The present study has shown that both age and AMH are important factors for determining the outcome of IVF/ICSI. Comparing an age-matched group of women with normal AMH level to the study group, the mean clinical and live birth rates were significantly higher in women with normal AMH. This denotes that low AMH reduces pregnancy rates in IVF/ICSI patients at all age groups. However, there was no significant difference in clinical or live birth rates between the low and the extremely low AMH, in the same age group. In women with low level of AMH, age became the most important prognostic factor and not how low AMH level is.
Based on this study, the age becomes the crucial factor during counseling. Even one or two oocytes can result in a reasonable pregnancy rate in this group of young women.
AMH has been gaining popularity as its intra-cycle stability makes it a more convenient tool [7, 8].
Evidence is accumulating suggesting that AMH is the best currently available test in terms of sensitivity and specificity. However, it should be combined with age, to allow for a better assessment of the fertility potential of a given woman .
The immediate clinical implication of the present finding is that AMH combined with age provides strong information for couples considering assisted reproduction. However, its diagnostic accuracy in live birth alone is poor and could not be used to alter clinical decisions. Adoption of an AMH threshold for access to assisted reproduction was not possible in our study as the live birth rate in the same age group did not differ between low and very low AMH levels.
Several studies evaluated the outcome of IVF/ICSI in extremely low levels of AMH. It was reported in a study with 101 women and 188 embryos with extremely low AMH levels (below 0.4 ng/ml) that pregnancy can be achieved in this group and AMH helped to counsel the patients . In another study, the chance of pregnancy and the number of obtained embryos, high-quality embryos, and transferred embryos were positively correlated with the level of AMH. Therefore, it might be argued that the correlation between AMH and pregnancy depends on the number of obtained oocytes and embryos available for transfer, rather than embryo quality. So, although AMH levels might compromise pregnancy outcomes, lower levels of AMH do not impair the embryo developmental competence .
A study of 128 women with extremely low AMH concentrations (below 0.4 ng/ml), including 70 women aged < 42 years, resulted in 16 clinical pregnancies and 10 deliveries .
Counseling women with extremely low AMH concentrations can be difficult, because the predictive value for AMH concentrations is not absolute; its false-positive rate may have previously prohibited women from entering an IVF program .
In the prediction of a live birth following IVF, a distinction, however moderate, can be made between couples with a good and a poor prognosis. The success of IVF was found to mainly depend on maternal age and serum AMH concentrations, one of the most relevant and valuable markers of ovarian reserve . Age, AMH, AFC, and cause, when sub-classified, are independently associated with the results of an IVF/ICSI treatment. These results enable couples to face real expectations in their particular scenario .
Women with very low AMH levels (< 0.5 ng/mL) undergoing IVF still have a chance of achieving a pregnancy, but their prognosis is significantly affected by chronological age. Very low AMH levels are associated with a relevant risk of cycle cancelation but should not be considered a reason to exclude a couple from IVF .
In young patients with low AMH levels who have good quality embryos, AMH is not associated with clinical pregnancy, spontaneous miscarriage, or live birth rates .