Follicle-stimulating hormone (FSH)-containing gonadotropin preparations have been commercially available since the 1960s. Their first use was in ovulation induction in women with anovulatory disorders. Since 1978, however, after the first in vitro fertilization (IVF) baby was born, they have been used increasingly in assisted reproductive technologies (ART) such as IVF or intracytoplasmic sperm injection (ICSI) but also in intrauterine insemination (IUI) as ovarian stimulation to achieve multifollicular growth. Now, in many countries, ovulation induction stimulation comprises only 10% of gonadotropin usage, while 90% is used for ovarian (hyper) stimulation in ART, of which about half of the gonadotropin usage is for IVF and the other half is used for stimulated IUI cycles.

Laparoscopic ovarian drilling (LOD) is suggested as optional treatment in CC-resistant women with PCOS in all guidelines. Treatment with LOD does not result in more live birth and probably results in less live births when compared to letrozole. Laparoscopic ovarian drilling does result in less multiple pregnancies than gonadotrophins. On the other hand, using a strict cancellation protocol, lower multiple pregnancy rates can also be obtained in gonadotrophin protocols. Ovarian drilling appears safe but remains an invasive procedure with risk of adhesion formation. The required anaesthesia can be problematic in obese women, representing the majority of the PCOS population. LOD should therefore not be first choice fertility treatment in CC-resistant PCOS.

Infertility is defined by WHO-ICMART as a disease of the reproductive system defined as the failure to achieve a clinical pregnancy after 12 of more months of regular unprotected sexual intercourse. As all women lose their ability to conceive with age, this definition only holds within the womens’ reproductive age-span between the menarche and menopause. On average the woman’s fertility is highest in the early and mid-twenties, then slowly declines and drops even faster at 35 years and older.