Ongoing pregnancy rates in women with low and extremely low AMH levels. A multivariate analysis of 769 cycles

Seasonal AMH variability implies a positive effect of UV exposure on the deterioration of ovarian follicles

Anti-Müllerian hormone (AMH) is produced exclusively by granulosa cells of ovarian follicles and is an indicator of ovarian reserve which declines with age. Seasonality in AMH levels have been reported to be correlated with variations in Vitamin D levels, which is dependent on sunlight exposure. However, the effects of age and its association with solar radiation intensity with respect to AMH was never studied before. In this study, we investigated the relationship between AMH levels with season and with solar radiation intensity in a cohort of 2235 women aged 19-40 years undergoing hormonal work-up over a four-year period. Our findings revealed that among women aged 20-29 years, there was no significant association between AMH levels and either season or solar radiation intensity. However, for women aged 30-40 years, a seasonal pattern was observed, with higher AMH levels during spring and autumn months characterized by moderate solar radiation intensity. Women in their declining ovarian reserve age were found to be more sensitive to the effects of moderate solar radiation. Moderate solar radiation exposure positively impacted AMH levels, whereas low and high intensity exposure had a negative effect. Our findings indicate that age and solar radiation intensity must be considered when assessing AMH levels and provide valuable insights into the intricate relationship between AMH, seasonality, and UVB exposure in the context of reproductive health.

Screening for diminished ovarian reserve in Portugal: a cost-saving answer to shorten the fertility journey

Aim: Assess the budget impact of nationwide screening for diminished ovarian reserve (OR), via anti-Müllerian hormone (AMH) levels, to the Portugal National Health System (NHS). Patients & methods: The clinical journey was determined using literature and the family planning decision-making process/response using survey results. A panel of four local clinicians validated all assumptions/inputs. Results: Screening for OR led to an expected savings of € 9.4 million for the NHS, driven by a 24% reduction in medically assisted reproduction (MAR) use. When needed, referral for MAR was earlier and more women used first-line versus second-line techniques. The model estimated a 12% decrease in failure. Conclusion: This model shows AMH screening may allow more informed decisions, leading to a shorter fertility journey, more efficient use of treatments, and substantial cost-savings for the NHS.

Determination of serum anti-Mullerian hormone levels in a low-prognosis women treated in-vitro fertilization/intracytoplasmic sperm injection: A cohort study

Background

Outcome prediction of participants treated with in-vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) using anti-Mullerian hormone (AMH) concentration has been widely used. According to the patient-oriented strategies encompassing individualized oocyte number (POSEIDON) definition, low prognosis Bologna responders have changed from poor. This definition divides low prognosis into 4 groups.

Objective

The purpose of this study was to assess blood AMH levels in the group of women treated with IVF/ICSI who were thought to have a low prognosis.

Materials and Methods

A retrospective cohort study among 252 suspected low-prognosis group participants was assessed between January 2016 and December 2019 at Morula IVF, National hospital, Surabaya, Indonesia. Observed AMH serum levels and pregnancy rates were compared among 4 subgroups.

Results

The AMH cutoff value was 1.7 ng/mL with a sensitivity of 86.7% and a specificity of 70% for diagnosing low-prognosis women using POSEIDON criteria. There was no difference in the pregnancy rate between those groups (p > 0.05).

Conclusion

AMH levels may indicate a poor prognosis for women having IVF/ICSI in accordance with POSEIDON guidelines. To predict the poor prognosis in women, the cutoff value must be identified.

A survey of ovarian reserve and quality of life in female survivors of pediatric cancer

INTRODUCTION

Childhood cancer is rare; the incidence in Sweden is approximately 16 new cases/100 000 children each year. Reduced reproductive function and fertility are well-known side effects of cancer treatment. Anti-Müllerian hormone (AMH) has been shown to correlate well with antral follicle count in healthy women but is currently not recommended as the primary surveillance modality for evaluation of premature ovarian insufficiency in this patient group. Psychological wellbeing related to fertility could affect quality of life and should be included in long-term follow-up. The aim of the study is to present the baseline data from inclusion for a prospective follow-up study of fertility surveillance where both medical and psychological aspects of fertility in female childhood cancer survivors are considered.

MATERIAL AND METHODS

These are the first results from this longitudinal follow-up cohort study. Female adolescent and young adult survivors of pediatric cancer in Western Sweden were included from January 2016 to December 2018, a total of 54 participants. Median age at inclusion was 21 (15-29) years and median age at cancer diagnosis was 10 (1-17) years. AMH levels, antral follicle count, and data on fertility were recorded at inclusion and will be prospectively followed up. The study includes questionnaires and interviews concerning quality of life. This study is planned to continue until the participants reach the age of 40 years.

RESULTS

Eighteen of 54 (33%) participants had AMH levels below 1.0 µg/L and were considered to have high or very high risk of infertility. Median AMH level was 2.50 µg/L. Six women had immediate need of oocyte cryopreservation. Psychological assessment showed that more than one-third of participants (n = 20) had elevated anxiety scores.

CONCLUSIONS

One-third of female survivors of pediatric cancer in the study had high risk of low ovarian reserve, measured by a combination of AMH and antral follicle count, and many had signs of anxiety. The longitudinal study could contribute to better knowledge in the changes of AMH over time for this patient group. Psychological follow-up with questionnaires and interviews evaluating signs of depression and anxiety may serve as a model for future screening programs.

FSH versus AMH: age-related relevance to ICSI results

Background

Women’s fecundity is known to decrease with the increase in chronologic age. Several biomarkers of the ovarian reserve, including follicle stimulating hormone (FSH), anti Müllerian hormone (AMH), have been proposed as possible predictors for the response to controlled ovarian stimulation (COS). Although there are assumptions indicating that the relationship between age and ovarian reserve is highly variable and the potential different validity of ovarian reserve markers in women in different age groups remains to be demonstrated. The purpose of our study was evaluating FSH and AMH as potential predictors of response to controlled ovarian stimulation and prediction of intracytoplasmic sperm injection (ICSI) outcome according to age. This prospective study has been carried out on 218 women having ICSI cycles. Cases were divided into two groups, group 1 (n 148), their age < 35 years, and group 2 (n 70), their age ≥ 35 years. All women received antagonist protocol during their ICSI cycles. Basal FSH and AMH were measured and correlated to the number of follicles on the day of trigger, the number of oocytes retrieved, chemical, and clinical pregnancies.

Results

The fertilization rate in group 1 was 68.15%, while in group 2 was 77.82% (p = 0.003) while the implantation rate (number of gestational sacs observed at 6 weeks of pregnancy divided by the number of transferred embryos) was 18.95 and 11.98% in group 1 and group 2, respectively (p = 0.041). The clinical pregnancy rate among both groups was 38.51% in group 1, while 24.29% in group 2 (p = 0.038). Women who got pregnant among those aged < 35 years had significantly lower basal FSH (p < 0.001), while women who got pregnant among those aged ≥ 35 years had significantly higher AMH levels (p value < 0.001) and higher E2 levels on the day of trigger (p = 0.007).

Conclusion

We found that below the age of 35 years, the chances of pregnancy are more correlated to FSH levels, while above the age of 35 years, AMH was a more relevant test.

Double HCG trigger improves recovery of oocytes in women with a paucifollicular response to ovarian stimulation: A pilot study

OBJECTIVE

To examine whether adding a second HCG trigger, 12.5 h after the first (36.5 h before ovarian puncture), can facilitate recovery of oocytes in women with a paucifollicular response to ovarian stimulation.

METHODS

A total of 85 women aged 35-42 years, with a paucifollicular response to ovarian stimulation and who had experienced a total failure of oocyte recovery after the standard HCG ovulation trigger 36.5 h before ovarian puncture, were subsequently treated by the same protocol but with the addition of a second HCG trigger 12.5 h later. The recovered oocytes were inseminated by intracytoplasmic sperm injection (ICSI) and all available embryos were transferred 3 days later.

RESULTS

The double trigger enabled recovery of cumulus oophorus cells from most of the follicles in the women who experienced failure of total recovery of oocytes after a single trigger. Fifteen patients became pregnant, and no signs of ovarian hyperstimulation syndrome were observed. Nine women delivered a healthy child.

CONCLUSION

In women aged 35-42 years with a paucifollicular response to ovarian stimulation, a double HCG trigger appears to improve the rate of oocyte recovery. The conclusion of this pilot study needs to be confirmed by larger prospective trials.

Influence of age on response to controlled ovarian stimulation in women with low levels of serum anti-Müllerian hormone

This study aims at detecting and evaluating differences in quantitative response to controlled ovarian stimulation (COS) with high doses of gonadotropins in women with low serum anti-Müllerian hormone (AMH). About 369 first cycles in a real-life scenario in women between 21 and 43 years old and with AMH ≤0.9 ng/ml were analyzed. Older women had a significantly worse outcome with respect to young women, not only qualitatively, but also in terms of quantitative ovarian response to COS [odd ratio (OR) to obtain at least three MII oocytes with each increasing year of female age: 0.89, 95% CI: 0.85 - 0.94; p < .001]. This study endorses that age is a significant factor when counseling patients with low AMH. AMH levels per se are not a reason to exclude patients from a COS treatment, since pregnancy and live birth can be achieved, especially in younger patients. However, with an AMH equally low, the ovarian response worsens with age, making questionable the effectiveness of a stimulation with high-dose gonadotropins in the older subgroup.

Anti-müllerian Hormone for the Prediction of Ovarian Response in Progestin-Primed Ovarian Stimulation Protocol for IVF

Background: The ability of anti-Müllerian hormone (AMH) to predict ovarian response has been studied extensively in gonadotropin-releasing hormone agonist and antagonist treatments, but no information is available regarding its value in progestin-primed ovarian stimulation (PPOS) protocol. Methods: This retrospective data analysis included 523 patients without polycystic ovary syndrome who underwent their first in vitro fertilization/intracytoplasmic sperm injection cycle with PPOS protocol at our center between Jan. 2015 and Jul. 2018. Serum AMH measurements were acquired within 12 months prior to ovarian stimulation using the automated Access AMH assay. Results: AMH exhibited a significantly positive correlation with the number of retrieved oocytes (r = 0.744, P < 0.001). For the prediction of poor (<4 oocytes) and high (>15 oocytes) response, AMH had an area under the receiver operating characteristic curve (AUC) of 0.861 and 0.773, corresponding with an optimal cutoff point of 1.26 and 4.34 ng/mL, respectively. When stratified according to the dose of medroxyprogesterone acetate (MPA) (4 mg vs. 10 mg per day), AMH retained its similarly high predictive value for poor (AUC = 0.829 and 0.886, respectively) and high response (AUC = 0.770 and 0.814, respectively) in both groups. Amongst the 314 women who received their first frozen embryo transfer (FET) following PPOS protocol, no significant differences were observed on the rates of biochemical pregnancy, clinical pregnancy, implantation, early miscarriage, multiple pregnancy and ectopic pregnancy (all P > 0.05) across AMH quartiles (≤1.43, 1.44-2.55, 2.56-4.35, >4.35 ng/mL). In a multivariable logistic regression model, age was suggested to be the only independent risk factor for clinical pregnancy (P = 0.011). Conclusions: Our data demonstrated that AMH is an adequate predictor of both high and poor ovarian response in PPOS protocol regardless of MPA dose, but it does not associate with pregnancy outcomes in the first FET cycles in a freeze-all strategy.

Women with extreme low AMH values could have in vitro fertilization success

Circulating anti-müllerian hormone (AMH) and antral follicle count (AFC) are the best predictors of IVF outcomes. However, in extreme low AMH range especially for young patients, AMH prediction power loose its specificity to give real idea of pregnancy chance with IVF treatments and good prognosis of an extremely reduced ovarian reserve and expected poor response. Indeed, this retrospective study was conducted to evaluate IVF outcomes in patients following IVF-ICSI program with extremely low AMH levels (≤0.4 ng/ml; n = 390) compared to those presenting normal AMH range (1.3-2.6 ng/ml; n = 352) considered as control group. As expected, number of oocytes retrieved per patient, and embryological outcomes were significantly lower in the extremely low AMH levels group compared to control. Moreover, it was same trend concerning clinical outcomes but we have to note that even in extreme low AMH, patients could reach ineligible satisfying clinical pregnancy rate compared to control (17% vs 41%). For patients younger than 35 years, clinical pregnancy rate improved to 27%. Women with extreme low AMH values and especially younger ones, still have reasonable chances of achieving pregnancy, highlighting the default view of this category generally excluded from IVF program.

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.

Impact of very low anti-Müllerian hormone on pregnancy success

PURPOSE OF REVIEW

Biomarkers are useful tool to help clinicians to estimate the chances of pregnancy of an infertile couple prior to assisted reproductive treatment. One proposed candidate is anti-Müllerian hormone (AMH), but its role as a predictor of reproductive success, especially in patients with low or very low levels, is under discussion. This review highlights recent findings from literature regarding to reproductive outcome in women with very low levels of AMH.

RECENT FINDINGS

Although there is a general agreement about the lower pregnancy rates of patients with very low levels of AMH compared with patients with normal AMH levels, the role of AMH as a predictor of success is still under discussion. In this sense, some authors establish a cutoff level below which the reproduction treatment is not successful; by contrast, other published data show a significant percentage of success is still observed in this group of patients, especially in young women.

SUMMARY

In the following review, we discuss the usefulness of AMH as a predictor of reproductive outcome in patients with very low AMH levels and provide an update of the clinical results after assisted reproductive treatment in this group of patients. We also analyzed the different assays used to measure the AMH, focused on the differences between the manual and the new automated systems.

Supporting the One-Carbon Cycle Restores Ovarian Reserve in Subfertile Women: Absence of Correlation with Urinary Bisphenol A Concentration

Environmental endocrine disrupting chemicals (EDCs), including bisphenol A (BPA), induce DNA methylation errors and oxidative stress, and alter fertility. Animal studies have demonstrated that supporting the one-carbon cycle (1-CC) with appropriate dietary supplements can reduce the effects of EDCs. Anti-Mullerian hormone (AMH), a marker of ovarian functionality, has been tested in subfertile female patients, to control this hypothesis in humans. Fifty-five women with a history of 3-7 years of infertility, with at least two assisted reproductive technology (ART) treatment failures, and low serum levels of AMH were enrolled in the study. Before starting any further ART treatment, they were tested for AMH and for follicular count. A urinary control of BPA was proposed. Then a support of the 1-CC, already tested in other clinical studies, was initiated and continued for 4 months. At the end of this period, antral follicle count and serum AMH levels were re-evaluated. The AMH levels before and after treatment were compared using the Wilcoxon test (nonparametric test, non-Gaussian population). Out of the 55 patients, 35 accepted a BPA dosage in the urine. No correlation was found between BPA and serum AMH concentrations. Forty-nine patients followed the full treatment with 1-CC supplements, which resulted in increased AMH levels, independent of initial AMH levels and maternal age (in the range studied), p = 0.0001. Eight patients spontaneously conceived ongoing pregnancies within 3 months, at the end of the protocol. A support of the 1-CC can partly alleviate metabolic derangements induced by environment, as observed in animal models, and improve endocrine background in women.

Successful Spontaneous Conception and Live Birth in a Woman with an Extremely Low Level of Anti-Müllerian Hormone Who Received Korean Herbal Medicine (Bogungsamul-tang): A Case Report

Conventional treatments do not appreciably improve fecundity in women with extremely low-serum levels of anti-Müllerian hormone (AMH). In Korea, herbal medicine is widely used to treat female infertility. We report a case in which an infertile woman with a very low AMH level naturally conceived after two months of herbal treatment (Bogungsamul-tang), ultimately giving birth to a full-term baby. Although AMH levels were not measured immediately before and after treatment, our study suggests that Korean herbal remedies are a viable option for infertile women with negligible AMH levels. Further studies should be performed to fully assess the clinical effects of Bogungsamul-tang in such women.

Fertility in women of late reproductive age: the role of serum anti-Müllerian hormone (AMH) levels in its assessment

INTRODUCTION

Fertility is referred to the capability for having offspring and can be evaluated by fertility rate. Women's fertility is strictly dependent on individual's age. The fertility peak occurs in the early 20s, and it starts to decline in the third and fourth decades of life (falling sharply after age 35).

AIM

The aim of this work is to review the available data concerning fertility in women of late reproductive age, especially the role of serum anti-Müllerian hormone (AMH) levels.

RESULTS

There are a lot of factors responsible for decrease of fertility in women of late reproductive age. These factors can be classified as oocyte-dependent (decrease in oocyte quantity and quality) and oocyte-independent (reproductive organs [uterus, oviducts] status and general health). Anti-Müllerian hormone (AMH) is a dimeric glycoprotein of the transforming growth factor-β (TGF-β) superfamily produced directly by the ovarian granulosa cells of secondary, preantral, and early antral follicles. It has been used as an ovarian reserve marker since 2002. Anti-Müllerian hormone seems to be the best endocrine marker for assessing the age-related decline of the ovarian pool in healthy women. Evaluation of AMH's predictive value in the naturally aging population is important for counseling women about reproductive planning as well as for treatment planning for women experiencing hormone-sensitive gynecological conditions such as endometriosis and fibroids.

CONCLUSIONS

AMH can be considered as an indicator of fertility in late reproductive age women and pregnancy outcome in assisted reproductive technology cycles. AMH can strongly predict poor response in the controlled ovarian stimulation.

How FSH and AMH reflect probabilities of oocyte numbers in poor prognosis patients with small oocyte yields

In poor prognosis patients undergoing in vitro fertilization, advance determinations of likely oocyte yields are especially important since oocyte numbers to large degree determine in vitro fertilization cycle outcomes. Based on baseline follicle stimulating hormone and anti-müllerian hormone levels at time of initial presentation, we here, therefore, determined at all ages the probabilities of obtaining 1-≥5 oocytes in a retrospective analysis of 1554 consecutive patients undergoing in vitro fertilization cycles at an academically affiliated private fertility center. At lowest levels (≤2.5 mIU/mL), Follicle stimulating hormone at all ages was highly predictable for ≥1 oocyte (88-96 %). Probabilities declined and diverged between ages with increasing follicle stimulating hormone, though narrowed again at high follicle stimulating hormone. Anti-Müllerian hormone demonstrated at higher levels (2.5-≥5 ng/ml) at all ages almost perfect probabilities (99-100 %). With declining anti-Müllerian hormone, age categories, however, increasingly diverged, though to lesser degree than follicle stimulating hormone. In poor prognosis patients, follicle stimulating hormone and anti-Müllerian hormone, thus, offer at different ages very specific probabilities for retrieval of 1-≥5 oocytes. Since oocyte numbers are associated with embryo numbers, and numbers of transferable embryos with live birth rates, here presented probability tables should facilitate improved prognostication of poor prognosis patients. Discrepancies in here reported probabilities between follicle stimulating hormone and anti-müllerian hormone also further define follicle stimulating hormone and anti-müllerian hormone in their respective abilities to represent functional ovarian reserve at different ages.

IVF results in patients with very low serum AMH are significantly affected by chronological age

PURPOSE

The aims of this study were to assess the outcome of in vitro fertilization (IVF) in women with very low circulating anti-müllerian hormone (AMH) and to investigate factors affecting their probability of pregnancy.

METHODS

The outcome of 448 IVF cycles in 361 women with circulating AMH <0.5 ng/ml was retrospectively analyzed.

RESULTS

Cycle cancellation rate was 14.5 %; patients whose cycle was cancelled had significantly lower AMH than women who reached oocyte pickup (OPU). Among those who reached OPU, age significantly affected the success rate: despite comparable AMH levels, patients below 35 years obtained significantly more oocytes and a better clinical pregnancy rate (CPR)/OPU than patients aged 35-39 or 40-43 (31 % vs. 23.2 % vs. 10.2 %, respectively; p = 0.001). Differently, comparable IVF results were observed stratifying patients for AMH levels in the range 0.14-0.49 ng/ml. Multivariable logistic regression analysis confirmed that the probability of pregnancy was significantly affected by age, but not by small differences in AMH level.

CONCLUSIONS

Women with very low (<0.5 ng/ml) AMH levels undergoing IVF still have reasonable chances of achieving a pregnancy, but their prognosis is significantly affected by chronological age. Very low AMH levels are associated with a relevant risk of cycle cancellation but should not be considered a reason to exclude a couple from IVF.

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.

The Bologna criteria for poor ovarian response: a contemporary critical appraisal

Postponement of child bearing and maternal age at first pregnancy are on the rise, contributing considerably to an increase in age-related infertility and the demand for assisted reproductive technologies (ART) treatment. This brings to the infertility clinics many women with low ovarian reserve and poor ovarian response (POR) to conventional stimulation. The Bologna criteria were released to standardize the definition of POR and pave the way for the formulation of evidence-based, efficient modalities of treatment for women undergoing IVF-ET. More than four years have passed since the introduction of these criteria and the debate is still ongoing whether a revision is due. Women with POR comprise several sub-groups with diverse baseline distinctiveness, a major issue that has fueled the discussion. Although antral follicle count (AFC) and anti-Müllerian hormone (AMH), are considered good predictors of ovarian reserve, their threshold values are still not universally standardized. Different definitions for sonographic AFC and diverse assays for AMH are held responsible for this delay in standardization. Adding established risk factors to the criteria will lead to more reliable and reproducible definition of a POR, especially in young women. The original criteria did not address the issue of oocyte quality, and the addition of risk factors may yield specific associations with quality vs. quantity. Patient’s age is the best available criterion, although limited, to predict live-birth and presumably oocyte quality. High scale studies to validate these criteria are still missing while recent evidence raises concern regarding over diagnosis.

Prognostic indicators of assisted reproduction technology outcomes of cycles with ultralow serum antimüllerian hormone: a multivariate analysis of over 5,000 autologous cycles from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database for 2012-2013

OBJECTIVE

To assess cycle outcomes when antimüllerian hormone (AMH) is ultralow (≤0.16 ng/mL) and to determine which parameters contribute to the probability of cycle cancellation and/or outcome.

DESIGN

Retrospective analysis.

SETTING

Not applicable.

PATIENT(S)

5,087 (7.3%) fresh and 243 (1.5%) thawed cycles with ultralow AMH values.

INTERVENTION(S)

Linear and logistic regression, comparison with age-matched cycles with normal AMH concentrations.

MAIN OUTCOME MEASURE(S)

Cancellation rate; number of retrieved oocytes, embryos, transferred embryos, and cryopreserved embryos; clinical pregnancy, live-birth, and multiple birth rates.

RESULT(S)

The total cancellation rate per cycle start for fresh cycles was 54%. Of these, 38.6% of the cycles were canceled before retrieval, and 3.3% of cycles obtained no oocytes at time of retrieval. Of all retrieval attempts, 50.7% had three oocytes or fewer retrieved, and 25.1% had no embryo transfer. The live-birth rates were 9.5% per cycle start. Cycles with ultralow AMH levels compared with age-matched normal AMH cycles demonstrated more than a fivefold greater pre-retrieval cancellation rate, a twofold less live-birth rate per cycle and a 4.5-fold less embryo cryopreservation rate.

CONCLUSION(S)

Refusing treatment solely on the basis of ultralow AMH levels is not advisable, but patients should be counseled appropriately about the prognostic factors for cancellation and outcomes.

Assessing ovarian response: antral follicle count versus anti-Müllerian hormone

Oocyte number and quality decline with age; however, fertility varies significantly even among women of the same age. Various measures have been developed to predict response to ovarian stimulation and reproductive potential. Evaluation of ovarian reserve can identify patients who may experience poor response or hyper-response to exogenous gonadotrophins and can aid in the personalization of treatment to achieve good response and minimize risks. In recent years, two key methods, antral follicle count (AFC), an ultrasound biomarker of follicle number, and the concentration of serum anti-Müllerian hormone (AMH), a hormone biomarker of follicle number, have emerged as preferred methods for assessing ovarian reserve. In this review, a live debate held at the American Society for Reproductive Medicine 2013 Annual Meeting is expanded upon to compare the predictive values, merits, and disadvantages of AFC and AMH level. An ovarian reserve measure without limitations has not yet been discovered, although both AFC and AMH have good predictive value. Published evidence, however, as well as the objectivity and potential standardization of AMH level and the convenience of testing any time throughout the menstrual cycle, leans towards AMH level becoming the gold-standard biomarker to evaluate ovarian reserve and predict ovarian response to stimulation.

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.

Anti Müllerian Hormone (AMH) level and expression in mural and cumulus cells in relation to age

Background

Serum AMH is declining with age and is highly associated with ovarian follicular reserve and disordered folliculogenesis. However, the precise role of AMH in the process of human follicular aging has still to be determined.

Aim

This study investigates AMH level in the follicular fluid (FF) and mRNA expression pattern in cumulus and mural granulosa cells of human ovarian follicles in relation to age.

Methods

We conducted a prospective study. Sixty-eight women undergoing In vitro fertilization (IVF) treatment were enrolled in the study. We obtained FF, mural and cumulus granulosa cells from large preovulatory follicles (17-20 mm) of 21–35 years old women (n = 40) and 40–45 years old women (n = 28) during oocyte pickup.

Results

Higher level of AMH mRNA expression in cumulus cells was observed in the older age group compared to the younger (P <0.01). In accordance with AMH mRNA expression results, FF AMH protein levels were significantly higher in the older group than in the younger group (4.7 ± 1.1 ng\ml and 2.3 ± 0.2 ng\ml respectively, p < 0.002).

Conclusions

AMH is highly expressed and secreted from cumulus GCs of advanced age patients. This remarkable correlation between AMH mRNA levels in cumulus cells in respect to age suggests that AMH may be involved in follicular aging process.