How should I manage a patient with polycystic ovary syndrome (PCOS) who is seeking fertility treatment?

Management of a patient with polycystic ovary syndrome (PCOS) seeking fertility treatment should begin with lifestyle interventions, especially if the patient is overweight or obese. Encouraging healthy eating, regular physical activity, and weight loss can improve ovulation rates and enhance response to fertility treatments by reducing insulin resistance and hyperandrogenism. A weight reduction of as little as 5% can significantly improve hormonal and metabolic profiles and may restore spontaneous ovulation ¹.

If ovulation does not resume after lifestyle modification, pharmacological ovulation induction is the next step. First-line pharmacological options include clomifene citrate, metformin, or a combination of both, with choice tailored to the patient's BMI, preferences, and potential side effects ². Clomifene citrate is commonly used, with ultrasound monitoring recommended during the first cycle to minimize the risk of multiple pregnancy ². Treatment with clomifene should not exceed six months ².

For patients resistant to clomifene citrate, second-line treatments include laparoscopic ovarian drilling, combined clomifene and metformin therapy if not previously tried, or gonadotrophin therapy. Gonadotrophins should be used cautiously, with ultrasound monitoring to reduce risks of ovarian hyperstimulation and multiple pregnancies, and concomitant use of gonadotrophin-releasing hormone agonists is not recommended due to lack of benefit and increased risks ².

Throughout management, it is important to assess and address cardiovascular risk factors, impaired glucose tolerance, and psychological wellbeing, as these are commonly associated with PCOS and can impact fertility and pregnancy outcomes ¹.

Recent expert opinion literature supports this approach, emphasizing the importance of lifestyle modification as foundational, followed by tailored pharmacological ovulation induction, and careful monitoring to optimize pregnancy outcomes and minimize risks (Stadtmauer and Oehninger, 2005; Goodman et al., 2015; Bahri Khomami et al., 2022).