clomiphene citrate + metformin + highly purified urinary FSH

This is a combination therapy consisting of three agents—clomiphene citrate, metformin, and highly purified urinary follicle-stimulating hormone (FSH)—used primarily for ovulation induction in women with polycystic ovary syndrome (PCOS), particularly those who are resistant to clomiphene citrate alone. - **Clomiphene citrate** is a selective estrogen receptor modulator that induces ovulation by blocking estrogen receptors in the hypothalamus, leading to increased secretion of gonadotropins (FSH and LH). - **Metformin** is an insulin sensitizer from the biguanide class; it improves insulin resistance and can restore normal menstrual cycles and ovulation in women with PCOS. - **Highly purified urinary FSH** directly stimulates ovarian follicular development by providing exogenous FSH. The combination aims to address both endocrine/metabolic dysfunctions (with metformin) and direct stimulation of ovarian function (with clomiphene citrate and FSH), thereby increasing the chances of successful ovulation and conception in infertile women with PCOS who have not responded adequately to monotherapy or dual therapy[1][2].