Whatever its variability, AMH remains the most stable hormonal predictor

8 04 2013

To the Editor:

Dr. Hadlow and colleagues argue that antimüllerian hormone (AMH) levels decrease in the luteal phase and that the hormone should be measured in the follicular phase, since this variability may lead to misprediction of ovarian response in IVF. This assumption was made on the basis of few, not frequent, blood samples performed on a very limited sample of women (1).

In the study, the intra-individual variability of AMH was found to be similar to that of FSH. This finding is really surprising and points out a critical revision of the results obtained. Both of the largest available studies to date (2, 3) reported that 89% of the variation in AMH was due to between-subjects variation, while only 11% was due to true individual fluctuations. AMH may exhibit some variability, but the important point is that the fluctuations are randomly distributed throughout the menstrual cycle (4), raising the possibility that a fixed day for its measurement, as proposed, would be useless. The suggested cyclic moifications of AMH in Dr. Hadlow’s study need to be confirmed in studies investigating hormonal variability through more frequent samples and across at least two menstrual cycles. A logical and agreeable hypothesis explaining why AMH should reduce in the luteal phase needed to be formulated by the authors. If AMH is produced by antral follicles, the number of which shows no significant reduction in the luteal phase, and since AMH seems to be only marginally influenced by gonadotropins, why should its concentration reduce in the second part of the cycle? Read the rest of this entry »





Response to commentary of Drs. Rosenwaks and Reichman: “But isn’t AMH still better than FSH?”

27 03 2013

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

Reference:

(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





AMH and Repetitive Oocyte Donation

27 09 2010

To the Editor:

The data that Bukulmez et al. present on increases in AMH with each oocyte donation cycle (Figure 2) is unexpected and provocative (1). The increase appeared to be most pronounced when donation cycles occurred in rapid succession, as demonstrated most convincingly in Group 6. The increase could be due to FSH stimulation of preantral and early antral follicles, the follicular stages that produce the most AMH (2). Read the rest of this entry »





Variability in Anti-Müllerian hormone levels. A comment on Sowers et al, “Anti-Müllerian hormone and inhibin B variability during normal menstrual cycles”

7 06 2010

To the Editor:

The paper by Sowers et al. (1) presents valuable and carefully collected data on the variability of serum Anti-Müllerian hormone (AMH) over the menstrual cycle, with 20 women each providing daily blood samples for one complete cycle. It is unfortunate that sampling were not prolonged giving data for all or part of a second cycle which would have allowed them to estimate repeatability and obtain rigorous statistical tests of cycle effects – this should be considered for future similar studies. Read the rest of this entry »





Measures of ovarian function in galactosemia — a response to Gubbels et al.

4 06 2009

To the Editor:

We are writing in response to a recent case report by Gubbels and colleagues (1) describing a woman with classic galactosemia who became pregnant shortly after a low anti-mullerian hormone (AMH) blood measurement. The authors contrast their case with results published by our group from a study of 35 galactosemic girls and women (2). Read the rest of this entry »