IVF protocol for PCOS: the injections, the doses and how over-response is kept in check

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Women with PCOS (polycystic ovary syndrome) often show many follicles on the scan, yet IVF stimulation in PCOS needs more care, not less. In this video, our consultant explains why the polycystic ovary responds differently, opens the stimulation injections used, such as HMG, highly purified urinary FSH and recombinant FSH, shows how each one is prepared, and walks through a dose chart for a PCOS cycle. This guide explains the same plan in English. Every protocol is tailored to the woman, so treat it as general information.

Pai Hospital is registered as a Level 2 ART clinic under the Assisted Reproductive Technology (Regulation) Act, 2021 (Reg. No. GA/AC/2022/12689/L2/South Goa/02, valid to 14 January 2030).

Why IVF in PCOS needs a different plan

In a woman without PCOS, a group of follicles starts to grow each month and one is chosen to mature. In PCOS, the ovaries already hold a large number of small follicles, which is what the scan shows as polycystic ovaries. Read about pregnancy with PCOS for the wider picture.

In the video, our consultant explains that polycystic ovaries tend to respond with a threshold. Below a particular dose there may be little response at all; once the threshold is crossed, a very large number of follicles can start growing together.

An over-response brings the main risk of IVF in PCOS: ovarian hyperstimulation syndrome (OHSS), in which the enlarged ovaries leak fluid into the tummy. It ranges from bloating and discomfort to, rarely, a serious illness that needs hospital care. Too many eggs grown at once may also not all be of good quality. The aim is a balance: enough mature eggs for the IVF cycle, without pushing the ovaries too far. How the follicles grow in PCOS, and what too many follicles mean, is explained in egg growth in PCOS.

PCOS IVF injections: the stimulation medicines

The stimulation injections are gonadotropins, which carry FSH, sometimes with LH activity. In the video, our consultant opens and explains the main types:

• HMG, with both FSH and LH activity, as a powder mixed with its diluent. Read about the HMG injection.
• Highly purified urinary FSH, which carries FSH with very little LH activity, as a powder in vials.
• Recombinant FSH, made with DNA technology, available as vials and as ready-to-use pens. A pen lets the dose be set in small steps, which helps when a PCOS dose has to be fine-tuned.

Some forms may be given into the muscle and some only under the skin; the doctor or nurse shows you which. The choice between them, alone or in combination, depends on the woman, her hormone results and any earlier response to stimulation.

The IVF protocol for PCOS, step by step

1. Before starting: blood tests and a baseline scan. Some women are first advised weight, diet or medicine changes to settle the cycle.
2. A careful starting dose: often lower than for a woman of the same age without PCOS, chosen from the AMH, the follicle count on the scan and the weight.
3. Close scans: every one or two days, with the dose adjusted to the response in small steps.
4. Preventing early ovulation: an antagonist injection such as cetrorelix is added partway through. This antagonist protocol is commonly chosen in PCOS because it allows an agonist trigger at the end.
5. The trigger: when the follicles are mature. If many follicles have grown, an agonist trigger may be used instead of HCG, because its effect fades faster. Read the HCG, agonist and dual trigger explained.
6. Egg collection: about 35 to 36 hours after the trigger, under light anaesthesia.

In the video, our consultant explains that stimulation usually lasts about ten to twelve days, and a little longer in some women with PCOS, because the dose is raised slowly.

Freeze-all cycle in PCOS

In a freeze-all cycle, no embryo is transferred straight after the egg collection. The good embryos are frozen by vitrification, and one is transferred in a later, calmer cycle, once the ovaries have settled. In PCOS this is often advised when many eggs were collected or an agonist trigger was used, because the pregnancy hormone of an early pregnancy in the same cycle can make OHSS worse. It also lets the womb lining be prepared in a planned way. Read what a frozen embryo transfer involves.

Warning signs during stimulation

Call the hospital at once if, during stimulation or in the days after the egg collection, you notice severe tummy pain or swelling, a quick weight gain over a day or two, vomiting, breathlessness, or passing very little urine. These can be signs of OHSS and need to be checked the same day.

About this guide

This guide is by the Pai Hospital Team. Pai Hospital is at Vaddem, Vasco-da-Gama, Goa, with its own operating theatre and IVF laboratory. Consultations are held in Panjim, Margao, Mapusa and Vasco; the scans, the egg collection and the embryo transfer are done at the hospital at Vaddem, Vasco-da-Gama. The fees for IVF and the other fertility treatments are on our IVF cost in Goa page.

This article is for education only and is not personal medical advice; please speak to your own doctor about your situation.

Your questions

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This page is for general education and is not personal medical advice. Treatment depends on your own examination and reports, so please speak to a doctor about your situation. We do not carry out or offer sex determination of any kind.