Anti-Mullierian Hormone Testing--Is this the best way to predict IvF success?
AMH is defined as: “Anti-mullerian hormone, or AMH, is a protein released by the ovaries and is related to the development of follicles in the ovary. AMH levels correspond to the number of antral follicles, which can be used to indicate the number of eggs available in the ovaries. A very low level of AMH may indicate poor ovarian reserves. A very high level of AMH may correspond to PCOS.”
AMH is a serum marker that reflects the number of follicles that have made the transition from the primordial pool (the number of immature oocytes available to be recruited every month) into the growing follicle pool. With a lower number, the primordial pool is being prematurely exhausted faster and the number of antral follicles available for recruitment in a given month will be lower.
So how does this translate into a test for ovarian reserve in oocyte donors? Recent data suggests that “AMH based prediction model for a live birth in assisted reproduction” can be useful as a predictive tool. This study, published in Reproductive Biology Online, in April 2011 was from Modena, Italy. The authors assessed whether AMH concentrations could be correlated to live birth rates in couples undergoing ART (assisted reproductive technology). Only AMH and age were used to predict live birth in this model. The success of IVF was able to be predicted to 79.2% in those couples with a good prognosis of age and AMH level. With age being the better predictor over all.
While this study does indicate that there is a strong correlation between AMH and live birth, other authors are not so quick to embrace AMH as a predictor of live birth. Rather, the test, with a “normal” range from 1.5 to 6.5 (depending on lab and reagents used) can also be correlated with age as a better predictor of ovarian reserve and the ability to be stimulated in an assisted technology cycle.
The best current use of AMH testing shows that AMH levels are strongly correlated with the number of oocytes retrieved during an IVF cycle. Women with an AMH level higher than .6ng/ml or higher had twice the number of oocytes retrieved and a greater number of Day 3 embryos compared to those women with AMH levels below .6 ng/ml. This study was found in the July 2011 issue of Fertility and Sterility from researchers at Albert Einstein College of Medicine.
One of the best uses currently of the AMH test is the ability to titrate fertility medications based on ovarian reserve and the ability to differentiate between PCOS and those patients with a PCOS like ovarian response. By utilizing AMH, those woman with higher numbers may stimulate faster on less fertility medication and it can help decrease hyperstimuation in the high AMH and basal antral follicle count donors.
Normal ranges of AMH in the under 30 population tend to be higher than a 1.0 ng/ml. Most fertility professionals use a cut-off of 1.5 up to 8.0 to gauge fertility potential in oocyte donors and many will use an AMH up to 14-15 ng/ml even though this could indicate PCOS. With higher AMH numbers the need for special attention in medication titration is warranted.
When looking at different oocyte candidates, the experts tend to agree that a patient that falls in the “normal” range of 2.0 and above is a better candidate than one who falls below! But, always bear in mind that the AMH is still only one test of fertility potential and has not yet been able to be used as a consistent marker of live birth after ART treatment.
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