1. Do you have what it takes – from follicle to healthy baby?
Scott Nelson
Muirhead Chair in Obstetrics & Gynaecology

2. The big challenge of assessing variability
Jane
Oocyte
number
Melisa
Age
Wallace and Kelsey PLOS One 2010

3. Aim to demonstrate that:
Technical issues with AMH measurement are now resolved by Roche
Randomised controlled trials now confirm AMH better than all other biomarkers for ovarian response prediction
Optimising ovarian response is critical for optimal outcome

4. Measuring AMH

5. We had developed the global reference range
DSL assay
Gen II assay
25,000 women
10,984 women
Nelson et al Fertil Steril 2011
Nelson et al RBMOnline 2012
Nelson et al Fertil Steril 2013

6. Different labs gave different results
Bias from mean (%)
Average AMH concentration(pmol/L)
Zuvela, et al Reprod Biol 2013

7. Different labs gave different results
Bias from sample mean (%)
Laboratory
Bias from mean (%)
Average AMH concentration(pmol/L)
Data from 10 laboratories for all samples analysed by that laboratory (each laboratory returned between 4 and 20 results)
Zuvela, et al Reprod Biol 2013

8. Our previous AMH assay options
Iliodromiti, Anderson and Nelson Hum Reprod Update 2015

9. Manual assays show huge day to day variability
1.7
0.6

10. Is your lab ensuring you get reproducible results?

11. Beckman Coulter release an automated AMH assay
Beckman Coulter Access 2 AMH
Iliodromiti, Anderson and Nelson Hum Reprod Update 2015

12. Supposed to give almost identical values to Gen II
Y = 0.968(x)
Beckman Coulter Access AMH assay documentation

13. Beckman Coulter new assay does not behave as expected – again!
Slope: (95% CI 0.758, 0.805)
Intercept: (95% CI 0.070, 0.198)
Nelson et al Fertil Steril (in press)

14. Roche release their automated assay
Elecsys/cobas
Iliodromiti, Anderson and Nelson Hum Reprod Update 2015

15. Multicentre study confirms Roche automated AMH assay reproducible
AMH (ng/ml)
Age (years)
Anderson et al Fertil Steril 2015
Nelson et al Fertil Steril (in press)

16. Multicentre study confirms Roche automated AMH assay reproducible
AFC
AMH (ng/ml)
Age (years)
Age (years)
Anderson et al Fertil Steril 2015
Nelson et al Fertil Steril (in press)

17. Roche: sensitive robust automated AMH assay
Elecsys AMH serum (ng/ml)
Elecsys AMH Li Heparin (ng/mL)
Robust to short and long-term storage
Elecsys AMH Li Heparin stressed
Elecsys AMH serum fresh
Robust to sample storage temperature
Elecsys AMH serum stressed
Elecsys AMH serum fresh
Robust to type of collection
Gassner and Jung Clin Chem Lab Med 2014

18. Factors that affect AMH

19. GWAS identified 3 major SNPs for AMH
Illumina HumanHap550 quad
113 SNPs
0.8% in girls
Perry and Nelson submitted

20. AMH is dynamic across the lifecourse
Dewailly et al Hum Repro Update 2014

21. We can measure AMH on any day of the cycle
4.0
Menses
Follicular
Ovulation
Luteal
AMH (ng/mL)
5.0
≤20 years
21–25
26–30
31–35
>35
AMH
Oestradiol
Progesterone
4.5
3.5
4.0
3.5
3.0
3.0
AMH (ng/mL)
2.5
2.5
2.0
1.5
2.0
1.0
0.5
1.5
0.0
Menses
Follicular
Ovulation
Luteal
Kissell et al Hum Reprod 2014

22. Ethnic differences may not exist in ovarian reserve
Geometric Mean AMH
Although initial comparison showed South Asian women
to have a higher serum AMH, compared with white European
and Afro-Caribbean women (F = 3.817; P < 0.005), South Asian
women attending the clinic were significantly younger and less
likely to be smokers than women from other ethnic groups.
The prevalence of polycystic ovary syndrome (PCOS) was
significantly higher in South Asian and South East Asian
women than in other ethnic groups. Differences in serum
AMH were no longer significant after controlling for
confounding factors: age, body mass index (BMI), and smoking
status with (P = 0.869) and without (P = 0.215) controlling for
PCOS.
Age (years)
Bleil et al Fertil Steril 2013
Bhide et al BJOG 2014

23. GnRHa alters AMH in time dependent manner
Months
Su et al JCEM 2013
Anderson et al Hum Repro 2006

24. Combined contraception reduces AMH
combined OCs (ethinyl E2 [EE] and desogestrel), transdermal patches (EE and norelgestromin),
or vaginal rings (EE and etonogestrel)
Kallio et al Fertil Steril 2013

25. Smoking can reduce AMH independent of COCP
Median AMH values in subgroups
AMH (ng/ml)
Age (years)
Dolleman et al JCEM 2013

26. PCOS women have higher AMH
AFC
Webber et al Lancet 2003
Bhide et al Fertil Steril 2014 Iliodromiti et al JCEM 2013
PCO ovary has x6 the density of pre-antral follicles compared with normal ovary

27. PCOS women have higher AMH
4.7ng/ml
Webber et al Lancet 2003
Bhide et al Fertil Steril 2014 Iliodromiti et al JCEM 2013
PCO ovary has x6 the density of pre-antral follicles compared with normal ovary

28. Disease can temporarily reduce your AMH
AMH at initial diagnosis relative to age matched controls
Van Dorp et al Hum Repro 2013

29. How does AMH compare to its competitors

30. The major competitor - AFC
Image from 2001
Image from 2009
Dewailly, et al. Hum Reprod Update 2013

31. We will always be improving US resolution18
Follicle number per ovary 16 14 12 10
Max Transducer Freq (MHz) 8 6 6 7
7.5 8
8.5 9 12 4 2
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
Year of data collection
Dewailly, et al Hum Reprod Update 2013

32. AFC normal ranges are just being established
Infertility population
Oocyte donor population
5,724 women
9,978 women
Iliodromiti et al submitted

33. MRI determined AFC – the next step in resolution
Hagen et al JCEM 2014

34. MRI determined AFC strongly correlates with AMH
Hagen et al JCEM 2014

35. Are AMH and AFC equivalent?

36. We thought AMH and AFC were interchangeable
Poor
Excessive
IMPORT Consortia Hum Repro Update 2013
Export Consortia Fertil Steril 2014

37. Only AMH predicted oocyte yield in antagonist RCT
AFC performed poorly
Arce et al Fertil Steril 2013

38. At each clinic AMH better than AFC
Nelson et al Fertil Steril 2015

39. At each clinic AMH better than AFC
Nelson et al Fertil Steril 2015

40. AMH is consistently better in both RCTs
GnRH agonist RCT
DSL AMH assay
GnRH antagonist RCT
Gen II AMH assay
Nelson et al ASRM 2014

41. AFC adds little to prediction of oocyte yield
GnRH antagonist RCT
GnRH agonist RCT
AMH
Panels illustrating the capability of AMH and AFC to predict the number of oocytes retrieved for the long GnRH agonist (left panels) and GnRH antagonist (right panels) trial, respectively. The upper panels (A and B) show the partial residuals from the model including study cohort, AFC and ‘Study Center’ plotted against AMH. The lower panels (C and D) show the partial residuals from the model including study cohort, AMH and ‘Study Center’ plotted against AFC.
AFC
Nelson et al Fertil Steril 2015

42. Only AMH required in Xpect trial
Screening
assessment of candidate
predictors
Baseline
assessment of candidate
predictors
Prediction of high response
AUROC
AMH
0.77
AMH & AFC & FSH
0.80
Cycle 1
Stimulation day 1
assessment of candidate
predictors
Smoking added to poor response prediction
Cycle 2
Nyboe Andersen, et al Hum Reprod 2011

43. Prediction of high response (>18 oocytes)
Only AMH required in the PURSUE trial
Prediction of high response (>18 oocytes)
AUROC
AMH
0.86
AMH & AFC
0.88
AMH, AFC, FSH & age
0.89
Corifollitropin alfa arm of the Pursue Study (n=686)
Women aged 35 to 42 years,
Body weight ≥50 kg, BMI ≥18 and ≤32 kg/m2
Oehninger, Nelson et al RBOnline (in press)

44. No added value of additional predictors
Only AMH required in novel recFSH Phase II trial
Oocytes retrieved
rhFSH (fixed daily dose, ug/day)
No added value of additional predictors R2
AFC
26%
AMH
35%
AMH & AFC
38%
Arce et al Fertil Steril 2014

45. Why is AFC so bad – the variability is huge
Difference between paired measurements
Mean of two counts  
Intraobserver variability
Deb, et al Ultrasound Obstet Gynecol 2009

46. Why is AFC so bad – the variability is huge
Difference between paired measurements
Mean of two counts
Interobserver variability
Mean of two counts
Difference between paired measurements  
Intraobserver variability
Deb, et al Ultrasound Obstet Gynecol 2009

47. How AMH can inform clinical practice

48. Low AMH does not reduce short term fecundability
AMH quintiles, middle 3 combined
Hagen et al Fertil Steril 2012

49. AMH can individualize fertility prognosis for oncology patents
Courtesy of RA Anderson 2015

50. We can use AMH to individualize fertility preservation
Age
FSH
Inhibin B ** *
pmol/L
Years
IU/L
pg/ml
Anderson and Cameron JCEM 2011
Anderson and Nelson Maturitas 2012
Anderson et al Eur J Cancer 2013

51. We can use AMH to predict the menopause
Zoe
Chloe
Dolleman et al JCEM 2013

52. We can use AMH for family planning
OK to delay family
Ellie
Have a family or work for Apple/Google
Dawn
Anderson and Nelson Hum Repro 2012

53. AMH should not be used to exclude from treatment
Sensitivity
Specificity
1.0
0.8
0.6
0.4
0.2
live birth DOR 2.39 (95%CI 1.85 – 3.08)
Iliodromiti et al Hum Reprod Update 2014

54. With Univfy we showed that AMH enhanced prediction
Validation Parameters
AMH-PM
AFC-PM
AMH-AFC-PM
AUC of Receiver-Operating Characteristic Analysis
0.716
0.706
Control AUC
0.674
AUC Improvement
6.3%
4.8%
PLORA – log scale
29.1
22.5
28.3
PLORA Improvement
76.2%
59.0%
73.3%
% Reclassified to have higher LB rate
62%
71%
67%
% Reclassified to have lower LB rate
14% 8%
12%
Tier-specific prediction error – See next slide for details
≤ 4%
≤ 8%
Nelson et al Fertil Steril 2015

55. We now know 15 is an optimal oocyte yield40 30
Live birth rate (%) 20 10 1 5 10 15 20 25 30 35 40
Oocyte yield
Sunkara, et al Hum Reprod 2011
Steward et al Fertil Steril 2014

56. Plateau even in the US after 15 but OHSS increases
256,381 in vitro fertilization cycles
Steward et al Fertl Steril 2014

57. AMH can optimise stimulation
Optimal
Population %
Inadequate gonadotrophin exposure
Iatrogenic Poor response
Excessive gonadotrophin exposure
Iatrogenic OHSS
Oocyte yield

58. We can use AMH to stratify care
AMH (pmol/L)
Antagonist
hCG/GnRHa trigger 40 20
Standard treatment 7
Maximise oocyte yield 1
Nelson et al Hum Reprod 2009 Yates et al Hum Reprod 2011

59. We can use AMH to stratify care
Excessive response
AMH (pmol/L)
P < 0.001 10 20 30
Antagonist
% Cycles
HighAMH
>15
Pmol/L
Antagonist
hCG/GnRHa trigger 40 20
Standard treatment 7
Maximise oocyte yield
Reduced OHSS 1
Nelson et al Hum Reprod 2007 Nelson et al Hum Reprod 2009

60. We can use AMH to stratify care
Excessive response
Increased live births
AMH (pmol/L)
High AMH
>15
Pmol/L
Antagonist
Agonist
P < 0.001
P < 0.001 80 10 20 30
Antagonist
% Cycles
HighAMH
>15
Pmol/L
Antagonist
hCG/GnRHa trigger 60 40
Live Birth % 40 20 20
Standard treatment 7
Maximise oocyte yield
Reduced OHSS 1
Nelson et al Hum Reprod 2007 Nelson et al Hum Reprod 2009

61. We can use AMH to stratify care
AMH (pmol/L) 30
Antagonist
hCG/GnRHa trigger 25 40
Live birth rate (%) 20 20
Standard treatment 15 7 10
Maximise oocyte yield
Pre-AMH
Post-AMH 1
Nelson, et al Hum Reprod 2009 Yates, et al Hum Reprod 2011

62. AMH may allow truly individualised dosing
AMH (pmol/L) 5 10 15 20 25 30 35 40
100 80 60
Optimum range (8–14 oocytes)
≥20 oocytes
15–19 oocytes
4–7 oocytes ≤3
FE (ug/kg) targeting 11 oocytes
Proportion of subjects %
AMH pmol/L
Ferring ESTHER-1 RCT ongoing

63. AMH will be the biomarker of choice for individualising stimulation
Iliodromiti, Anderson & Nelson Hum Repro Update 2014

64. Conclusions: We now have a robust automated AMH assay from Roche
RCTs confirm that AMH is superior to all other biomarkers
AMH can be used to personalise reproductive potential and therapy