Do you have what it takes –
from follicle to healthy baby?
Scott Nelson
Muirhead Chair in Obstetrics & Gynaecology
The big challenge of assessing variability
Jane
Oocyte
number
Melisa
Age
Wallace and Kelsey PLOS One 2010
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
Measuring AMH
We had developed the global reference range
DSL assay
25,000 women
Gen II assay
10,984 women
Nelson et al Fertil Steril 2011
Nelson et al RBMOnline 2012
Nelson et al Fertil Steril 2013
Bias from mean (%)
Different labs gave different results
Average AMH concentration(pmol/L)
Zuvela, et al Reprod Biol 2013
Bias from mean (%)
Bias from sample mean (%)
Different labs gave different results
Laboratory
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
Our previous AMH assay options
Iliodromiti, Anderson and Nelson Hum Reprod Update 2015
Manual assays show huge day to day variability
1.7
0.6
Is your lab ensuring you get reproducible results?
Beckman Coulter release an automated AMH assay
Beckman Coulter
Access 2 AMH
Iliodromiti, Anderson and Nelson Hum Reprod Update 2015
Supposed to give almost identical values to Gen II
Y = 0.968(x) + 0.11
Beckman Coulter Access AMH assay documentation
Beckman Coulter new assay does
not behave as expected – again!
Slope: 0.781 (95% CI 0.758, 0.805)
Intercept: 0.128 (95% CI 0.070, 0.198)
Nelson et al Fertil Steril (in press)
Roche release their automated assay
Roche
Elecsys/cobas
Iliodromiti, Anderson and Nelson Hum Reprod Update 2015
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)
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)
Elecsys AMH Li Heparin stressed
Elecsys AMH serum stressed
Elecsys AMH Li Heparin (ng/mL)
Roche: sensitive robust automated AMH assay
Elecsys AMH serum (ng/ml)
Robust to
type of collection
Elecsys AMH serum fresh
Robust to sample
storage temperature
Elecsys AMH serum fresh
Robust to short
and long-term storage
Gassner and Jung Clin Chem Lab Med 2014
Factors that affect AMH
GWAS identified 3 major SNPs for AMH
N=2,815
Illumina HumanHap550 quad
113 SNPs
0.8% in girls
Perry and Nelson submitted
AMH is dynamic across the lifecourse
Dewailly et al Hum Repro Update 2014
We can measure AMH on any day of the cycle
5.0
4.0
4.0
AMH (ng/mL)
AMH (ng/mL)
4.5
AMH
Oestradiol
Progesterone
3.5
3.0
2.5
≤20 years
21–25
26–30
31–35
>35
3.5
3.0
2.5
2.0
1.5
2.0
1.0
0.5
1.5
0.0
Menses
Follicular
Ovulation
Luteal
Menses
Follicular
Ovulation
Luteal
Kissell et al Hum Reprod 2014
Ethnic differences may not exist in ovarian reserve
Geometric
Mean
AMH
Age (years)
Bleil et al Fertil Steril 2013
Bhide et al BJOG 2014
GnRHa alters AMH in time dependent manner
GnRHa
Months
Su et al JCEM 2013
Anderson et al Hum Repro 2006
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
Smoking can reduce AMH independent of COCP
Median AMH values in subgroups
AMH
(ng/ml)
Age (years)
Dolleman et al JCEM 2013
PCOS women have higher AMH
AMH
PCO ovary has x6 the density of pre-antral
follicles compared with normal ovary
AFC
Webber et al Lancet 2003
Bhide et al Fertil Steril 2014
Iliodromiti et al JCEM 2013
PCOS women have higher AMH
4.7ng/ml
PCO ovary has x6 the density of pre-antral
follicles compared with normal ovary
Webber et al Lancet 2003
Bhide et al Fertil Steril 2014
Iliodromiti et al JCEM 2013
Disease can temporarily reduce your AMH
AMH at initial diagnosis relative to age matched controls
Van Dorp et al Hum Repro 2013
How does AMH compare
to its competitors
The major competitor - AFC
Image from 2001
Image from 2009
Dewailly, et al. Hum Reprod Update 2013
We will always be improving US resolution
18
Follicle number
per ovary 16
14
12
Max
Transducer
Freq (MHz)
6
7
7.5
8
8.5
9
12
10
8
6
4
2
1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
Year of data collection
Dewailly, et al Hum Reprod Update 2013
AFC normal ranges are just being established
Oocyte donor population
Infertility population
90th
95th
99th
95th
35
35
75th
99th
20
30
30
90th
25
25
75th
50th
25th
15
15
25th
15
Predicted AFC
20
AFC
AFC
20
50th
10th
10
10th
10
5th
5th
10
1st
5
1st
5
0
5
Donor
20
25
30
35
Age
9,978 women
40
45
20
25
30
35
40
Infertility
45
20
25
30
35
40
45
Age
Age
5,724 women
Iliodromiti et al submitted
MRI determined AFC – the next step in resolution
Hagen et al JCEM 2014
MRI determined AFC strongly correlates with AMH
Hagen et al JCEM 2014
Are AMH and AFC equivalent?
We thought AMH and AFC were interchangeable
Poor
Excessive
IMPORT Consortia Hum Repro Update 2013
Export Consortia Fertil Steril 2014
Only AMH predicted oocyte yield in antagonist RCT
AFC performed
poorly
Arce et al Fertil Steril 2013
At each clinic AMH better than AFC
MEGASET Trial (n=749)
Alt. 1)Clinic
MERIT
AFC
AMHbTrial (n=623)
a
Clinic
AMH
-0.04 AFC
0.26
1
1 0.37 0.21 0.23 -0.16
2
2 0.49 0.31 0.35 0.28
3
3 0.51 0.32 0.33 -0.01
4
4 0.51 0.49 0.57 0.37
5
5 0.52 0.50 0.45 0.16
6
6 0.54 0.53 0.47 0.37
7
7 0.57 0.53 0.19 0.46
8
8 0.57 0.55 0.51 0.49
9
9 0.59 0.56 0.44 -0.09
10
10 0.59 0.56 0.51 0.58
11
11 0.61 0.59 0.41 -0.06
12
12 0.65 0.60 0.27 0.23
13
13 0.65 0.61 0.46 0.59
14
14 0.65 0.62 0.48 0.39
15
15 0.67 0.65 0.75 0.75
16
16 0.71 0.68 0.49 -0.18
17
17 0.75 0.68 0.26 0.35
18
18
0.68
0.44
19
0.77
0.34
coefficientTrial (n=749)
CorrelationMEGASET
Clinic
AMHb
AFC
1
0.26
-0.04
Highest
2
0.37
0.23
3
0.49
0.35
Lowest
4
0.51
0.33
5
0.51
0.57
6
0.52
0.45
7
0.54
0.47
8
0.57
0.19
9
0.57
0.51
10
0.59
0.44
11
0.59
0.51
12
0.61
0.41
13
0.65
0.27
14
0.65
0.46
15
0.65
0.48
16
0.67
0.75
17
0.71
0.49
18
0.75
0.26
Innmunotech, bBeckman Coulter Gen II
AMH assay: aBeckman Coulter Innmunotech, bBeckman Coulter Gen II
Correlation coefficient
Highest
Lowest
Nelson et al Fertil Steril 2015
At each clinic AMH better than AFC
MEGASET Trial (n=749)
Alt. 1)Clinic
MERIT
AFC
AMHbTrial (n=623)
a
Clinic
AMH
-0.04 AFC
0.26
1
1 0.37 0.21 0.23 -0.16
2
2 0.49 0.31 0.35 0.28
3
3 0.51 0.32 0.33 -0.01
4
4 0.51 0.49 0.57 0.37
5
5 0.52 0.50 0.45 0.16
6
6 0.54 0.53 0.47 0.37
7
7 0.57 0.53 0.19 0.46
8
8 0.57 0.55 0.51 0.49
9
9 0.59 0.56 0.44 -0.09
10
10 0.59 0.56 0.51 0.58
11
11 0.61 0.59 0.41 -0.06
12
12 0.65 0.60 0.27 0.23
13
13 0.65 0.61 0.46 0.59
14
14 0.65 0.62 0.48 0.39
15
15 0.67 0.65 0.75 0.75
16
16 0.71 0.68 0.49 -0.18
17
17 0.75 0.68 0.26 0.35
18
18
0.68
0.44
19
0.77
0.34
MERIT Trial (n=623)
MEGASET
coefficient
Correlation
AFC
AMHaTrial (n=749)
Clinic
b
Clinic
AMH
AFC
-0.16
0.21
1
0.26
-0.04
Highest
0.28
0.31
2 1
0.37
0.23
-0.01
0.32
3 2
0.49
0.35
Lowest
0.37
0.49
4 3
0.51
0.33
0.16
0.50
5 4
0.51
0.57
0.37
0.53
6 5
0.52
0.45
0.46
0.53
7 6
0.54
0.47
0.49
0.55
8 7
0.57
0.19
-0.09
0.56
9 8
0.57
0.51
0.58
0.56
10 9
0.59
0.44
-0.06
0.59
11 10
0.59
0.51
0.23
0.60
12 11
0.61
0.41
0.59
0.61
13 12
0.65
0.27
0.39
0.62
14 13
0.65
0.46
0.75
0.65
15 14
0.65
0.48
-0.18
0.68
16 15
0.67
0.75
0.35
0.68
17 16
0.71
0.49
0.44
0.68
18 17
0.75
0.26
0.34
0.77
19 18
Alt. 1)
MEGASET Trial (n=749)
AMHb
Clinic
Correlation
coefficient
0.26
1
0.37
2
Highest
0.49
3
0.51
4
Lowest
0.51
5
0.52
6
0.54
7
0.57
8
0.57
9
0.59
10
0.59
11
0.61
12
0.65
13
0.65
14
0.65
15
0.67
16
0.71
17
0.75
18
AFC
-0.04
0.23
0.35
0.33
0.57
0.45
0.47
0.19
0.51
0.44
0.51
0.41
0.27
0.46
0.48
0.75
0.49
0.26
AMH assay: aBeckman Coulter Innmunotech, bBeckman Coulter Gen II
Innmunotech, bBeckman Coulter Gen II
AMH assay: aBeckman Coulter Innmunotech, bBeckman Coulter Gen II
Nelson et al Fertil Steril 2015
AMH is consistently better in both RCTs
GnRH antagonist RCT
GnRH agonist RCT
Gen II AMH assay
DSL AMH assay
Nelson et al ASRM 2014
AFC adds little to prediction of oocyte yield
GnRH antagonist RCT
GnRH agonist RCT
AMH
AFC
Nelson et al Fertil Steril 2015
Only AMH required in Xpect trial
Screening
Baseline
assessment assessment
of candidate of candidate
predictors
predictors
Prediction of high response
AMH
AMH & AFC & FSH
AUROC
0.77
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
Only AMH required in the PURSUE trial
Prediction of high response (>18 oocytes)
AMH
AMH & AFC
AMH, AFC, FSH & age
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
AUROC
0.86
0.88
0.89
Oehninger, Nelson et al RBOnline (in press)
Only AMH required in novel recFSH Phase II trial
No added value of additional
predictors
R2
AFC
26%
AMH
35%
AMH & AFC
38%
Oocytes
retrieved
rhFSH (fixed daily dose, ug/day)
Arce et al Fertil Steril 2014
Difference between
paired measurements
Why is AFC so bad – the variability is huge


Mean of two counts
Intraobserver variability
Deb, et al Ultrasound Obstet Gynecol 2009


Difference between
paired measurements
Difference between
paired measurements
Why is AFC so bad – the variability is huge
Mean of two counts
Mean of two counts
Intraobserver variability
Interobserver variability
Deb, et al Ultrasound Obstet Gynecol 2009
How AMH can
inform clinical practice
Low AMH does not reduce short term fecundability
70
60
AMH (pmol/L)
50
40
30
20
10
0
19
21
23
25
27
29
31
33
35
Cumulative proportion of women achieving pregnancy
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Age (years)
AMH quintiles, middle 3 combined
0
0
1
2
3
4
5
6
Time from cessation of birth control (cycles)
Hagen et al Fertil Steril 2012
AMH can individualize fertility
prognosis for oncology patents
Courtesy of RA Anderson 2015
We can use AMH to individualize fertility preservation
AMH **
50
20
40
15
30
Years
pmol/L
25
10
5
20
0
Amenorrhea
Menses
Amenorrhea
60
FSH
5
50
pg/ml
IU/L
*
10
0
7.5
Age
Menses
Inhibin B
40
30
20
2.5
10
0
0
Amenorrhea
Menses
Amenorrhea
Menses
Anderson and Cameron JCEM 2011
Anderson and Nelson Maturitas 2012
Anderson et al Eur J Cancer 2013
We can use AMH to predict the menopause
Zoe
Chloe
Dolleman et al JCEM 2013
We can use AMH for family planning
Ellie
Have a family
or work for
Apple/Google
OK to delay
family
Dawn
Anderson and Nelson Hum Repro 2012
AMH should not be used to exclude from treatment
live birth DOR 2.39 (95%CI 1.85 – 3.08)
1.0
Sensitivity
0.8
0.6
0.4
0.2
0
1.0
0.8
0.6
Specificity
0.4
0.2
0
Iliodromiti et al Hum Reprod Update 2014
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
0.716
Control AUC
0.674
0.674
0.674
AUC Improvement
6.3%
4.8%
6.3%
PLORA – log scale
29.1
22.5
28.3
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%
≤ 4%
PLORA Improvement
Nelson et al Fertil Steril 2015
We now know 15 is an optimal oocyte yield
Live birth rate (%)
40
30
20
10
0
1
5
10
15
20
25
Oocyte yield
30
35
40
Sunkara, et al Hum Reprod 2011
Steward et al Fertil Steril 2014
Plateau even in the US after 15 but OHSS increases
256,381 in vitro fertilization cycles
Steward et al Fertl Steril 2014
Population %
AMH can optimise stimulation
Inadequate
gonadotrophin
exposure
Iatrogenic
Poor response
Excessive
gonadotrophin
exposure
Optimal
Oocyte yield
Iatrogenic
OHSS
We can use AMH to stratify care
AMH (pmol/L)
40
Antagonist
hCG/GnRHa trigger
20
Standard
treatment
7
1
Maximise
oocyte yield
Nelson et al Hum Reprod 2009
Yates et al Hum Reprod 2011
We can use AMH to stratify care
Excessive response
P < 0.001
AMH (pmol/L)
20
Standard
treatment
20
10
Antagonist
HighAMH
>15
7
1
30
% Cycles
40
Antagonist
hCG/GnRHa trigger
Maximise
oocyte yield
Pmol/L
Reduced OHSS
Nelson et al Hum Reprod 2007
Nelson et al Hum Reprod 2009
We can use AMH to stratify care
Excessive response
P < 0.001
AMH (pmol/L)
Standard
treatment
20
10
Antagonist
HighAMH
>15
7
1
Live Birth %
20
% Cycles
40
Antagonist
hCG/GnRHa trigger
30
Maximise
oocyte yield
Increased live births
P < 0.001
80
Pmol/L
Antagonist
60
40
Agonist
20
0
High AMH
>15
Pmol/L
Reduced OHSS
Nelson et al Hum Reprod 2007
Nelson et al Hum Reprod 2009
We can use AMH to stratify care
AMH (pmol/L)
40
Antagonist
hCG/GnRHa trigger
20
Standard
treatment
25
20
15
10
7
1
Live birth rate (%)
30
Maximise
oocyte yield
Pre-AMH
Post-AMH
Nelson, et al Hum Reprod 2009
Yates, et al Hum Reprod 2011
AMH may allow truly individualised dosing
FE 999049 (ug/kg)
FE 999049 dose targeting 11 oocytes (ug/kg)
11 oocytes
targeting
0.10
0.12
0.14
0.16
0.18
0.20
Proportion of subjects %
0.22
100
15
20
25
30
AMH pmol/L
AMH (pmol/L)
35
40
≥20 oocytes
15–19 oocytes
80
Optimum range
(8–14 oocytes)
60
40
20
0
4–7 oocytes
5
10
15
20
25
30
35
40
≤3
AMH (pmol/L)
Ferring ESTHER-1 RCT ongoing
AMH will be the biomarker
of choice for individualising stimulation
Iliodromiti, Anderson & Nelson Hum Repro Update 2014
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