A 30-year-old woman with PCOS and infertility undergoes IVF stimulation with gonadotropins. On day 8 of stimulation, she has 18 follicles ≥11 mm. Her estradiol is 4,800 pg/mL. She is at high risk for ovarian hyperstimulation syndrome (OHSS). Which trigger is recommended instead of hCG to minimize severe OHSS risk in GnRH antagonist protocols?

• A GnRH agonist trigger (e.g., leuprolide 2 mg SC) to induce an endogenous LH/FSH surge ✓
• B Kisspeptin 6.4 nmol/kg IV as a physiological trigger
• C Recombinant LH 75 IU SC daily for 2 days
• D Progesterone vaginal supplementation to trigger luteal phase

Explanation

In GnRH antagonist IVF protocols, the final oocyte trigger can be switched from exogenous hCG (which has a long half-life of 36 hours, prolonging corpus luteum stimulation) to a GnRH agonist trigger (e.g., leuprolide acetate 2 mg SC or triptorelin 0.2 mg SC). The GnRH agonist triggers an endogenous pituitary LH and FSH surge, which is shorter in duration (24–36 hours) than exogenous hCG and does not sustain corpus luteum stimulation, dramatically reducing the risk of late-onset OHSS. The limitation is reduced endogenous progesterone support, necessitating more intensive luteal support. This strategy is particularly recommended in high-risk OHSS patients (high AFC, high AMH, high estradiol, previous OHSS). Kisspeptin has been investigated but is not standard practice.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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