Ovulation Induction — Protocols and Resistance

A 32-year-old woman with WHO Group II anovulation (normal FSH, normal prolactin, normal thyroid function) presents with secondary infertility for 18 months. She has failed clomiphene citrate therapy (150 mg daily for 5 days) for two consecutive cycles with no follicular development. Her partner's semen analysis is normal. What is the most appropriate next step in management?

A 28-year-old woman from Delhi presents with primary infertility of 3 years duration. Menarche at age 13, cycles regular (28–30 days), no dysmenorrhea. BMI 32 kg/m², hirsutism grade 2, acne present. Pelvic ultrasound shows bilateral polycystic ovaries. FSH 6 mIU/mL, LH 18 mIU/mL, testosterone 0.8 ng/mL (elevated). Husband's semen analysis is normal. She was started on clomiphene citrate 50 mg daily for 5 days; after 2 cycles, no ovulation occurred. What is the most appropriate next step in management?

A 32-year-old woman from Mumbai with secondary infertility (1 child, 4 years ago) presents with amenorrhea for 8 months. She had undergone a dilatation and curettage (D&C) for postpartum hemorrhage 4 years ago. Serum FSH 8 mIU/mL, LH 5 mIU/mL, estradiol <20 pg/mL. Hysteroscopy reveals intrauterine adhesions (Asherman syndrome, grade 2). After adhesiolysis and insertion of an intrauterine device (IUD), she is started on estrogen therapy (conjugated estrogens 2.5 mg thrice daily for 3 months). After 3 months, repeat hysteroscopy shows minimal adhesion reformation. Menstruation resumes. She now desires ovulation induction. What is the most appropriate ovulation induction protocol for this patient?

A 28-year-old woman from Delhi presents with primary infertility of 3 years duration. Menarche at age 13, cycles regular (28–30 days), no dysmenorrhea. BMI 32 kg/m², hirsutism grade 2, acne present. Pelvic ultrasound shows bilateral polycystic ovaries. Serum LH 18 mIU/mL, FSH 6 mIU/mL, testosterone 0.8 ng/mL (elevated). Fasting insulin 22 mIU/mL, fasting glucose 98 mg/dL. Her husband's semen analysis is normal. She is counselled for ovulation induction. After 3 months of metformin monotherapy (1.5 g/day), she remains anovulatory. Which is the most appropriate next step in management?

A 32-year-old woman from Mumbai with secondary infertility (1 year duration) is diagnosed with PCOS after failing to conceive despite regular cycles. She has no metabolic comorbidities (BMI 23 kg/m², normal glucose tolerance, normal insulin levels). Baseline FSH 7 mIU/mL, LH 12 mIU/mL, testosterone 0.6 ng/mL. She is started on clomiphene citrate 50 mg daily for 5 days from cycle day 3. Transvaginal ultrasound on day 12 shows a single dominant follicle 12 mm, endometrial thickness 6 mm. On day 14, LH surge is not detected. Repeat ultrasound on day 16 shows follicle 14 mm, endometrium 6 mm. What is the most appropriate next management?