Trying to Conceive With PCOS: Test First, Then Letrozole

Last updated November 12, 2026 · Reviewed by the Gala Health team

Why PCOS makes it harder to get pregnant

Polycystic ovary syndrome is diagnosed in adults when two of three features are present, once other causes are excluded: irregular or absent ovulation, high androgens (on a blood test or as excess hair growth), and polycystic ovaries on ultrasound, for which the 2023 guideline now accepts a high AMH level instead. If cycles are irregular and androgens are high, no ultrasound or AMH is needed for the diagnosis.

The fertility problem is usually ovulation. Without a regular egg release there are few chances each year to conceive. The guideline defines irregular cycles, from three years after the first period, as shorter than 21 days, longer than 35 days, or fewer than eight a year. ASRM's committee opinion puts ovulatory dysfunction behind up to 40% of infertility in women.

Do not wait a year: test both of you first

The usual advice to try for 12 months before testing (6 months from age 35) does not apply here. ASRM says diagnostic testing should start without delay when a woman has irregular cycles, infrequent periods or none, and that when a male partner is involved both partners are evaluated at the same time, with at least one semen analysis.

That matters for PCOS because the guideline's letrozole recommendation is limited to women with "no other infertility factors". The trial behind it, PPCOS II, only enrolled women with at least one open fallopian tube and a partner with a sperm concentration of at least 14 million per milliliter. A workup answers the questions letrozole cannot fix:

Test	What it answers in PCOS
Her hormones (AMH, FSH, estradiol, LH, prolactin, TSH)	Whether something other than PCOS is stopping ovulation, such as a thyroid or prolactin problem
Pelvic ultrasound	Follicle count, the uterus and the ovaries before medication
His semen analysis	Whether a male factor needs its own plan; an ovulation pill does not help sperm

The guideline also asks clinicians to weigh tubal testing case by case before ovulation induction, when the semen analysis is normal and the only issue seems to be ovulation.

Ovulation test strips can mislead with PCOS. ASRM notes that women with PCOS may have a constantly raised LH level, which can make urine LH tests read positive when no surge is happening. More on what home kits can and cannot show in are at-home fertility tests accurate.

Weight, lifestyle and preparing for pregnancy

The guideline asks clinicians to tell women with PCOS that excess weight lowers clinical pregnancy and live birth rates and raises miscarriage after fertility treatment. It also says a healthy lifestyle has benefits even without weight loss, so this is a reason to plan, not a reason to delay testing.

Diet: the guideline found no evidence that any one diet composition is better than another for reproductive outcomes in PCOS. Any healthy eating pattern you can sustain counts.
Exercise: likewise, no type or intensity was shown to be better than another. Follow population guidelines.
Preconception basics: weight, blood pressure, smoking, alcohol, nutrition, sleep and mental health should be optimized, and folate started, at a higher dose for a BMI above 30.
Inositol: the guideline calls it experimental for fertility in PCOS, with benefits and risks too uncertain to recommend.

If you take a GLP-1 such as Wegovy or Zepbound

Many women with PCOS use a GLP-1 medicine for weight. The 2023 guideline says GLP-1 receptor agonists such as semaglutide could be considered alongside lifestyle changes for higher weight in adults with PCOS, but that effective contraception should be in place whenever pregnancy is possible, because pregnancy safety data are lacking. For fertility itself, it recommends using anti-obesity medicines only in research settings.

In practice that means a planned stop before you start trying. The Wegovy label says to stop semaglutide at least 2 months before a planned pregnancy. The Zepbound label says to stop tirzepatide once pregnancy is recognized and warns that it can make birth control pills less reliable. Read trying to conceive on a GLP-1 before your last dose, and tell your fertility clinician which medicine and dose you take.

Letrozole: the first-line pill for PCOS

In its central fertility recommendation for PCOS, the guideline says letrozole should be the first-line drug for ovulation induction in infertile women who do not ovulate and have no other infertility factor, a recommendation it rates as high-certainty evidence. It recommends letrozole over clomiphene to improve ovulation, pregnancy and live birth, and states that there is no difference in fetal abnormality rates between letrozole, clomiphene and natural conception.

PPCOS II, 750 women with PCOS	Letrozole	Clomiphene
Cumulative live birth	27.5%	19.1%
Ovulation, share of treatment cycles	61.7%	48.3%

Letrozole is FDA-approved for breast cancer, so this use is off-label, and the guideline says it should not be given if there is any chance of an existing pregnancy. Dosing, side effects and monitoring are covered in letrozole for fertility.

If letrozole is not the answer

The guideline lays out the next steps:

Clomiphene. FDA-approved for ovulatory dysfunction, and its label lists PCOS among the patients most likely to respond. The guideline prefers it to metformin alone, says metformin can be added, and notes that clomiphene cycles may need ultrasound monitoring because of twins. See Clomid prescription online.
Metformin alone. It could be used, but women should be told there are more effective ovulation medicines.
Gonadotropin injections or laparoscopic ovarian surgery. Second-line options after oral medicines fail, handled by a fertility clinic with close ultrasound monitoring.
IVF. The guideline says it could be offered when first- or second-line ovulation induction has failed, with single embryo transfer to limit multiples.

Oral ovulation induction can be managed remotely with testing and a check-in each cycle; the later steps need a clinic. A good program tells you early which group you are in.

How Gala Fertility handles PCOS

The Gala Fertility intake asks each of you about your history, including a PCOS diagnosis, how many periods she has a year, and any medicine, from a GLP-1 to Clomid, already tried. You start with a $29.99 introductory video meeting with our care team. If you go ahead, both of you are tested: her bloodwork at a Quest lab, a pelvic ultrasound near you, and his semen analysis with a kit sent home.

A licensed clinician goes over every result with you on video. When the picture is PCOS with no other factor, that usually means letrozole or clomiphene, one month at a time, shipped to your door, with a check-in after every cycle for up to six cycles. When it is not, you get a clear reason and a referral to a fertility clinic.

Frequently asked questions

What is the best fertility treatment for PCOS?

For women with PCOS who do not ovulate and have no other infertility factor, the 2023 International PCOS Guideline recommends letrozole as the first-line medicine, ahead of clomiphene and metformin. A workup of both partners comes first to confirm there is no other factor.

Should I lose weight before trying to conceive with PCOS?

The guideline says excess weight lowers pregnancy and live birth rates after fertility treatment, and that a healthy lifestyle helps even without weight loss. It does not ask you to delay testing, so plan both at once with your clinician.

Do ovulation tests work if you have PCOS?

Not reliably. ASRM notes that women with PCOS may have a constantly raised LH level, which can cause false-positive urine LH tests. A progesterone blood test in the second half of the cycle is a more direct check.

Can I keep taking a GLP-1 while trying to conceive with PCOS?

The PCOS guideline asks for effective contraception while taking a GLP-1 because pregnancy safety data are lacking, and the Wegovy label says to stop at least 2 months before a planned pregnancy. Plan the stop with your prescriber.

Does metformin help you get pregnant with PCOS?

It can be used alone, but the guideline says women should be told there are more effective ovulation medicines. It may be added to clomiphene to improve ovulation and pregnancy rates.

How long should I try before testing if I have PCOS?

No set wait. ASRM says testing should start without delay when cycles are irregular or absent, which is common with PCOS.

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Sources

This article is for general information and is not medical advice. Talk to a licensed provider about your own health.

Trying to Conceive With PCOS: Testing First, Then Letrozole