A woman with PCOS and BMI 32 kg/m² undergoes ovulation induction with clomiphene citrate for 6 cycles without conception. Her husband's semen analysis is normal. The next most appropriate step is:

• A Proceed directly to IVF
• B Laparoscopic ovarian drilling
• C Addition of metformin to clomiphene for further ovulation induction cycles
• D Gonadotropin ovulation induction with monitoring ✓

Explanation

After failure of 6 cycles of clomiphene in PCOS, the next step is gonadotropin (FSH) ovulation induction with careful ultrasound and estradiol monitoring to minimize ovarian hyperstimulation and multiple pregnancy risk. Laparoscopic ovarian drilling is an alternative, particularly when gonadotropin monitoring is unavailable or in clomiphene-resistant PCOS. IVF is typically reserved after failure of these second-line approaches.

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

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Written and medically reviewed by the StethoPrep medical team.