Ovulation induction with clomiphene or gonadotropins

Clomiphene citrate (CC) results in ovulatory cycles in about 75-90% of patients with PCOS and is particularly successful in the leaner, oligomenorrheic non-amenorrheic patient with only limited signs of hyperandrogenism. Of those that ovulate 60-70% conceive with 40-50% resulting in live births. Traditionally the method following unsuccessful ovulation induction with CC, either because anovulation persists or because no pregnancy occurs, is to administer gonadotropins directly. The gonadotropin step-down protocol for the PCOS patient is highly attractive from a physiological point of view. Nevertheless, practically and taking into account safety, the low-dose step-up protocol seems the first choice approach. Almost all patients become ovulatory after adequate dosages of gonadotropins with a high BMI, clomiphene resistance, higher IGF1 and FSH serum levels that indicate the need of higher doses of FSH. The overall conception rate is 50-60%. Pregnancy rates are lower in case of obesity, insulin resistance and higher age.