Strategies for Ovulation Induction in the Management of Anovulatory Polycystic Ovary Syndrome

The management of anovulatory infertility in the polycystic ovary syndrome (PCOS) has traditionally involved the use of clomiphene citrate (CC) and then gonadotropin therapy or laparoscopic ovarian surgery, in those who are clomiphene resistant. There is no clear role for insulin sensitizing and insulin lowering drugs, and algorithms for their place in therapy are still to be agreed upon. Newer therapeutic approaches include aromatase inhibitors and the potential use of in vitro maturation (IVM) of oocytes collected from unstimulated (or minimally stimulated) polycystic ovaries. There has been an unfortunate shift away from monofollicular ovulation induction to the use of in vitro fertilization treatment (IVF), based on a false premise of greater cumulative conception rates and appropriate concerns about multiple pregnancy. Superovulation for IVF presents significant risks for women with polycystic ovaries, namely the potentially life-threatening complication of ovarian hyperstimulation syndrome (OHSS). Carefully conducted and monitored ovulation induction can achieve good cumulative conception rates, and, furthermore, multiple pregnancy rates can be minimized with strict adherence to criteria that limit the number of follicles that are permitted to ovulate.