Objective: The aim of this study is to evaluate the stimulatory effect ofcombination of thermal aqua puncture and clomiphene citrate on ovulationinduction in patients with PCOS who are resistant to clomiphene citrate.Setting: The procedure was carried out in Kasr Al-Aini, Department of OBS & GYN- IVF Unit.Study design: Cohort study.Participants: Twenty-five anovulatory infertile females diagnosed as PCOS byclinical, chemical and ultrasound criteria were recruited for the study. All caseswere resistant to clomiphene citrate for more than 6 months. All casescompleted the follow up period for three cycles.Intervention: injection of hot sterile saline (15C) into the ovarian stroma undertransvaginal monitoring using ovum pickup needle.Outcome measures: cycle regularity, ovulation rate and safety were primaryoutcomes. Pregnancy rate and patient convenience were our secondaryoutcomes.Results: ovulation has been achieved in 84.0% (21/25) of clomiphene citrateresistant PCOS cases at 1st cycle, 82.9% (19/23) at 2nd cycle and 80% (16/20) at3rd cycle. Also resulted in pregnancy in 20.0% (5/25) of these cases. No adverseeffects were recorded and the procedure was tolerable in most of cases. Conclusion: Transvaginal ultrasound guided ovarian stroma hydrocoagulationin an office setting seems to be a safe, economic and practical procedure that isacceptable by the patients. If larger studies confirmed its effectiveness it may bean attractive alternative to conventional ovarian drilling.