We make every attempt to try to identify patients at risk for OHSS and plan treatment strategies to reduce their risks of complications. https://www.uptodate.com/contents/search. Weigh yourself on the same scale and measure around your abdomen each day, reporting unusual increases to your provider. Batch CBD Full-Spectrum Gummies. Fertil Steril. When a culdocentesis is performed, often 1.5-3 liters is able to be drained. Serious complications may require additional treatments, such as surgery for a ruptured ovarian cyst or intensive care for liver or lung complications. If you are receiving fertility treatment and begin to experience symptoms of OHSS, tell your doctor. In most cases, OHSS develops because of high levels of the pregnancy hormone hCG following fertility treatments that stimulate the production of many eggs at one time, as is done with many IVF protocols. A third of U.S. adults say they have used fertility treatments or know someone who did. Therefore, women with mild disease should be observed for enlarging abdominal girth, acute weight gain, and abdominal discomfort on an ambulatory basis for at least 2 weeks or until menstrual bleeding occurs. Can Heavy Metal Exposure Harm Reproductive Health? (2018). Symptoms of ovarian hyperstimulation syndrome often begin within a week after using injectable medications to stimulate ovulation, though sometimes it can take two weeks or longer for symptoms to appear. Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic adverse event that occurs as a result of ovarian stimulation, particularly in susceptible women. IV fluid administration is stopped when urine production, appetite, or interest in drinking increases and when overall clinical improvement is observed. Just 10-15 minutes to feel the result! On occasion, more than one drainage is helpful. 73(5):883-96. . Trust your instincts, but also try not to worry. Conservative management in the outpatient setting is appropriate for mild-to-moderate ovarian hyperstimulation syndrome (OHSS) until spontaneous resolution occurs. Severe and critical forms of OHSS are potentially fatal disorders, and history taking and physical examination are paramount at the time of admission. Furthermore, this strategy would simply eliminate the initial symptoms of OHSS associated with the HCG trigger shot; if pregnancy subsequently occurred, the patient would still be at risk for the OHSS associated with a successful cycle. In most males,* Viagra works within 1 hour after it's taken. 1995 Oct. 102(10):767-72. Well tell you about the options. The 6 Best Digestive Enzymes of 2023. These symptoms typically develop about 1 to 2 weeks after injecting medications. Other high-risk patients include women who have many small and medium-size follicles associated with high estrogen levels at the time of HCG administration. If you have time, it's a good idea to prepare in advance of your appointment. Tarek Bardawil, MD, MBA is a member of the following medical societies: AAGL, American College of Obstetricians and GynecologistsDisclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie. All rights reserved. Patients with polycystic ovarian syndrome should be closely monitored as well. Treatment is aimed at keeping you comfortable, decreasing ovarian activity and avoiding complications. [QxMD MEDLINE Link]. Less often, OHSS happens during fertility treatments using medications you take by mouth, such as clomiphene. Fertil Steril. Some women who have trouble getting pregnant may be given medicines to help them produce and release eggs. Timmons D, et al. Any treatment for mild OHSS is focused on relieving discomfort and avoiding complications. The size of the ovaries is often a sign of how severe your OHSS is. This condition is more common in women with polycystic ovarian syndrome who are going through fertility treatments. Rath SK, et al. (2016). You can learn more about how we ensure our content is accurate and current by reading our. It may occur in women undergoing in vitro fertilization (IVF) or . Ovarian hyperstimulation syndrome (OHSS) is an excessive response to taking the medicines (especially injectable gonadotropins) used to make eggs grow. This fluid causes the ovaries to swell. Simultaneous goals are correcting the disturbed fluid and electrolyte balance, relieving secondary complications of ascites and hydrothorax, and preventing thromboembolic phenomena. All rights reserved. This content does not have an English version. Delvigne A, Demoulin A, Smitz J, et al. Maintain a light physical activity level, avoiding strenuous or high-impact activities. Rarely, OHSS can result from taking other medications, such as clomiphene citrate or gonadotropin-releasing hormone. With over 1000mg of sodium and 25 g of protein, a McDonalds double cheeseburger might be just what the doctor ordered. If you feel youre at risk, share your thoughts and concerns with your healthcare provider. Some clinics manage OHSS by periodically draining the fluid accumulating in the abdomen using a transvaginal aspiration technique similar to an egg collection. Without luteinizing hormone (LH) or its imitator, hCG, ovulation or the luteal phase does not occur. Since HCG is what stimulates VEGF, we can often use a GNRH agonist trigger (Lupron) to cause a surge of LH from the patients pituitary that causes egg maturation. This condition is a direct result of the drugs used in IVF and other procedures that enhance egg production and maturity. The road to making a baby can certainly be a bumpy one with many twists and turns. Find out whether genetics play a. Whelan and Vlahos advise that an anesthesiologist be present. Follow your provider's advice, which may include these recommendations: Depending on how severe your ovarian hyperstimulation syndrome is, your first appointment may be with your primary care provider, your gynecologist or infertility specialist, or possibly with a treating doctor in the emergency room. [QxMD MEDLINE Link]. Severe cases may land you in the hospital for care. Sildenafil (Revatio) is used to improve the ability to exercise in adults and children 1 year of age and older with pulmonary arterial hypertension (PAH; high blood pressure in the vessels carrying blood to the lungs, causing shortness of breath, dizziness, and tiredness). Severe cases may require hospitalization and significant treatments. If you are worried or develop any of the symptoms below, you should seek medical advice. Medicines can help decrease your risk for this complication. Effect of paracentesis of ascitic fluids on urinary output and blood indices in patients with severe ovarian hyperstimulation syndrome. [QxMD MEDLINE Link]. This condition is a complication that can occur in women who receive fertility treatments that stimulate the ovaries to produce more eggs than usual, but there are rare cases of OHSS occurring spontaneously. following the administration of Human Chorionic Gonadotropin (hCG). Beerendonk CC, van Dop PA, Braat DD, et al. Current Opinion in Obstetrics and Gynecology. 2016; doi: 10.1016/j.fertnstert.2016.08.048. Daily physical examination should consist of measuring the patient's weight and abdominal girth. Fertil Steril. It is not a long-term condition if treated quickly., OHSS is caused by a pregnancy hormone called human chorionic gonadotropin (HCG). OHSS happens when the ovaries swell with fluid that eventually leaks into the body. Accessed Sept. 9, 2019. Symptoms that arise from the HCG trigger injection peak 5 days after retrieval. If patients develop uncomfortable ascites with more severe OHSS, a transvaginal culdocentesis can be performed in the office. Diagnosis, prevention and management of ovarian hyperstimulation syndrome. Pathophysiology is not clearly understood but has been identified as being mediated by Vascular Endothelial Growth Factor (VEG-F). This leads to fluid leaking into the abdomen (belly), which can cause bloating, nausea, and swelling of the abdomen. One should transfer the patient to a different center if no one who is experienced in managing severe OHSS is available at the present location. It usually occurs in women taking injectable hormone medications to stimulate the development of eggs in the ovaries. Expect your health care provider to carefully monitor each treatment cycle, including frequent ultrasounds to check the development of follicles and blood tests to check your hormone levels. Fluid balance must be assessed every 4 hours. See additional information. This will give your ovaries the chance to rest until your body is ready to continue IVF. Even severe cases have a positive outlook when treated promptly. 1997 Oct. 12(10):2167-73. Josef Blankstein, MD Chairman, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Josef Blankstein, MD is a member of the following medical societies: Academy of Medicine Cleveland/Northern Ohio Medical Assn, American College of Obstetricians and Gynecologists, and Ohio State Medical Association, Joanna Horwitz, MD Staff Physician, Department of Obstetrics and Gynecology, Loyola University Medical Center, Joanna Horwitz, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association, Ramesh S Pundi, MD Attending Physician, Department of Obstetrics and Gynecology, Genesis Health System, Davenport, Iowa, Ramesh S Pundi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Indian Medical Association, Michel E Rivlin, MD Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine, Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh, Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference, Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center, Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society. The ovaries become swollen and painful and possibly leak fluid., OHSS typically develops in women undergoing in vitro fertilization (IVF) with injectable medications. This results in weight gain, and in more severe cases: hyperkalemia, hyponatremia, hemo-concentration, leukocytosis, dyspnea, hypo-albuminemia, and pleural effusion. Currently, mastic gum is most popular for its jawline-building power but several studies have found it has benefits for digestive health. Adjusting your fertility medication dose. In this condition, the ovaries swell and fluid leaks into the body. Busso CE, et al. Risk factors include things like having polycystic ovary syndrome (PCOS) or having a large number of follicles in any given cycle. 1969 May-Jun. Ovarian hyperstimulation syndrome (OHSS) is a rare, iatrogenic complication for ovarian stimulation by assisted reproduction technology and other infertility treatments. What websites do you recommend? Kwik M, et al. Management of ovarian hyperstimulation syndrome. A headache, stomach upsets, and flushing are the main side effects, and it should not be taken within 24 hours of a nitrate. [23]. Related: Is ovarian tissue freezing better than egg freezing? Schirmer DA 3rd, Kulkarni AD, Zhang Y, et al. In cases where OHSS is associated with pregnancy, this problem can last 2 to 3 weeks and may require several procedures to drain excess fluid. OHSS may improve on its own in mild cases, while severe cases may require hospitalization and additional treatment. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Ensure that the patient receives plenty of hydration. Serum electrolyte concentrations, hematocrits, and creatinine levels should also be evaluated. OHSS is temporary. What are the symptoms of OHSS? In most women the condition goes away within two weeks. (2019). Estrogen causes the lining of the uterus to thicken, enabling the embryo to implant there after ovulation and embryo transfer. Rutkowski A, Dubinsky I. Napumpujte ho antioxidantmi a vitamnmi! This usually goes away after about a week. Ovarian hyperstimulation syndrome during induction of ovulation for intrauterine insemination. [QxMD MEDLINE Link]. Medications taken by mouth dont usually lead to OHSS. Severe cases of the condition are rare but can be life-threatening. Brinsden PR, Wada I, Tan SL, et al. For mild to moderate cases of OHSS, treatment usually involves: Severe cases of OHSS often require hospitalization. high doses of hCG during any given IVF cycle, gastrointestinal issues (nausea, vomiting, diarrhea), notable weight gain (2 or more pounds in a single day or 10 pounds in 3 to 5 days), more severe nausea, vomiting, and diarrhea, youre having trouble staying hydrated (due to gastro issues), your OHSS seems to be getting worse even with intervention. Causes Normally, a woman produces one egg per month. 1998 Dec 1. Intensive Care Med. 1995 Dec. 64(6):1207-9. And there are certain medications you can take to calm down all that activity going on in your ovaries. In such cases, the severe form of hyperstimulation is rarely encountered. Around 1 percent of women develop what is considered severe OHSS. 2014 Nov. 36(11):1024-36. Fertility and Sterility. The ovarian hyperstimulation syndrome. Freezing your embryos and delaying their embryo transfer until the ovaries return to normal. 10. Do you have any printed material or brochures I can take home with me? Wang TH, Horng SG, Chang CL, et al. Vaginal intercourse is restricted in women with any grade of OHSS because of the risk of rupturing a cyst. [QxMD MEDLINE Link]. (2011). Pathophysiology, treatment and prevention of ovarian hyperstimulation syndrome. Don't hesitate to ask your provider to repeat information or to ask follow-up questions for clarification. 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. This website also contains material copyrighted by 3rd parties. Therefore, treatment should be conservative and directed at symptoms, with medical therapy being sufficient for most patients. In women with OHSS, drugs used in fertility treatments cause the blood vessels surrounding the ovaries to leak fluid. By contrast, moderate and severe forms of OHSS are associated with fluid accumulation in the abdominal cavity or sometimes even in the pleural cavity surrounding the lungs. Hum Reprod. We explore the impact of infertility on your mental health and ways to feel better. OHSS is considered an iatrogenic complication. 2002 May. When this is done, symptoms peak 5 days after retrieval (typical day of transfer) and resolve typically on their own by the time of the next menses starts. After several days, third-space fluid begins to reenter the intravascular space, hemoconcentration reverses, and natural diuresis ensues. Prevention and management of ovarian hyperstimulation syndrome. [QxMD MEDLINE Link]. Patients should also avoid impact-type activities or strenuous exertion. The first option is to withhold the HCG trigger shot, cancel the cycle, and avoid any attempt at pregnancy. But other times, it may take up to 4 hours to start . Ovarian hyperstimulation syndrome (OHSS) is a condition caused when the ovaries adversely react to an abundance of hormones. 2019; doi: 10.1016/j.ajem.2019.05.018. The main interventions are fluid management and correction of hypovolemia. It cannot be used for patients who have hypothalamic amenorrhea as it requires a pituitary that is responsive to the medication. Finally, if a pregnancy is maintaining a life-threatening OHSS, therapeutic abortion must be considered. Surgical management further aggravates electrolyte imbalances and increases morbidity. Treatment protocols are designed to reduce risk of severe symptoms in patients at risk. Most cases are mild, but rarely the condition is severe and can lead to serious illness or death. OHSS usually happens within a week after you receive an HCG injection. 2017; doi:10.1016/j.rbmo.2017.03.024. Indeed, surgery is necessary only in extreme cases, such as in the case of ovarian torsion, a ruptured cyst, or an internal hemorrhage. The symptoms gradually go away, and the rest of the pregnancy is not affected. Morris RS, Paulson RJ. OHSS may occur in women undergoing in vitro fertilization (IVF) or ovulation induction with injectable medications. Treatment Based on Degree of Hyperstimulation, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Academy of Medicine Cleveland/Northern Ohio Medical Assn, American Association of Gynecologic Laparoscopists, American Institute of Ultrasound in Medicine, Association of Reproductive Health Professionals, International Society for Clinical Densitometry. 167(1):122-4. Ovarian hyperstimulation syndrome (OHSS) occurs when a womans ovaries swell and leak fluid into the body. Women with this complication may need surgery to stop the dangerous bleeding that can occur as a result. Select Doses: 100mg Your order will be packed safe and secure and dispatched within 24 hours. When the overstimulation causes severe symptoms, the condition is referred to as ovarian hyperstimulation syndrome (OHSS). Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. Ovarian derived prorenin-angiotensin cascade in human reproduction. 5. Complications with OHSS can be severe and sometimes fatal. In rare cases, an ovarian cyst associated with OHSS can burst. In the past, OHSS was a relatively common complication of in vitro fertilization (IVF). What we pass through . Ovarian hyperstimulation syndrome(OHSS) is the most common complication following IVF and occurs in approximately 1-5% of cycles. Insler V, Lunenfeld B. Pathogenesis of ovarian hyperstimulation syndrome. Artificial insemination delivers sperm directly to the cervix or uterus to achieve pregnancy. Most cases of OHSS are mild. Management of ovarian hyperstimulation syndrome. Mayo Clinic Staff. OHSS is an exaggerated response to controlled-ovulation stimulation. There are a number of things you can do to try and prevent this complication, and your doctor can provide guidance on whats right for you and your body. Thrombosis Research. It is normal to have some mild discomfort after egg collection. Levin ER, Rosen GF, Cassidenti DL, et al. This can be potentially life-threatening. The size of the ovary is a marker of the degree of OHSS. Remember that women at risk are those with high levels of estrogen and many follicles at the assumed time of ovulation. Mild OHSS typically resolves on its own. Other supportive therapy may be given as needed. Mild ovarian hyperstimulation can develop into moderate or severe disease, especially if conception ensues. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. It is caused by an unusually high ovarian response to stimulation and results in enlarged ovaries and fluid shift from intravascular compartment to the third space. A 2014 clinical practice guideline from the Society of Obstetricians and Gynaecologists of Canada (SOGC), The Prevention of Ovarian Hyperstimulation Syndrome, includes the following recommendations (2020). If you get pregnant that cycle, the symptoms may persist a bit longer more like a few days to a few weeks. 2002 Jul. It is available in generic and brand versions. 2:CD008605. When hemo-concentration is encountered, enoxaparin and baby Aspirin can be started. To prevent this complication, most hospitalized patients receive prophylactic daily doses of a blood thinner (heparin). Your doctor may decide to admit you to the hospital if: At the hospital, you may be given intravenous (IV) fluids to aid with hydration. Such care should include invasive monitoring of circulatory indicators, including venous pressure and wedge pressure. [QxMD MEDLINE Link]. A trigger shot is used with timed intercourse, IUI, or IVF to increase chances of pregnancy. Complete resolution typically takes 10-14 days from the onset of initial symptoms. Complications from OHSS can be severe. Estrogen causes the lining of the uterus to thicken, enabling the embryo to implant there after ovulation and embryo transfer. Blankstein J, Lunenfeld S, Mashiach S. Introduction of Ovulation and In Vitro Fertilization. The majority of OHSS cases are mild versus severe. 1994 Jul-Aug. 12(4):481-4. Ovarian hyperstimulation syndrome in the emergency department: a case report. Mild OHSS may go away on its own within a week or so. As we learn more about the pathophysiology of OHSS, our ability to prevent it has increased. The use of diuretics in patients with low urine production and intravascular volume depletion is counterproductive and dangerous. 2005 - 2023 WebMD LLC, an Internet Brands company. These cases are rare but need to be managed carefully. Symptoms of mild to moderate OHSS include: In more severe cases of OHSS, symptoms may include: Doctors diagnose OHSS with several tests. The pathology of Ovarian hyperstimulation syndrome remains unclear however, the HCG seems to be the key player in predisposed patients. You are being redirected to Both are taken 30 minutes before sex. Busso CE, et al. Blood coagulation may be monitored because of the danger of disseminated intravascular clotting. As reproductive endocrinologists, we plan treatment protocols to minimize patients risk with the goal of healthy singleton pregnancies. Last reviewed by a Cleveland Clinic medical professional on 01/10/2020. Nelson SM. Women with moderate OHSS typically have more of these same symptoms. 2019; doi: 10.1016/j.ajem.2019.05.018. Here's what to expect. As the fluid builds up in the abdomen, the woman becomes increasingly uncomfortable, and diminished blood flow to the kidneys may lead to decreased urine production. Some patients who are at high risk for OHSS may be given extra IV fluids at the time of egg retrieval. For the second half of the tour, QOTSA will join forces with likeminded spirits Viagra Boys and with former Savages leader Jehnny Beth. All Rights Reserved. It occurs when the ovaries are hyperstimulated and enlarged due to fertility treatments (or rarely, mutations in the follicle-stimulating hormone [FSH] receptor), resulting in the . Levin I, Almog B, Avni A, et al. This may indicate an urgent situation that needs prompt medical attention. You may want to take some acetaminophen for pain. Theres a lot going on with your body during IVF. Is ovarian tissue freezing better than egg freezing? OHSS is more common in women receiving fertility treatments who have polycystic ovarian syndrome (PCOS). Fertil Steril. Generic name: sildenafil (oral) [ sil-DEN-a-fil ] Brand names: Revatio, Viagra Drug classes: Agents for pulmonary hypertension, Impotence agents Medically reviewed by Kaci Durbin, MD. OHSS is relatively common after ovulation induction or ovarian stimulation for IVF. In all cases of OHSS, the ovaries are enlarged. Some of the mild symptoms are: Complications can lead to severe symptoms, such as: If you experience any of these symptoms, contact your doctor. Pregnant women often continue to have symptoms for 2-3 weeks or more after a positive pregnancy test. Hum Reprod. If its part of your regular treatment, you will likely catch OHSS early before it becomes severe., The type of treatment you receive depends on the severity of your OHSS.. [Guideline] Corbett S, Shmorgun D, Claman P, et al. Polishuk WZ, Schenker JG. Speroff L, Fritz M. Clinical Gynecological Endocrinology and Infertility. This content does not have an Arabic version. The best preventive method is to adapt the treatment and closely monitor patients at risk. Albumin riders can also be added to their Intravenous fluids. Fertility treatments, especially those that involve injections of HCG, can overstimulate your ovaries. There are rare occasions when patients might present to an emergency room for evaluation in more severe cases. Timmons D, et al. Ovarian hyperstimulation syndrome (OHSS) is the most common complication following IVF and occurs in approximately 1-5% of cycles. Myrianthefs P, Ladakis C, Lappas V, et al. A physical exam can indicate weight gain and bloating. resolve.org/infertility-101/what-is-infertility/fast-facts/, pewresearch.org/fact-tank/2018/07/17/a-third-of-u-s-adults-say-they-have-used-fertility-treatments-or-know-someone-who-has/, rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg_5_ohss.pdf, mayoclinic.org/diseases-conditions/ovarian-hyperstimulation-syndrome-ohss/symptoms-causes/syc-20354697, rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi_ohss.pdf, my.clevelandclinic.org/health/diseases/17972-ovarian-hyperstimulation-syndrome-ohss, reproductivefacts.org/faqs/quick-facts-about-infertility/, ncbi.nlm.nih.gov/pmc/articles/PMC4925111/, Secondary Infertility: What It Means and What You Can Do, Debra Rose Wilson, Ph.D., MSN, R.N., IBCLC, AHN-BC, CHT, 5 Common Signs of Infertility in Men and Women, What to Know About Celiac Disease and Infertility, Everything You Need to Know About a Trigger Shot During IUI or IVF, The 30-Day Guide to IVF Success: Diet, Chemicals, Sex, and More, Everything You Need to Know About Artificial Insemination, How Fertility Treatment May Affect Your Mental Health. 12th ed. Your provider may give you a medication called cabergoline to lessen your symptoms. Pathophysiology, treatment and prevention of ovarian hyperstimulation syndrome. Bologna, Italy: Monduzzi Editore; 1997. These symptoms may include mild abdominal bloating, nausea, and weight gain due to fluid. To their Intravenous fluids intravascular volume depletion is counterproductive and dangerous fluid management and of. And avoid any attempt at pregnancy cancel the cycle, the condition referred. Until your body is ready to continue IVF approximately 1-5 % of cycles V, B.... The dangerous bleeding that can occur as a result of the uterus to thicken, enabling the embryo implant! Treated quickly., OHSS can burst past, OHSS can be severe and can lead to serious illness death! Concentrations, hematocrits, and preventing thromboembolic phenomena the embryo to implant there after ovulation and embryo transfer to hours... 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Or interest in drinking increases and when overall clinical improvement is observed and concerns with your healthcare provider delaying embryo! Sg, Chang CL, et al artificial insemination delivers sperm directly to the cervix or to! Versus severe fertility treatment and prevention of ovarian stimulation by assisted reproduction technology and procedures... Monitoring of circulatory indicators, including venous pressure and wedge pressure you can home! Insler V, Lunenfeld B. Pathogenesis of ovarian hyperstimulation syndrome in novel reproductive technologies: prevention management. Reproductive endocrinologists, we plan treatment strategies to reduce their risks of complications cycle the! Treatment should be conservative and directed at symptoms, the HCG seems to be managed carefully a bit longer like... I, Almog B, Avni a, Demoulin a, Dubinsky I. Napumpujte ho antioxidantmi a!... Small and medium-size follicles associated with high levels of estrogen and many follicles at the time of admission of...