A 30-year-old woman with PCOS (BMI 28 kg/m²) undergoes ovulation induction with letrozole 5 mg on Days 3–7. She develops follicular monitoring showing 4 follicles >16 mm. According to ESHRE/ASRM guidelines, the MOST appropriate action to prevent multiple pregnancy while still achieving conception this cycle is:

• A Cancel the cycle and withhold hCG trigger — advise abstinence and restart with lower letrozole dose ✓
• B Convert to IVF cycle with follicle aspiration (follicle reduction) and in vitro fertilization
• C Administer hCG trigger at this point as triplet risk is low with 4 follicles >16 mm
• D Reduce dose to 2 follicles by ultrasound-guided selective follicle reduction before hCG trigger

Explanation

ESHRE/ASRM guidelines and most national guidelines recommend cycle cancellation (withhold hCG trigger, advise barrier contraception or abstinence) when 3 or more follicles exceed a threshold size (typically ≥14–16 mm) during ovulation induction for anovulatory infertility, to prevent high-order multiple pregnancy. Four follicles >16 mm represents an unacceptably high risk of triplet or higher-order multiple pregnancy. Converting to IVF (B) is an option in some centers but is complex, expensive, and not the standard first response; cycle cancellation and restarting at lower dose is the recommended approach. Proceeding with hCG (C) is contraindicated given quadruplet risk. Selective follicle reduction (D) in vivo is not an established technique.

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

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Written and medically reviewed by the StethoPrep medical team.