What guidelines should I follow for the management of women with polycystic ovary syndrome (PCOS) who are seeking fertility treatment?

Management of women with PCOS seeking fertility treatment should follow these key guidelines:

• Lifestyle modification is the first-line treatment, especially for overweight or obese women. Encourage healthy eating, regular physical activity, and weight loss, as even a 5% reduction in body weight can restore spontaneous ovulation and improve response to ovulation induction agents.

• Ovulation induction is recommended for women who do not ovulate after lifestyle changes. First-line pharmacological treatments include clomifene citrate, metformin, or a combination of both, considering the woman's BMI, preferences, and potential side effects.

• Monitoring during clomifene citrate treatment should include ultrasound in the first cycle to minimize the risk of multiple pregnancy, and treatment should not continue beyond 6 months if ineffective.

• Second-line treatments for clomifene-resistant women include laparoscopic ovarian drilling, combined clomifene and metformin therapy if not previously used, or gonadotrophins. Gonadotrophin-releasing hormone agonists should not be used concomitantly with gonadotrophins due to increased risk of ovarian hyperstimulation without improved pregnancy rates.

• Inform women about the risks of multiple pregnancy and ovarian hyperstimulation when using gonadotrophins, and ensure appropriate ultrasound monitoring during treatment.

These recommendations are based on the International PCOS Network 2023 guideline and NICE fertility guidelines (CG156) for ovulation disorders classified as WHO Group 2, which predominantly includes PCOS-related anovulation ¹,².