Ovuklatiion Induction

 Point 1: No routine metformin. Metformin is given only to those pts who do not want immediate pregnancy to delay the onset of  DM, But Metformin can be supplemented to minimize abortion rate .

Point 2: LOD for whom?? Ovarian drilling has excellent results in lean PCO with ovarian volumes > 15 ml ³ with high testosterone > 0.8 ng /ml

Point 3:   CC + gonadotrophin reduces the requirement of gonadotrophins but does not increase the pregnancy rate. But such combination has a definite role in IUI cycles and also  in minimal stimulation IVF( Mini IVF-MOS).

Point 4 : Letrozole is very useful in CC resistant cases and PCOS, when baseline E2 is >35pgm/ml.

Point 5: Letrozole+ gonadotrophins offers excellent pregnancy rates with less number of gonadotrophins used and lower multiple pregnancy rate, The results will be superior if IUI is combined.

 Point 6:  Step up protocol I can be recommended for high responders with AMH of > 6 (PCO) : Low dose FSH can be  used as a first line treatment for anovulatory PCOS patients.(Step up-but in close contact with an nearby ART center , because sometimes OHSS can ensue and may need ICU back up and aspiration of follicles with cryopreservation)  . Antagonist Cetrolix 2.5 mg may be supplemented to prevent unwanted LH surge when E 2 is > 200 pg and D F is 14 mm or above.

r-FSH and rhCG are superior over the urinary products(which contains many proteins, some organisms  and LH in some cases (like u-HMG)  and give very high pregnancy rates.

Gonadotrophins + antagonist + IUI have offered excellent results in patients with thin lean PCOS. But timing of antagonist should be perfect as mentioned above.

 There are two protocols of administering antagonist A) Fixed dose protocol   of administering antagonist on day 7 at evening daily and pushing the gonadotrophins at morning sessions   B)  Flexible dose of starting antagonists along with continuation of HMG : Day of ignition antagonist (inj Cetrolix either depot from or daily form ) depending on Serum  E 2 (> 200 pg) and Size of lead follicle(> 14 mm)