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 -20-30

Coming to Chicago

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

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

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

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

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

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

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

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

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

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 0.006-0.017 ng/ml. Beckman-Coult Gen II 0.08 ng/ml.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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??

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

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

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

OR marker = predictor AMHGE

Predicting Poor OR (< 5 oocytes) Broer, IMPORT study, HRU 2013 AUC age: 0.60 (0.57-0.64) AUC age+FSH: 0.69 (0.66-0.72) AUC age+AFC: 0.76 (0.72-0.80) AUC age+AMH: 0.80 (0.76-0.84) AUC AMH: 0.81 (0.77-0.84) AUC age+AMH+AFC+FSH: 0.81 (075-0.86)

Predicting Excessive OR (> 15 oocytes) Broer, EXPORT study, HRU 2013 AUC age: 0.61 (0.58-0.64) AUC age+AFC: 0.75 (0.71-0.79) AUC age+AMH: 0.81 (0.77-0.85) AUC AMH: 0.82 (0.77-0.86) AUC AMH+AFC: 0.85 (0.80-0.90) AUC age+AMH+AFC+FSH: 0.85 (080-0.90)

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

Predict and select in ART Can we..??

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

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

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

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

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

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

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

The Poor Responder: AGO or ANTA or FLARE? Significant Significant Ongoing Pregnancy rate 16.2% 8.1% 8.1% Underpowered Long Suppression Is MORE expensive Yields more ETs The PRINT trial Sunkara FS 2014

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%

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

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

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

Predicting…

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

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

Female age Cumulative cycles Hendriks, RBM 2008

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

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

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

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

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

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

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

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