The effect of methotrexate injection for treatment of an ectopic pregnancy on ovarian reserve

7 01 2014

To the Editor:

We read with great interest the paper “Does methotrexate administration for ectopic pregnancy after in vitro fertilization (IVF) impact ovarian reserve or ovarian responsiveness?” by Boots et al. (1). In the article, the authors evaluated the effects of methotrexate (MTX) on the future fertility of women undergoing IVF by comparing markers of ovarian reserve (day 3 FSH, antral follicle count), measures of ovarian responsiveness (duration of stimulation, peak E2 level, total dose of gonadotropins, number of oocytes retrieved, fertilization rate), and time from MTX administration to subsequent IVF cycle, in the IVF cycle before and after an ectopic pregnancy (EP) treated with MTX. They concluded that MTX treatment of an EP does not compromise ovarian reserve or ovarian responsiveness in subsequent cycles. However, other studies have demonstrated that when gonadotropin stimulation dose remains unchanged, fewer oocytes may be collected after MTX is taken as management of an ectopic pregnancy, suggesting a decrease in ovarian reserve (2). Read the rest of this entry »


Whatever its variability, AMH remains the most stable hormonal predictor

8 04 2013

To the Editor:

Dr. Hadlow and colleagues argue that antimüllerian hormone (AMH) levels decrease in the luteal phase and that the hormone should be measured in the follicular phase, since this variability may lead to misprediction of ovarian response in IVF. This assumption was made on the basis of few, not frequent, blood samples performed on a very limited sample of women (1).

In the study, the intra-individual variability of AMH was found to be similar to that of FSH. This finding is really surprising and points out a critical revision of the results obtained. Both of the largest available studies to date (2, 3) reported that 89% of the variation in AMH was due to between-subjects variation, while only 11% was due to true individual fluctuations. AMH may exhibit some variability, but the important point is that the fluctuations are randomly distributed throughout the menstrual cycle (4), raising the possibility that a fixed day for its measurement, as proposed, would be useless. The suggested cyclic moifications of AMH in Dr. Hadlow’s study need to be confirmed in studies investigating hormonal variability through more frequent samples and across at least two menstrual cycles. A logical and agreeable hypothesis explaining why AMH should reduce in the luteal phase needed to be formulated by the authors. If AMH is produced by antral follicles, the number of which shows no significant reduction in the luteal phase, and since AMH seems to be only marginally influenced by gonadotropins, why should its concentration reduce in the second part of the cycle? Read the rest of this entry »

Response to commentary of Drs. Rosenwaks and Reichman: “But isn’t AMH still better than FSH?”

27 03 2013

To the Editor:

We sincerely appreciate Drs. Rosenwaks’ and Reichman’s commentary (1) on our opinion piece. We are especially grateful for their explicit reporting of their program’s IVF outcomes in cases of low AMH levels, which is the largest experience yet reported. (Perhaps our admittedly provocative title spurred their useful and pertinent report of these results.) Finding that 6.2 eggs were retrieved from 1,052 patients with an AMH below 0.5 ng/mL, resulting in a 25.7% clinical pregnancy rate per retrieval, is reassuring. Perhaps more surprising is the 19% clinical pregnancy rate per retrieval among the 224 patients with AMH levels below the limit of detection (<0.16 ng/mL), who on average produced 3.9 eggs. Pertinent to our case, however, is the high cancellation rate they report for these groups: 26.1% for those with an AMH <0.50 ng/mL, and 38.8% when the AMH was <0.16 ng/mL.

We agree with Drs. Rosenwaks and Reichman that patients “should not be dissuaded from pursuing IVF solely because of a low AMH value,” as one of us (JPT) previously cautioned regarding elevated FSH values (2). Nonetheless, we do believe we have an obligation to warn that low AMH levels predict low ovarian response, higher cancellation rates, and lower pregnancy rates. We also continue to believe that AMH is a more sensitive and specific marker of low response than FSH ever was, so we still prefer it to FSH for this purpose.

James P. Toner, M.D., Ph.D.
Atlanta Center for Reproductive Medicine, Atlanta, GA
David B. Seifer, M.D., Ph.D.
Genesis Fertility and Reproductive Medicine, Brooklyn, NY


(1) Rosenwaks Z, Reichman DE. Use of antimüllerian hormone: the risks of interpreting ovarian reserve markers in isolation. Fertil Steril 2013, in press.

(2) Toner JP. Modest FSH elevations in young women: warn but don’t disqualify. Fertil Steril 2004; 81: 1493-5.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2012.04.045

Laparoscopic excision of endometriomas and ovarian reserve

6 09 2012

To the Editor:

We read with great interest the article by Celik et al. (1) about the reduction of ovarian reserve in patients submitted to laparoscopic ovarian endometrioma excision. The topic of endometriosis and ovarian reserve is extremely interesting and has been extensively debated in the literature. Our group was the first to report a reduction of AMH levels in patients with endometriosis (2), and others have shown also a significant reduction of ovarian reserve after surgery in this group of patients (3). However, what caught our attention in this paper was the finding that after endometrioma excision, patients presented significantly lower levels of AMH while a significantly higher number of antral follicles was observed. Read the rest of this entry »

Ovarian reserve and oocyte maturity in cancer patients

17 05 2011

To the Editor:

With great interest we read the article on ovarian reserve and oocyte maturity in cancer patients undergoing in vitro maturation treatment (IVM) by Moria et al. (1). Detailed information concerning this topic is of great value to doctors counselling cancer patients with regard to their wish to conceive in the (near) future.

The authors studied ovarian reserve and oocyte maturity in cancer patients in comparison to infertile patients (1). We wonder whether it is correct to compare cancer patients to infertile patients. Ideally, one would like to compare to healthy subjects to investigate the effect of cancer on fertility. We are aware that it would be ethically impossible to acquire these parameters on a group of fertile individuals as they would have to undergo unnecessary IVM. However, a viable solution to this problem would be to compare cancer patients with couples who are infertile due to an andrological factor. Read the rest of this entry »

The impact on ovarian reserve after laparoscopic ovarian cystectomy

9 08 2010

To the Editor:

The importance of ovarian preservation in patients with infertility related endometriosis has long been debated (1). Endometriomas do impair fertility and studies have demonstrated improved IVF outcomes after ovarian cystectomy and treatment of endometriosis in matched controlled studies (2). The article by Tsolakidis et al. (1) deserves praise for several points and also raises some concern, as others may use this information as a guide in the treatment of their patients with endometriomas. Read the rest of this entry »

Variability in Anti-Müllerian hormone levels. A comment on Sowers et al, “Anti-Müllerian hormone and inhibin B variability during normal menstrual cycles”

7 06 2010

To the Editor:

The paper by Sowers et al. (1) presents valuable and carefully collected data on the variability of serum Anti-Müllerian hormone (AMH) over the menstrual cycle, with 20 women each providing daily blood samples for one complete cycle. It is unfortunate that sampling were not prolonged giving data for all or part of a second cycle which would have allowed them to estimate repeatability and obtain rigorous statistical tests of cycle effects – this should be considered for future similar studies. Read the rest of this entry »