A 27-Year-Old Woman Comes to the Office for an Infertility

A 27-year-old woman comes to the office for an infertility evaluation.  She has been unable to conceive despite 2 years of frequent unprotected intercourse with her husband.  The patient had a progestin-containing intrauterine device for 5 years, during which time she was amenorrheic.  The intrauterine device was removed 2 years ago, but since then her periods have occurred every 2-4 months.  The patient has no chronic medical conditions and has had no previous surgery.  She had Chlamydia trachomatis cervicitis as a teenager but no other sexually transmitted infections.  Pap tests, including the most recent a year ago, have all been normal.  She takes a prenatal vitamin daily and does not use tobacco, alcohol, or illicit drugs.  The patient is a graduate student and works at the university library.  Blood pressure is 100/50 mm Hg and pulse is 68/min.  BMI is 33 kg/m².  Terminal hair is noted above the upper lip.  Breast examination shows terminal hair around the areola but no masses or discharge.  The abdomen is soft and obese with no masses or tenderness.  Nodulocystic acne is noted over the upper back.  Pelvic examination shows a small, mobile uterus and no adnexal masses.  TSH and FSH levels are normal but total testosterone level is elevated.  The husband's semen analysis is normal.  A hysterosalpingogram shows bilateral intraabdominal spill from the fallopian tubes.  Which of the following is the best next step in management of this patient?

A) Gonadotropins
B) In vitro fertilization
C) Oral contraceptive pills
D) Spironolactone
E) Weight loss