A 28-year-old woman with PCOS undergoes ovulation induction with clomiphene citrate. After 3 failed cycles with maximum dose, she is started on gonadotrophins. Ultrasound monitoring shows 4 follicles ≥18 mm. What is the most appropriate management to avoid ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy?
- A Cancel the cycle and withhold hCG trigger ✓
- B Trigger with hCG 10,000 IU and proceed with intrauterine insemination
- C Aspirate two follicles and trigger with hCG
- D Reduce gonadotrophin dose and re-scan in 48 hours
Correct answer: A. Cancel the cycle and withhold hCG trigger
Explanation
With four mature follicles (≥18 mm) in an ovulation induction (non-IVF) cycle, the risk of high-order multiple pregnancy and OHSS is unacceptably high. The cycle should be cancelled by withholding the hCG trigger. Proceeding with IUI in this scenario risks triplets or higher-order multiples. Follicle aspiration (coasting) is used in IVF protocols, not in ovulation induction for IUI. Reducing gonadotrophin after multiple mature follicles are already present does not reduce the existing follicle count.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.