To the Editor:
We sincerely appreciate Drs. Rosenwaks’ and Reichman’s commentary (1) on our opinion piece. We are especially grateful for their explicit reporting of their program’s IVF outcomes in cases of low AMH levels, which is the largest experience yet reported. (Perhaps our admittedly provocative title spurred their useful and pertinent report of these results.) Finding that 6.2 eggs were retrieved from 1,052 patients with an AMH below 0.5 ng/mL, resulting in a 25.7% clinical pregnancy rate per retrieval, is reassuring. Perhaps more surprising is the 19% clinical pregnancy rate per retrieval among the 224 patients with AMH levels below the limit of detection (<0.16 ng/mL), who on average produced 3.9 eggs. Pertinent to our case, however, is the high cancellation rate they report for these groups: 26.1% for those with an AMH <0.50 ng/mL, and 38.8% when the AMH was <0.16 ng/mL.
We agree with Drs. Rosenwaks and Reichman that patients “should not be dissuaded from pursuing IVF solely because of a low AMH value,” as one of us (JPT) previously cautioned regarding elevated FSH values (2). Nonetheless, we do believe we have an obligation to warn that low AMH levels predict low ovarian response, higher cancellation rates, and lower pregnancy rates. We also continue to believe that AMH is a more sensitive and specific marker of low response than FSH ever was, so we still prefer it to FSH for this purpose.
James P. Toner, M.D., Ph.D.
Atlanta Center for Reproductive Medicine, Atlanta, GA
David B. Seifer, M.D., Ph.D.
Genesis Fertility and Reproductive Medicine, Brooklyn, NY
(1) Rosenwaks Z, Reichman DE. Use of antimüllerian hormone: the risks of interpreting ovarian reserve markers in isolation. Fertil Steril 2013, in press.
(2) Toner JP. Modest FSH elevations in young women: warn but don’t disqualify. Fertil Steril 2004; 81: 1493-5.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2012.04.045