A 34-year-old woman with PCOS (BMI 30 kg/m²) and anovulatory infertility has been trying to conceive for 2 years. She has failed 6 cycles of ovulation induction with letrozole. Her tubes are patent and her partner's semen analysis is normal. According to ESHRE guidelines, which is the recommended next step in management?

• A Laparoscopic ovarian drilling as the next line before ART
• B Gonadotropin ovulation induction or IVF ✓
• C Continue letrozole for up to 12 cycles before changing strategy
• D Add metformin to letrozole for another 3 cycles

Explanation

ESHRE guidelines recommend that after failure of letrozole (first-line) for ovulation induction in PCOS, the next step is either gonadotropin ovulation induction or proceeding to IVF, depending on patient factors and local resources. Ovarian drilling is an alternative to gonadotropins but not mandatory. Continuing failed therapy beyond the recommended number of cycles is not advised. Adding metformin does not significantly improve live birth rates in clomiphene/letrozole failures.

Reference: ESHRE PCOS Guideline / Fritz MA, Clinical Reproductive Medicine, 2018 ESHRE Guideline ed.

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Written and medically reviewed by the StethoPrep medical team.