Predictive value of serum FSH in anovulatory women: reply of the author

tion. Compared with ovulatory women, increasing basal FSH level and age correlated inversely with response to COH (fewer follicles, lower peak estradiol level, and fewer pregnancies). We have likewise reported on the utility of basal FSH and estradiol profiles in anovulatory PCOS women undergoing COH and IUI cycles (5). Although there were no differences in age or mean basal serum FSH level between pregnant and nonpregnant women, cycle day 3 serum estradiol level was significantly lower in pregnant women and was more predictive of outcome than FSH. However, cut-off thresholds for normal vs. abnormal were significantly higher than in ovulatory women. Although these two studies (3, 5) pertain to COH-IUI cycles, they suggest that assessment of ovarian reserve for predicting outcomes differs in anovulatory women and ovulatory women. We hope that additional studies will be performed with this difference in mind. Steven R. Lindheim, M.D. David Olive, M.D. Department of Obstetrics and Gynecology University of Wisconsin-Madison Madison, Wisconsin June 3, 2003

References 1. Lambalk CB. Value of elevated basal follicle-stimulating hormone levels and the differential diagnosis during diagnostic subfertility work-up. Fertil Steril 2003;79:489 –90. 2. van Rooij IA, Bancsi LF, Broekmans FJ, Looman CW, Habbena JD, te Velde ER. Women older than 40 years of age and those with elevated follicle-stimulating hormone levels differ in poor response rate and embryo quality in in vitro fertilization. Fertil Steril 2003;79:482–8. 3. Burwinkel TH, Buster JE, Scoggan JL, Carson SA. Basal follicle stimulating hormone (FSH) predicts response to controlled ovarian hyperstimulation (COH)-intrauterine (IUI) therapy. J Assist Reprod Genet 1994;11:24 –7. 4. Witt B, Barad DH, Barg P, Cohen BL, Lindheim SR, Testiuti L, et al. Basal serum follicle stimulating hormone (FSH) and estradiol levels as predictors of pregnancy in unstimulated donor insemination cycles. J Assist Reprod Genet 1995;12:157–60. 5. Lindheim SR, Chang PL, Ditkoff EC, Sauer MV. The utility of day 3 FSH and estradiol in women with PCOS undergoing ovarian hyperstimulation and IUI. J Assis Repro Rev 1997;7:137–8.

not come as a surprise. Aside from the potential problem of how to obtain a valid early follicular phase FSH value (5), apparently the adequate solving of their main subfertility problem, i.e. anovulation, by ovulation induction overshadows possibly lower fertility that is related to reduced ovarian reserve. On top of that, it is likely that because of an age-related decline of their initially oversized cohort of available follicles and in parallel changes of endogenous FSH secretion, many older patients with the polycystic ovary syndrome naturally become ovulatory (6). Under such conditions, lower FSH levels may not be the optimal variable to predict pregnancy. I fully agree with Lindheim and Olive that ovarian reserve should be assessed in the context of a patient’s ovulatory status. Cornelis B. Lambalk, Ph.D. Division of Reproductive Medicine Department of Obstetrics and Gynecology Vrije Universiteit Medical Centre Amsterdam, The Netherlands June 26, 2003

References 1. Lambalk CB. Value of elevated basal follicle-stimulating hormone levels and the differential diagnosis during diagnostic subfertility work-up. Fertil Steril 2003;79:489 –90. 2. van Rooij IA, Bancsi LF, Broekmans FJ, Looman CW, Habbena JD, te Velde ER. Women older than 40 years of age and those with elevated follicle-stimulating hormone levels differ in poor response rate and embryo quality in in vitro fertilization. Fertil Steril 2003;79:482–8. 3. Witt B, Barad DH, Barg P, Cohen BL, Lindheim SR, Testiuti L, et al. Basal serum follicle stimulating hormone (FSH) and estradiol levels as predictors of pregnancy in unstimulated donor insemination cycles. J Assist Reprod Genet 1995;12:157–60. 4. Lindheim SR, Chang PL, Ditkoff EC, Sauer MV. The utility of day 3 FSH and estradiol in women with PCOS undergoing ovarian hyperstimulation and IUI. J Assis Repro Rev 1997;7:137–8. 5. van Hooff MHA, van der Meer M, Lambalk CB, Schoemaker J. Variation of LH and androgens in oligomenorrhea and its implications for the study of PCO. Hum Reprod 1999;14:1684 –9. 6. Elting MW, Kwee J, Korsen TJM, Rekers-Mombarg LTM, Schoemaker J. Aging women with polycystic ovary syndrome who achieve regular menstrual cycles have a smaller follicle cohort than those who continue to have irregular cycles. Fertil Steril 2003;79:1154 –60.

doi:10.1016/S0015-0282(03)02182-4

doi:10.1016/S0015-0282(03)02181-2

Reply of the Author: The bottom line of the editorial that accompanied the study by van Rooij et al. was that there are several physiologic and pathophysiologic causes of elevated basal FSH in ovulatory women who attend the fertility clinic (1, 2). This would explain to some extent the limitations for its use in predicting definitive infertility. Lindheim and Olive point out the difficulties that occur when basal FSH is used to predict the outcome of infertility treatment in anovulatory patients (3, 4). In particular, in anovulatory patients with polycystic ovarian syndrome, FSH levels seem to be of little value. Perhaps, after all, this does FERTILITY & STERILITY威

Differing results for efficacy—sampling bias or purposive sampling? To the Editor: I read with great interest the recent article by Grigorieva et al. entitled “Use of a levonorgestrel-releasing intrauterine system to treat bleeding related to uterine leiomyomas” (1). The authors concluded that for women with leiomyomas and total uterine size ⱕ12 weeks gestation, the levonorgestrelreleasing intrauterine system (LNG IUS) can provide both contraception and effective treatment of troublesome bleeding. Our results from a similar study published shortly before 1291