A 34-year-old woman with PCOS and anovulatory infertility fails to ovulate after 6 cycles of clomiphene citrate 150 mg. She is BMI 29 kg/m². The NEXT recommended ovulation induction strategy according to current guidelines is:

• A Add metformin to clomiphene citrate for 3 more cycles
• B Letrozole (aromatase inhibitor) 2.5–7.5 mg daily
• C Laparoscopic ovarian drilling
• D Gonadotrophin injection (FSH/LH) with monitoring ✓

Explanation

After failure of clomiphene citrate (CC-resistant PCOS, defined as failure to ovulate after 150 mg for ≥3 cycles), the recommended step-up is exogenous gonadotrophins (FSH with or without LH) with ultrasound monitoring to prevent ovarian hyperstimulation. Letrozole is now preferred over clomiphene as first-line (per ESHRE 2023 guidelines, PPCOS II trial), but if letrozole was not used and CC has failed, gonadotrophins are next. Ovarian drilling is reserved for CC/letrozole/gonadotrophin failure, particularly when ongoing monitoring for OHSS is difficult.

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

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Written and medically reviewed by the StethoPrep medical team.