acetate (Orgalutran) as an antagonist, and hCG 36hrs prior to egg retrieval. Ovarian response was monitored by ultrasound and serum estradiol levels. The expected oocyte number to be retrieved, based on follicle size of 1.8 cms when decision made to give HCG, was 12 to 14.
Results. A total of 2,400 IU of Gonal-F, 1,250 μg of Orgalutran, and 10,000 IU of HCG were used. On day 15, ultrasound revealed 12 matured follicles (>1.8 cm). Oocyte retrieval was done 36hrs after HCG injection. All follicles 1.1 cm or larger were aspirated. Much to our surprise 45 oocytes were retrieved. Patient was instructed to start back on her OC’s, oral hydration with electrolyte solution and Cabergoline 0.5 mg/day for 10 days in order to prevent OHSS. Within 63hrs post HCG, patient presented with signs of right sided hemiparesis. On admission to ER, laboratory results (electrolytes and Hemoglobin/Ht) showed signs of mild OHSS, only a small amount of pelvic fluid, minimal tenderness and both ovarian diameters less than 10cm3. However, a toxicological urine test revealed the presence of cannabis and benzodiazepines. Her Dostinex was stopped by her Neurologists. Starting 3 days after admission, she went on to develop severe OHSS and required paracentesis of 2.7 lts. Acidic fluid. She mad a full recovery from her stroke signs and symptoms within 2 weeks.
This is the first case of an actual stroke, published in the literature, that occurred less than 65hrs post HCG inj. The first CNS side effect post egg retrieval was a case of aphasia without signs of OHSS,27 she did not have a drug screen as in this case, so the cause of stroke due to drug abuse, as a causation, cannot be excluded. The beneficial medical effects of Cannabis Indica has been known since 1847.26 Cannabis has been in use in humans for at least 2,000 yrs. Aronow in 197427 was one of the first authors to alert the medical community of the severe vascular effects of Cannabis on the Coronary and Cerebral arterioles leading to Cannabis being the leading cause of Strokes and Heart attacks in Men and Women under 30 yrs of age world wide. Caplan in 198228 expanded on this and multiple publications from all around the world have reiterated the vasospastic effects of Cannabis, Wolff29 and Malinowska,30 especially due to the contaminants now found in “street “ available cannabis, leading to a potency of this drug being 30 to 50 times more “potent “ that the product from the late 1970’s.31-34 We know that approximately 125 million cycles of COH have been performed for either IUI cycles or IVF so this poor unfortunate lady had a “stroke “ from which she made a complete recovery, as per her neurologist, within 2 weeks of the event report, either as a side effect of her ovarian stimulation and egg retrieval, or from some “more sinister “ side effect of her drug use?
Should we do a urine drug test on all our egg donors as a medico-legal preventative measure to protect ourselves?
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