A 28-year-old woman with PCOS undergoes ovulation induction with letrozole. Despite 5 days of letrozole 5 mg (days 3–7), follicular monitoring at day 12 shows 3 dominant follicles (22 mm, 20 mm, 18 mm). What is the MOST appropriate clinical decision?
- A Proceed with hCG trigger and intrauterine insemination as planned
- B Administer GnRH antagonist to prevent premature LH surge and limit follicle growth
- C Cancel the cycle and advise barrier contraception to prevent multiple pregnancy ✓
- D Coasting by withholding letrozole for 3 more days to allow smaller follicles to regress
Explanation
When ovulation induction with oral agents (letrozole or clomiphene) results in ≥ 3 dominant follicles (≥ 14 mm), the cycle should be cancelled and patients advised to avoid unprotected intercourse or use barrier contraception due to unacceptably high risk of high-order multiple pregnancy (triplets or higher). Unlike IVF where all embryos can be cryopreserved, an IUI or timed intercourse cycle with ≥ 3 mature follicles poses significant risk. GnRH antagonist is not used for this purpose in an oral agent cycle. 'Coasting' (a strategy used in IVF to prevent OHSS by withholding gonadotropins) is not applicable with letrozole in an IUI setting.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.