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Polycystic ovary syndrome - Management
What treatments are available for infertility in secondary care?

  • Clomifene citrate remains the first-line treatment to induce ovulation in women with polycystic ovary syndrome (PCOS).
    • GPs should prescribe clomifene citrate only as part of a formal shared-care agreement between primary and secondary care.
    • The National Institute for Health and Clinical Excellence (NICE) recommends that:
      • Women with PCOS should be offered clomifene citrate or tamoxifen as first-line treatment for up to 12 months, because it is likely to induce ovulation.
      • Women should be informed of the risk of multiple pregnancies associated with both clomifene citrate and tamoxifen.
      • Women undergoing treatment with clomifene citrate should be offered ultrasonographic monitoring during at least the first cycle of treatment, to ensure that they receive a dose that minimizes the risk of multiple pregnancy.
      • Women with PCOS who ovulate with clomifene citrate but have not become pregnant after 6 months of treatment should be offered clomifene citrate-stimulated intrauterine insemination.
  • NICE recommends that women with PCOS who have not responded to clomifene citrate should be offered treatment with gonadotrophins or laparoscopic ovarian drilling.
  • Laparoscopic ovarian drilling is not associated with an increased risk of multiple pregnancy, but it takes longer to achieve pregnancy compared with treatment with gonadotropins.
  • Gonadotrophins are ovulation induction agents and may be recommended for some women with PCOS who have not responded to clomifene citrate. They should always be prescribed under specialist supervision, as careful monitoring is required to reduce the risk of multiple pregnancy.
    • Human menopausal gonadotrophin is a purified extract from human postmenopausal urine. It contains both follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
    • FSH alone is either derived from human menopausal urine or as a recombinant peptide produced by cultured cells.
    • NICE recommends that:
      • Women with PCOS who do not ovulate with clomifene citrate (or tamoxifen) can be offered treatment with gonadotrophins. Human menopausal gonadotrophin, urinary FSH, and recombinant FSH are all equally effective in achieving pregnancy.
      • Women with PCOS who are being offered treatment with gonadotrophins should not be offered concomitant treatment with a gonadotrophin-releasing hormone agonist, because it does not improve pregnancy rates and there is a higher risk of ovarian hyperstimulation syndrome.
  • Metformin is no longer recommended for the routine management of anovulatory PCOS.

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