Frank J BroekmansProfessor Reproductive Medicine and SurgeryUniversity Medical Center Utrecht -20-30

Checking AMH as an initial evaluation of ovarian reserveMidwest Reproductive SymposiumChicago, USA June 19-21, 2014

Coming to Chicago

Disclosures Member external advisory board Merck SeronoMember external advisory board Gideon RichterEducational work MerckSharpDomeEducational activities Ferring BVConsultancy 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?

1.Assessment of Time to Menopause/future fertility

2.Predicting prognosis for spontaneous pregnancy in Infertility

3.Predicting Pregnancy after ART

4.Prediction Ovarian response ART

5.Ovarian Damage quantification (chemo, UAE, ovarian surgery)

6.POI diagnosis

Initial evaluation of ovarian reserve

For what purpose?

1.Assessment of Time to Menopause/future fertility

2.Predicting prognosis for spontaneous pregnancy in Infertility

3.Predicting Pregnancy after ART

4.Prediction Ovarian response ART

5.Ovarian Damage quantification (chemo, UAE, ovarian surgery)

6.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 - 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

Ovarian AMH inhibits a. Initial recruitment of primordial follicles into primary folliclesb. Sensitivity of Antral follicles to FSH

AMH Physiology – Paracrine!!

8-10 mm

2-7 mm

0,1-2 mm

Primordial pool

Primary follicles

Pre-antral follicles

Circulating AMH

?

The source of Serum AMH

Jeppesen, MHR 2013Broer, COOG 2009

AMH processing

Signal peptide

Proregion 55 kD

Mature peptide 12.5 kD

Signal peptide cleavage

Dimerization

Cleavage by proprotein convertases Furin, PC5

RAQR

Serum

Granulosa Cell

DSL-I

AMH assay - enzymatically amplified two-site immunoassay.

2/6detector AB

9/6capture AB

detector AB capture AB

F2B/7Adetector AB

F2B/12Hcapture AB

DSL-II0.006-0.017 ng/ml.

Detection limit

0.078 ng/ml.

Beckman-Coult Gen II 0.08 ng/ml.

ultra-sensitive

2 ng/ml

Immunotech-Beckmantraditional

0.1 ng/ml

Serum AMH declines with..

• Ovarian Stimulation• Pituitary/gonadal

suppression by• Oral contraceptive• GnRH agonist

• Smoking• Pregnancy Li, JARG 2013

Koninger RBE 2013Hagen, FS 2012Dolleman, JCEM 2013

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%

AMH assay BC Gen II systemDo’s and don’t’s

F2B/7Adetector AB

F2B/12Hcapture 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 PathologySevere Male factorAnovulation

Unexplained: 60%

What is wrong here??Advanced Ovarian Ageing??Poor Gamete Quality??Poor Implantation Conditions?

DiagnosisPrognosis

Indication for ARTIUI mild stimulationIVF/ICSI/ Oocyte donation

Start Indicated treatment

Cycle 1 Cycle 3Cycle 2

Spontaneous Pregnancy

ART related ongoing Pregnancy

Drop Out

The Success of your patient(s)

Time

No Pregnancy, Miscarriage

Assessment of Success

The Infertile Couple

Inf Work Up

IUI ±Stim IVF ICSI

AMH ??

Diagnosis

AMH ??AMH ??

Treatment Expectant

Prognosis

UnexplainedMild Semen

UnexplainedMild SemenModerate Semen

UnexplainedAll SemenTubal

Hunault Model prediction for chance of spontaneous Live BirthDoes AMH or other ORT add value??

Prognostic Model – Who treatment? Who wait?

Prediction by Model Hunault:(%)

0 10 20 30 40 50 60 70 80 90 100

Pre

dic

tio

n b

y M

od

el I (%

)

0

10

20

30

40

50

60

70

80

90

100

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=3219vd Steeg, 2007

Will an ORT add anything to the Hunaull Prediction Model

No such data on AMH

Will AMH 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

Will an ORT add anything to the Hunaull Prediction Model

The Infertile Couple

Inf Work Up

IUI ±Stim IVF ICSI

AMH ??

Diagnosis

AMH ??AMH ??

Treatment Expectant

Prognosis

DiagnosisUnexplainedMild Semen

UnexplainedMild SemenModerate Semen

UnexplainedAll SemenTubal

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

The significance of antral follicle count in controlled ovarian stimulation and intrauterine insemination.

Ng EH, et al, JARG 2005

N=107 casesAFC< 5 foSens 19%Spec 96%LR+ 3.2Post test prob of non pregn: 95%Abn test 16% N=150 cases

AFC< 6 foSens 23%Spec 83%LR+ 1.3Post test prob of non pregn: 88%Abn test 22%

One cycle studies…

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

IUI ±Stim IVF ICSI

AMH ??

Diagnosis

AMH ??AMH ??

Treatment Expectant

Prognosis

UnexplainedMild Semen

UnexplainedMild SemenModerate Semen

UnexplainedAll SemenTubal

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

Live birth rate and oocyte yield

0

5

10

15

20

25

30

35

1 3 5 7 9 11 13 15 17 19 21 23 25

Oocyte number

LB

RLBR ↓Costs↑Burden↑

Discomfort ↑Risks ↑LBR ↓

Optimal

Predicting the variation: Ovarian Response

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??

Predicting the variation: Ongoing Pregnancy

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 Pregnancy1. Ovarian Reserve - Quantity

Continuous

Intermittent

AMH, AFC, basal FSH, basal Inhibin B: Quantity Markers

Ata, RBM 2012

With increasing female age the proportion of euploid embryo’s goes down from ~75% to ~25%

Predictors of Response and Pregnancy2. Ovarian Reserve – Quality

OR marker = predictor

AMHGE

Predicting Poor OR(< 5 oocytes)

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)

Broer, IMPORT study, HRU 2013

Predicting Excessive OR (> 15 oocytes)

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)

Broer, EXPORT study, HRU 2013

AMH in ANTA or AGO cycles

ROC Curve

1 - Specificity

1,00,75,50,250,00

Sensiti

vity

1,00

,75

,50

,25

0,00

0.90

PredictingWith false negatives and positives

PersonalisingCan we • increase the antral follicle number• mitigate excessive response

= Accurate predictor of Response Category, …but…

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 2009Yajaprakasan, BJOG 2010Berkkanoglu, FS 2010

• 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

Prediction of poor 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

Prediction of excessive response Individualize dose of FSH?

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

The OPTIMIST trialOPTIMisation of cost effectiveness through Individualised FSH Stimulation dosages for IVF Treatment: a randomised trial. Dutch RM consortium

N=300

N=300

N=300

18 months treatment approach

N=600

Completed March, 31st

1530 inclusions

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

Ongoing Pregnancy rate 16.2% 8.1% 8.1% Underpowered

Significant

Significant

The PRINT trial Sunkara FS 2014

The Poor Responder: AGO or ANTA or FLARE?

Long Suppression Is MORE expensiveYields more ETs

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

CP rate

Xiao, FS 2013

Poor Responder: antagonist??

Meta-Analysis by Pu, HR 2011:

Not fewer oocytesPR Anta: 22%Pr Ago: 19%

Predicted Excessive responders: antagonist with standard dose ??

Nelson, 2009, non randomised

Antagonist is More SAFEMore Efficacious

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…

0%

15%

10%30%50%

20% 5%

60%

8%

Individual Patient Data Analysis: the IMPORT study

Female age with or without any ORT fails to predict accuratelyzero prognosis casesN=5500

ART Success Prediction one cycle

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

IPD data, n=1007Broeze 2009

<0,4 0,4-0,8 0,8-1,6 1,6-2,8 >2,8<31 16% (8-29%) 25% (15-39%) 31% (21-43%) 32% (22-45%) 34% (24-46%)n 13 20 58 58 102

31-35 15% (8-28%) 24% (15-37%) 30% (20-11%) 32% (21-43%) 33% (23-46%)n 21 32 99 74 74

36-38  14% (7-26%) 23% (13-35%) 28% (18-40%) 29% (20-42%) 31% (21-44%)n 24 37 65 54 37

38-40 11% (5-23%) 18% (10-32%) 23% (14-36%) 24% (14-39%) 26% (15-41%)n 22 19 46 18 7

>40  5% (2-12%) 9% (4-18%) 11% (5-22%) 12% (6-24%) 13% (6-26%)n 48 38 28 8 6

AMH pg/l

Age yrs

Age and AMH in concert indicate prognosis for live birth – one cycle agonist

Useful for Counseling CouplesUseful for IVF Program Restrictions

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

LaMarca, HRU 2013

Nelson Yates

Individualization of ovarian stimulation in IVF using ORTs: from theory to practice

LaMarca, HRU 2013

Nelson Yates

Individualization of ovarian stimulation in IVF using ORTs: from theory to practice

LaMarca, HRU 2013

No Evidence for 300 IU for Anta

Evidence for 150 IU

Some Evidence for Dose for Anta

Nelson Yates

Take Homer

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

Frank BroekmansProfessorReproductive Medicine and SurgeryUniversity Medical Centre UtrechtThe Netherlands

Simone Broer Jeroen van DisseldorpMonique SterrenburgMarieke VerbergDave HendriksEllen KlinkertIlse van RooijLaszlo BancsiMarlies VoorhuisKim Broeze (AMC)Brent Opmeer (AMC)Madeleine DollemanOuijdane HamdineMartine Depmann

Bart FauserNick Macklon (Southampton)

Ben W Mol (AMC)Nils Lambalk (VUMC)

Thank You the IMPORT* studygroup Richard A. AndersonMahnaz 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 TomásPaul J.Q. Van der Linden,K.Vladimirov, Patrick Bossuyt

Genetic DepartmentEdwin CuppenEpidemiology DepartmentYvonne vd SchouwCharlotte Onland-Moret