A 27-year-old woman with PCOS and anovulatory infertility has failed 3 cycles of clomiphene citrate (150 mg). Her BMI is 28 kg/m². Serum AMH is 8 ng/mL. What is the MOST appropriate next intervention?
- A Increase clomiphene to 200 mg for 3 more cycles
- B Laparoscopic ovarian drilling
- C Letrozole 5 mg for ovulation induction ✓
- D Immediate IVF with antagonist protocol
Correct answer: C. Letrozole 5 mg for ovulation induction
Explanation
Letrozole (an aromatase inhibitor) is now the first-line ovulation induction agent in PCOS (ASRM/ESHRE 2023 International Evidence-Based Guideline), showing superior live birth rates over clomiphene (NEJM PPCOS II trial). After clomiphene failure, letrozole should be attempted before proceeding to gonadotrophins or laparoscopic ovarian drilling. Maximum clomiphene dose is 150 mg; increasing further is not standard practice. IVF is a later option.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.