Anti Mullerian Hormone Assay

Ovarian Reserve Assessment for Patient Tailored Management

Ovarian reserve is a term that is used to determine the capacity of the ovary to provide egg cells that are capable of fertilization resulting in a healthy and successful pregnancy. This ovarian reserve declines dramatically with age which decreases fertility and rate of decline varies between individuals.

Assessment of a woman’s ovarian reserve includes measurement of:

FSH (and/or estradiol on Day 3 of the menstrual cycle)
Vaginal ultrasound assessment of ovarian volume and antral follicle counts
Anti-Mullerian hormone (AMH)

Anti-Mullerian Hormone

AMH is secreted by pre-antral and antral follicles and regulates follicle recruitment for the cycle. Lately, it is considered as one of the best indicators of ovarian reserve. Overcoming the variations of intra / inter cycle variability and test restrictions to specific menstrual days, serum levels of AMH can be measured at any point during the menstrual cycle, increasing its clinical utility.

Automated AMH Testing

The last three decades have seen a steady evolution in AMH assay technology, in tandem with shift to automation. Development of automated AMH assay systems has been driven by the need for greater precision & consistency in measurement of AMH levels. The first fully automated AMH assay was developed by Roche Diagnostics.

At Suburban we employ the Roche platform and the Roche Elecsys assay to ensure maximum accuracy, precision and consistency in AMH assessment.

Roche Elecsys Anti-Mullerian Hormone Assay

Roche Elecsys AMH is the first fully automated FDA approved assay. Developed in 2014 the assay offers better precision and consistency in reporting with the elimination of complement interferences which are a major interfering element in AMH assessment.

Clinical Utility: Elecsys AMH assay is used for the assessment of the ovarian reserve and prediction of response to Controlled Ovarian Stimulation in (COS) conjunction with other clinical and laboratory findings. Based on its performance as a predictor of poor and excessive response to COS, AMH could be used to create patient-tailored stimulation protocols
Reliable Assessment of Ovarian Reserve: With an improved precision Roche Elecsys AMH assay provides a confidence that results are reliable, consistent and reproducible. A comparative study revealed the higher precision levels of Roche assay over other available automated platforms

More Non-zero Values: 2.25% of patient cases show AMH between 0.03 and 0.08 ng/ml and 1 in every 40 patients will show a result of ‘O’ due to limited sensitivity of the available automated AMH assays. But with the wider measuring range of Roche assay and an increased precision at lower levels, Roche Elecsys AMH assay provides more of non-zero values and helps in accurate reporting

More non-zero results because every patient counts

Addressing the unmet needs: As age is one of the biggest factor affecting the AMH values so their cannot be one low, normal or high values that fits for all age groups. So, in order to address this need, Roche Elecsys AMH offers age specific reference ranges (20-50 years) studied over a Caucasian population of 148 males,887 females not taking contraceptives and 149 women with Polycystic Ovary Syndrome. These reference ranges aid interpretation of AMH measurements and subsequent patient management

The superior assay design and the above mentioned features of Roche Elecsys Assay makes it an ideal test to access the ovarian reserve and design AMH-tailored COS protocols.

AMH Guided COS Protocol

Roche Elecsys AMH aids in generating a patient tailored management protocol by assessing the eligibility of the couple to enter in an IVF cycle and also provides AMH/AFC agreement which helps in the stimulation protocol selection.

		Poor	Normal	High
		AFC 0-7	AFC 8-15	AFC >15	N
Poor	AMH ≤ 0.681 ng/mL	63.2%	32.4%	4.45%	68
Normal	0.681ng/mL <AMH≤ 2.27ng/mL	12.0%	56.9%	31.1%	167
High	AMH> 2.27ng/mL	1.4%	24.1%	74.5%	216
	N	66	169	216	451

Elecsys AMH results and AFC subgroup, in a multi-centre evaluation, three AFC groups were defined based on two cut-offs (7 and 15), corresponding topoor, normal and high values.

Poor response to COS affects 2 – 30% of patients and affects the success of Assisted Reproductive Technology (ART). Predicted poor response could be used to assess eligibility and potentially refrain couples from entering a cycle, thus reducing cancellations rates, avoiding disappointment and reducing costs.

Patient-tailored stimulation protocols may help reduce cancellations due to excessive response, potentially increasing pregnancy prospects and reducing clinical risk costs

Roche Elecsys AMH values are in sync with the BOLOGNA and POSEI DON criteria

The identification of patients with a poor ovarian response (POR) to ovarian stimulation is essential as managing this group of patients is challenging. The Bologna criteria for defining POR is based on advanced maternal age or any other risk factor for POR, a previous POR and an abnormal ovarian reserve test (ORT) and uses the AMH cut off in the range between 0.5 and 1.1 ng/ml and Antral Follicle Count (AFC) between <5 and < 7.The 2014 update of the Bologna criteria recommends a cutoff of 0.7to 1.3 ng/ml.
The Poseidon criteria for stratification of low prognosis patients in ART uses a AMH cut-off of <1.2 ng/ml and AFC <5.The Elecsys AMH assay cut-off of <0.681ng/ml has a good agreement of 62.5% with the poor AFC of 0-7
The Elecsys AMH cut off of 1.134 ng/ml (8.1pmol/L) has been shown in the study by Fairbairn to be associated with a poor. ovarian response
The Elecsys AMH cut-offs are thus within the range of the Bologna and Poseidon criteria

Validation of Hyper response Cut-offs

Mild to moderate Ovarian Hyperstimulation Syndrome (OHSS) occurs in 15-20% of all cases of ovarian stimulation, requiring careful observation. Severe OHSS occurs in 1-3% of all cases of ovarian stimulation, requiring hospitalization and intensive care due to its potentially life threatening nature. Complete prevention of OHSS is still not possible, but with early identification of potential risk factors and careful clinical management of patients undergoing COS, the incidence of OHSS can be significantly reduced, leading to better outcomes and reduced health care costs.

With Elecsys assay AMH was determined in 149 women undergoing an antagonist treatment protocol in the course of their first cycle of COS and among this population hyper response was observed in 16women.The clinical performance of Roche Elecsys AMH to predict hyper-response to COS was evaluated by ROC analysis, applying a pre specified cut off of 15 pmol/L (2.1ng/ml)

AMH cutoff	15.0 pmol/L (2.1o ng/m)
	Point estimate	95% CI
Sensitivity	81.3%	54.4-96.0%
Specificity	64.7%	55.9-72.8%
PPV	21.7%	12.1-34.2%
NPV	96.6%	90.5-99.3%

AMH-tailored stimulation protocols seem to be effective in improving I VF outcomes, thereby justifying their introduction into routine IVF practice. As a consequence, the average cost per patient and cycle was reduced by 31%.

References:

De Bruin et al. Preservation of fertility. London UK: Taylor and Francis; 2004. p 3
Jirge PR. J Hum Reprod Sci 2011;4:108-113
Grynnerup AG et al. Curr Opin Obstet Gynecol 2014;26:162-167
Anderson RA et al. Mauritas 2012;71:28-33
Van Disseldorp J et al. Hum Reprod 2010;25:221-227
Tsepelidis S et al. Hum Reprod 2007;22:1837-1840
-{AMH Package Insert, Roche Diagnostics GmbH, Mannheim, 2017-12, V 4.0
Dr. Ernesto Bosch. IVF Educational Workshop. EuroMedLab. 21-25 June, 2015. Paris
Nelson SM, et al. Fertil Steril, 2015 Oct; 104(4); 1016-1021.eS
Broer SL et al. 2010. Curr Opin Obstet Gynecol 22(3):193-201
Loh J and Maheshwari A. 2011. Hum Reprod 26(11) :2925-32
The Practice Committee of the American Society for Reproductive Medicine. 2008
Fertil Steril 90(5 Suppl) :S188-93
La Marca A et al. 2010. Hum Reprod Update 16(2):113-30
Yates AP et al. 2011. Hum Reprod 26(9):2353-62
Ferraretti AP et al. Hum Reprod 2011;26:1616-1624
Van TiIborg TC et al. BMC Womens Health 2012;18;12:29