A 27-year-old woman with PCOS (Rotterdam criteria: oligomenorrhoea, polycystic ovaries on USS, biochemical hyperandrogenism) has BMI 32 kg/m² and is planning pregnancy. She fails to conceive after 6 months of lifestyle modification. The ESHRE 2023 PCOS guidelines recommend which agent as first-line ovulation induction?
- A Letrozole (aromatase inhibitor) as first-line over clomiphene citrate due to higher live birth rates ✓
- B Clomiphene citrate 50 mg days 2–6, as it remains first-line in all international guidelines
- C Recombinant FSH with careful monitoring, as gonadotropins yield higher cumulative pregnancy rates than oral agents
- D Metformin alone for 3 months before adding any ovulation induction agent
Explanation
The ESHRE 2023 International Evidence-Based PCOS Guideline upgrade (from 2018) now recommends letrozole as the FIRST-LINE pharmacological ovulation induction agent in anovulatory PCOS over clomiphene citrate, based on multiple RCTs and a large meta-analysis showing significantly higher live birth rates, ovulation rates, and fewer multiple pregnancies with letrozole. Letrozole inhibits aromatase, reducing estrogen, which disinhibits FSH via reduced negative feedback — a more physiological mono-follicular induction. Clomiphene was long first-line but is now second-line after letrozole in most updated guidelines.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.