Anti-Mullerian hormone-based approach to controlled ovarian stimulation for assisted conception

Individualization of controlled ovarian stimulation (COS) for assisted conception is complicated by variable ovarian response to follicle stimulating hormone. We hypothesized that anti-Mullerian hormone (AMH), a predictor of oocyte yield, may facilitate treatment strategies for women undergoing COS, to optimize safety and clinical pregnancy rates. Prospective cohort study of 538 patients in two centres with differential COS strategies based on a centralized AMH measurement. AMH was associated with oocyte yield after ovarian stimulation in both centres, and a 'reduced' AMH (1 to < 5 pmol/l) was associated with a reduced clinical pregnancy rate. Women with a 'normal' AMH (5 to < 15 pmol/l) treated with a long GnRH-agonist protocol (both centres) showed a low incidence of excess response (0%) and poor response (0%). In women with 'high' AMH (> 15 pmol/l), the antagonist protocol eliminated the need for complete cryopreservation of embryos due to excess response (P < 0.001) and showed a higher fresh cycle clinical pregnancy rate than agonist cycles [OR 4.40 (95% CI 1.95-9.93), P < 0.001]. The use of circulating AMH to individualize treatment strategies for COS may result in reduced clinical risk, optimized treatment burden and maintained pregnancy rates, and is worthy of prospective randomized examination.