A 28-year-old woman presents with infertility, oligomenorrhoea, moderate hirsutism, and acne. Serum LH:FSH ratio is 3:1, fasting insulin is elevated, AMH is 8.2 ng/mL, and ultrasound shows 14 follicles per ovary, each 2–9 mm. She desires pregnancy. The first-line ovulation induction agent is:
- A Clomiphene citrate 50 mg orally on cycle days 5–9
- B Recombinant FSH (gonadotropin) injections
- C Letrozole 2.5 mg orally on cycle days 3–7 ✓
- D Laparoscopic ovarian drilling (LOD)
Correct answer: C. Letrozole 2.5 mg orally on cycle days 3–7
Explanation
Letrozole (an aromatase inhibitor) is now the recommended first-line ovulation induction agent for PCOS according to ASRM/ESHRE 2023 guidelines, surpassing clomiphene citrate. Letrozole achieves higher live birth rates (27.5% vs 19.1% per cycle in the Legro 2014 NEJM trial), lower multiple pregnancy rates, and does not have the anti-estrogenic effect on endometrium seen with clomiphene. Gonadotropin injections are second-line due to OHSS risk. Laparoscopic ovarian drilling is reserved for clomiphene/letrozole-resistant PCOS.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.