“History” of elevated serum FSH and ovarian response

LETTERS TO THE EDITOR Paul G. McDonough, M.D. Associate Editor “History” of elevated serum FSH and ovarian response To the Editor: The Center for Reproductive Medicine and Infertility at Weill-Cornell Medical Center is one of the most prestigious IVF centers in the world and has demonstrated consistently high pregnancy rates over the years. Thus, the article by Roberts et al. (1) demonstrating that patients with a history of three or more elevated FSH levels achieved no pregnancies, regardless of age, after IVF-ET should have a pronounced influence on other reproductive endocrinologists. These data might suggest to them not to initiate IVF in this patient group and to advise these patients to consider donor oocytes, donor embryos, adoption, or not having children (1). I have to admit, however, that I am extremely puzzled over their findings. Even without IVF and no controlled hyperstimulation (COH), we found a 46.1% clinical pregnancy rate and a 34.6% viable pregnancy rate over 6 months in women aged ⱕ39 years with consistently elevated serum FSH levels (2). Thus, I considered that because we have some data supporting the concept that COH might adversely affect implantation in approximately 20% of women with normal serum FSH levels, that possibly the adverse effect of COH is even more magnified in the circumstance of decreased egg reserve (3). This theory could explain how we achieved a viable pregnancy rate per transfer of single embryos in women with high FSH levels and markedly decreased egg reserve of 27.3% for ages ⱕ35 years, 30.8% for ages 36 –39 years, and 21.7% for ages 40 – 42 years because we used minimal or no gonadotropin stimulation (4). We have also previously published data from a group of women with high serum FSH levels with more egg reserve than the aforementioned group, as evidenced by the fact that they could stimulate multiple follicles after COH, who had a viable pregnancy rate of 21.4% (5). These women had a mean of 2.9 embryos transferred (5) vs. 1.06 in the more severe group (4). The results are still consistent with the hypothesis of an adverse effect of COH because the implantation rate per embryo in the group receiving 2.9 embryos was 10%, vs. 33.3% and 28.6%, respectively, for women aged ⱕ35 years and 36 –39 years receiving 1.06 embryos (4, 5). However, the theory of an adverse effect of COH still does not explain why, even with COH, we get a 21% viable pregnancy rate compared with at Cornell, especially when in general they produce higher pregnancy rates than our IVF center for women in the normal IVF population. I write this letter for the main purpose of promulgating our data published in journals with less circulation than Fertility and Sterility, to convince reproductive endocrinologists to 260

give women with decreased egg reserve a chance of conceiving with their own gametes. For many women, the very effective choice of donor oocyte might not be a viable option for religious, ethical, or financial reasons. I also would be very interested in any theory that Dr. Roberts might have to explain the discordant outcomes found in our two IVF centers. Jerome H. Check, M.D., Ph.D. Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology Cooper Hospital/University Medical Center Robert Wood Johnson Medical School at Camden The University of Medicine and Dentistry of New Jersey Camden, New Jersey February 18, 2005

REFERENCES 1. Roberts JE, Spandorfer S, Fasouliotis SH, Kashyap S, Rosenwaks Z. Taking a basal follicle-stimulating hormone history is essential before initiating in vitro fertilization. Fertil Steril 2005;83:37– 41. 2. Check JH, Peymer M, Lauri D. Effect of age on pregnancy outcome without assisted reproductive technology in women with elevated early follicular phase serum follicle-stimulating hormone levels. Gynecol Obstet Invest 1998;45:217–20. 3. Check JH, Choe JK, Katsoff D, Summers-Chase D, Wilson C. Controlled ovarian hyperstimulation adversely affects implantation following in vitro fertilization-embryo transfer. J Assist Reprod Genet 1999; 16:416 –20. 4. Check ML, Check JH, Wilson C, Choe JK, Krotec J. Outcome of in vitro fertilization-embryo transfer according to age in poor responders with elevated baseline serum follicle stimulation hormone using minimal or no gonadotropin stimulation. Clin Exp Obstet Gynecol 2004;21:183– 4. 5. Check JH, Nazari P, Check ML, Choe JK, Liss JR. Prognosis following in vitro fertilization-embryo transfer (IVF-ET) in patients with elevated day 2 or 3 serum follicle stimulating hormone (FSH) is better in younger vs. older patients. Clin Exp Obstet Gynecol 2002;29:42– 4.

doi:10.1016/j.fertnstert.2005.03.017

Reply of the Author: We would like to thank Dr. Check for his interest in our article, and for sharing his published work on the use of basal FSH ovarian reserve testing in controlled ovarian hyperstimulation (COH). We agree that COH might have negative effects on reproduction, at several levels. Supraphysiologic E2 levels generated during IVF, as measured on the day of hCG administration, might predict a lesser IVF outcome (1, 2), and as other groups have also found, less stimulation or even natural cycle IVF might be a better option for certain patients (3). Some data suggest that exogenous FSH might

Fertility and Sterility姞 Vol. 84, No. 1, July 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.

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