scopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels'' (1). In their letter, Genro et al. question the ...
LETTER TO THE EDITOR REPLY OF THE AUTHORS: We read with interest the letter by Genro et al. commenting on our article, ‘‘Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antim€ ullerian hormone levels’’ (1). In their letter, Genro et al. question the unexpected increase in the antral follicle count (AFC) while antim€ ullerian hormone (AMH) levels were decreasing after endometrioma excision. We agree that there was an unexpected increase in AFC in our study. In the discussion section of our article we speculated that this finding may be either due to a reactive response of ovarian parenchyma after surgery or due to the presence of endometriomas, which prevents the correct measurement of AFC preoperatively, and underestimating of AFC. In clinical practice we have seen that large endometriomas may prevent the visualization of the normal ovarian cortex. This increased AFC after endometrioma surgery was also reported by Tsolakidis et al. (2) in the three-step laser vaporization group of their study population. Similar results were also reported by Pados et al. (3). They compared one-stage laparoscopic cystectomy with ‘‘three-stage management’’ (laparoscopic drainage, followed by 3 months of GnRH agonist treatment, and then laser vaporization of the cyst wall during a second laparoscopic surgery) in 20 patients with ovarian endometriomas. Interestingly, AFC on the operated ovary was significantly increased after 6 months of surgery in the three-stage management group compared with the one-stage laparoscopy group. In their letter, Genro et al. refer to an article by Klein et al. (4) for the physiologic explanation of this increase in AFC. We agree that the reactive response of ovarian tissue after surgery may have led to the production of larger follicles because of the high luteo-follicular phase FSH levels. This may also be a plausible explanation for the AFC increase. Because more advanced stages of maturation do not produce AMH, higher numbers of antral follicles and lower levels of AMH may be encountered after endometrioma excision.
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In our article, because of this unexpected increase in AFC, we concluded that AFC may not be a suitable ovarian reserve marker in patients undergoing endometrioma surgery. Antral follicle count may be measured as erroneously increased after surgery, whereas AMH is truly decreased. Obviously, more studies with longer follow-up periods are needed to better understand the impact of laparoscopic endometrioma excision on ovarian reserve. Hale Goksever Celik, M.D.a Erbil Dogan, M.D.b a Department of Obstetrics and Gynecology, Kayseri Develi General Hospital, Kayseri Develi; and b Department of Obstetrics and Gynecology, Dokuz Eylul University, Izmir, Turkey August 23, 2012 http://dx.doi.org/10.1016/j.fertnstert.2012.09.008
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Celik HG, Dogan E, Okyay E, Ulukus C, Saatli B, Uysal S, et al. Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antim€ ullerian hormone levels. Fertil Steril 2012; 97:1472–8. Tsolakidis D, Pados G, Vavilis D, Athanatos D, Tsalikis T, Giannakou A, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril 2010;94:71–7. Pados G, Tsolakidis D, Assimakopoulos E, Athanatos D, Tarlatzis B. Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study. Hum Reprod 2010;25:672–7. Klein NA, Harper AJ, Houmard BS, Sluss PM, Soules MR. Is the short follicular phase in older women secondary to advanced or accelerated dominant follicle development? J Clin Endocrinol Metab 2002;87: 5746–50.
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