What to Do if Letrozole is Not Working
If you’ve taken letrozole to induce ovulation and it’s still not working, what do you do next?
Maybe you’ve gone through multiple rounds. Maybe your dosage keeps increasing. Maybe you’ve been diagnosed with PCOS or unexplained infertility, but something about that diagnosis—or the treatment plan that followed—still doesn’t seem to explain what’s happening in your body.
In this episode of the Nourished Fertility Podcast, Victoria is digging into a question she’s hearing again and again from clients and women in her DMs: What do you do when letrozole isn’t helping you ovulate or get pregnant?
And the answer starts with getting curious about why you’re not ovulating in the first place.
How Does Letrozole Work?
Letrozole is an aromatase inhibitor, meaning it inhibits an enzyme involved in estrogen production. It’s commonly used in fertility care to induce ovulation, particularly in cases of anovulatory infertility and PCOS.
But not every case of missing, irregular, or weak ovulation has the same root cause.
Victoria explains why this distinction matters—especially when your estrogen is already low or suboptimal.
For some women, missing or irregular ovulation may be connected to functional hypothalamic amenorrhea (HA) rather than PCOS. In these cases, the overall hormone picture can look very different, with low estrogen alongside low FSH and LH. A history of restrictive eating, overexercise, chronic stress, malnutrition, or chronic illness can also provide important clues about what’s happening beneath the surface.
That’s why Victoria encourages you to look beyond the label of “not ovulating” and understand why ovulation has become disrupted.
What If You Really Do Have PCOS?
PCOS isn’t one-size-fits-all either.
Victoria discusses how different presentations of PCOS can come with very different hormone and metabolic patterns. For example, someone may have an elevated LH-to-FSH ratio or signs of insulin resistance while still having low-to-low-normal estrogen.
On the other hand, in cases involving more significant insulin resistance, blood sugar dysregulation, and normal-high or elevated estrogen, Victoria explains why letrozole may make more sense clinically.
The takeaway isn’t that letrozole is inherently “good” or “bad.” It’s that your fertility treatment needs to make sense for your unique physiology and the reason you aren’t ovulating.
What About Unexplained Infertility?
There’s another group Victoria wants you to pay attention to: women who technically ovulate but may still be experiencing ovulatory dysfunction.
You might have been told everything looks “normal,” yet your cycle is giving you clues that something isn’t functioning optimally.
Victoria discusses signs she looks for, including a luteal phase shorter than 11 days, short or light bleeding, spotting before your period, or low progesterone suggesting weaker ovulation.
In these situations, simply pushing the body to ovulate harder may miss the bigger question:
Why isn’t your body producing strong, consistent ovulation in the first place?
If Letrozole Isn’t Working, Start Asking Better Questions
Instead of immediately adding another supplement, increasing a medication dosage, or jumping to the next fertility intervention, Victoria encourages you to ask:
What is my body trying to communicate to me?
What does my body need?
What are we missing?
This is where Victoria uses functional fertility testing with clients to connect the dots.
Rather than looking at estrogen and testosterone alone, she discusses assessing hormones including FSH, LH, prolactin, total and free testosterone, sex hormone-binding globulin, and DHEAS.
She also looks deeper at thyroid function rather than relying solely on TSH, because thyroid function is deeply interconnected with reproductive health.
Beyond blood work, Victoria discusses using a Hair Tissue Mineral Analysis (HTMA) to investigate mineral status and a GI-MAP to better understand gut health, inflammation, immune function, and dysbiosis.
But labs are only one part of the story.
Victoria also wants to know about you: your history with birth control, dieting and restriction, your current eating and exercise patterns, your stress levels, sleep, symptoms, digestion, energy, and everything else your body has been trying to tell you.
From there, the goal is to connect the dots and build a personalized plan that may include nutrition, supplementation, mineral support, exercise adjustments, nervous system regulation, circadian rhythm support, and other lifestyle changes.
Because your hormones aren’t operating in isolation.
Root-Cause Support + Fertility Treatment Can Coexist
One of the biggest messages in this episode is that addressing root causes doesn’t mean you have to reject fertility treatment.
If medication, gonadotropins, IUI, or IVF are part of the path you and your partner choose, Victoria supports you in making that choice.
But pursuing fertility treatment doesn’t mean you have to stop asking why your body isn’t ovulating.
Supporting your nutrition, metabolic health, thyroid function, mineral status, gut health, stress response, and overall health can still matter as you prepare your body for pregnancy.
Your next step may not be doing more.
It may be finally understanding what your body has needed all along.
Ready to Take the Next Step?
If you’re eating “healthy,” you’ve cut back on cardio, you’ve taken the supplements, and fertility medications like letrozole still aren’t working, Victoria has several resources to help you dig deeper.
14-Day Fertility Jump Start — only $27
Spend 14 days focusing on two foundational fertility habits: how you nourish your body first thing in the day and how consistently you support hydration and mineral intake.
Free Training: How to Get Pregnant When You’re Not Ovulating
Learn Victoria’s five-step approach to digging deeper into why you aren’t ovulating and begin your own root-cause investigation.
Free Quiz: Why You’re Not Ovulating
Answer questions about your specific fertility picture to identify what may be happening in your body and what your next step could be.
Dig deeper with functional fertility testing designed to help uncover why you’re not ovulating and identify potential next steps.
Victoria’s six-month premier fertility coaching program combines functional fertility testing, customized protocols, and high-touch support throughout your fertility journey.
Connect with Victoria on Instagram
Have a question after listening? Victoria is active in her DMs at @nourishedfertility.
If this episode helped you better understand your fertility journey, subscribe to the Nourished Fertility Podcast, share this episode with someone who needs it, and leave a rating and review to help more women find the fertility care and education they deserve.
Hey, I'm Victoria!
Founder and Functional Fertility Dietitian with over 15+ years of experience helping women balance hormones, restore their fertility, finally get pregnant and reclaim a life of true nourishment. My own journey with disordered eating and losing my period after coming off birth control is what brought me here. I made peace with food, reconnected with my body, and found what I now call wellness without obsession. Now I get to help other women do the same!
Why aren't you ovulating, even after trying Letrozole?
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