Ovarian Hyperstimulation Syndrome (OHSS)
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What is Ovarian Hyperstimulation Syndrome?
Ovarian hyperstimulation syndrome (OHSS) is an excessive response to taking the medicines (especially injectable gonadotropins) used to make eggs grow. Rarely, OHSS can result from taking other medications, such as clomiphene citrate or gonadotropin-releasing hormone.
Women with OHSS have a large number of growing follicles along with high estradiol levels. This leads to fluid leaking into the abdomen (belly), which can cause bloating, nausea, and swelling of the abdomen. When OHSS is severe, blood clots, shortness of breath, abdominal pain, dehydration, and vomiting are possible. Rare deaths are reported.
How severe can OHSS get?
OHSS can be classified as mild, moderate, or severe. One out of three women has symptoms of mild OHSS during controlled ovarian stimulation for in vitro fertilization (IVF). These symptoms may include mild abdominal bloating, nausea, and weight gain due to fluid. Women with moderate OHSS typically have more of these same symptoms. Women with severe OHSS usually have vomiting and cannot keep down liquids. They experience significant discomfort from swelling of the abdomen. They can develop shortness of breath, and blood clots can form in the legs.
In all cases of OHSS, the ovaries are enlarged. The size of the ovary is a marker of the degree of OHSS. If symptoms are present, a transvaginal or abdominal ultrasound can be done to measure ovary size and the amount of fluid collected.
How is OHSS treated?
OHSS can be serious, so careful monitoring and managing the symptoms are important whenever it occurs. Office visits for ultrasound exams to measure the ovaries and fluid in the abdomen, and blood tests, are routinely done. Decreased activity and drinking lots of electrolyte-rich fluids (over ounces per day) are recommended. Medicines for nausea are available. If there is fluid in the abdomen, drainage of fluid using a syringe (paracentesis) can provide significant relief in most cases. On occasion, more than one drainage is helpful. A medicine called cabergoline also can reduce the fluid accumulation. There is rarely a need for hospitalization.
If OHSS does not improve with outpatient care, the woman may be treated in the hospital with close monitoring. The doctor may order intravenous (IV) fluids and medicines for nausea and may remove fluid from the abdomen. Other supportive therapy may be given as needed.
What other complications occur with severe OHSS?
Complications from OHSS can be severe. You may become dehydrated and pressure in your abdomen may increase from too much fluid. These problems can lead to blood clots forming within the blood vessels. Blood clots can travel to your lungs or to other important organs. This can be potentially life-threatening.
These complications can usually be avoided by recognizing the signs, symptoms, and laboratory evidence that OHSS is getting worse and getting appropriate treatment.
How long does it take for OHSS to get better?
OHSS symptoms usually appear a few days after ovulation. Symptoms usually resolve within two weeks, unless pregnancy occurs. Pregnant women often continue to have symptoms for weeks or more after a positive pregnancy test. The symptoms gradually go away, and the rest of the pregnancy is not affected.
Is there anything that can reduce the risk of having OHSS?
There are several strategies used to lower the risk of OHSS. Reducing the dose of ovarian stimulation medications may reduce the risk of OHSS. Use of a medicine called leuprolide instead of human chorionic gonadotripin (hCG) to prepare the eggs for release can prevent OHSS. Another medicine called cabergoline also can help reduce the fluid accumulation.
Pregnancy can make OHSS worse or last longer. If a woman develops OHSS, avoiding immediate pregnancy by freezing her eggs/embryos for transfer at a later time can help the OHSS resolve more quickly and keep it from progressing.
Some patients who are at high risk for OHSS may be given extra IV fluids at the time of egg retrieval. Giving IV fluids early can help prevent worsening of symptoms later on.
- OHSS is relatively common after ovulation induction or ovarian stimulation for IVF.
- Women with symptoms of OHSS should see a doctor familiar with assisted reproduction as soon as they have symptoms.
- A standard pelvic exam is NOT generally recommended because the ovaries are enlarged and the cysts that are present may burst under pressure.
- Women should notify their doctor when they have:
- Difficulty breathing
- Continued vomiting or nausea
- Difficulty tolerating fluids
- Abdominal swelling
- Decreased urination
- Weight gain of over 3 pounds in 2 days
- Sudden onset of abdominal pain
- Other symptoms such as facial numbness, weakness, lower extremity swelling, or redness
- OHSS often can be managed with decreased activity, drinking electrolyte-rich fluids, draining fluid that accumulates in the abdomen, medication for nausea and pain, careful monitoring, and frequent doctor visits.
- Severe OHSS (continued vomiting, severe swelling of the abdomen, shortness of breath, inability to drink fluids or abnormal laboratory results) may require hospitalization for intensive monitoring and treatment. The risk of OHSS can be reduced by use of lower doses of gonadotropins, leuprolide (vs. hCG) to trigger ovulation, and cabergoline.
Ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome (OHSS) is a medical condition that can occur in some women who take fertility medication to stimulate egg growth, and in other women in very rare cases. Most cases are mild, but rarely the condition is severe and can lead to serious illness or death.
Signs and symptoms
Symptoms are set into 3 categories: mild, moderate, and severe. Mild symptoms include abdominal bloating and feeling of fullness, nausea, diarrhea, and slight weight gain. Moderate symptoms include excessive weight gain (weight gain of greater than 2 pounds per day), increased abdominal girth, vomiting, diarrhea, darker urine, decreased urine output, excessive thirst, and skin and/or hair feeling dry (in addition to mild symptoms). Severe symptoms are fullness/bloating above the waist, shortness of breath, pleural effusion, urination significantly darker or has ceased, calf and chest pains, marked abdominal bloating or distention, and lower abdominal pains (in addition to mild and moderate symptoms).
OHSS may be complicated by ovarian torsion, ovarian rupture, venous thromboembolism, acute respiratory distress syndrome, electrolytes imbalance, thrombophlebitis and chronic kidney disease. Symptoms generally resolve in 1 to 2 weeks, but will be more severe and persist longer if pregnancy occurs. This is due to human chorionic gonadotropin (hCG) from the pregnancy acting on the corpus luteum in the ovaries in sustaining the pregnancy before the placenta has fully developed. Typically, even in severe OHSS with a developing pregnancy, the duration does not exceed the first trimester.
Sporadic OHSS is very rare, and may have a genetic component. Clomifene citrate therapy can occasionally lead to OHSS, but the vast majority of cases develop after use of gonadotropin therapy (with administration of FSH), such as Pergonal, and administration of hCG to induce final oocyte maturation and/or trigger oocyte release, often in conjunction with IVF. The frequency varies and depends on a woman's risk factors, management, and methods of surveillance. About 5% of treated women may encounter moderate to severe OHSS. Risk factors include polycystic ovary syndrome, young age, low BMI, high antral follicle count, the development of many ovarian follicles under stimulation, extreme elevated serum estradiol concentrations, the use of hCG for final oocyte maturation and/or release, the continued use of hCG for luteal support, and the occurrence of a pregnancy (resulting in hCG production). Mortality is low, but several fatal cases have been reported.
Ovarian hyperstimulation syndrome is particularly associated with injection of a hormone called human chorionic gonadotropin (hCG) which is used for inducing final oocyte maturation and/or triggering oocyte release. The risk is further increased by multiple doses of hCG after ovulation and if the procedure results in pregnancy.
Using a GnRH agonist instead of hCG for inducing final oocyte maturation and/or release results in an elimination of the risk of ovarian hyperstimulation syndrome, but a slight decrease of the delivery rate of approximately 6%.
OHSS has been characterized by the presence of multiple luteinized cysts within the ovaries leading to ovarian enlargement and secondary complications, but that definition includes almost all women undergoing ovarian stimulation. The central feature of clinically significant OHSS is the development of vascular hyperpermeability and the resulting shift of fluids into the third space.
As hCG causes the ovary to undergo extensive luteinization, large amounts of estrogens, progesterone, and local cytokines are released. It is almost certain that vascular endothelial growth factor (VEGF) is a key substance that induces vascular hyperpermeability, making local capillaries "leaky", leading to a shift of fluids from the intravascular system to the abdominal and pleural cavity. Supraphysiologic production of VEGF from many follicles under the prolonged effect of hCG appears to be the specific key process underlying OHSS. Thus, while the woman accumulates fluid in the third space, primarily in the form of ascites, she actually becomes hypovolemic and is at risk for respiratory, circulatory (such as arterial thromboembolism since blood is now thicker), and renal problems. Women who are pregnant sustain the ovarian luteinization process through the production of hCG.
Avoiding OHSS typically requires interrupting the pathological sequence, such as avoiding the use of hCG. One alternative is to use a GnRH agonist instead of hCG. While this has been repeatedly shown to "virtually eliminate" OHSS risk, there is some controversy regarding the effect on pregnancy rates if a fresh non-donor embryo transfer is attempted, almost certainly due to a luteal phase defect. There is no dispute that the GnRH agonist trigger is effective for oocyte donors and for embryo banking (cryopreservation) cycles.
OHSS is divided into the categories mild, moderate, severe, and critical. In mild forms of OHSS the ovaries are enlarged (5–12cm) and there may be additional accumulation of ascites with mild abdominal distension, abdominal pain, nausea, and diarrhea. In severe forms of OHSS there may be hemoconcentration, thrombosis, distension, oliguria (decreased urine production), pleural effusion, and respiratory distress. Early OHSS develops before pregnancy testing and late OHSS is seen in early pregnancy.
Criteria for severe OHSS include enlarged ovary, ascites, hematocrit > 45%, WBC > 15,, oliguria, creatinine mg/dl, creatinine clearance > 50 ml/min, liver dysfunction, and anasarca. Critical OHSS includes enlarged ovary, tense ascites with hydrothorax and pericardial effusion, hematocrit > 55%, WBC > 25,, oligoanuria, creatinine > mg/dl, creatinine clearance < 50 ml/min, kidney failure, thromboembolic phenomena, and ARDS.
Physicians can reduce the risk of OHSS by monitoring of FSH therapy to use this medication judiciously, and by withholding hCG medication.
Cabergoline confers a significant reduction in the risk of OHSS in high risk women according to a Cochrane review of randomized studies, but the included trials did not report the live birth rates or multiple pregnancy rates. Cabergoline, as well as other dopamine agonists, might reduce the severity of OHSS by interfering with the VEGF system. A systematic review and meta-analysis concluded that prophylactic treatment with cabergoline reduces the incidence, but not the severity of OHSS, without compromising pregnancy outcomes.
The risk of OHSS is smaller when using GnRH antagonist protocol instead of GnRH agonist protocol for suppression of ovulation during ovarian hyperstimulation. The underlying mechanism is that, with the GnRH antagonist protocol, initial follicular recruitment and selection is undertaken by endogenous endocrine factors prior to starting the exogenous hyperstimulation, resulting in a smaller number of growing follicles when compared with the standard long GnRH agonist protocol.
A Cochrane review found administration of hydroxyethyl starch decreases the incidence of severe OHSS. There was insufficient evidence to support routine cryopreservation and insufficient evidence for the relative merits of intravenous albumin versus cryopreservation. Also, coasting, which is ovarian hyperstimulation without induction of final maturation, does not significantly decrease the risk of OHSS.
Volume expanders such as albumin and hydroxyethyl starch solutions act providing volume to the circulatory system 
Treatment of OHSS depends on the severity of the hyperstimulation. Mild OHSS can be treated conservatively with monitoring of abdominal girth, weight, and discomfort on an outpatient basis until either conception or menstruation occurs. Conception can cause mild OHSS to worsen in severity.
Moderate OHSS is treated with bed rest, fluids, and close monitoring of labs such as electrolytes and blood counts. Ultrasound may be used to monitor the size of ovarian follicles. Depending on the situation, a physician may closely monitor a women's fluid intake and output on an outpatient basis, looking for increased discrepancy in fluid balance (over 1 liter discrepancy is cause for concern). Resolution of the syndrome is measured by decreasing size of the follicular cysts on 2 consecutive ultrasounds.
Aspiration of accumulated fluid (ascites) from the abdominal/pleural cavity may be necessary, as well as opioids for the pain. If the OHSS develops within an IVF protocol, it can be prudent to postpone transfer of the pre-embryos since establishment of pregnancy can lengthen the recovery time or contribute to a more severe course. Over time, if carefully monitored, the condition will naturally reverse to normal– so treatment is typically supportive, although a woman may need to be treated or hospitalized for pain, paracentesis, and/or intravenous hydration.
- ^ abShmorgun, Doron; Claman, Paul (). "The diagnosis and management of ovarian hyperstimulation syndrome"(PDF). Journal of Obstetrics and Gynaecology Canada. 33 (11): – doi/s(16)x. PMID Archived from the original(PDF) on Retrieved
- ^Ovarian hyperstimulation syndrome Updated by: Linda J. Vorvick and Susan Storck Update. Also reviewed by David Zieve. Date: 7/27/
- ^Humaidan, P.; Kol, S.; Papanikolaou, E. (). "GnRH agonist for triggering of final oocyte maturation: time for a change of practice?". Human Reproduction Update. 17 (4): – doi/humupd/dmr PMID
- ^ abcdefTextbook of Assisted Reproductive Techniques, Laboratory and Clinical Perspectives, edited by David K. Gardner, [pageneeded]
- ^Severi, F.M.; Bocchi, C.; Vannuccini, S.; Petraglia, F. (). "Ovary and ultrasound: from physiology to disease"(PDF). Archives of Perinatal Medicine. 18 (1): 7– Archived from the original(PDF) on Retrieved
- ^ abcdFarquhar, Cindy; Marjoribanks, Jane (17 August ). "Assisted reproductive technology: an overview of Cochrane Reviews". The Cochrane Database of Systematic Reviews. 8: CD doi/CDpub5. ISSNX. PMC PMID
- ^Gomez, Raul (). "Low-Dose Dopamine Agonist Administration Blocks Vascular Endothelial Growth Factor (VEGF)-Mediated Vascular Hyperpermeability without Altering VEGF Receptor 2-Dependent Luteal Angiogenesis in a Rat Ovarian Hyperstimulation Model". Endocrinology. (11): – doi/en PMID
- ^Youssef MA, van Wely M, Hassan MA, etal. (March ). "Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A systematic review and meta-analysis". Hum Reprod Update. 16 (5): – doi/humupd/dmq PMID
- ^ abLa Marca, A.; Sunkara, S. K. (). "Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: From theory to practice". Human Reproduction Update. 20 (1): – doi/humupd/dmt PMID
- ^Youssef, M. A.; Mourad, S. (). "Volume expanders for the prevention of ovarian hyperstimulation syndrome". The Cochrane Database of Systematic Reviews (8): CD doi/CDpub3. PMID
- ^Ovarian Hyperstimulation Syndrome~treatment at eMedicine
Ovarian Hyperstimulation Syndrome (OHSS)
Being familiar with the symptoms of ovarian hyperstimulation syndrome (OHSS) is key to preventing a severe case. Ovarian hyperstimulation syndrome is typically mild, but it can become life-threatening. Catching the symptoms early, along with careful monitoring of your treatment cycle by your doctor, can lower the risk of serious complications.
OHSS is a potential side effect of fertility drugs, particularly with injectables (gonadotropins) taken during an IVF treatment cycle. Anywhere from 20% to 33% of women going through IVF treatment will experience ovarian hyperstimulation syndrome. However, most of these are mild cases—moderate cases occur in between 3% and 6% of IVF cycles and severe cases occur less than 1% of the time.
Some enlargement of the ovaries is normal during fertility drug treatment. With OHSS, though, the ovaries become dangerously enlarged with fluid. This fluid can leak into the belly and chest area, leading to complications. But the majority of the fluid doesn't come from the follicles themselves. Most of it comes from blood vessels that are "leaky" due to substances released from the ovary.
What to Expect Along the Path to Conceiving With IVF
Ovarian hyperstimulation syndrome can only occur after ovulation has taken place. Symptoms may occur a few days after ovulation or IVF egg retrieval, or they may not show up for a week or more after ovulation.
Mild symptoms include:
- Mild nausea
- Mild pain or discomfort in the abdomen
- Mild weight gain
More serious symptoms include:
- Rapid heartbeat
- Rapid weight gain, more than 10 pounds in 3 to 5 days.
- Severe abdominal pain
- Severe bloating
- Severe nausea (so much that you can't keep down any food or fluids)
- Shortness of breath
- Trouble with urinating
If you experience mild symptoms, you should contact your doctor as soon as possible, so he or she can monitor the situation.
If you experience any of the serious symptoms, contact your doctor immediately.
Some women are at a higher risk of developing OHSS than others. Your doctor should take these factors into account before your treatment cycle begins.
Your risk for OHSS may be higher if:
- You have PCOS.
- You're age 30 or younger.
- Your AMH levels are high.
- You've developed OHSS in the past.
- You're thin or underweight.
Prescribing lower dosages of hormones, or using alternative treatment protocols, can reduce your risk. Your doctor may also more closely monitor your cycle. Even though OHSS can only occur after ovulation, there are signs your doctor can watch for that may indicate your risk is higher during a particular treatment cycle.
For example, if your ovaries develop "too many" follicles in response to the fertility drugs, or your levels of estradiol are rising rapidly, this may indicate your risk for OHSS this cycle is high.
Your doctor may cancel your treatment cycle if they suspect your risk is high. If you're having an IUI cycle, this may mean canceling the insemination and asking you not to have sexual intercourse. If you're having IVF, any fertilized embryos from the IVF treatment cycle can be frozen and saved for use during a future cycle.
What to Do With Extra Frozen Embryos After IVF
One reason for canceling the treatment cycle is because if you get pregnant, recovery from OHSS may take longer. Pregnancy can worsen OHSS.
Another option your doctor can take is to delay ovulation by a few days. They may prescribe a GnRH antagonist, which will prevent the body's natural LH surge, preventing or delaying ovulation. Or, your doctor may simply delay administering the hCG trigger shot, a fertility drug that triggers ovulation.
Delaying ovulation to lessen the risk of ovarian hyperstimulation syndrome is sometimes referred to as "coasting." This delay of a few days can lower the risk and severity, without seriously decreasing your chances of a successful pregnancy.
Behind the Scenes of an Infertility Diagnosis
Having your treatment cycle canceled can be very disappointing. You may be tempted to have sexual intercourse against the instructions of your doctor, not wanting to "waste" the cycle. Don't do this.
OHSS can be dangerous and even life-threatening. If you develop a severe case of OHSS and get pregnant, your risk of miscarriage may also be higher.
Some of the possible complications of OHSS include:
- Dangerous blood clots (usually in the leg)
- Death (extremely rare)
- Difficulty breathing
- Fluid build-up in the lungs or abdomen
- Kidney failure
- Pregnancy loss
- Ruptured ovarian cyst
- Twisted ovary (the ovary gets so heavy with fluid, it twists on its own weight)
Prevention and Treatment
Your doctor should monitor your body's response to fertility drugs with blood tests and ultrasounds. Rapidly increasing estrogen levels or ultrasounds that show a large number of medium-sized follicles are all possible indicators of ovarian hyperstimulation syndrome risk.
If you develop a mild case of ovarian hyperstimulation syndrome, you probably won't need special treatment.
Here are some things you can do at home to feel better:
- Don't drink alcohol or caffeinated drinks, such as coffee, colas or caffeinated energy drinks.
- Don't overexert yourself; take it easy while you recover.
- Drink plenty of fluids, around 10 to 12 glasses a day. Drinks with electrolytes, such as Gatorade, are a good choice.
- Put your feet up. This can help your body get rid of the extra fluid.
- Sex should be avoided until you feel better. Sexual activity may increase your discomfort, and in the worst-case scenarios, may cause ovarian cysts to leak or rupture.
- Take over-the-counter pain relievers, such as Tylenol.
- While you shouldn't overexert yourself, you should maintain some light activity. Total bed rest can increase the risk of some complications.
Your doctor will give you instructions on what to watch for and when to contact him. If your symptoms get worse, you should definitely let them know. She may ask you to weigh yourself daily, to monitor weight gain. If you find yourself gaining 2 or more pounds per day, you should call your doctor.
How to Talk About Infertility and Miscarriage
A Word From Verywell
In rare cases, you may need to be hospitalized. Hospitalization may include receiving fluids intravenously (through an IV), and they may remove some of the excess fluids in your belly via a needle. You may also be kept in the hospital for careful monitoring until your symptoms lessen. Usually, symptoms will decrease and go away once you get your period.
If you get pregnant, though, your symptoms may be prolonged. It may take several weeks to feel completely better. Pregnancy can also make the symptoms worse, so your doctor will want to monitor your situation carefully.
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Ovulation cramp symptoms and what they mean
Cramps that occur outside of a menstrual period might be a sign that a person is ovulating. Being aware of the symptoms of ovulation may help a person identify when they are most fertile.
Ovulation cramps occur when one of the ovaries releases an egg, which typically happens halfway through a person’s cycle. Doctors sometimes call them “mittelschmerz,” which translates as “middle pain.”
In this article, we explore what ovulation cramps feel like and what they mean for fertility. We also look at other symptoms of ovulation and other causes of mid-cycle cramps.
What are ovulation cramps?
An ovary typically releases an egg about midway through a person’s menstrual cycle. This is ovulation.
For some people, ovulation creates a sensation of cramping or pain once a month on one side of the abdomen. If a person has these cramps every month, the sensation may switch sides from month to month, depending on which ovary releases the egg.
Ovulation cramping may happen before, during, or shortly after the release of an egg.
Not everyone who menstruates has ovulation cramps. According to the University of Florida, about 1 in 5 people who menstruate have cramping around the time of ovulation.
Some people do not experience the cramping every month or do not have the same amount of discomfort every month.
Ovulation cramping may occur if:
- the follicle where the egg develops stretches the ovary
- the release of blood and other fluid from the ovary irritates surrounding tissue
The sensation of ovulation cramping can range from mild discomfort to intense pain. It may be difficult to identify the cause of the pain, especially if ovulation cramps do not occur every month.
The primary symptom of ovulation cramping is pain on one side of the abdomen, and this typically lasts . However, a person who has had ovarian surgery may experience the pain until menstruation.
Below are characteristics of ovulation cramping:
- pain or cramping on one side of the abdomen
- pain or cramping that starts midway through the menstrual cycle
- pain or cramping that switches sides, month by month
- pain that is sharp and may be severe
Ovulation pain and fertility
Ovulation pain occurs right before, during, or right after the release of an egg, which is also when a female is most likely to become pregnant. As a result, the sensation may help with recognizing fertility.
However, people who do not want to conceive should not use ovulation cramps to determine when it is safe to have unprotected sex — this method is not accurate, the University of California note, and could result in unintended pregnancy.
Other ovulation symptoms
Some people who menstruate do not experience any discomfort during ovulation.
A person might also recognize that they are ovulating by the following signs:
- increased cervical mucus
- breast tenderness
- spotting or light bleeding
- increased libido
- increased basal body temperature
Ovulation cramps vs. implantation cramps
Ovulation cramps occur when one ovary releases an egg. If sperm do not fertilize the egg, the menstrual cycle continues: the egg breaks and the uterus sheds its lining.
If sperm do fertilize the egg, the fertilized egg attaches to the lining of the uterus. This attaching is called “implantation.”
Implantation can cause cramping. It can also cause a small amount of bleeding or spotting, which can occur 3–14 days after fertilization. Implantation bleeding is typically brownish and the flow is light.
Beyond implantation bleeding and cramping, early pregnancy can cause:
- a frequent urge to urinate
Other causes of cramps
Various health conditions cause abdominal cramps, which may happen to occur in the middle of the menstrual cycle and resemble ovarian cramping.
Some other causes of abdominal cramping or pain include:
- acute appendicitis, which can present with to ovulation cramps
- endometriosis, which involves uterine lining tissue growing outside the uterus and affects at least of females in the United States ages 15–44
- uterine fibroids, which are noncancerous growths in the walls of the uterus and can cause pain, bleeding, and a feeling of fullness in the abdomen
Ovulation cramps typically go away on their own. To relieve the pain, the following can often help:
- over-the-counter pain medications, such as ibuprofen (Advil)
- a warm compress or bath
- hormonal contraceptives that prevent ovulation
When to see a doctor
If ovulation cramps go away within a few hours, a person usually does not need medical attention.
A person should contact a healthcare provider if they have cramping and:
- pain that lasts longer than 24 hours
- unusual vaginal bleeding
- painful urination
- have missed a period
Ovulation cramping is often mild and goes away after a few hours. It can let people who want to conceive know that the time might be right.
However, people who do not want to conceive should not rely on ovulation cramps to indicate fertility. This is not an effective way to time unprotected sex.
If the cramping or pain is intense, a warm bath and over-the-counter pain medication may help. Anyone who experiences severe pain or cramps accompanied by vomiting or unusual bleeding should contact a doctor.
Symptoms pain hyperovulation
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Have you ever noticed a twinge or ache on one side of your lower abdomen? Did it happen a couple of weeks before your period? It could be ovulation.
Ovulation pain, sometimes called mittelschmerz, can feel like a sharp, or like a dull cramp, and happens on the side of the abdomen where the ovary is releasing an egg (1–3). It generally happens days before the start of your period, is not dangerous, and is usually mild. It generally lasts a few hours, and for some people can last a few days.
Tracking ovulation pain in the Clue app can help you determine when to expect it.
Clue’s research finds that 1 in 3 people regularly track ovulation pain.
Ongoing research by Clue collaborator Ruben Arslan at the Max Planck Institute has found that about 1 in 3 people—36% to be exact—regularly track ovulation pain in Clue. (This is of Clue users not taking hormonal birth control who track relatively consistently).
Other interesting findings about ovulation pain:
People will often not feel it in every cycle. This is similar to what's been found in other small-sample research.
People who track ovulation pain often reported in about half of their cycles. Others report it in every cycle.
Most people track ovulation pain for just one day per cycle, but some track it for two or more.
Download Clue to track ovulation pain.
Can ovulation pain help predict the timing of ovulation?
Statistically, the timing of ovulation pain tracked in Clue seems to be fairly promising as a predictor of ovulation. This doesn’t mean you should incorporate it into your fertility awareness method just yet—but it’s interesting for researchers.
In alignment with previous research that used ultrasounds to determine the day someone ovulated, people in Clue most often tracked ovulation pain on the day just before an estimated ovulation. This may be an additional finding to support one theory of why ovulation pain happens—follicular growth pressure (we describe this below). But more research is needed to know for sure.
Others track ovulation pain on the same day as their estimated ovulation in Clue, or outside of that window altogether. The timing of ovulation is estimated by luteinizing hormone (LH) tests, or retroactively by the date of the start of the next period. Both these methods can be inexact (ultrasound is considered the gold standard).
This is the largest dataset of recorded ovulation pain to be included in research, ever.
Seeing what aligns with or differs from small-sample studies is a novel and exciting endeavor that will help pave the way for future findings.Thanks to all Clue users who contribute to this research through tracking.
How to treat ovulation pain
There are no official treatment recommendations for ovulation pain, and for most people it’s not painful enough or too short-lived to bother with pain treatment.
If that’s not the case for you, an over-the-counter pain medication might help. A hot compress or a bath may also help relieve the pain for some people. If the pain is severe enough, talk to your healthcare provider. Hormonal medications are sometimes used to stop ovulation if other methods haven’t worked and the pain is getting in the way of someone’s day-to-day life.
What causes ovulation pain?
Researchers still don’t know exactly what causes ovulation pain. Attempts to answer this question in medical literature date back to the mids. Over a century later, the answer is still unclear.
Here are some theories for the cause.
Tension of a growing follicle on the ovary, and the inflammatory response that tension creates (4).
Follicles are sacs that contain your eggs. They typically grow to be about two centimeters in diameter before they’re released into the fallopian tube (5–8). Prostaglandins (the same inflammatory compounds involved in menstruation) are produced as the ovarian muscle contracts around the growing follicle, possibly causing pain.
Research that used ultrasounds to determine the timing of ovulation found that ovulation pain was typically felt around the time of the luteinizing hormone (LH) peak, about hours before ovulation (4). The pain came and went before the follicle ruptured. This has been challenged in other studies.
The release of the egg itself is also an inflammatory event, but it’s not considered as a probable source of ovulation pain. Prostaglandins may help facilitate the release of the egg as the follicle's tissue breaks down so the egg can pass (9). Research has found that taking high doses of anti-inflammatory pain medication leading up to ovulation may actually prevent it from occurring (10).
Irritation of the abdominal cavity from the follicle’s blood when it ruptures to release the egg (1).
Ultrasound evidence in one study found that in 2 in 3 cycles, 5ml of fluid was visible in the abdomen. These cycles were more likely to be associated with ovulation pain. The “fluid” is suspected to be blood, and is released when the follicle releases an egg. They found this fluid could be seen for up to two days after ovulation (1).
There was also a theory that cramps in the uterus, fallopian tubes, or large bowel caused the pain (4), but this has been largely disregarded.
How to know whether you’re feeling ovulation pain
Track the timing of it with your cycle
Some people feel ovulation pain for the first time when they first begin menstruating. For others it begins later in life, but is most common in people under the age of 30 (3).
For some people, ovulation pain happens around the same time each cycle (when it does happen). For others, it’s more irregular. This depends on the regularity of ovulation. The pain is typically reported just before ovulation occurs.
For some people, ovulation pain is also accompanied by ovulation bleeding (3).
2. Track whether you feel it on the left side, right side, or both
Ovulation pain is typically felt on the side of the ovary that is releasing an egg that cycle.
For about half of women, ovulation alternates between the left and right ovary (11), which may explain why some people report that it alternates from side to side (3).
In the other half, ovulation side is more random, meaning it doesn’t just go back and forth between. Even so, each ovary usually ends up ovulating just as much as the other overall (11).
Most people feel the pain on one side or the other, but others have reported feeling it on both sides at the same time, but with more pain on one side than the other (12). People have also reported equal ovulation pain on both sides in some cycles, possibly indicating cycles in which each ovary releases its own egg.
Some people might only ever feel pain on one side or another, since it’s possible that only one ovary is a source of pain. One early (read: macabre, cringeworthy) study found that the pain was sometimes resolved in early treatments where a single ovary was surgically removed (3). A theory is that some people may have adhesions on only one of two ovaries (2). Adhesions could restrict the follicles or ovary somehow, and pain is felt when the LH spike occurs to trigger ovulation.
3. Track how long it occurs
Most people report that their ovulation pain lasts between 6 and 12 hours (4). In Clue, the majority of people who track ovulation pain do so for only one day. Others track it for two or more days, but it’s difficult to know to what extent other factors play a role, such as ovulatory pain due to endometriosis.
4. Track the sensation or severity
The sensations or pain of ovulation is as unique as the person who experiences it. For some, it’s not painful, but just uncomfortable—some have described it as a sense of fullness or tension (3). For others, it’s been described as cramp-like, sharp, dull, and intermittent. It’s mild for most but more acute and painful for others (1,3).
You can track severity of ovulation pain by using the custom Tags option in Clue.
Other causes of pain in the general area of your ovaries
An appendicitis, ectopic pregnancy, or complications of an ovarian cyst can all have similar symptoms as ovulation pain, but tend to be more severe and unexpected. These conditions require immediate medical treatment. Ongoing pelvic pain can be a sign of a condition or infection such as pelvic inflammatory disease or endometriosis, which also require treatment or management from a healthcare provider.
People with ovarian cysts have follicles that grow large and can rupture. Ovarian cyst ruptures are similar to ovulation, but they are associated with irregular ovulation, involve abnormally large cysts, and tend to be more severe. The rupture causes moderate to severe pain and can lead to other complications (13). Ovarian cysts are not uncommon, and can be caused by some types of hormonal birth control, like hormonal IUDs (14, 15). Other types of hormonal birth control that stop ovulation are sometimes used to treat persistent ovarian cysts. Talk to your healthcare provider about any moderate to severe abdominal pain.
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- Hann LE, Hall DA, Black EB, Ferrucci JT. Mittelschmerz: sonographic demonstration. JAMA. Jun 22;(25)
- Marinho AO, Sallam HN, Goessens L, Collins WP, Campbell S. Ovulation side and occurrence of mittelschmerz in spontaneous and induced ovarian cycles. British medical journal (Clinical research ed.). Feb 27;()
- Wharton LR, Henriksen E. Studies in ovulation: the operative observations in periodic intermenstrual pain. Journal of the American Medical Association. Oct 31;(18)
- O'Herlihy C, Robinson HP, De Crespigny LJ. Mittelschmerz is a preovulatory symptom. British medical journal. Apr 5;()
- Lujan ME, Kepley AL, Chizen DR, Lehotay DC, Pierson RA. Development of morphologically dominant follicles is associated with fewer metabolic disturbances in amenorrheic women with polycystic ovary syndrome: a pilot study. Ultrasound in Obstetrics & Gynecology. Dec 1;36(6)–
- Macklon NS, Fauser BC. Regulation of follicle development and novel approaches to ovarian stimulation for IVF. Human Reproduction Update. Jul 1;6(4)–
- Ojengbede OA, Abidogun KA, Fatukasi UI. Ultrasound monitoring of ovarian follicular growth during spontaneous cycles in Nigerian women. African journal of medicine and medical sciences. Dec;21(2)–
- Kerin JF, Edmonds DK, Warnes GM, Cox LW, Seamark RF, Matthews CD, Young GB, Baird DT. Morphological and functional relations of Graafian follicle growth to ovulation in women using ultrasonic, laparoscopic and biochemical measurements. BJOG: An International Journal of Ob stetrics & Gynaecology. Feb 1;88(2)–
- Jones RE, Lopez KH. Human reproductive biology. Academic Press; Sep
- Norman RJ. Reproductive consequences of COX-2 inhibition. The Lancet. Oct 20;()
- Ecochard R, Gougeon A. Side of ovulation and cycle characteristics in normally fertile women. Human Reproduction. Apr 1;15(4)
- Krohn PL. Cyclical intermenstrual pain: The Mittelschmerz. The Journal of Clinical Endocrinology & Metabolism. Jun 1;14(6)
- Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best practice & research Clinical obstetrics & gynaecology. Oct 1;23(5)
- Product monograph Mirena. Mississauga: Bayer; Available from: https://www.bayer.ca/omr/online/mirena-pm-en.pdf
- Inki P, Hurskainen R, Palo P, Ekholm E, Grenman S, Kivelä A, Kujansuu E, et al. Comparison of ovarian cyst formation in women using the levonorgestrel-releasing intrauterine system vs. hysterectomy. Ultrasound Obstet Gynecol. Oct;20(4)
Horror !!!), I thought: would I like to see them ALL now ?. The answer is: I would like to. But NOT ALL.
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Letting her go in a circle in the company and putting her in different poses with an approach from all sides. Sex with the guest this time was banal and not long, and after they finished her again, they just got dressed and sat in their places in waiting for my return.
Of course, after having smoked what I saw, our friend quickly got ready and unfortunately left. Although, as I understood from the words of my wife and her desire, we could try to fuck her together all night, and I even think, at the same.