A 25-year-old woman with PCOS (Rotterdam criteria: oligo-ovulation, polycystic ovarian morphology, biochemical hyperandrogenism) fails to ovulate on clomiphene citrate 150 mg for 3 cycles. According to current ESHRE/ASRM 2023 guidelines, which is the FIRST-LINE next step?

• A Letrozole (aromatase inhibitor) for ovulation induction ✓
• B Increase clomiphene to 200 mg for further cycles
• C Gonadotrophin injections (FSH) with transvaginal monitoring
• D Laparoscopic ovarian drilling

Explanation

ESHRE/ASRM PCOS guidelines (2023) now recommend letrozole (aromatase inhibitor) as the preferred first-line ovulation induction agent in anovulatory PCOS due to superior live-birth rates over clomiphene (PPCOS II trial, NEJM 2014). After clomiphene failure (which includes resistance at 150 mg for ≥3 cycles), letrozole is the recommended next step. Gonadotrophins are second-line after both letrozole and clomiphene failure. Laparoscopic ovarian drilling is third-line, used mainly for clomiphene/letrozole-resistant patients or in those needing laparoscopy for another indication.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.