Anti-Mullerian hormone: poor assay reproducibility in a large cohort of subjects suggests sample instability.

STUDY QUESTION: What is the variability of anti-Müllerian hormone (AMH) concentration in repeat samples from the same individual when using the Gen II assay and how do values compare to Gen I [Diagnostic Systems Ltd (DSL)] assay results? SUMMARY ANSWER: The Gen II AMH assay displayed appreciable variability, which can be explained by sample instability. WHAT IS KNOWN ALREADY: AMH is the primary predictor of ovarian performance and is used to tailor gonadatrophin dosage in cycles of IVF/ICSI and in other routine clinical settings. Thus, a robust, reproducible and sensitive method for AMH analysis is of paramount importance. The Beckman Coulter Gen II ELISA for AMH was introduced to replace earlier DSL and Immunotech assays. The performance of the Gen II assay has not previously been studied in a clinical setting. STUDY DESIGN, SIZE AND DURATION: We studied an unselected group of 5007 women referred for fertility problems between 1 September 2008 and 25 October 2011; AMH was measured initially using the DSL AMH ELISA and subsequently using the Gen II assay. AMH values in the two assays were compared using a regression model in log(AMH) with a quadratic adjustment for age. Additionally, women (n = 330) in whom AMH had been determined in different samples using both the DSL and Gen II assays (paired samples) identified and the difference in AMH levels between the DSL and Gen II assays was estimated using the age-adjusted regression analysis. A subset of 313 women had repeated AMH determinations (n = 646 samples) using the DSL assay and 87 women had repeated AMH determinations using the Gen II assay (n = 177 samples) were identified. A mixed effects model in log(AMH) was utilized to estimate the sample-to-sample (within-subject) coefficients of variation of AMH, adjusting for age. Laboratory experiments including sample stability at room temperature, linearity of dilution and storage conditions used anonymized samples. MAIN RESULTS AND THE ROLE OF CHANCE: In clinical practice, Gen II AMH values were ∼20% lower than those generated using the DSL assay instead of the 40% increase predicted by the kit manufacturer. Both assays displayed high within-subject variability (Gen II assay CV = 59%, DSL assay CV = 32%). In the laboratory, AMH levels in serum from 48 subjects incubated at RT for up to 7 days increased progressively in the majority of samples (58% increase overall). Pre-dilution of serum prior to assay, gave AMH levels up to twice that found in the corresponding neat sample. Pre-mixing of serum with assay buffer prior to addition to the microtitre plate gave higher readings (72% overall) compared with sequential addition. Storage at -20°C for 5 days increased AMH levels by 23% compared with fresh samples. The statistical significance of results was assessed where appropriate. LIMITATIONS, REASONS FOR CAUTION: The analysis of AMH levels is a retrospective study and therefore we cannot entirely rule out the existence of differences in referral practices or changes in the two populations. WIDER IMPLICATIONS OF THE FINDINGS: Our data suggests that AMH may not be stable under some storage or assay conditions and this may be more pronounced with the Gen II assay. The published conversion factors between the Gen II and DSL assays appear to be inappropriate for routine clinical practice. Further studies are urgently required to confirm our observations and to determine the cause of the apparent instability. In the meantime, caution should be exercised in the interpretation of AMH levels in the clinical setting. CONFLICT OF INTEREST/STUDY FUNDING: S. Roberts is supported by the NIHR Manchester Biomedical Research Centre.

Social correlates of female infertility in Uzbekistan.

The purpose of this matched case-control study was to investigate the social correlates of primary infertility among females aged 35 years or less. The study was conducted in the Clinics of Samarkand Medical Institute, Uzbekistan, among 120 infertile and 120 healthy women matched by age, residential area, and occupation from January to June 2009. Data were collected by face-to-face interviews using a structured questionnaire. Median duration of infertility was 10.0 months (interquartile range = 6.0-13.0). The rate of remarriage was 3.5 times higher among infertile women compared with healthy subjects. Insufficient family income, poor quality of life, life stress, and discontentment with daily routines as well as 'bad' relationships with family members (husband, mother- and father-in-law) were significant correlates of female infertility. Infertile women were more likely to underestimate the importance of sexual intimacy, and a negative attitude to sex. Female infertility is associated with various social correlates leading to higher remarriage rates and to further complicating the problem of infertility. Thus, a correction of women's basic attitudes and their relationships to their surrounding social habitat should be an essential component of any program of infertility management.

How much variation in oocyte yield after controlled ovarian stimulation can be explained? A multilevel modelling study.

STUDY QUESTION: How much variation in oocyte yield after controlled ovarian stimulation (COS) can be accounted for by known patient and treatment characteristics? SUMMARY ANSWER: There is substantial variation in the COS responses of similar women and in repeated COS episodes undertaken by the same woman, which cannot be accounted for at present. WHAT IS ALREADY KNOWN: The goal of individualized COS is to safely collect enough oocytes to maximize the chance of success in an ART cycle. Personalization of treatment rests on the ability to reduce variation in response through modifiable factors. STUDY DESIGN SIZE DURATION: Multilevel modelling of a routine ART database covering the period 1 October 2008-8 August 2012 was employed to estimate the amount of variation in COS response and the extent to which this could be explained by immutable patient characteristics and by manipulable treatment variables. A total of 1851 treatment cycles undertaken by 1430 patients were included. The study was not subject to attrition, as cancelled cycles were included in the analysis. PARTICIPANTS/MATERIALS SETTING METHODS: Women aged 21-43 years undergoing ovarian stimulation for IVF (possibly with ICSI) using their own eggs at a tertiary care centre. MAIN RESULTS AND THE ROLE OF CHANCE: Substantial unexplained variation in COS response (oocyte yield): was observed (3.4-fold (95% CI: 3.12 to 3.61)). Only a relatively small amount of this variation (around 19%) can be explained by modifiable factors. A significant, previously undescribed predictor of response was the practitioner performing oocyte retrieval, with 1.5-fold variation between surgeons with the highest and lowest yields. LIMITATIONS REASONS FOR CAUTION: Although a large number of covariables were adjusted for in the analysis, including those that were used for dosing and determination of the stimulation regimen, this study is subject to confounding due to unmeasured variables and measurement error. WIDER IMPLICATIONS OF THE FINDINGS: The present study suggests that there are limits to the extent that COS response can be predicted on the basis of known factors, or controlled by manipulation of treatment factors. Moreover, modifiable variation in response appears to be partially attributable to differences between surgeons performing oocyte retrieval. Consequently, consistent prevention of ineffective or unsafe responses to COS is not likely to be possible at present. Our results highlight the importance of blinding surgeons in RCTs. The data also suggest that there is likely to be limited scope for personalized treatment unless additional predictors of ovarian response can be identified. STUDY FUNDING/COMPETING INTERESTS: J.W. is funded by a Doctoral Research Fellowship from the National Institute for Health Research (DRF-2014-07-050) supervised by S.A.R. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. J.W. is a statistical editor of the Cochrane Gynaecology and Fertility Group. S.A.R. is a statistical editor for Human Reproduction. J.W. also declares that publishing peer-reviewed articles benefits his career. A.L.M. has received consultation fees from MSD, Merck Serono, Ferring, TEVA, Roche, Beckman Coulter.

Effect of salpingectomy, ovarian cystectomy and unilateral salpingo-oopherectomy on ovarian reserve.

Pelvic surgery can affect ovarian reserve, but estimates of the potential effect of different surgical procedures are lacking. This study examines the markers of ovarian reserve after different procedures in order to help the provision of informed consent before surgery. Anti-Müllerian hormone (AMH), antral follicle count (AFC) and follicle-stimulating hormone (FSH) of women with a history of salpingectomy, ovarian cystectomy or unilateral salpingo-oophorectomy were compared to those without history of surgery using cross-sectional data adjusting for patient and clinical factors in multivariable regression model. There were 138 women who had had salpingectomy, 36 unilateral salpingo-oopherectomy, 41 cystectomy for ovarian cysts that are other than endometrioma and 40 women had had excision of endometrioma. There was no significant difference in AMH (9 %; p = 0.33), AFC (-2 %; p = 0.59) or FSH (-14 %; p = 0.21) in women with a history of salpingectomy compared to women without surgery. Women with a history of unilateral salpingo-oophorectomy were found to have significantly lower AMH (-54 %; p = 0.001). These women also had lower AFC (-28 %; p = 0.34) and higher FSH (14 %; p = 0.06), the effect of which did not reach statistical significance. The study did not find any significant associations between a history of cystectomy, for disease other than endometrioma and AMH (7 %; p = 0.62), AFC (13 %; p = 0.18) or FSH. (11 %; p = 0.16). Women with a history of cystectomy for ovarian endometrioma had 66 % lower AMH (p = 0.002). Surgery for endometrioma did not significantly affect AFC (14 %; p = 0.22) or FSH (10 %; p = 0.28). Salpingo-oopherectomy and cystectomy for endometrioma cause a significant reduction in AMH levels. Neither salpingectomy nor cystectomy for cysts other than endometrioma has appreciable effects on ovarian reserve.

The measurement of anti-Müllerian hormone: a critical appraisal.

CONTEXT: Measurement of anti-Müllerian hormone (AMH) is perceived as reliable, but the literature reveals discrepancies in reported within-subject variability and between-method conversion factors. Recent studies suggest that AMH may be prone to preanalytical instability. We therefore examined the published evidence on the performance of current and historic AMH assays in terms of the assessment of sample stability, within-patient variability, and comparability of the assay methods. EVIDENCE ACQUISITION: We reviewed studies (manuscripts or abstracts) measuring AMH, published in peer-reviewed journals between January 1, 1990, and August 1, 2013, using appropriate PubMed/Medline searches. EVIDENCE SYNTHESIS: AMH levels in specimens left at room temperature for varying periods increased by 20% in one study and by almost 60% in another, depending on duration and the AMH assay used. Even at -20°C, increased AMH concentrations were observed. An increase over expected values of 20-30% or 57%, respectively, was observed after 2-fold dilution in two linearity-of-dilution studies, but not in others. Several studies investigating within-cycle variability of AMH reported conflicting results, although most studies suggest that variability of AMH within the menstrual cycle appears to be small. However, between-sample variability without regard to menstrual cycle as well as within-sample variation appears to be higher using the GenII AMH assay than with previous assays, a fact now conceded by the kit manufacturer. Studies comparing first-generation AMH assays with each other and with the GenII assay reported widely varying differences. CONCLUSIONS: AMH may exhibit assay-specific preanalytical instability. Robust protocols for the development and validation of commercial AMH assays are required.

The reproducibility of serum anti-Müllerian hormone in subfertile women: within and between patient variability.

Serum anti-Müllerian hormone concentrations vary significantly over time and this should be taken into account when tailoring treatment protocols for patients undergoing controlled ovarian hyperstimulation (COH). Compared with FSH, serum anti-Müllerian hormone may have greater discriminatory power because of its modest intrapatient variation and the larger interpatient variation.