Objective: To compare the hormonal-metabolic profiles and reproductive outcomes in clomiphene-resistant patients with polycystic ovary syndrome and insulin resistance between women receiving metformin and those undergoing laparoscopic ovarian drilling. Methods: A total of 110 eligible participants were randomly allocated to diagnostic laparoscopy plus metformin therapy (group 1, n=55) or laparoscopic ovarian drilling (group 2, n=55). The t test was used for mean comparisons of hormonal-metabolic parameters and OGTT values before and after treatment. The χ2 test was used for comparisons of ovulation, pregnancy, and abortion rates. Results: Groups 1 and 2 showed a significant decline in testosterone, insulin-like growth factor-1 (Pb0.001 vs Pb0.001), and luteinizing hormone (Pb0.05 vs Pb0.001), while the glucose to insulin ratio was significantly increased (Pb0.001 vs Pb0.05) compared with baseline. Group 2 patients had more regular cycles and higher rates of ovulation and pregnancy compared with group 1: 76.4% [42/55] vs 58.2% [32/55], Pb0.04; 50.8% [131/258] vs 33.5% [94/281], Pb0.001; and 38.2% [21/55] vs 20.0% [11/55], Pb0.03, respectively. The difference in the early abortion rate between the groupswas not statistically significant. Conclusion: Although metformin results in a better attenuation of insulin resistance, laparoscopic ovarian drilling is associated with higher rates of ovulation and pregnancy.