1. Checking AMH as an initial evaluation of ovarian reserve Midwest Reproductive Symposium Chicago, USA June 19-21, 2014
Frank J Broekmans
Professor Reproductive Medicine and Surgery
University Medical Center Utrecht

2. Coming to Chicago

3. Disclosures Member external advisory board Merck Serono
Member external advisory board Merck Serono
Member external advisory board Gideon Richter
Educational work MerckSharpDome
Educational activities Ferring BV
Consultancy work Roche

4. Learning Objectives Appreciate the biology of Ovarian Reserve
Know the limitations of predicting Poor and Excessive Ovarian Response by using AMH
Believe the very limited relation ship between FSH dosage and Ovarian Response
Appreciate the inability of AMH to predict Quality

5. Initial evaluation of ovarian reserve
For what purpose?
Assessment of Time to Menopause/future fertility
Predicting prognosis for spontaneous pregnancy in Infertility
Predicting Pregnancy after ART
Prediction Ovarian response ART
Ovarian Damage quantification (chemo, UAE, ovarian surgery)
POI diagnosis

6. Initial evaluation of ovarian reserve
For what purpose?
Assessment of Time to Menopause/future fertility
Predicting prognosis for spontaneous pregnancy in Infertility
Predicting Pregnancy after ART
Prediction Ovarian response ART
Ovarian Damage quantification (chemo, UAE, ovarian surgery)
POI diagnosis

7. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

8. AMH Physiology AMH - dimeric glycoprotein
member of the transforming growth factor β (TGF-β) family of growth and differentiation factors (Inhibins and Activins)
Produced from Mural Granulosa Cells
Basically a Paracrine Inhibitor

9. AMH Physiology – Paracrine!!
Ovarian AMH inhibits
a. Initial recruitment of primordial follicles into primary follicles
b. Sensitivity of Antral follicles to FSH

10. The source of Serum AMH Circulating AMH Primordial pool ? 8-10 mm
Pre-antral follicles
Primary follicles
Jeppesen, MHR 2013
Broer, COOG 2009
Primordial pool

11. AMH processing Granulosa Cell Serum Signal peptide Proregion 55 kD
Mature peptide 12.5 kD
Signal peptide cleavage
Dimerization
Cleavage by proprotein convertases Furin, PC5
RAQR
Granulosa Cell
Serum

12. AMH assay - enzymatically amplified two-site immunoassay.
detector AB
capture AB
Immunotech-Beckman
Detection limit
traditional
2 ng/ml
ultra-sensitive
0.1 ng/ml
2/6
detector AB
9/6
capture AB
DSL-I
0.078 ng/ml.
F2B/7A
detector AB
F2B/12H
capture AB
DSL-II
ng/ml.
Beckman-Coult Gen II
0.08 ng/ml.

13. Serum AMH declines with..
Ovarian Stimulation
Pituitary/gonadal suppression by
Oral contraceptive
GnRH agonist
Smoking
Pregnancy
Li, JARG 2013
Koninger RBE 2013
Hagen, FS 2012
Dolleman, JCEM 2013

14. AMH assay BC Gen II system Do’s and don’t’s
Use your Own or the Same Laboratory
Standardise Storage and Shipping conditions: Deep Frozen -80 is best…??
Reference values based on your own data..and check pill and smoking
GEN II = DSL + 40%
F2B/7A
detector AB
F2B/12H
capture AB

15. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

16. Infertility Tubal Pathology Severe Male factor Anovulation
Unexplained: 60%
What is wrong here??
Advanced Ovarian Ageing??
Poor Gamete Quality??
Poor Implantation Conditions?

17. The Success of your patient(s)
Diagnosis
Prognosis
Indication for ART
IUI mild stimulation
IVF/ICSI/ Oocyte donation
Assessment of Success
Start Indicated treatment
Cycle 1
Cycle 2
Cycle 3
Time
Spontaneous Pregnancy
ART related ongoing Pregnancy
Drop Out
No Pregnancy, Miscarriage

18. The Infertile Couple Inf Work Up
Prognosis
AMH ??
AMH ??
AMH ??
Treatment
Expectant
IUI ±Stim
IVF ICSI
Unexplained
Mild Semen
Moderate Semen
Unexplained
All Semen
Tubal
Unexplained
Mild Semen
Diagnosis

19. Prognostic Model – Who treatment? Who wait?
Hunault Model prediction for chance of spontaneous Live Birth
Does AMH or other ORT add value??

20. Will an ORT add anything to the Hunaull Prediction Model
In 42 (1.3%) de probability for Ongoing pregnancy shifts from > 30% into < 30%, if basal FSH is added to the Hunault model
These 42 couples would have been advised “TREATMENT” in stead of “EXPECTANT”
N=3219
vd Steeg, 2007

21. Will AMH add anything to the Hunaull Prediction Model
No such data on AMH

22. Will an ORT add anything to the Hunaull Prediction Model
N=474 - In 20 cases (5.4%) the probability of ongoing pregancy shifts from ≥ 30% into < 30%, if bFSH is added to the Hunault model.
Haadsma, HR 2009

23. The Infertile Couple Inf Work Up
Diagnosis
Prognosis
AMH ??
AMH ??
AMH ??
Treatment
Expectant
IUI ±Stim
IVF ICSI
Unexplained
Mild Semen
Moderate Semen
Unexplained
All Semen
Tubal
Unexplained
Mild Semen
Diagnosis

24. ORT before starting IUI/Stim?
Only Few studies, and not on AMH
The aim could be: skip IUI/Stim if prognosis is too poor for succes in thta treatment modality and proceed directly to IVF

25. FSH and CCCT useful in IUI/stim??
Cases with 30-50% reduction in cumulative chance of pregnancy can be identified.
Skip the treatment?? 3 Cumulative cycles…
Magendzo, 2006

26. AFC prior to IUI with ovarian stimulation - No consistent data
N=107 cases
AFC< 5 fo
Sens 19%
Spec 96%
LR+ 3.2
Post test prob of non pregn: 95%
Abn test 16%
N=150 cases
AFC< 6 fo
Sens 23%
Spec 83%
LR+ 1.3
Post test prob of non pregn: 88%
Abn test 22%
One cycle studies…
The significance of antral follicle count in controlled ovarian stimulation and intrauterine insemination.
Ng EH, et al, JARG 2005

27. ORT when indication for IUI/Stim
No consistent prediction of poor prognosis cases
Should we skip IUI/STIM in women over 38 and/or abnormal ORT, and then do….
direct IVF….?????
Or The PRORAILS study: AFC and AMH as predictors of response and outcome

28. The Infertile Couple Inf Work Up
Diagnosis
Prognosis
AMH ??
AMH ??
AMH ??
Treatment
Expectant
IUI ±Stim
IVF ICSI
Unexplained
Mild Semen
Moderate Semen
Unexplained
All Semen
Tubal
Unexplained
Mild Semen
Diagnosis

29. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

30. Predicting the variation: Ovarian Response
LBR ↓
Costs↑
Burden↑
Discomfort ↑
Risks ↑
LBR ↓
Optimal

31. Predicting the variation: Ongoing Pregnancy
Out of every 100 couples starting IVF..
..only 50 will achieve an ongoing pregnancy within a 1 year treatment period…
Lintsen, HR 2007
Predictable??
or..Preventable??

32. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

33. Predictors of Response and Pregnancy 1. Ovarian Reserve - Quantity
Continuous
Intermittent
AMH, AFC, basal FSH, basal Inhibin B: Quantity Markers 33

34. Predictors of Response and Pregnancy 2. Ovarian Reserve – Quality
With increasing female age the proportion of euploid embryo’s goes down from ~75% to ~25%
Ata, RBM 2012

35. OR marker = predictor
AMHGE

36. Predicting Poor OR (< 5 oocytes)
Broer, IMPORT study, HRU 2013
AUC age: ( )
AUC age+FSH: ( )
AUC age+AFC: ( )
AUC age+AMH: 0.80 ( )
AUC AMH: ( )
AUC age+AMH+AFC+FSH:
0.81 ( )

37. Predicting Excessive OR
(> 15 oocytes)
Broer, EXPORT study, HRU 2013
AUC age: ( )
AUC age+AFC: ( )
AUC age+AMH: 0.81 ( )
AUC AMH: ( )
AUC AMH+AFC: 0.85 ( )
AUC age+AMH+AFC+FSH:
0.85 ( )

38. AMH in ANTA or AGO cycles
= Accurate predictor of Response Category, …but…
Predicting
With false negatives and positives
Personalising
Can we
increase the antral follicle number
mitigate excessive response

39. Predict and select in ART
Can we..??

40. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

41. Dose – Response….? Sterrenburg, HRU 2009 Yajaprakasan, BJOG 2010
Berkkanoglu, FS 2010

42. Prediction of poor response Individualize dose of FSH?
No: predicted poor responders based on AFC (<5 [2–5 mm] follicles) did not have better pregnancy rates with 300 IU compared to 150 IU rec FSH (n=52)
Klinkert ER, et al. Hum Reprod 2005
No: predicted poor response cases based on AMH (<14 pmol/L) did not have improvement of oocyte yield nor pregnancy rates when 150 IU rec FSH was compared to 200–300 IU in a pseudorandomized design (n=122)Lekamge DN, et al. J Assist Reprod Genet 2008
No: In cases with moderately decreased OR (FSH > 8.5 U/l) no benefit was observed from 400 versus 300 IU stimulation dose for response or pregnancy (n-48)
Harrison R, et al Fertil Steril, 2001
No: In cases with AFC<12, no difference was observed in oocyte yield nor live birth rate comparing 300, 450 and 600 IU of FSH.
Berkkanoglu FS 2010
Could we change the prediction? 42

43. Prediction of excessive response Individualize dose of FSH?
Yes: an individual stimulation dose, based on a model with age, AFC, basal FSH and BMI suggests that reduced dosages mitigates response without effects on pregnancy rates (n=161) (wait for RCT, CONSORT)
Olivennes, RBM 2009
Could we change the prediction? 43

44. Predicted Poor Responders: and then do what? RCT design
In cases with normal basal FSH, an individual stimulation dose, based on a model with AFC, ovarian volume, ovarian flow, female age and smoking resulted in reduced poor response rate and higher pregnancy rates compared to a standard dose (n=262)
Popovic-Todorovic B, et al. Hum Reprod 2003

45. Completed 1530 inclusions March, 31st The OPTIMIST trial
OPTIMisation of cost effectiveness through Individualised FSH Stimulation dosages for IVF Treatment: a randomised trial Dutch RM consortium
Completed
March, 31st
1530 inclusions
18 months treatment approach
N=300
N=300
N=600
N=300

46. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

47. The Poor Responder: AGO or ANTA or FLARE?
Significant
Significant
Ongoing Pregnancy rate % % %
Underpowered
Long Suppression
Is MORE expensive
Yields more ETs
The PRINT trial Sunkara FS 2014

48. Poor Responder: antagonist??
Compared with GnRH agonist the GnRH antagonist protocol is associated with
Fewer oocytes retrieved
“Similar” Cancellation rates
“Similar” Clinical Pregnancy rates
Cancellation rate
Oocyte number
Xiao, FS 2013
CP rate
Meta-Analysis by Pu, HR 2011:
Not fewer oocytes
PR Anta: 22%
Pr Ago: 19%

49. Predicted Excessive responders: antagonist with standard dose ??
Antagonist is
More SAFE
More Efficacious
Nelson, 2009,
non randomised

50. AMH based Personalised ART treatment historical cohort design
10 versus 8 oocytes
Yates, HR 2011

51. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

52. Predicting…

53. Prognosticating…
15%
60%
50% 0%
30%
10% 8%
20% 5%

54. ART Success Prediction one cycle
Individual Patient Data Analysis: the IMPORT study
Female age
with or without any ORT
fails to predict accurately
zero prognosis cases
N=5500
AUC
Age 0.57
AFC 0.50
AMH 0.55
Age + AFC 0.58
Age + AMH 0.57
Broer, HRU 2012

55. Female age Cumulative cycles
Hendriks, RBM 2008

56. Age and AMH in concert indicate prognosis for live birth – one cycle agonist
Useful for Counseling Couples
Useful for IVF Program Restrictions
IPD data, n=1007
Broeze 2009

57. Agenda AMH and Ovarian Physiology AMH in Infertility Work Up
Why predict and select in ART
Can we really predict and select:
FSH dosage
Stim protocol
Egg quality
Conclusions

58. Individualization of ovarian stimulation in IVF using ORTs: from theory to practice
Nelson Yates
LaMarca, HRU 2013

59. Individualization of ovarian stimulation in IVF using ORTs: from theory to practice
Nelson Yates
LaMarca, HRU 2013

60. Individualization of ovarian stimulation in IVF using ORTs: from theory to practice
Nelson Yates
Some Evidence
for Dose
for Anta
Evidence for 150 IU
No Evidence
for 300 IU
for Anta
LaMarca, HRU 2013

61. Take Homer We need more Science!! Use not more than 225 IU
Individualisation in IVF:
We need more Science!!
Use not more than 225 IU

62. Take Homer 2 Quality is…. Mostly Female age
And (knowing) Quantity will help a bit

63. Thank You
the IMPORT* studygroup Richard A. Anderson Mahnaz Ashrafi László Bancsi, Ettore Caroppo, Alan B. Copperman, Thomas Ebner, Talia Eldar-Geva, Mehmet Erdem, Ellen M. Greenblatt, Kannamannadiar. Jayaprakasan, Nick Raine-Fenning, Ellen Klinkert, Janet Kwee, Antonio La Marca, MyvanwyMcIlveen, Luis T. Merce, Shanthi Muttukrishna, Scott M. Nelson, Ernest H.Y. Ng, Biljana Popovic Todorovic, Jesper M.J. Smeenk, Candido Tomás Paul J.Q. Van der Linden, K.Vladimirov, Patrick Bossuyt
Simone Broer Jeroen van Disseldorp Monique Sterrenburg Marieke Verberg Dave Hendriks Ellen Klinkert Ilse van Rooij Laszlo Bancsi Marlies Voorhuis Kim Broeze (AMC) Brent Opmeer (AMC) Madeleine Dolleman Ouijdane Hamdine Martine Depmann Bart Fauser Nick Macklon (Southampton) Ben W Mol (AMC) Nils Lambalk (VUMC)
Genetic Department
Edwin Cuppen
Epidemiology Department
Yvonne vd Schouw
Charlotte Onland-Moret
Frank Broekmans
Professor
Reproductive Medicine and Surgery
University Medical Centre Utrecht
The Netherlands 63