A woman with PCOS-associated infertility who is obese (BMI 34 kg/m²) undergoes ovulation induction with clomiphene citrate (CC) 150 mg without success for 3 cycles. What is the first-line management option for CC-resistant PCOS, as per current ESHRE 2023 evidence-based guidelines?
- A Letrozole (aromatase inhibitor) ✓
- B Gonadotropin stimulation with FSH
- C Laparoscopic ovarian drilling (LOD)
- D In vitro fertilisation (IVF)
Correct answer: A. Letrozole (aromatase inhibitor)
Explanation
Letrozole, an aromatase inhibitor, is now the first-line pharmacological ovulation induction agent for PCOS-related infertility, including for CC-resistant cases, according to ESHRE/ASRM 2023 guidelines. The NEJM PCOSACT trial (Legro et al, 2014) demonstrated superior live birth rates with letrozole compared to CC in PCOS. Letrozole works by temporarily reducing oestrogen, relieving negative feedback on the pituitary and stimulating FSH release for follicular development. Gonadotropins are second-line; LOD is an alternative second-line option; IVF is third-line for PCOS.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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