Reserve metformin for second line treatment for women with clomifene resistance

Polycystic ovary syndrome is the commonest cause of anovulatory infertility and is managed with numerous drugs.1 Before starting drug treatment, women should be helped to optimise their body weight to improve the chance of spontaneous ovulation and natural conception, improve the chance of successful response to ovulation induction drugs, and maximise their health in pregnancy.

Extremes of opinion on weight loss have been eloquently outlined: Balen and colleagues suggested that drug treatment should be withheld from women with a body mass index greater than 35 owing to the dangers of pregnancy in obese women,2 and Laredo emphasised the concern of stigmatising overweight women by such withholding of fertility treatment.3 Options for drug treatment may seem more straightforward, but a multicentre placebo controlled trial of metformin reported in this week's BMJ by Moll and colleagues (p 1485) challenges that view.4

First line drug treatment for women …