A 28-year-old woman with PCOS and a BMI of 32 kg/m² has oligomenorrhea and anovulatory infertility. AMH is 8.2 ng/mL, antral follicle count is 18 per ovary. Clomiphene citrate 150 mg for 5 cycles failed to achieve ovulation. The next most appropriate intervention is:
- A Letrozole 2.5–7.5 mg days 3–7 ✓
- B Gonadotropin ovulation induction with careful monitoring
- C Laparoscopic ovarian drilling
- D Immediate IVF-ICSI
Correct answer: A. Letrozole 2.5–7.5 mg days 3–7
Explanation
The PPCOS-II trial and subsequent meta-analyses established letrozole (aromatase inhibitor) as superior to clomiphene citrate for ovulation induction in PCOS, with higher live birth rates and lower multiple pregnancy rates. After clomiphene failure, letrozole is the recommended next step before gonadotropins. Laparoscopic ovarian drilling is an option for clomiphene-resistant PCOS but is invasive and reserved for women who need laparoscopy for other reasons or have failed letrozole. Direct IVF is premature at this stage.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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