AMH is defined as: “Anti-mullerian hormone, it is a protein
released by the ovaries that start the growth of an egg in the ovaries
and is related to the development of follicles in the ovary. AMH
levels correspond to the number of antral follicles, that can be used
to indicate the number of eggs available in the ovaries [1,2]. It is
virtually undetectable but increases gradually until puberty and
remains relatively stable through the reproductive period [3,4]. A
very low level of AMH may indicate poor ovarian reserves. A very
high level of AMH may correspond to PCOS. One of the best uses
currently of the AMH test is the ability to titrate fertility medications
based on ovarian reserve and the ability to differentiate between
polycystic Ovary Syndrome (PCOS) and those potential donors with
a PCOS like ovarian response. By utilizing AMH, those woman with
higher numbers may stimulate faster on less fertility medication
and it can help decrease hyper stimulation in the high AMH and
basal antral follicle count donors [1].
Level of AMH hormone corresponds to the number of eggs
a woman has left in her ovarian reserve. That decline with age,
however, not every woman is borne with the same number of eggs
or loses them at the same rate [5]. There are some factors influence
ovarian reserve such as genetics, exposure to chemotherapy,
radiation and some medical conditions [5]. AMH detection is very
good test because it indicates some information about biological
clock, where no reliable test give such information before. [5].
AMH can be tested on any day of the menstrual cycle and It’s levels
correlate with the number of oocytes retrieved and treatment can
be individualized for optimal cycle [6-8], although level variation
between different blood samples for the same patient was reported
during the same menstrual cycle especially in young patients
[9,10] never the less AMH can still show 80% sensitivity and 93%
specificity in predicting poor ovarian response at random blood test
[11] and It’s levels correlate with the number of oocytes retrieved
and treatment can be individualized for optimal cycle [6-8].
The facts that AMH reported to show assays controversies
[12], pregnancies even at undetectable levels [13] and intracycle
variations level [14,15] raise question about the possible role of
AMH to assist reproduction. It is widely accepted that the reduction
of AMH levels in serum is the first indication for decline in the
follicular reserve of the ovaries and can be measured in the blood at
any time in the menstrual cycle due to its stability [14,15]. Normal
ranges of AMH in under 30 population tend to be higher than a
1.0ng/ml. Most fertility professionals use a cut-off of 1.5 up to 8.0
to gauge fertility potential in oocyte donors and many will use an
AMH up to 14-15ng/ml even though this could indicate PCOS. With
higher AMH numbers the need for special attention in medication
titration is warranted [1]. Until now, a woman’s ovarian reserve
was checked using methods that have been around for decades [5].
Follicular-stimulating hormone (FSH) for instant must be measured
using a blood test on day three of a woman’s menstrual cycle, but it
can fluctuate from month to month, unlike AMH also antral follicle
count is done using vaginal ultrasound, but it is highly dependent
on equipment quality and the precision of the technician [6].
AMH on the other hand, is not yet familiar to all family doctors
and gynecologists, who would need to refer a woman to a fertility
specialist for the test [5]. AMH level found to be lower in women
over 40 year of age and higher in younger female with Polycystic
ovaries (PCO) and polycystic Ovary Syndrome (P OCS) [6,15]
therefore, AMH is considered to be more specific marker of ovarian
response to gonadotrophins [9] and more significance fertility
markers over other hormones such as FSH,E2 and antral follicle
count (AFC) for treatment female infertility [16,17]. However, both
AMH and FSH are still used as ovarian reserve tests [14] despite
that FSH test showed several obstacles [18,19] and it needs to be
measured during early follicular phase [20-23].
Therefore AMH test believed to has advantages over FSH test
[24-26], although AMH level shows variation in different blood
samples for the same patient during the same menstrual cycle
AMH can still show 80% sensitivity and 93% specificity to predict
poor ovarian response at random and treatment can be monitor for
optimal cycle [27,28]. The facts that AMH reported to show assays
controversies [29-31] raise question mark about the possible role
of AMH in assisted reproduction. Although other studies showed
that levels of FSH and E2 were used as biochemical markers
for assessment of low ovarian reserve for many years however,
identification of AFC at later stage considered more reliable marker
in assessment of the ovarian reserve where, Follicle count can be
determined easily using high resolution sonographic systems [32-
34].
Although difficulties were reported in obtaining AFC however,
it has been recommended over basal FSH [32]. Thus, by some
investigators AFC is considered as the first choice test [32,34]. FSH
and AMH are two different hormones to predict ovarian reserve at
two different stages of follicular development. FSH levels reflect
antral and postantral follicular development while AMH values
are representative of post primordial prenatal follicular pool [15].
Despite the use of both these hormones in parallel to determine
ovarian reserve, there is not much literature about the frequency
of discordance and concordance between them and its clinical
significance [15]. Therefore, some studies have been conducted to
determine the frequency of concordance and discordance between
AMH and other markers such as FSH levels in female infertility
patients [35].
Professor, Chief Doctor, Director of Department of Pediatric Surgery, Associate Director of Department of Surgery, Doctoral Supervisor Tongji hospital, Tongji medical college, Huazhong University of Science and Technology
Senior Research Engineer and Professor, Center for Refining and Petrochemicals, Research Institute, King Fahd University of Petroleum and Minerals (KFUPM), Dhahran, Saudi Arabia
Interim Dean, College of Education and Health Sciences, Director of Biomechanics Laboratory, Sport Science Innovation Program, Bridgewater State University