In patients with PCOS undergoing ovulation induction with gonadotropins, a particular protocol minimizes ovarian hyperstimulation syndrome (OHSS) risk by avoiding an LH surge. Which protocol best achieves this while preserving cycle efficacy?

• A Step-down protocol with high initial FSH dose reducing to maintenance
• B Long GnRH agonist protocol starting in the luteal phase
• C Clomiphene citrate combined with letrozole for sequential induction
• D Step-up protocol with FSH starting from a very low dose (37.5 IU), slowly titrating up ✓

Explanation

The low-dose step-up protocol for gonadotropin ovulation induction in PCOS starts at a very low daily dose of FSH (37.5–50 IU) and slowly increases every 5–7 days based on follicle response until a dominant follicle ≥17 mm is achieved. This approach respects the low FSH threshold and minimizes multifollicular development and OHSS risk in the hypersensitive PCOS ovary. The chronic low-dose step-up protocol achieves monofollicular ovulation in approximately 70% of cycles. The step-down protocol mimics the natural follicular phase fall but carries higher multifollicular risk. In ART settings, GnRH antagonist protocols with GnRH agonist trigger (instead of hCG) are preferred to prevent OHSS.

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

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Written and medically reviewed by the StethoPrep medical team.