We have now posted several blogs discussing the impact of anti-mullerian hormone (AMH) and fertility. AMH levels predict number of eggs that will be retrieved during in vitro fertilization (IVF) and pregnancy rates. AMH levels vary based on age and we have previously discussed what constitutes a “normal” AMH level. Young patients with low AMH levels will do better than their older counterparts. IVF success rates in patients with low AMH levels have also been discussed previously.
A recent study (Seifer et al. Fertil Steril 2015, In press) analyzes IVF success rates in patients with ultralow AMH levels. They defined ultralow AMH level as < 0.16 ng/ml, the lowest level detectable by a standard clinical AMH assay (Gen II enzyme-linked immunosorbent assay Beckman-Coulter). They retrospectively analyzed data from Society for Assisted Reproductive Technology (SART) clinic outcome reporting system database for 2012 – 2013.
5,087 (7.3% of total cycles) fresh and 243 (1.5%) frozen embryo transfer cycles were analyzed. Comparison was made with age-matched cycles with normal AMH levels (controls).
Here is what they found:
Mean age of the patients was 39.4 years.
Mean BMI was 26 kg/cm2.
Mean day-3 follicle stimulation hormone (FSH) level was 12.2 mIU/mL.
65.5% of the patients with ultralow AMH levels were white
The IVF cycle details were as follows:
The total cancellation rate per cycle start for fresh cycles was 54%. Of these 38.6% of the cycles were canceled before egg retrieval, and 3.3% of cycles obtained no eggs at time of retrieval.
Of all retrieval attempts, 50.7% had three eggs or fewer retrieved, and 25.1% had no embryo transfer.
Mean number of eggs retrieved was 4.4, mean number of embryos transferred was 1.96 and 5.7% had embryos available for freezing.
The clinical pregnancy rates were 13% per cycle start, 22.4% per retrieval, and 28.3% per transfer.
The live-birth rates were 9.5% per cycle start, 16.3% per retrieval, and 20.5% per transfer.
The clinical pregnancy rates with the frozen embryos were 40.3% per cycle start and 41.7% per transfer. The live birth rates were 30% per cycle start and 31.1% per transfer.
Cycles with ultralow AMH levels when compared with controls demonstrated more than a fivefold greater pre-retrieval cancellation rate, a two-fold less live-birth rate per cycle and a 4.5-fold less embryo cryopreservation rate.
Which patients had the greatest chance of success?
Women less than 37 years of age,
had embryos that reached day-5 for transfer,
had two or more embryos transferred,
had at least one extra blastocyst for freezing.
These were the patients that had the greatest chance of a successful outcome despite their ultralow AMH levels.
What does all this mean? Patients with ultralow AMH levels should not be denied access to IVF. They, however, should be counseled about the high cancellation rate and relatively low pregnancy rates with IVF.
Dr. Karande is Board Certified in the specialty of Obstetrics and Gynecology as well as the subspecialty of Reproductive Endocrinology and Infertility. He is a Fellow of the American College of Obstetricians and Gynecologists and Member of the American Society for Reproductive Medicine.