We read with interest the article from Liu and Zanotti. The authors state that recent evidence suggests that fertility drug use is not an independent risk factor for ovarian cancer, citing the review from Mahdavi et al and a Danish population study. However, this review showed that there was a stronger association between fertility drug use and borderline tumors of the ovary. The Danish study did not provide sufficient data for women who had undergone repeated stimulation cycles with gonadotropins. Moreover, the median age at the end of follow-up (47 years) was below the usual peak age (early 60s) for ovarian cancer. Therefore, women with an adnexal mass and who had a history of several treatments with gonadotropins should require more cautious treatment. We totally agree that intermediate-risk adnexal masses are the most problematic diagnostic and management challenges. We think that one of the main factors that should be considered in the decision-making process is fertility status. The treatment of women with a desire for future fertility or of infertile women should be different from that of women who do not desire future pregnancy or postmenopausal women. Adnexal masses frequently are detected during infertility work-up. It is well-known that any kind of ovarian surgery negatively affects follicular reserve. Therefore, follicular reserve should be assessed before operative decisions by measuring anti-Mullerian hormone plasma levels.
