Category: IVF

Ovarian hyperstimulation syndrome - OHSS

This syndrome develops as a result of exogenous therapy with gonadotrophins and occurs in 1-5% of women treated in this way. The greatest risk factor for the development of ovarian hyperstimulation syndrome is the PCO syndrome.

Symptoms of OHSS are:

  • Pain in the lower part of the abdomen
  • Nausea / vomiting
  • Increase in body weight

The expression of the symptoms varies, can be easily or severely expressed.

In severe forms of OHSS, there is:

  • Strong abdominal pain
  • Distended abdomen
  • Ascites (free fluid in the abdomen)
  • Dyspnoea (difficulty breathing)
  • Oliguria (reduced urine secretion)
  • Thromboembolism

The diagnosis is based on the above symptoms and the ultrasound findings of the enlarged ovary, with a multitude of follicular cysts, a free fluid in the abdomen.

Treatment depending on the severity of the symptoms may be outpatient or hospital.

Reviews and analyzes necessary for the involvement of the insured person (couple) in the BPO procedure through the HIF

  1. Medical documentation that one or more of the following methods have been performed: HSC and / or laparoscopy and hysteroscopy, and / or laparotomy; echographic examination is not a proof method other than 4D ultrasound of the cavity in the case of:
    • Determined male infertility factor, with number of moving spermatozoa and after preparation less than a million.
    • A severe disorder of the male factor, with less than 4% spermatozoa with normal morphology
  2. Documents for two or more sperm analyzes with at least one month difference between them in more than one health institution, which is licensed by the Ministry of Health to carry out that activity, and the last analysis was not carried out more than a year before the submission the request
  3. Infertility data for a period of at least three years, treated with conventional methods, with at least four intrauterine insemination cycles (IUI);
  4. Results of the hormonal status analysis: FSH, LH, PRL, E2, TSH - third day of the cycle, (not older than six months);
  5. PAP screening (not older than one year if it was arranged);
  6. Microbiological swabs of vagina and cervix including Chlamidia trachomatis (not older than six months);
  7. Markers for Hepatit B and C, HIV for both spouses (not older than six months);
  8. Blood count, glycemia, sedimentation (not older than six months);
  9. Other medical documentation depending on the health status of the couple (performed diagnostic or operational interventions regarding sterility, performed insemination, in vitro fertilization, other diseases, therapy and opinion from specialists, etc.).

Drugs used in ART (Assisted Reproductive Techniques)

Clomiphene citrate

It is structurally similar to estrogens. It binds to estrogen receptors in the hypothalamus (part of the brain that takes part in the regulation of the menstrual cycle) and thus continues the secretion of GnRH from the hypothalamus, which in turn stimulates the pituitary gland to protect the FSH and LH. These two hormones participate in the stimulation of the growth and maturation of the follicles in the ovaries.
Clomiphene citrate is taken orally (by mouth) in the form of tablets of 50 mg. The therapy starts from 3-7 days of the cycle. The dose is individual, taking into account the body weight index, the response of the ovaries.
The effect of stimulation is followed by ultrasound-folliculometry, ie, the number and size of the growing follicles is monitored.


These are hormones that normally emerge from the anterior part of the pituitary gland and include FSH (follicle-stimulating hormone) and LH (luteinizing hormone).

In the ART process these hormones are applied in the form of injections that are administered subcutaneously.

Induction to ovulation usually begins with low doses (50-75 IU / day) and gradually the dose can be increased if there is no good response from the ovaries. Each stimulation requires the ultrasound of the number and size of the follicles to be monitored because there is a risk of ovarian hyper stimulation.

GnRH analogues

Drugs used to desensitize the pituitary, that is, serve to prevent premature leap of LH in the process of controlled ovarian hyperstimulation (COH)

These include:

GnRH agonists

Leuprolide acetate - this drug binds to GnRH receptors and leads to the release of substances that stimulate secretion of FSH and LH. Continuous administration of this medication initially leads to increased secretion of the above hormones, and then to desensitization of the pituitary and fall in the production of FSH and LH, thereby preventing the LH leap in the stimulation phase. Such drugs are used in the so-called. long protocols of stimulation.

GnRH antagonists

Unlike GnRX agonists whose action requires 2-3 weeks, GnRH antagonists act immediately, within a few hours they perform desensitization of the pituitary, with subsequent reduction of FSH, LH and estradiol. Short stimulation protocols.

HCG - (Human Chorionic Gonadotropin)

It is a polypeptide hormone that is synthesized in the placenta (placenta). It consists of one alpha and one beta subunit. The alpha subunit is identical to the alpha subunit of LH, FSH and TSH. This medication serves to prepare the puncture follicles. After receiving the injection with HCG, ovulation occurs at the 40th hour. This is a key point because puncturing eggs should be performed before ovulation occurs, ie, at 34-36 h after administration of the medicine.


It is a hormone that is produced from the ovaries, the yellow body after ovulation and the placenta. It is important for the preparation of the mucous membrane of the uterus for implantation of the fertilized egg. Progesterone preparations are in the form of vaginal or injection with a depot (prolonged) effect. Progesterone therapy starts from the day of ET (embryo transver) or insemination until the 10-12 gestation week when the placenta is already developed and can produce it on its own.

Examination of seed material - Spermogram

We are witnessing that the modern way of life (polluted air, stress, food we eat, alcohol...) leads to many diseases and disorders in our body.

Proof that all these factors also affect the quality of the seed material is the fact that male sterility compared with ever, now more and more percentage increases and almost equates to the female sterility factor.


Insemination is a procedure in which sperm is processed, concentrated and with the help of a thin catheter is injected directly into the woman's uterus. Thus sperm in the optimal concentration reach the tubes (fallopian tubes) where fertilization of the ripe egg is performed.

Insemination is recommended for partners with vague infertility, who have attempted to become pregnant for at least a year. In order to apply this method it is necessary that sperm indicators in a man be within the norm or slightly below the norm. An indispensable condition for successful insemination is transmissible tubes (oviducts), therefore a preliminary examination called hysterosalpyngography (HHS) is required.

Sperm from a partner or donor sperm can be used.


Insemination can be done without stimulation (natural cycle) in cases when there is neither a male nor female infertility factor and when a woman has proven the presence of ovulation. This means that before the procedure, the level of luteinizing hormone (LH) is monitored and ultrasound examinations are performed to determine when the insemination is performed without the use of medicaments. If a woman has proven absent ovulation then stimulation of the same with medication is applied. The goal of the stimulation is that more eggs reach maturity. This is achieved with the help of drugs such as Clomiphene Citrate in the form of tablets or gonadotrophins as injections to stimulate the ovaries and achieve ovulation.

When the patient is under stimulation for ovulation, the number and dimensions of the follicles are continuously monitored ultrasound, and when two or three follicles reach the optimum size, an injection with HCG can be induced to induce (induce) ovulation. About the time of expected ovulation, sperm is processed in the laboratory and so prepared using a thin catheter is injected into the cavity of the uterus.

The procedure is painless and compares to the feeling of taking PAP swabs. After the insemination, the woman stays on the gynecological chair for about 15 minutes.

Urinary pregnancy test can be done on the 15th day of the procedure. A blood test for pregnancy can be done 11-14 days of the procedure. Before the procedure, you and your partner should have tested for HIV, Hepatitis B, Hepatitis C, a microbiological examination of the ejaculate.


The success of insemination is low if:

  • Woman is over 40 years old
  • Women with moderate to severe endometriosis
  • Sperm is with bad indicators
  • Egg cells are few or poor quality
  • In women with any degree of tubal damage

The advantage of insemination is that there is no puncture of the follicles (more invasive procedure) and no need for anesthesia.

Risks are an infection of the uterine lining, spasms, and extra uterine pregnancy (pregnancy outside the uterus)

Female infertility

About 15% of married couples have difficulty in creating offspring. Female infertility (infertility) accounts for 45% of infertility in married couples, 45% due to male factors, and 10% for unknown reasons.
The most common causes of female infertility are:

  1. Ovarial factors:

Disorders of normal ovulation anovulation (absence of ovulation) or oligovuilation (rare ovulation) as a result of the PCS syndrome, premature ovarian failure, endocrine disorders-high levels of prolactin or thyroid hormones.

  1. Endometriosis:

    Disease in which the cells that build the lining of the uterus are nested out of it (ovary, abdominal cavity, scars from previous operations, cervix, vagina). Symptoms are chronic pain in the lower abdomen and infertility. The diagnosis is confirmed laparoscopic and histopathological.

  2. Uterine factors:

    Structural abnormalities of the uterus are a common cause of conceiving difficulties, as well as abortions in early pregnancy.
    These include the myoma of the uterus, which, depending on the size, can deform the cavity itself and thus interfere with the embedding of the fertilized egg.
    Anatomical anomalies of the uterus - like unicorn, uterine uterus, the presence of septum in the cavity of the uterus are also a common cause of female infertility or loss of pregnancy in the early period.

  3. Tubarine Factors:

    Impotence of the fallopian tubes as a result of previous infection (adnexitis, salpingitis, hydrosalpyxin), operative involvement, endometriosis. This leads to the inability of the sperm to reach the fallopian tubes and fertilize the ripe egg. Appropriate reconstructive microsurgery can improve the chances of spontaneous conception, but in cases where it is not possible IVF is the most appropriate solution.

  4. Factors related to the age of a woman:

    As the woman's age increases, her reproductive capacity decreases.

  5. Unexplained infertility (idiopathic):

    When modern methods of medicine can not diagnose a cause for it.

Infertile partners evaluation

  1. Ovulation:
    • proving the presence or absence of ovulation using test strips that are immersed in urine, measure the peak (maximum) of the concentration of LH hormone, basal temperature measurement. Chlomiphene citrate challenge test would give us information about the ovarian reserve, the ability of the cephalopods to respond to hormonal stimuli.
  2. Ultrasound evaluation of genital organs:
    • In the 2D, 3D or 4D projection, the uterus, tubes, ovaries are excluded / confirmed by changes in them (myomas, hydrosalpings, endometrial polyps, cysts and ovarian tumors).
  3. Hormone status: analysis on TSH, FSH, LH, Estradiol, Testosterone, Prolactin, AMH. 
  4. HIV Testing, Hepatitis B / C, Siphilis, Gonnorhea, Chlamidia 
  5. Hysterosalpingography (HSG):
    • a procedure for inserting a contrast fluid through the cervix into the cavity of the uterus and using a X-ray to take a shot. In doing so, defects in the fulfillment of the uterus and the permeability of the tubes are required.
  6. Diagnostic Hysteroscopy:
    • with the help of a hysteroscope, in short intravenous anesthesia it enters the uterus, where the entire cavity, the openings of the tubes are visualized, and if there are changes such as septum, submucous myoma, polyp, they can be removed. This procedure is performed immediately after menstruation, ie between 5 and 12 days of the cycle.
  7. Diagnostic laparoscopy:
    • micro invasive method, whereby three small openings of the abdomen enter a small pelvis and with the help of a camera the anatomy of the uterus, ovaries, tubes, the removal of cysts, myomas, and adhesions from previous operations is observed. During the intervention, a chromotherapy is also performed, which means the introduction of methylene blue in the tubes and their transitability is seen (the same can have a therapeutic effect if the inflammation is low).
  8. Seed material analysis:
    • to exclude or confirm male infertility factor.