The PPCOSII trial (Legro et al., NEJM 2014) compared letrozole versus clomiphene citrate as first-line ovulation induction in women with PCOS. The primary finding that changed clinical practice was:

• A Clomiphene citrate achieved significantly higher live birth rates than letrozole
• B Both agents had equivalent live birth rates, but letrozole had fewer multiple gestations
• C Letrozole was superior only in obese PCOS women, not in lean PCOS
• D Letrozole achieved significantly higher cumulative live birth rates than clomiphene citrate ✓

Explanation

The PPCOSII trial (Legro et al., NEJM 2014) demonstrated that letrozole achieved significantly higher cumulative live birth rates (27.5% vs 19.1%) and ovulation rates compared to clomiphene citrate in women with PCOS-related infertility. This led to letrozole replacing clomiphene as the preferred first-line oral ovulation induction agent in PCOS per major international guidelines (ESHRE/ASRM). The benefit was seen across BMI categories.

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

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