Correlation between three assay systems for anti-Müllerian hormone (AMH) determination

Limited Recommendations and Evidence for Timing and Frequency of Anti-Mullerian Hormone Screening in Female Pediatric Cancer Survivors: A Systematic Review from the Pediatric and Adolescent Committee of the Oncofertility Consortium

Guidelines regarding the optimal use and timing of anti-Mullerian hormone (AMH) screening in childhood cancer survivors to evaluate for the risk of premature ovarian insufficiency or reduced fertility potential are lacking. We conducted a systematic review of the current evidence supporting AMH screening of female childhood cancer survivors with the overall objective to identify gaps in the literature needing further study, to allow for future data-driven recommendations. Search terms included "cancer, fertility, and anti-Mullerian hormone." We included original research articles that had ≥20 female childhood cancer survivors and excluded studies not including pediatric oncology survivors (≤18 years of age), did not include raw AMH values, were a mixed pediatric/young adult population which were minority pediatric, or did not separate pediatric from adult AMH data. In total, 17 studies (8 case-control, 5 cross-sectional, and 4 longitudinal prospective cohorts), encompassing 1106 total survivors met inclusion criteria and were further evaluated. Three studies evaluated the relationship of AMH to antral follicle count with generally good concordance. Four studies analyzed longitudinal changes in AMH with chemotherapy demonstrating that most patients will have an acute drop in AMH during therapy, and recovery of AMH over time is dependent on treatment intensity. No studies evaluated the optimal timing or interval of AMH testing. AMH correlates well with other markers of ovarian reserve, but there is insufficient data regarding the utility of AMH to predict the ability to conceive or timing of menopause. Optimal AMH screening initiation, duration, and intervals also require further study.

The impact of treatment for childhood classical Hodgkin lymphoma according to the EuroNet-PHL-C2 protocol on serum anti-Müllerian Hormone

STUDY QUESTION

What is the impact of the EuroNet-PHL-C2 treatment protocol for children with classical Hodgkin lymphoma (cHL) on gonadal function in girls, based on assessment of serum anti-Müllerian hormone (AMH)?

SUMMARY ANSWER

Serum AMH levels decreased after induction chemotherapy and increased during subsequent treatment and 2 years of follow-up, with lowest levels in patients treated for advanced stage cHL.

WHAT IS KNOWN ALREADY

Treatment for cHL, particularly alkylating agents and pelvic irradiation, can be gonadotoxic and result in premature reduction of primordial follicles in females. The current EuroNet-PHL-C2 trial aims to reduce the use of radiotherapy in standard childhood cHL treatment, by intensifying chemotherapy. This study aims to assess the gonadotoxic effect of the EuroNet-PHL-C2 protocol.

STUDY DESIGN, SIZE, DURATION

This international, prospective, multicenter cohort study is embedded in the EuroNet-PHL-C2 trial, an European phase-3 treatment study evaluating the efficacy of standard cHL treatment with OEPA-COPDAC-28 (OEPA: vincristine, etoposide, prednisone, and doxorubicin; COPDAC-28: cyclophosphamide, vincristine, prednisone, and dacarbazine) versus intensified OEPA-DECOPDAC-21 (DECOPDAC-21: COPDAC with additional doxorubicin and etoposide and 25% more cyclophosphamide) in a randomized setting. Participants were recruited between January 2017 and September 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Female patients aged ≤18 years, treated according to the EuroNet-PHL-C2 protocol for cHL were recruited across 18 sites in the Netherlands, Belgium, Germany, Austria, and Czech Republic. All parents and patients (aged ≥12 years old) provided written informed consent. Serum AMH levels and menstrual cycle characteristics were evaluated over time (at diagnosis, one to three times during treatment and 2 up to 5 years post-diagnosis) and compared between treatment-levels (TL1, TL2, and TL3) and treatment-arms (OEPA-COPDAC-28 and OEPA-DECOPDAC-21). Serum samples obtained from patients after receiving pelvic radiotherapy were excluded from the main analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 104 females, with median age at diagnosis of 15.6 years (IQR 13.7; 17.0), were included in the analysis. Ninety-nine were (post)pubertal. Eighteen girls were diagnosed with an early stage of cHL (TL1) and 86 with intermediate or advanced stage disease (50 TL2 and 36 TL3, 66% received COPDAC-28 and 34% DECOPDAC-21). Five patients received pelvic radiotherapy. Median AMH level at diagnosis was 1.7 µg/l (IQR 0.9; 2.7). After two courses of OEPA chemotherapy, AMH levels decreased substantially in all patients (98% <0.5 µg/l), followed by a significant increase during the consolidation treatment and follow-up. After 2 years, 68% of patients reached their baseline AMH value, with overall median recovery of 129% (IQR 75.0; 208.9) compared to baseline measurement. Five patients (7%) had AMH <0.5 µg/l. In patients treated for advanced stage disease, AMH levels remained significantly lower compared to early- or intermediate stage disease, with median serum AMH of 1.3 µg/l (IQR 0.8; 2.1) after 2 years. Patients who received DECOPDAC-21 consolidation had lower AMH levels during treatment than patients receiving COPDAC-28, but the difference was no longer statistically significant at 2 years post-diagnosis. Of the 35 postmenarchal girls who did not receive hormonal co-treatment, 19 (54%) experienced treatment-induced amenorrhea, two girls had persisting amenorrhea after 2 years.

LIMITATIONS, REASONS FOR CAUTION

The studied population comprises young girls with diagnosis of cHL often concurring with pubertal transition, during which AMH levels naturally rise. There was no control population, while the interpretation of AMH as a biomarker during childhood is complex. The state of cHL disease may affect AMH levels at diagnosis, potentially complicating assessment of AMH recovery as a comparison with baseline AMH. The current analysis included data up to 2-5 years post-diagnosis.

WIDER IMPLICATIONS OF THE FINDINGS

The current PANCARE guideline advises to use the cyclophosphamide-equivalent dose score (CED-score, as an estimation of cumulative alkylating agent exposure) with a cut-off of 6000 mg/m2 to identify females aged <25 years at high risk of infertility. All treatment-arms of the EuroNet-PHL-C2 protocol remain below this cut-off, and based on this guideline, girls treated for cHL should therefore be considered low-risk of infertility. However, although we observed an increase in AMH after chemotherapy, it should be noted that not all girls recovered to pre-treatment AMH levels, particularly those treated for advanced stages of cHL. It remains unclear how our measurements relate to age-specific expected AMH levels and patterns. Additional (long-term) data are needed to explore clinical reproductive outcomes of survivors treated according to the EuroNet-PHL-C2 protocol.

STUDY FUNDING/COMPETING INTEREST(S)

The fertility add-on study was funded by the Dutch charity foundation KiKa (project 257) that funds research on all forms of childhood cancer. C.M-K., D.K., W.H.W., D.H., M.C., A.U., and A.B. were involved in the development of the EuroNet-PHL-C2 regimen. The other authors indicated no potential conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Anti-Mullerian hormone and spontaneous puberty in a diverse US Turner syndrome clinic cohort: A cross-sectional study

OBJECTIVE

Serum Anti-Mullerian Hormone (AMH) concentrations have been proposed as a marker of spontaneous puberty and future fertility in Turner syndrome (TS). Gonadotropins during minipuberty may also provide a clue to ovarian function but there is insufficient data to inform utility in the routine clinical management of TS. Our objective was to describe the distribution of AMH in a cross-sectional cohort of patients in a TS specialty clinic, and correlate with spontaneous puberty and karyotype, as well as gonadotropins during the minipuberty of infancy in a smaller subset of patients aged 2-9 months.

DESIGN

Retrospective chart review of patients seen in the TS clinic at Children's National Hospital from 1/1/2019 to 8/24/2022, to assess AMH and correlate with karyotype and spontaneous puberty.

RESULTS

Among 114 patients (median age 9.6 year, 0.08-22 year), AMH values were detectable in only (40/104) 38%, and higher mean AMH (2.7 ± 0.95 ng/mL) was seen in mosaic 45,X/46,XX karyotype compared to 45,X (0.03 ± 0.14 ng/mL) (p < .001), and structurally abnormal-X karyotype (0.11 ± 0.5) (p = .0003). Mean AMH was higher (1.4 ± 1.6 ng/mL) among those with spontaneous menarche compared with spontaneous thelarche but no menarche. AMH was detectable in 2/10 during minipuberty in those with the lowest luteinizing hormone (LH).

CONCLUSIONS

Our institutional data reflects a diverse cohort of patients seen in a TS specialty clinic in the United States, showing correlation of AMH with karyotype and spontaneous menarche, as well as description of gonadotropins during minipuberty highlighting their clinical relevance. Studies in larger, prospective longitudinal cohorts will help determine their predictive value and role in the care of TS.

Follicle development and its prediction in patients with primary ovarian insufficiency: Possible treatments and markers to maximize the ability to conceive with residual follicles

Background

Primary ovarian insufficiency (POI) is characterized by the development of hypergonadotropic hypogonadism before 40 years of age and leads to intractable infertility. Although in vitro fertilization and embryo transfer with donated eggs enables pregnancy, not a few patients desire pregnancy using their oocytes. However, follicular development is rare and unpredictable in patients with POI. Thus, there is a need for treatments that promote the development of residual follicles and methods to accurately predict infrequent ovulation.

Methods

This review discusses the effects of various treatments for obtaining eggs from POI patients. Furthermore, this study focused a potential marker for predicting follicular growth in patients with POI.

Main Findings

Different treatments such as hormone-replacement therapy, dehydroepiandrosterone supplementation, platelet-rich plasma injection, and in vitro activation have shown varying degrees of effectiveness in retrieving oocytes from patients with POI. To predict follicle development in the cycle, elevated serum estradiol and reduced follicle-stimulating hormone (FSH) levels are important. However, these markers are not always reliable under continuous estradiol-replacement therapy. As a novel marker for predicting follicle growth, serum anti-Müllerian hormone (AMH) levels, measured using the picoAMH enzyme-linked immunosorbent assay, were found to predict follicle growth in patients and the cycle.

Conclusion

This review highlights the challenges and available interventions for achieving pregnancy using a patient's oocytes in cases of POI. We believe that a combination of currently available treatments and prediction methods is the best strategy to enable patients with POI to conceive using their own eggs. Although AMH levels may predict follicle growth, further research is necessary to improve the chances of successful follicular development and conception in patients with POI.

Challenges in Measuring AMH in the Clinical Setting

Serum anti-Mullerian hormone (AMH) is a widely used marker of functional ovarian reserve in the assessment and treatment of infertility. It is used to determine dosing of gonadotropins used for superovulation prior to in vitro fertilization, as well as to determine the degree of damage to ovarian reserve by cytotoxic treatments such as chemotherapy. AMH is also now used to predict proximity to menopause and potentially provides a sensitive and specific test for polycystic ovarian syndrome. Twenty one different AMH immunoassay platforms/methods are now commercially available. Of those compared, the random-access platforms are the most reliable. However, to date there has not been an agreed common international AMH reference preparation to standardize calibration between the various immunoassays. Recently, a purified human AMH preparation (code 16/190) has been investigated by the World Health Organization as a potential international reference preparation. However, this was only partially successful as commutability between it and serum samples was observed only in some but not all immunoassay methods. Development of a second generation reference preparation with wider commutability is proposed.

The interchangeability of two assays for the measurement of anti-Müllerian hormone when personalizing the dose of FSH in in-vitro fertilization cycles

OBJECTIVE

Study the interchangeability of Roche Elecsys and Beckman Coulter Access anti-Müllerian Hormone (AMH) assays to select the gonadotropin starting dose in IVF cycles.

METHODS

Patients' AMH was measured using both Elecsys and Access automated assays. AMH values were then used to calculate the FSH starting dose. The main outcome is the percentage of women that would have been stratified to a different dose of gonadotropin due to differences in AMH values from the two tests.

RESULTS

The Access assay systematically gives higher values compared with the Elecsys assay (slope = 0.88). For Follitropin Alfa, the difference in starting dose was > 15% in 2/113 patients, when Access AMH was used instead of Elecsys. For Follitropin Delta the difference in the starting dose was >15% in 21/113 patients when using Access AMH. When considering women with high ovarian reserve, only 4/51 would have received a Follitropin Delta dose that exceeded a 15% difference using Access AMH as a substitute for the Elecsys value.

CONCLUSIONS

The use of the Roche Elecsys or Beckman Coulter Access leads to modest differences in AMH values, which seem to little affect the calibration of FSH dose used for ovarian stimulation.

Label-free anti-Müllerian hormone sensor based on polyaniline micellar modified electrode

A label-free electrochemical immunosensor based on polyaniline (PANI) micellar electrode was firstly fabricated for direct AMH detection. To control the size regularity of PANI, a micelle-based method using ammonium peroxydisulfate (APS) as a reducing agent was employed in the polymerization process. The Anti-AMH antibodies were readily immobilized onto PANI via peptide bond to enhance the sensor specificity and sensitivity. This sensor was applied for the detection of AMH, an ovarian response indicator in female related to residual eggs during a woman's monthly cycle. The sensor performances were systematically investigated by differential pulse voltammetry. The anodic peak current decreases with the increase of AMH concentration owing to blocking of electron transfer by AMH. Under the optimal conditions, this sensor offers high sensitivity with a low detection limit of 0.1 ng mL^-1 and a wide linear range of 0.1-4 ng mL^-1, which is sensitive enough to indicate the ability to produce eggs during a woman's monthly cycle. Furthermore, this system requires lower sample volume (5 μL), while offers the simple fabrication with low cost and no synthetic challenge and faster analysis compared with a standard ELISA. Ultimately, this sensor was successfully applied for the detection of AMH in human serum with satisfactory results. Thus, it might be an alternative tool for AMH screening in clinical setting.

Variation in the Measurement of Anti-Müllerian Hormone - What Are the Laboratory Issues?

Anti-Müllerian Hormone (AMH) is a 140 kDa homodimeric glycoprotein consisting of two identical subunits linked by disulphide bonds and is synthesised by the testes and ovaries. Its clinical applications are prediction of ovarian response and gonadotropin dose selection upon in vitro fertilization. In males, AMH is used to investigate sexual developmental disorders and gonadal function. AMH is commonly assayed by enzyme-linked immunosorbent assay or automated immunoassay formats that show variation between methods. This review applies fundamental chemical pathology concepts to explain the observed analytical variation of AMH measurement. We examine the lack of standardisation between AMH assays, the impact of antibody design on variable measurements, consider the analytical detection of AMH isoforms, review analytical interference in AMH measurement, and briefly assess systematic bias between AMH assays. The improved attempt at standardising AMH measurement by the recent approval of a WHO Reference Reagent offers promise for harmonising immunoassay results and establishing consensus medical cut-off points for AMH in disease. Standardisation, however, will need to redress the issue of poor commutability of standard reference material and further assign a standard reference procedure to quantify AMH standard reference material. The improvement of the analytical phase of AMH testing will support harmonised method development and patient care.

Ovarian biomarkers predict controlled ovarian stimulation for in vitro fertilisation treatment in Singapore

INTRODUCTION

Ovarian biomarkers have been shown to predict responses to controlled ovarian hyperstimulation (COH) during in vitro fertilisation (IVF) in predominantly Caucasian populations, with limited studies performed in Southeast Asian women in Singapore.

METHODS

We evaluated the performance of serum anti-Müllerian hormone (AMH), follicle-stimulating hormone and oestradiol levels, antral follicle count (AFC), body mass index, ovarian volume, and age to establish thresholds for the prediction of poor (< 4 oocytes retrieved) and excessive responses (> 19 oocytes retrieved) in 263 women undergoing COH. Univariate and multivariate logistic regression analysis and receiver operating characteristic curves were used to calculate probabilities for poor and excessive responders to COH.

RESULTS

36 (13.7%) and 50 (19.0%) women had poor and excessive response to COH, respectively. An AMH value of 0.69 ng/mL predicted poor ovarian response with positive likelihood ratio (LR) of 2.94, compared to an AFC of ≤ 5 when the positive LR is 2.36. Conversely, an AMH value of ≥ 3.06 ng/mL predicted excessive ovarian response with positive LR of 2.24, compared to an AFC cut-off of ≥ 12 with positive LR of 1.93.

CONCLUSION

AMH levels and AFC are equivalent in the prediction of both poor and excessive ovarian response in women undergoing IVF. Our study highlights the importance of establishing population-specific cut-off biomarker values so that protocols can be tailored to optimise IVF treatment.

Age-specific values of Access anti-Müllerian hormone immunoassay carried out on Japanese patients with infertility: a retrospective large-scale study

BACKGROUND

The ovarian reserve in women is known to correlate with anti-Müllerian hormone (AMH) levels, and currently the latest, third-generation, fully-automated AMH immunoassays, such as Access and Cobas, are beginning to be used for measuring AMH levels. However, the age-specific reference values obtained for AMH levels have been based on samples from an American population, measured using first-generation immunoassays. In this study, we attempted to determine the age-specific AMH reference values based on a large set of samples taken from Japanese infertile women measured by Access so that they could be used by infertility centers treating Japanese and those with similar racial and life-style characteristics.

METHODS

The study included 5483 Japanese patients who enrolled in infertility treatment programs at two in-vitro fertilization centers, Shimbashi YUME Clinic and Natural ART Clinic Nihombashi in Tokyo, and who had their serum AMH levels measured between December 2015 and November 2017 by Access. Each patient was represented only once in the study. The mean, median, and standard deviation values were obtained from the measured values for single-year intervals from 28 through 48 years of age (21 age groups in total). The 3D-fitted curve of age-specific mean and median values measured by Access was obtained by regression analysis.

RESULTS

The mean and median values decreased with advancing age (mean: R² = 0.9864; median: R² = 0.9926). In all age groups, the mean values were higher than the median values; however, the differences between these values decreased with increasing age.

CONCLUSIONS

The age-specific AMH reference values measured by Access in this study may serve as a useful diagnostic marker in infertility centers, especially those treating Japanese patients or patients with similar characteristics.

A retrospective analysis of the follicle-stimulating hormone starting dose in expected normal responders undergoing their first in vitro fertilization cycle: proposed dose versus empiric dose

Objective

Methods

Results

Conclusion

Ovarian activity regulation by anti-Müllerian hormone in early stages of human female life, an overview

The present study aimed at describing the anti-Müllerian hormone (AMH), with special focus on molecular background for ovarian activity, in particular the role AMH plays in sex determination and gonadogenesis process in early stages of prenatal life and folliculogenesis in postnatal life. It is a review of the literature currently indexed and abstracted in MEDLINE, SCOPUS and Google Scholars. The process of sex determination and gonad differentiation occurring during embryogenesis was discussed along with underlying molecular mechanisms. In the postnatal life the impact of AMH on the process of folliculogenesis was described. Clinical use of recent findings was shown as well. Genetic studies and molecular analyses have demonstrated that AMH is highly conservative, indicating its significance in reproductive process on the background of evolutionary processes.

Clinical application of serum anti-Müllerian hormone as an ovarian reserve marker: A review of recent studies

It has been more than 15 years since the measurement of serum anti-Müllerian hormone (AMH) first allowed the quantitative assessment of ovarian reserve. Meanwhile, the clinical implication of serum AMH has been expanding. The measurement of serum AMH has been applied in various clinical fields, including assisted reproduction, menopause, reproductive disorders and assessment of ovarian damage/toxicity. Well-known findings about the usefulness of serum AMH revealed by numerous studies executed in the early era include decline with aging, a good correlation with oocyte yield in assisted reproduction, upregulation in polycystic ovarian syndrome and a decrease on ovarian surgery and toxic treatment. More intensive research, including a meta-analysis, cutting-edge clinical trial and advances in AMH assays, has yielded newer findings and firmer clinical interpretations in serum AMH in the past few years. Variations in the AMH decline trajectory in the general population do not support the accurate prediction of menopause. The ability to predict pregnancy in infertility treatment and natural conception is poor, while a nomogram integrating serum AMH as a stimulation protocol is useful for avoiding poor and/or hyper-responses. On the other hand, improvements in measuring very low concentrations of serum AMH may be capable of distinguishing women with poor ovarian function. Age-independent standardization of AMH values may be helpful for comparing ovarian reserves among women at different ages.

Age-related decline in AMH is assay dependent limiting clinical interpretation of repeat AMH measures across the reproductive lifespan

PURPOSE

The aim of the study was to determine whether the assays exhibit an interaction with age and exhibit heterogeneous age related declines in AMH. Apart of chronological age, AMH variation was investigated with relation to menstrual cycle day (MCD). The goal implicates two questions: Are distributions of AMH concentrations homogenous after adjustment for the specific AMH assay? Does age-assay product has an effect on AMH depletion?

METHODS

The study was conducted by examining results of AMH tests performed for 12,917 women with four types of AMH assays: Immunotech I generation kit (IMI, 4016 samples), Beckman Coulter II generation kit RUO (BCII RUO, 3430 samples), Beckman Coulter II generation kit with IVD certificate (BCII IVD, 830 samples), and Ansh Labs I generation kit (AnshLabs, 4641 samples). Statistical analysis included ACNOVA and least square regression technique.

RESULTS

Menstrual cycle day has no effect on AMH measurements. On the other hand, AMH values differed substantially between the four assays, with a marked discordance in the rate of age-related AMH decline for the four assays (ranging from -8.16% (95% CI: -8.79, -7.54) to -11.53% (95% CI -12.20, -10.87), with a significant interaction between age and assay.

CONCLUSIONS

(1) The distribution of AMH concentration is heterogeneous after controlling the age across assays; (2) the rate of AMH decline as a function of age is different for the four manual AMH ELISA assays.

Clinical utility of different anti-Müllerian hormone - AMH assays for the purpose of pregnancy prediction

PURPOSE

Comparison of outcomes of IVF cycles where the AMH levels was measured with five different AMH kits: Immunotech (IOT), Beckman Coulter II Gen. RUO, Beckman Coulter II Gen. IVD (BC II IVD), Ansh Labs ultrasensitive (Ansh) and the automated Elecsys Roche assay.

METHODS

Retrospective analysis of clinical data for 3693 cycles.

RESULTS

In women < 35 years with low (<0.6 ng/ml) and high (>1.4 ng/ml) AMH concentrations, and in those > 39 years with medium (≥0.6 and ≤1.4 ng/ml) and high AMH concentrations the clinical pregnancy rate differed significantly among groups of patients whose AMH level was measured with different kits. In those subgroups, the highest rates were recorded for the BC II IVD and Ansh groups, while the lowest in the IOT group. AMH concentrations differed significantly between different kits in all age groups (the highest in each age group was for the IOT kit and the lowest for BC II IVD). AMH correlates positively with antral follicle count, MII and number of oocytes retrieved.

CONCLUSIONS

This study demonstrated that we could expect very different pregnancy rates with the same AMH results depending on the AMH kit used. That would means, different values of AMH could similarly lead to misleading clinical decisions in IVF.

Reference Values for the Revised Anti-Müllerian Hormone Generation II Assay: Infertile Population-based Study

Anti-Müllerian hormone (AMH) is now accepted as an important clinical marker of ovarian reserve and is increasingly measured as an initial evaluation at infertility clinics. The aim of this study was to establish reference values for the revised second generation (Gen II) assay using population-based data. In this population-based cohort study, AMH data from unselected infertile women aged 25-45 years from June 2013 to June 2014 (n = 15,801) were collected. The AMH values were measured using the revised Gen II assay. We established and validated 5 AMH-age regression models. Based on the optimal AMH-age model, reference values and centile charts were obtained. The quadratic model (log AMH = 0.410 × age -0.008 × age² -3.791) was the most appropriate for describing the age-dependent decrease in AMH measured using the revised Gen II assay. This is the largest population-based study to establish age-specific reference values of AMH using the revised Gen II assay. These reference values may provide more specific information regarding the ovarian reserve estimation of infertile women.

A quantitative comparison of anti-Müllerian hormone measurement and its shifting boundaries between two assays

OBJECTIVE

Anti-Müllerian hormone (AMH), a quantitative marker of ovarian reserve, is used for both clinical and research purposes in the field of reproductive medicine. Numerous AMH assays have been developed. Among other factors, the lack of large-scale comparisons of the various assays hinders the universal interpretation of AMH levels. Moreover, little is known of the practical performance of highly sensitive assays compared with conventional assays with regard to the very low AMH levels found in women nearing menopause. This study aimed to compare the measurements of the Gen II (Beckman Coulter) assay with those of the highly sensitive picoAMH (AnshLabs) assay.

METHODS

This cross-sectional study included 1985 premenopausal women who completed the second visit of the population-based Doetinchem Cohort Study, with a mean age of 42±7years. AMH levels were measured with the Gen II and picoAMH assays. Passing-Bablok and Bland Altman analyses were performed and differences in the proportion of detectable samples were assessed.

RESULTS

The results from the Gen II and picoAMH assays were highly correlated, with a Spearman correlation coefficient of 0.91. The Passing-Bablok regression formula was picoAMH=0.01+1.69*GenII, meaning that on average picoAMH levels were 69% higher than Gen II levels. Of the 670 samples with an undetectable AMH value with the Gen II assay, AMH could be detected in 78% with the picoAMH assay, at a median concentration [interquartile range] of 0.05 [0.01-0.14] ng/mL.

CONCLUSION

These results indicate that, despite a high correlation, there is a large relative difference between results of the Gen II and picoAMH assays. The use of a highly sensitive AMH assay is likely to result in a large increase in the proportion of samples with detectable levels. This may enable research into women's health across the menopausal transition and research into the potential clinical benefits of distinguishing between women with very low ovarian reserve.

Effect of sleeve gastrectomy bariatric surgery-induced weight loss on serum AMH levels in reproductive aged women

OBJECTIVE

This study aims to evaluate the change in serum anti-Mullerian hormone (AMH) levels in patients with morbid obesity undergoing bariatric surgery for weight loss.

MATERIAL AND METHODS

In this prospective observational study, 75 patients of reproductive age (20-35 years) undergoing bariatric surgery for morbid obesity were followed up after six months to determine the changes in weight, Body Mass Index (BMI), menstrual pattern and serum AMH. The results were further studied on basis of pre operative classification of patients in polycystic ovary syndrome (PCOS) and non-PCOS group.

RESULT

The serum AMH levels were statistically higher in patients of PCOS group pre operatively and at the end of six months in comparison to non-PCOS patients. The AMH values reduced post operatively in both groups significantly so much in the values though not significant statistically. Non-PCOS patients had lower AMH values pre operatively and showed a trend towards reducing ovarian reserve after six months. The overall change in AMH values in both groups was statistically significant as was the normalization of menstrual irregularity.

CONCLUSION

Morbidly obese patients with PCOS appear to benefit from bariatric surgery both in terms of regularization of menstrual function and normalization of serum AMH values.

Baseline AMH Level Associated With Ovulation Following Ovulation Induction in Women With Polycystic Ovary Syndrome

CONTEXT

Anti-Müllerian hormone (AMH) reduces aromatase activity and sensitivity of follicles to FSH stimulation. Therefore, elevated serum AMH may indicate a higher threshold for response to ovulation induction in women with polycystic ovary syndrome (PCOS).

OBJECTIVE

This study sought to determine the association between AMH levels and ovulatory response to treatment among the women enrolled into the Pregnancy in PCOS II (PPCOS II) trial.

DESIGN AND SETTING

This was a secondary analysis of data from a randomized clinical trial in academic health centers throughout the United States Participants: A total of 748 women age 18-40 years, with PCOS and measured AMH levels at baseline, were included in this study.

MAIN OUTCOME MEASURES

Couples were followed for up to five treatment cycles to determine ovulation (midluteal serum progesterone > 5 ng/mL) and the dose required to achieve ovulation.

RESULTS

A lower mean AMH and AMH per follicle was observed among women who ovulated compared with women who never achieved ovulation during the study (geometric mean AMH, 5.54 vs 7.35 ng/mL; P = .0001; geometric mean AMH per follicle, 0.14 vs 0.18; P = .01) after adjustment for age, body mass index, T, and insulin level. As AMH levels increased, the dose of ovulation induction medication needed to achieve ovulation also increased. No associations were observed between antral follicle count and ovulation.

CONCLUSIONS

These results suggest that high serum AMH is associated with a reduced response to ovulation induction among women with PCOS. Women with higher AMH levels may require higher doses of medication to achieve ovulation.

Assessment of the Access AMH assay as an automated, high-performance replacement for the AMH Generation II manual ELISA

BACKGROUND

The manual Generation II (Gen II) ELISA method used to measure Anti-Müllerian Hormone (AMH) from Beckman Coulter has recently been superseded by a fully automated AMH immunoassay. The aim of this study was to evaluate the performance of the Access AMH assay and directly compare it to the modified Gen II ELISA method. A secondary aim was to verify that the fertile age-related AMH range previously established using the Gen II ELISA could be used to interpret results from the new automated Access assay.

METHODS

The precision, stability, linearity, measurement range and detection limits were determined using recombinant AMH and patient serum samples. Different diluents and their effects on AMH concentration were compared. A correlation study was performed on patient samples to compare the Access AMH assay to the ELISA method on the Access2 and DxI800 analysers. The fertile AMH range was verified by comparing the 10th, 50th and 90th percentile values from both methods obtained from 489 natural conception pregnant women.

RESULTS

The Access AMH assay showed good performance across the measuring range for both intra-assay (CV 1.41-3.30 %) and inter-assay (CV 3.04-5.76 %) precision and acceptable sample stability. Dilution of the high concentration samples with the recommended diluent resulted in a small but significant downward shift in values. The assay was linear over the range of values recommended by the manufacturer, allowing for accurate reporting within the reported range. The two assay types were highly correlated (R(2) = 0.9822 and 0.9832 for Access2 and DxI800, respectively), and the differences observed between the Access2 and DxI800 analysers were within clinically acceptable ranges, indicating that the methods are interchangeable. Furthermore, we demonstrated that results from the published reference range for the Gen II ELISA correlate with those from the automated Access AMH assay.

CONCLUSION

Here, we verified the published performance of the Access AMH assay and showed excellent correlation with the Gen II ELISA method. Moreover, we validated this correlation by confirming that the results from a fertile AMH reference range established using the preceding Gen II ELISA are interchangeable with the new automated Access AMH assay.

Is anti-Mullerian hormone a good diagnostic marker for adolescent and young adult patients with Polycystic ovary syndrome?

OBJECTIVE

To evaluate serum anti-Mullerian hormone (AMH) levels in adolescent and young adult (AYA) Turkish patients with Polycystic ovary syndrome (PCOS), and to determine whether it had a diagnostic value.

MATERIALS AND METHODS

A total of 90 AYA patients were recruited for this study. The study group consisted of 43 patients diagnosed as having PCOS, and the control group comprised 47 age-matched patients. The diagnosis of PCOS was made in accordance with the recent Amsterdam European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine PCOS consensus workshop group's proposal that all three of the Rotterdam criteria for diagnosing PCOS in adolescents be present. In all patients, serum AMH levels were measured using enzyme-linked immunosorbent assay. Receiver operator characteristics (ROC) curve analysis was performed to reveal diagnostic potential of AMH.

RESULTS

Serum AMH levels were higher in the PCOS group compared with controls, but the difference was not statistically significant (10.1±6.9 ng/mL vs. 9.4±5.5 ng/mL, p=0.198). There was a significant age-related decrease in AMH levels in both the study and control groups (r=-0.331, p=0.001). There was also a significant inverse correlation between serum AMH and follicle-stimulating hormone levels in all patients (r=-0.227, p=0.031). ROC analyses demonstrated that the area under the curve indicative of AMH value for discriminating PCOS was 0.579 with a 95% confidence interval of 0.453-0.705 (p=0.198). The cut-off value according to the highest Youden index was calculated to be 14.0 ng/mL with a sensitivity of 48.8% and specificity of 77.1%.

CONCLUSION

Serum AMH levels are slightly higher in AYA patients with PCOS than in controls. However, AMH is not a good marker for the diagnosis of PCOS in AYA patients.

Usefulness of the Ultrasensitive Anti-Müllerian Hormone Assay for Predicting True Ovarian Reserve

Serum concentration of anti-Müllerian hormone (AMH) is a useful marker for ovarian reserve. Measurement of AMH in clinical practice has gained widespread use to predict parameters such as the ovarian response, menopause, and recovery after chemotherapy. However, undetectable AMH levels assayed by conventional enzyme-linked immunosorbent assay (ELISA) kits fail to predict depletion of follicles because of low sensitivity of the kits. We investigated whether a recently developed ultrasensitive ELISA kit, picoAMH, would be more effective at detecting very low AMH levels in association with menstrual status. We analyzed 68 women with undetectable serum AMH levels using an ELISA kit, AMH Gen II. The AMH concentration of the same samples was detected in 36 samples using picoAMH; 32 samples were within the standard range, and 4 samples were out of the standard range but still detectable. Thirty-two women whose AMH levels were undetectable using the picoAMH all showed amenorrhea. We also found a significant correlation between the classes of serum AMH levels (undetectable, detectable under the limit of quantification, and measurable within the assay range) and menstrual status. Five of the 6 amenorrheic women with detectable AMH eventually achieved follicle growth. The present study demonstrated that very low AMH levels detectable using picoAMH correspond well to current and future ovulation status. This suggests that serum AMH levels can be useful for the assessment of ovarian reserve and follow-up of women with a declined ovarian reserve.

Anti-Müllerian hormone as a marker of ovarian reserve: What have we learned, and what should we know?

Ovarian reserve reflects the quality and quantity of available oocytes. This reserve has become indispensable for the better understanding of reproductive potential. Measurement of the serum anti-Müllerian hormone (AMH) level allows quantitative evaluation of ovarian reserve. It has been applied to a wide range of clinical conditions, and it is well established that the measurement of serum AMH levels is more useful than qualitative evaluation based on the menstrual cycle. AMH levels are monitored during infertility treatments; in patients undergoing medically assisted reproductive technology; and in the diagnosis of ovarian failure, polycystic ovarian syndrome, and granulosa cell tumor. It is also useful in the evaluation of iatrogenic ovarian damage. Population-based studies have indicated a potential role for serum AMH in the planning of reproductive health management. While AMH is currently the best measure of ovarian reserve, its predictive value for future live births remains controversial. Furthermore, there is a serious practical issue in the interpretation of test results, as currently available assay kits use different assay ranges and coefficients of variation due to the absence of an international reference standard. The pros and cons of the serum AMH level as a definitive measure of ovarian reserve merits further review in order to guide future research.

Can anti-Mullerian hormone replace ultrasonographic evaluation in polycystic ovary syndrome? A review of current progress

Several studies over the past decade have now consistently indicated that the serum anti-Mullerian hormone (AMH) levels are at least 2-3-fold higher in the patients with polycystic ovary syndrome (PCOS), which also corresponds to the increased number of AMH producing preantral and small antral follicles. Moreover, AMH levels have been found to be associated in direct proportion to the follicle numbers per ovary or antral follicular count, assessed by the transvaginal ultrasound (TVS). Furthermore, AMH correlates directly with the rising serum testosterone and luteinizing hormone levels in PCOS. Hence, serum AMH in women with oligo-anovulation and/or hyperandrogenemia could indicate the presence of underlying PCOS, when reliable TVS is not feasible, or not acceptable, either due to the virginal status or psycho-social issue. In addition, the imaging quality of abdominal ultrasound is often impaired by obesity, which typically occurs in PCOS women. Indeed, PCOS occurs most commonly in young females who cannot be subjected to invasive TVS for various reasons; therefore, a desirable alternative to TVS is urgently required to diagnose the most prevalent endocrine abnormality of young women. This review will analyze the currently available evidence regarding the role of AMH in the diagnosis of PCOS.

The utility of measuring anti-Müllerian hormone in predicting menopause

Menopause is a relevant phase in a woman's reproductive life. Accurate estimation of the time of menopause could improve the preventive management of women's health. Reproductive hormones reflect the activity of follicle pools and provide information about ovarian aging. Anti-Mu llerian hormone (AMH) is secreted from small antral follicles and its level is correlated to the ovarian reserve. AMH declines with age, and data suggest that it can provide information on menopausal age and reproductive lifespan. Serum AMH levels become low approximately 5 years before the final menstrual period and are undetectable in postmenopausal women. The majority of studies indicate that AMH is relatively stable throughout the menstrual cycle; however, there are interindividual variabilites of serum AMH concentration under different conditions. AMH is an independent predictor of time to menopause. AMH coupled with age for menopause prediction provides stronger information than using age alone. Ongoing research is focused on constructing a multivariate model including AMH values, genes related to follicular recruitment and maternal age of menopause that would predict more precisily time to menopause.

Optimal cutoff value of basal anti-mullerian hormone in iranian infertile women for prediction of ovarian hyper-stimulation syndrome and poor response to stimulation

Aim

We intended to establish the threshold of Anti-Mullerian Hormone (AMH) for detection of Ovarian Hyper-Stimulation Syndrome (OHSS) and poor response to treatment in Iranian infertile women.

Methods

Pre-stimulation menstrual cycle day-3 hormonal indices including basal AMH values were measured in 105 infertile women aged 32.5 ± 4.3 years. Patients underwent long GnRH agonist Controlled Ovarian Hyperstimulation (COH) in a referral infertility center (Tehran, Iran). The gonadotropin dose was determined based on the age and basal serum Follicular Stimulating Hormone (FSH) level. The IVF/ICSI cycles were followed and the clinical and sonographic data were recorded.

Results

Sixteen cases developed OHSS. The prevalence of PCOS was higher in subjects with OHSS [62.5 % (38.8-86.2) vs. 17 % (9.2-24.9)]. The patients with OHSS had higher ovarian follicular count [23.7 (3.2) vs. 9.1 (0.5); p < 0.05], collected oocytes [13.5 (1.9) vs. 6.9 (0.5); p < 0.05] and AMH level [7.9 (0.7) vs. 3.6 (0.3); p < 0.05]. Basal AMH level and oocyte yields (but not age, BMI, and PCOS) correlated with occurrence of OHSS; and only the AMH levels were associated with poor ovarian response (oocytes yield ≤ 4). The optimal cutoff value for the prediction of OHSS was 6.95 ng/ml (area under the receiver operating characteristics curve: 0.86; CI: 0.78-0.95; sensitivity: 75 %; specificity: 84 %; odds ratio for occurrence of OHSS: 9 and p < 0.001). The optimal cut point to discriminate poor response (oocytes ≤4) was 1.65 ng/ml ( AUC : 0.8; CI: 0.69-0.91; sensitivity: 89 % specificity : 71 %; and OR = 23.8 and P value <0.001).

Conclusions

Iranian women with basal AMH level > 6.95 ng/ml are at high risk of developing OHSS and those with AMH level < 1.65 ng/ml are poor responders.

Association of anti-Mullerian hormone and small-dense low-density lipoprotein cholesterol with hepatosteatosis in young lean women with and without polycystic ovary syndrome

OBJECTIVE

To study the association of anti-Mullerian hormone (AMH) and small-dense low-density lipoprotein cholesterol (sd-LDL) with hepatosteatosis among young, lean, polycystic ovary patients.

STUDY DESIGN

A prospective, case control study was carried out including 79 young lean women. Fifty-eight women with polycystic ovary syndrome (PCOS) and 21 age-and BMI-matched healthy controls were recruited. Anthropometric variables, biochemical and hormonal parameters, insulin-resistance indices, lipid profiles including sd-LDL levels and serum AMH levels were determined. Hepatic lipid content was evaluated by abdominal ultrasonography (USG). Determining the best predictor(s) which discriminate normal USG and hepatosteatosis was analyzed by multiple logistic regression analyses. Adjusted odds ratios and 95% confidence intervals were also calculated.

RESULTS

PCOS patients had an increased prevalence of hepatosteatosis by 41.4% (P = 0.006) and they had significantly higher levels of sd-LDL and AMH when compared with the control group (P < 0.001). AMH and sd-LDL levels were positively and significantly associated with hepatosteatosis in young lean women with and without PCOS (OR: 2.877, 95%CI: 1.453-5.699, P: 0.02 and OR: 1.336, 95%CI: 1.083-1.648, P: 0.007, respectively). AMH and sd-LDL levels were positively correlated in PCOS patients (r = 0.626, P < 0.001). Both sd-LDL and AMH levels were the most predictive parameters for the determination of hepatosteatosis within the PCOS group. (OR: 3.347, 95%CI: 1.348-8.313, P = 0.009 and OR: 1.375, 95%CI: 1.072-1.764, P = 0.012, respectively). Statistically significant higher levels of AMH were associated with hepatosteatosis both in insulin resistance (IR) positive and IR negative PCOS patients (P < 0.001).

CONCLUSION

Hepatosteatosis is common in young lean PCOS patients. Increased AMH and sd-LDL levels may independently predict hepatosteatosis in young lean women with and without PCOS.

Age-specific serum anti-mullerian hormone and follicle stimulating hormone concentrations in infertile Iranian women

Background

Anti-Müllerian hormone (AMH) is secreted by the granulosa cells of growing follicles during the primary to large antral follicle stages. Abnormal levels of AMH and follicle stimulating hormone (FSH) may indicate a woman’s diminished ability or inability to conceive. Our aim is to investigate the changes in serum AMH and FSH concentrations at different age groups and its correlation with ovarian reserves in infertile women.

Materials and Methods

This cross-sectional study analyzed serum AMH and FSH levels from 197 infertile women and 176 healthy controls, whose mean ages were 19-47 years. Sample collection was performed by random sampling and analyzed with SPSS version 16 software.

Results

There were significantly lower mean serum AMH levels among infertile women compared to the control group. The mean AMH serum levels from different ages of infertile and control group (fertile women) decreased with increasing age. However, this reduction was greater in the infertile group. The mean FSH serum levels of infertile women were significantly higher than the control group. Mean serum FSH levels consistently increased with increasing age in infertile women; however mean luteinizing hormone (LH) levels were not consistent.

Conclusion

We have observed increased FSH levels and decreased AMH levels with increasing age in women from 19 to 47 years of age. Assessments of AMH and FSH levels in combination with female age can help in predicting ovarian reserve in infertile women.

Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention

OBJECTIVE

To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS).

METHODS

Two comprehensive systematic reviews were carried out: one examined methods of predicting either high ovarian response or OHSS and the other examined interventions aimed at reducing the occurrence of OHSS. Additionally, we describe the related pathophysiology and staging criteria.

RESULTS

Seven studies examining methods of predicting OHSS and eight more examining methods of predicting high ovarian response to controlled ovarian stimulation were included. Current evidence shows that the best methods of predicting high response are antral follicle count and anti-Müllerian hormone levels, and that a high ovarian response (examined by the number of large follicles, estradiol concentration or the number of retrieved oocytes) is the best method of predicting the occurrence of OHSS. Ninety-seven randomized controlled trials examining the effect of several interventions for reducing the occurrence of OHSS were included. There was high-quality evidence that replacing human chorionic gonadotropin by gonadotropin-releasing hormone agonists or recombinant luteinizing hormone, and moderate-quality evidence that antagonist protocols, dopamine agonists and mild stimulation, reduce the occurrence of OHSS. The evidence for the effect of the other interventions was of low/very low quality. Additionally, we identified and described 12 different staging criteria.

CONCLUSIONS

There are useful predictive tools and several preventive interventions aimed at reducing the occurrence of OHSS. Acknowledging and understanding them are of crucial importance for planning the treatment of, and, ultimately, eliminating, OHSS while maintaining high pregnancy rates.

Maximizing the clinical utility of antimüllerian hormone testing in women's health

Purpose of review

To provide an update on the latest clinical applications of serum antimüllerian hormone (AMH) testing with practical approaches to mitigate the impact of significant variability in AMH results.

Recent findings

Recent studies continue to demonstrate that AMH is the best single serum test for ovarian response management with, at most, a weak-to-moderate age-independent association with live-birth rate and time to conception. Data confirm serum AMH levels improve menopause prediction, monitoring of ovarian damage, and identification of women at risk for several ovary-related disorders such as polycystic ovary syndrome and premature or primary ovarian insufficiency. However, it is now recognized that serum AMH results can have dramatic variability due to common, biologic fluctuations within some individuals, use of hormonal contraceptives or other medications, certain surgical procedures, specimen treatment, assay changes, and laboratory calibration differences. Practical guidelines are provided to minimize the impact of variability in AMH results and maximize the accuracy of clinical decision-making.

Summary

AMH is an ovarian biomarker of central importance which improves the clinical management of women's health. However, with the simultaneous rapid expansion of AMH clinical applications and recognition of variability in AMH results, consensus regarding the clinical cutpoints is increasingly difficult. Therefore, a careful approach to AMH measurement and interpretation in clinical care is essential.

The role of serum AMH and FF AMH in predicting pregnancy outcome in the fresh cycle of IVF/ICSI: a meta-analysis

PURPOSE

This meta-analysis tries to find and confirm the true prognostic value of serum AMH and the follicle fluid AMH (FF AMH) on the outcome of ART.

METHOD

We identified all studies published by March 2014 with data related to in vitro fertilization", "intracytoplasmic sperm injection", "assisted reproductive technology" and "antimullerian hormone" in Pubmed database. Studies were included if 2 × 2 tables for outcomes of pregnancy in IVF patients in relation to AMH could be constructed or studies which used T-tests to compare clinical indexes including AMH in pregnant and non-pregnant women. And all the patients were less than 46 years old.

RESULTS

A total of 26 studies could be used for this meta-analysis. Of these articles 22 studies could be constructed 2 × 2 tables, with 15 for predicting pregnancy and 7 for non-pregnancy. 11 studies used the analysis of T-test, with 7 articles were duplicated. And of the 11 articles, 8 were for the analysis of serum AMH in prediction of pregnancy, 3 were for FF AMH. Because of heterogeneity among studies, calculation of a summary point estimate for sensitivity and specificity was not possible. For the analysis of serum AMH on non-pregnancy, the heterogeneity was moderate (I-squared of 65.9%), the curves indicated positive find (the AUROC is 0.73, 95% CI is 0.69-0.77.). In the T-test group of serum AMH, the DOR for women with pregnancy outcome was 0.232 (95% confidence interval (CI): 0.034-0.43), with less heterogeneity (I-squared of 45.1%). Unfortunately, the predictive value of FF AMH on pregnancy is still unclear because of large heterogeneity (I-squared of 90.5%).

CONCLUSION

Serum AMH, as an independent parameter, can predict pregnancy outcome after assisted conception and the positive correlation with serum AMH and non-pregnancy should not be ignored either. The predictive value of FF AMH on pregnancy is still unclear.

Recent progress in the utility of anti-Müllerian hormone in female infertility

PURPOSE OF REVIEW

To discuss the recent developments in the utility of anti-Müllerian hormone (AMH) in the context of female infertility.

RECENT FINDINGS

AMH measurements have entered the clinical practice in counseling of women before in-vitro fertilization (IVF) treatment. AMH measurements can predict both poor and hyperresponse, and can enable clinicians to individualize the treatment strategies. In natural conception, AMH is a good predictor of age at menopause, but it is unclear whether AMH correlates with the fecund ability in the normal population. AMH has also proven its utility in the assessment of ovarian damage due to gonadotoxic treatment or ovarian surgery. Lastly, AMH might assist in the initial diagnosis of oligomenorrhea or amenorrhea, as high levels of AMH are suggestive of polycystic ovarian syndrome and seem to correlate with the severity of the syndrome.

SUMMARY

AMH is a glycoprotein secreted by the granulosa cells of small growing follicles and indirectly reflects the primordial follicle pool. The ovaries contain a limited number of primordial follicles and their depletion marks the menopause. Thus, the remaining primordial follicle pool is referred to as the ovarian reserve. The clearest data for the clinical utility of AMH is in the context of IVF. The support for other indications is weaker, but rapidly increasing.

Validation of an immunoassay for anti-Müllerian hormone measurements and reference intervals in healthy Brazilian subjects

Background

Anti-Müllerian hormone is marker of ovarian and testicular reserve. The clinical use of this hormone requires proper standardization of reference intervals. The aims of this study were to validate the Anti-Müllerian hormone Gen II immunoassay, to establish Anti-Müllerian hormone reference intervals in healthy subjects, and to evaluate the influence of hormonal contraceptives, smoking, and body mass index on Anti-Müllerian hormone.

Methods

The validation of the Anti-Müllerian hormone Gen II assay (Beckman Coulter Company, TX, USA) was performed using a simplified protocol recommended by Clinical Laboratory Standard Institute. One-hundred and thirty-three healthy females and 120 males were prospectively selected for this study.

Results

The analytical and functional sensitivities of the Anti-Müllerian hormone Gen II immunoassay were 0.02 and 0.2 ng/mL, respectively. Intra-assay coefficients ranged from 5.2 to 9.0%, whereas inter-assay precision ranged from 4.6 to 7.8% at different concentrations. In females, Anti-Müllerian hormone showed progressive decline with increasing age (r = −0.4, p < 0.001), whereas in males, age showed no influence on Anti-Müllerian hormone concentrations. In females, Anti-Müllerian hormone concentrations did not differ between users and non-users of hormonal contraceptives, smokers, and non-smokers and obese and lean individuals. However, there was a negative and significant correlation between Anti-Müllerian hormone and body mass index in males (r = −0.3, p = 0.008).

Conclusions

Anti-Müllerian hormone Gen II assay was reliable for determining serum Anti-Müllerian hormone concentrations. Anti-Müllerian hormone concentrations declined with aging and presented a wide inter-individual variability. The lack of influence of hormonal contraceptives, smoking, and obesity on Anti-Müllerian hormone in both sexes allowed us to refine the normative concentrations for the Brazilian population.

BRCA1 germline mutations may be associated with reduced ovarian reserve

OBJECTIVE

To determine whether BRCA carriers have a decreased ovarian reserve compared with women without BRCA mutations, because BRCA mutations may lead to accelerated oocyte apoptosis due to accumulation of damaged DNA.

DESIGN

Cross-sectional study.

SETTING

Academic tertiary care center.

PATIENT(S)

A total of 143 women, aged 18-45 years, who underwent clinical genetic testing for BRCA deleterious mutations because of a family history of cancer, were included. The cohort was classified into three groups: BRCA1 carriers, BRCA2 carriers, and women without BRCA mutations (controls). None had a personal history of breast or ovarian cancer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The main outcome was serum antimüllerian hormone (AMH) level. Linear and logistic regression models adjusting for age and body mass index (BMI) were performed to determine the association between BRCA mutations and AMH.

RESULT(S)

BRCA1 mutation carriers had a significant decrease in AMH levels compared with controls after adjusting for age and BMI (0.53 ng/mL [95% confidence interval (CI) 0.33-0.77 ng/mL] vs. 1.05 ng/mL [95% CI 0.76-1.40 ng/mL]). Logistic regression confirmed that BRCA1 carriers had a fourfold greater odds of having AMH <1 ng/mL compared with controls (odds ratio 4.22, 95% CI 1.48-12.0). There was no difference in AMH levels between BRCA2 carriers and controls.

CONCLUSION(S)

BRCA1 carriers have lower age- and BMI-adjusted serum AMH levels compared with women without BRCA mutations. Our results contribute to the current body of literature regarding BRCA carriers and their reproductive outcomes. Larger prospective studies with clinical outcomes such as infertility and age at menopause in this population are needed to further substantiate our findings.

Anti-Müllerian hormone and assessment of ovarian reserve after ovarian toxic treatment: a systematic narrative review

Since serum anti-Müllerian hormone (AMH) levels enable quantitative evaluation of ovarian damage, we conducted a computer-based search, using key words, of all articles published in English through the PubMed database from inception until September 2013 to summarize available studies evaluating ovarian reserve after ovarian toxic interventions to discuss the usefulness of serum AMH levels. We found that most of the studies demonstrated a decline in serum AMH levels when compared to control or pretreatment levels, with levels dependent on the type of treatment modality. Measurement of serum AMH levels enables quantitative evaluation of ovarian damage caused by ovarian toxic interventions, such as chemotherapy and radiotherapy, instead of qualitative evaluation using menstrual condition or basal follicle-stimulating hormone levels. Serum AMH levels are becoming indispensable to assess the ovarian reserve of patients who desire preservation of ovarian function for fertility and endogenous sex steroid hormones.

May maternal anti-mullerian hormone levels predict adverse maternal and perinatal outcomes in preeclampsia?

BACKGROUND

Prediction of preeclampsia and adverse maternal and perinatal outcomes with biomarkers has been proposed previously. Anti-mullerian hormone (AMH) is a growth factor, which is primarily responsible of the regression of the mullerian duct, but also used to predict ovarian reserve and decreases with age similar to the fertility.

AIM

To evaluate the predictive role of maternal anti-mullerian hormone (mAMH) in adverse maternal and perinatal outcomes in preeclampsia.

METHODS

This prospective case-control study was conducted at current high-risk pregnancy department in a tertiary research hospital and 45 cases with preeclampsia classified as study group and 42 as control group. Data collected and evaluated were; age, body mass index (BMI), marriage duration (MD), gestational weeks (GW), gravidity, parity, mode of delivery, birth weight, newborn Apgar score, newborn gender, maternal complication, perinatal outcome, some laboratory parameters and mAMH. The association between mAMH levels and maternal and fetal outcomes were evaluated.

RESULTS

There were no statistically significant differences between groups in terms of age, BMI, MD, gravidity, parity and newborn gender (p > 0.05). GW, vaginal delivery, birth weight, newborn Apgar score, were statistically significantly lower in preeclamptic patients when compared with non-preeclamptic patients (p < 0.001). Adverse maternal and perinatal outcomes were statistically significantly higher in the study group (p < 0.001). The laboratory values [alanine transaminase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), creatinine, lactic dehydrogenase (LDH), uric acid and fibrinogen) were statistically significantly lower in the control group (p < 0.001). The mAMH level was significantly lower in the preeclamptic group (p: 0.035). There was no correlation between mAMH levels and demographic and clinical parameters. The area under the ROC curve (AUC) was 0.590 and the cut-off value was 0.365 ng/ml with sensitivity of 67.4% and specificity of 47.1% for mAMH. Logistic regression analysis showed a statistically insignificance between mAMH and maternal complication and perinatal outcome (p: 0.149).

CONCLUSION

According to this study, mAMH level was lower in preeclamptic patients than in normal pregnants, and is found to be a discriminative factor with low sensitivity and specificity. There was no relationship between mAMH and adverse maternal and perinatal outcomes. Further randomized controlled studies with more participants are needed to evaluate the accurate effects of mAMH levels on preeclampsia and should increase the power of mAMH levels in predicting the preeclampsia.

Comparability of antimüllerian hormone levels among commercially available immunoassays

OBJECTIVE

To compare antimüllerian hormone (AMH) levels among three commercially available AMH immunoassays: AMH Gen II (Beckman Coulter), Ultrasensitive AMH (Ansh Labs), and picoAMH (Ansh Labs).

DESIGN

Cross-sectional.

SETTING

Academic reproductive endocrinology program.

PATIENT(S)

90 newly diagnosed breast cancer patients before cancer treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Proportion of detectable AMH levels by immunoassay, and comparability among assays.

RESULT(S)

At a mean age of 38.1 years, the median (interquartile range) AMH level for the cohort was 0.92 [1.35] ng/mL for the Gen II assay, 1.68 [2.30] ng/mL for the Ultrasensitive assay, and 1.52 [2.41] ng/mL for the picoAMH assay. Significantly higher proportions of detectable AMH levels were observed with the picoAMH kit (97%) compared with both the Gen II (84%) and Ultrasensitive (92%) assays. Although the AMH results were highly correlated among the assays (r = 0.92-0.99), the Gen II AMH levels were consistently lower than both Ultrasensitive and picoAMH levels. Moreover, as AMH levels increased, the magnitude of difference grew larger between Gen II and each of the other two assays.

CONCLUSION(S)

Measurement of AMH levels with the picoAMH kit maximized detection at very low levels, particularly in contrast with the Gen II kit. Conversion of AMH levels from different immunoassays using regression equations is potentially highly inaccurate.

The measurement of anti-Müllerian hormone: a critical appraisal

CONTEXT

Measurement of anti-Müllerian hormone (AMH) is perceived as reliable, but the literature reveals discrepancies in reported within-subject variability and between-method conversion factors. Recent studies suggest that AMH may be prone to preanalytical instability. We therefore examined the published evidence on the performance of current and historic AMH assays in terms of the assessment of sample stability, within-patient variability, and comparability of the assay methods.

EVIDENCE ACQUISITION

We reviewed studies (manuscripts or abstracts) measuring AMH, published in peer-reviewed journals between January 1, 1990, and August 1, 2013, using appropriate PubMed/Medline searches.

EVIDENCE SYNTHESIS

AMH levels in specimens left at room temperature for varying periods increased by 20% in one study and by almost 60% in another, depending on duration and the AMH assay used. Even at -20°C, increased AMH concentrations were observed. An increase over expected values of 20-30% or 57%, respectively, was observed after 2-fold dilution in two linearity-of-dilution studies, but not in others. Several studies investigating within-cycle variability of AMH reported conflicting results, although most studies suggest that variability of AMH within the menstrual cycle appears to be small. However, between-sample variability without regard to menstrual cycle as well as within-sample variation appears to be higher using the GenII AMH assay than with previous assays, a fact now conceded by the kit manufacturer. Studies comparing first-generation AMH assays with each other and with the GenII assay reported widely varying differences.

CONCLUSIONS

AMH may exhibit assay-specific preanalytical instability. Robust protocols for the development and validation of commercial AMH assays are required.