We always welcome comments of experts; however, several criticisms presented by Palomba and La Sala do not seem to address our point.

The first criticism is that the only cause of infertility in polycystic ovary syndrome (PCOS) should be considered anovulation because for other factors, evidence is not strong enough. This may be true, but other factors cannot be excluded. We wrote that “it has been recognized that anovulation may not be the only reason for the failure to conceive”; we believe the statement is both factual and correct.

The second relates to the fact that women with PCOS cannot be definitively considered at increased risk of spontaneous abortion. What we wrote is: “Once a woman with PCOS has conceived, her problems are not over because she will be at a higher risk of miscarriage, both after spontaneous or assisted conception.” The evidence provided in the literature may not be “definitive,” but we saw no reason for ignoring it.

The third point deals with the usefulness of administering metformin. We do not want to be dragged into a discussion on its use, which is clearly outside the scope of our opinion: our issue is not infertility but a possible increased risk of obstetrical complications if pregnancy is achieved at a young age because deep placentation requires progressive preconditioning of the uterus by ovulatory cycles.

We agree that there is an issue requiring an explanation: the mentioned subanalysis of the Pregnancy in PCOS I trial showing lower conception and live birth rates after spontaneous menses, or progestin-induced withdrawal bleeding. Here 2 considerations are in order: first, spontaneous bleeding in PCOS may not be the consequence of an ovulatory cycle. Second, we have not advocated the use of progestins to induce bleeding; rather, we suggested that in young adolescents with PCOS, several cycles of ovulation induction prior to conception may help in achieving deep placentation in the ensuing pregnancy and decrease the risk of major obstetrical disorders.

The final point is that the risk of pregnancy complications in women with PCOS seems to be significantly influenced by menstrual patterns and is not increased in subjects with ovulatory phenotype. Although this comprehensive review was not available, even online, at the time we submitted our opinion (May 19, 2015), this finding does not influence our opinion and is in fact in line with the need of preconditioning the uterus by menstruations to achieve a successful pregnancy.