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Anti-Müllerian Hormone AssessR™

Test code(s) 16842

Question 1. What is anti-Müllerian hormone (AMH), and how is it used?

AMH, also called Müllerian inhibitory substance (MIS) or Müllerian inhibitory factor (MIF), is a glycoprotein dimer hormone. In males, AMH is secreted by the Sertoli cells of the developing testis; it causes regression of the Müllerian structures (ie, fallopian tube, uterus, and upper two-thirds of the vagina). AMH absence, defects in production, or receptor abnormalities in utero leads to retention of Müllerian structures. Because it is produced at higher levels in males under 2 years of age, it may be useful for evaluation of ambiguous genitalia and cryptorchidism (undescended testicles).

In females, AMH is produced by ovarian granulosa cells; production begins as the primordial follicles develop into primary follicles. Concentrations peak during the preantral and small antral stages of pubertal development and fall to undetectable levels at menopause. Thus, AMH may serve as a marker of ovarian function.

Question 2. Can AMH be useful in the diagnosis of polycystic ovarian syndrome (PCOS)?

Yes. Women with PCOS have been found to have a marked increase in antral follicles, which results in a 2 to 3 times higher concentration of AMH.1

AMH concentration may be associated with the severity of PCOS symptoms: higher levels are associated with amenorrhea and insulin-resistance. 

Question 3. How is AMH used to determine ovarian function?

As women age, the number of follicles decreases and, subsequently, so do AMH levels. As noted above, AMH levels peak during puberty and fall to undetectable levels at menopause. Thus, they represent “ovarian reserve.”

Many now believe that higher AMH concentrations suggest availability of more follicles and therefore a better response to ovarian stimulation during in vitro fertilization (IVF) procedures.

Unlike many other markers, AMH is secreted continuously by the granulosa cells; therefore, it is not affected by menstrual changes, pregnancy, or use of oral contraceptive agents. 

Question 4. Can AMH concentrations predict poor response to controlled ovarian stimulation during IVF procedures? What about predicting hyperstimulation?

Yes to both questions.

Many studies suggest a strong and positive correlation between the number of retrieved oocytes and AMH concentrations. They observed that AMH was as good as or better than most other biomarkers examined.1 However, cutoffs varied widely in these studies, and currently no consensus exists. Nelson et al found a 15% live birth rate in women with AMH concentrations <0.7 ng/mL but a 35% rate in those with AMH >1 ng/mL.2 Others have suggested a lower cutoff (eg, 0.1 to 0.35 ng/mL)3 or a higher cutoff (eg, 1.26 ng/mL4 or 1.5 ng/mL5). Based on these data, one would expect that women with AMH concentrations below these cutoffs may have some difficulty with oocyte harvesting and that the lower the concentration, the greater is the concern in this regard.

Ovarian hyperstimulation syndrome (OHSS) is also a concern. Mild OHSS occurs in 15% to 20% of all controlled ovarian hyperstimulation (COH) cycles, while severe OHSS occurs in 1% to 3% of COH cycles. The severe form is associated with respiratory distress, pleural effusion, ascites, kidney failure, thrombosis, and ovarian torsion or rupture. Several studies have suggested that a prestimulation AMH concentration may be used to predict OHSS. Unfortunately, there is no consensus regarding the cutoff to use; however, several studies did find that a cutoff of >3.5 ng/mL increased a woman’s risk of OHSS.1,2,6,7

Yates et al. proposed using AMH levels to individually tailor stimulation protocols and demonstrated an increase in embryo transfer rates, increased pregnancies, and a significant reduction in OHSS as compared to conventional protocols.8 Cost analysis showed that using AMH to tailor protocols could potentially reduce the average cost of IVF by 43%.8

 

References
 
  1. La Marca A, Sighinolfi G, Radi D, et al. Anti-Müllerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum Reprod Update. 2010;16:113-130.
  2. Nelson S, Yates R, Fleming R. Serum anti-Müllerian hormone and RSH: prediction of live birth and extremes of response in stimulated cycles--implications for individualization of therapy. Hum Reprod. 2007;22:2414-2421.
  3. Lekamge D, Barry M, Kolo M, et al. Anti-Müllerian hormone as a predictor of IVF outcome. Reprod Biomed Online. 2007;14:602610.
  4. Gnoth C, Schuring A, Friol K, et al. Relevance of anti-Müllerian hormone measurement in a routine IVF program. Hum Reprod. 2008;23:1359-1365.
  5. Celik H, Bildircin D, Guven D, et al. Random anti-Müllerian hormone predicts ovarian response in women with high baseline follicle stimulating hormone levels: Anti-Müllerian hormone in poor responders in assisted reproductive treatment. J Assist Reprod Genet. 2012;29:1472-1478.
  6. Lee T, Liu C, Huang C, et al. Serum anti-Müllerian hormone and estradiol levels as predictors of ovarian hyperstimulation syndrome in assisted reproduction technology cycles. Hum Reprod. 2008;23:160-167.
  7. Nardo L, Gelbaya T, Wilkinson H, et al. Circulating basal anti-Müllerian hormone levels as predictor of ovarian response in women undergoing ovarian stimulation for in vitro fertilization. Fertl Steril. 2009;92:1586-1593.
  8. Yates A, Rustamov O, Roberts S, et al. Anti-Müllerian hormone tailored stimulation protocols improve outcomes whilst reducing adverse effects and costs of IVF. Hum Reprod. 2011;26:2353-2362.
This FAQ is provided for informational purposes only and is not intended as medical advice. A physician’s test selection and interpretation, diagnosis, and patient management decisions should be based on his/her education, clinical expertise, and assessment of the patient.
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