PCOS is the number one cause of anovulatory infertility — but the important word is "anovulatory," not "infertility." Most people with PCOS can conceive with treatment.

Letrozole (Femara): • Now the first-line fertility medication for PCOS (recommended over clomiphene by the international PCOS guideline) • Works by temporarily reducing estrogen, which stimulates the body to produce FSH and trigger ovulation • Higher live birth rates than clomiphene in PCOS (27.5% vs 19.1% per cycle in the landmark trial) • Lower risk of multiple pregnancies compared to clomiphene • Typically taken days 3-7 of the cycle at 2.5-7.5mg

Clomiphene (Clomid): • The traditional first-line fertility medication (now second-line for PCOS) • Blocks estrogen receptors, tricking the body into producing more FSH • Effective for many people, but lower success rates than letrozole specifically in PCOS • Higher risk of multiple pregnancies (twins in ~10% of cycles) • Can thin the uterine lining with repeated cycles

What to expect: • Monitoring with ultrasound and blood work during treatment • Multiple cycles may be needed — success is cumulative • If medications alone don't work, the next steps may include adding metformin or moving to IVF • IVF success rates are actually quite good for PCOS

Timeline expectations: Most doctors recommend trying for 3-6 medicated cycles before moving to more intensive treatment.