Letters to the editor |
Reply: Which is more counterproductive: a brief delay or ‘start anyway’?
1 To whom correspondence should be addressed. E-mail: sam{at}easynet.co.uk
Sir,
Thank you for inviting us to respond to El-Toukhy and Taranissi’s comments upon our paper (Abdalla and Thum, 2006
). We provide a 7-day-a-week clinical service in our unit and could easily measure early follicular phase FSH levels for all patients. Indeed, as it is equally valid to measure the FSH on day 1, 2 or 3, any other unit offering a 5-day-a-week service could choose to do so. We suggest therefore that the reason the practice is unpopular is not related to the clinical service offered by units but rather to the lack of any clear evidence of benefit to patients from the practice.
The measurement of FSH is valuable for its prognostic value in identifying patients with a reduced ovarian reserve and possibly for assisting decision-making regarding the starting dose of gonadotrophins for stimulation. However, there is a wide variability of response to stimulation amongst patients with high FSH levels, and some patients with normal FSH levels will have an unpredicted poor response. We believe that the best test for ovarian response is to start a treatment cycle and stimulate the ovaries with FSH, having advised the patients during consultation of the potential for a reduced response. We will proceed with egg collection in such patients who have some follicular response, even if this is less than that expected in patients with a normal ovarian reserve.
The correspondents seem to suggest that using the long protocol is not appropriate for patients with high FSH levels (even if variable), although they provide many publications that suggest that the use of the flare or antagonist regime does not improve the response. Nevertheless, they later suggest that for patients with elevated FSH levels one should wait for a cycle in which the FSH is lower and use either the flare or the antagonist protocol. They provide no evidence why either of these protocols should be superior to or effective than the long protocol.
In our study design, we insisted that there should be no more than 1 year difference between the two treatment cycles so that the change in FSH or success rates could not be explained by a factor of time or ovarian ageing. The use of 12 months was a maximum period, and a substantial number of patients completed the two cycles within a much shorter period. Furthermore, they are suggesting that waiting for the FSH level to drop will result in a better outcome but—again—do not provide any evidence for this assertion. It would have been more valuable if they were able to provide a comparison between their patients who had a persistently raised FSH level and decided to proceed with treatment despite being ‘extensively counselled’ and those in whom the FSH had dropped before starting treatment.
It is reasonable to defer the start of treatment cycles pending completion of interventions with proven benefit to IVF outcome such as surgical treatment of hydrosalpinges. We are simply questioning whether there is any evidence that deferring treatment while repeatedly testing FSH levels improves outcome.
We believe that if the FSH level is elevated, the clinician should help the patient accept the situation and discuss the options of starting treatment or explore alternative options such as egg donation. The issue therefore is this: Should both clinician and patient accept a lower pregnancy rate for these patients? Or should they continue to hunt for a target FSH level with no proven benefit? We believe that the latter approach wastes valuable time for patients, with the ultimate result that some may give up altogether.
Reference
Abdalla H and Thum MY. (2006) Repeated testing of basal FSH levels has no predictive value for IVF outcome in women with elevated basal FSH. Hum Reprod 21:1171–174.
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