Reply of the Authors: Serum AMH, FSH, and LH levels in PCOS

LETTER TO THE EDITOR Reply of the Authors: We appreciate the interest of Dr. Georgopoulos and colleagues in our study. In response to our observation of an inverse relationship between FSH and anti-M€ullerian hormone (AMH) among women undergoing in vitro fertilization they have offered their own observation that among women with polycystic ovarian syndrome the FSH/AMH relationship is not present. They further offer evidence that AMH concentration is directly related to luteinizing hormone (LH) among women with polycystic ovaries (PCO). Although a relationship between serum AMH and LH concentration among women with PCO is plausible, we fail to see the utility of such an observation. Anti-M€ullerian hormone is produced by antral and preantral follicles. Antral follicles decrease with reproductive aging, and as a consequence, serum concentration of AMH falls (1). Fewer antral follicles result in a fall in both inhibin and sex steroids, leading to a consequent rise in FSH (2). Thus, although serum AMH is directly linked to ovarian reserve serum, FSH is a few steps removed from this process. Our study related the serum FSH to serum AMH (3). Such a relationship may be used to help clinical interpretation of AMH concentration with regard to prediction for ovarian reserve. We did not imply a direct physiologic relationship between AMH and FSH secretion other than the common link as a reflection of follicular dynamics. The observation of increased AMH among women with PCO-like ovaries is a further example of the direct relationship of serum AMH

to antral follicles, which are abundantly present in the ovaries of women with PCO. It is well known, and was at one time part of the diagnostic criteria for PCO, that women with this condition often have increased serum concentration of LH. Thus, a direct relationship of LH and AMH demonstrated in a population of women with PCO is not a surprise. Indeed, elevated serum concentration of AMH may have utility in the diagnosis of PCO (4), not as a surrogate for serum LH measurement, but as a direct reflection of the increased antral follicle pool. We did not propose that AMH levels are modulated by FSH, and do not believe that our correspondents have offered credible evidence to support their hypothesis that body mass index and LH directly modulate AMH among women with PCO. Instead, we interpret both our study and the data provided by Georgopoulos et al. as further support of the well-established relationship between antral follicle numbers and serum AMH. David H. Barad, M.D., M.S. Norbet Gleicher, M.D. Tomer Singer, M.D. Albert Einstein College of Medicine Obstetrics and Gynecology & Women’s Health New York, New York D.H.B. has nothing to disclose. N.G. has nothing to disclose. T.S. has nothing to disclose. doi:10.1016/j.fertnstert.2009.10.007

REFERENCES 1. Fanchin R, Schonauer LM, Righini C, Guibourdenche J, Frydman R, Taieb J. Serum antiMullerian hormone is more strongly related to ovarian follicular status than serum inhibin B, estradiol, FSH and LH on day 3. Hum Reprod 2003;18:323–7. 2. Scheffer GJ, Broekmans FJ, Dorland M, Habbema JD, Looman CW, te Velde ER. Antral follicle counts by

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transvaginal ultrasonography are related to age in women with proven natural fertility. Fertil Steril 1999;72:845–51. 3. Singer T, Barad DH, Weghofer A, Gleicher N. Correlation of antimullerian hormone and baseline folliclestimulating hormone levels. Fertil Steril 2009;91: 2616–9.

4. Piltonen T, Morin-Papunen L, Koivunen R, Perheentupa A, Ruokonen A, Tapanainen JS. Serum anti-Mullerian hormone levels remain high until late reproductive age and decrease during metformin therapy in women with polycystic ovary syndrome. Hum Reprod 2005;20:1820–6.

Fertility and Sterility Vol. 93, No. 3, February 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

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