Antimullerian hormone as a predictor of

controlled ovarian hyperstimulation

outcome: comparison of two commercial
immunoassay kits
This study was performed to compare antimullerian hormone (AMH) levels measured by two commercially avail-
able AMH measuring kits currently available, and to evaluate the AMH levels as predictor of controlled ovarian
hyperstimulation (COH) outcome using the two different kits. The two assays for AMH measurement provide sim-
ilar results, and serum AMH levels measured by the two kits both could be used as COH outcome predictors with
similar reference values. (Fertil Steril
2011;95:26024. 2011 by American Society for Reproductive Medicine.)
Key Words: Antimullerian hormone, outcome predictor, controlled ovarian hyperstimulation

Antimullerian hormone (AMH) is well known as an ovarian re-
serve marker (13). As a predictor of ovarian response to
controlled ovarian hyperstimulation (COH), basal AMH levels
have been shown to be correlated with total gonadotropin dose,
duration of COH, E2 levels on hCG day, and number of oocytes
retrieved (47). AMH levels were also found to be positively
related to the pregnancy rate in in vitro fertilization and embryo
transfer (IVF-ET) cycles (8, 9). In addition, many studies have
shown that AMH is associated with various clinical conditions,
such as polycystic ovarian syndrome, endometriosis, obesity, and
premature ovarian failure (1015).
There are two types of commercially available enzyme-linked
immunosorbent assay (ELISA) kits for measuring AMH levels.
One is the Immunotech Beckman Coulter (BC) kit and the other is
Jung Ryeol Lee, M.D.a,b
Seok Hyun Kim, M.D., Ph.D.b,c
Byung Chul Jee, M.D., Ph.D.a,b
Chang Suk Suh, M.D., Ph.D.a,b,c
Ki Chul Kim, M.D., Ph.D.d
Shin Yong Moon, M.D., Ph.D.b,c
a ous study (19). Women who hade both ovaries with no
Department of Obstetrics and Gynecology, Seoul National
University Bundang Hospital, Seongnam, South Korea
b malities, such as hyperprolactinemia or thyroid dysfunction,
Department of Obstetrics and Gynecology, Seoul National
University College of Medicine, Seoul, South Korea
c Review Board of Seoul National University Bundang Hospital.
Institute of Reproductive Medicine and Population, Medical
Research Center, Seoul, South Korea
d
Hamchoon Womens Clinics, Seoul National University, Seoul,
South Korea
Received September 23, 2010; revised January 16, 2011; accepted
January 18, 2011; published online February 11, 2011.
J.R.L. has nothing to disclose. S.H.K. has nothing to disclose. B.C.J. has
nothing to disclose. C.S.S. has nothing to disclose. K.C.K. has nothing
to disclose. S.Y.M. has nothing to disclose.
Reprint requests: Seok Hyun Kim, M.D., Ph.D., Department of Obstet-
rics and Gynecology, Seoul National University College of Medicine,
28 Yeongeon-dong, Jongno-gu, Seoul, 110-744, South Korea
(E-mail: seokhyun@snu.ac.kr).
the Diagnostic Systems Laboratories (DSL) kit. One of these two
kits was used for AMH measurement in almost all published studies.
If AMH levels measured by the two kits are different from each other,
the kit used for AMH measurement could be important for interpre-
tation of the study results. For clinical use, such as reference values
for poor and high responses to COH, whether the difference between
the levels measured by the two kits is more important.
There have been several studies that compared AMH levels mea-
sured using the two kits, but the results of those studies are contro-
versial. Studies performed by Freour et al. and Bersinger et al.
showed that there were significant differences between the AMH
levels measured by the two kits (16, 17). In contrast, Streuli et al.,
showed that the AMH levels measured by the two kits showed
similar results (18). We performed the present study to compare
AMH levels measured simultaneously by the two commercially
available kits that are currently available and to evaluate the AMH
levels as predictor of COH outcome using the two different kits.
A total of 172 women, aged 2246 years, undergoing COH with
GnRH agonist or GnRH antagonist protocols for IVF-ET were in-
cluded. The COH protocols were the same as described in a previ-
morphologic abnormalities and no evidence of endocrine abnor-
were included. This study was approved by the Institutional
Blood samples were obtained on the first day of FSH adminis-
tration. Serum was separated and frozen in aliquots at
20 C
for subsequent centralized analysis. Serum AMH levels were mea-
sured twice simultaneously using two different ELISA kits: the BC
(Marseille, France) and the DSL (Webster, TX) kits. Intra- and in-
terassay coefficients of each kit were, respectively, 12.3% and
14.2% for BC and 4.6% and 8.0% for DSL. Detection limits
were 0.14 ng/mL for BC and 0.006 ng/mL for DSL.
Correlation between AMH levels measured by the two kits and
between their AMH levels and COH outcomes were analyzed.
Fisher z-test was performed to evaluate agreement of these

2602 Fertility and Sterility Vol. 95, No. 8, June 30, 2011 0015-0282/$36.00
Copyright 2011 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2011.01.126
 TABLE 1
llerian hormone concentration discriminating
Results of the receiver operating characteristic curve analysis of serum antimu
controlled ovarian stimulation outcomes.
Outcome and method Cutoff ng/mL Sensitivity (%)
Poor response
BC 1.08 95.0
DSL 1.01 95.9
Cycle cancellation
BC 0.78 97.8
DSL 0.66 98.5
Clinical pregnancy
BC 3.02 60.0
DSL 3.28 60.0
Ongoing pregnancy
BC 3.02 62.5
DSL 3.28 62.5
Note: Poor response: fewer than four oocytes retrieved; clinical pregnancy: presence of at least one intrauterine gestational sac with pulsating fetal heart
beats 34 weeks after oocyte retrieval; ongoing pregnancy: clinical pregnancy maintained after 12 weeks of gestation. AUC area under the receiver
operating characteristic curve; CI confidence interval; BC Immunotech Beckman Coulter assay; DSL Diagnostic Systems Laboratories assay.
Lee. Correspondence. Fertil Steril 2011.
correlations between the two kits. Receiver operating characteris-
tic (ROC) curve analysis was performed, and cutoff value, sensi-
tivity and specificity for poor response, cycle cancellation,
clinical pregnancy, and ongoing pregnancy in AMH levels were
evaluated for each kit. The results were considered to be statisti-
cally significant at P values < .05.
Out of 172 women, 99 underwent COH using the GnRH agonist
protocol and 73 using the GnRH antagonist protocol. Mean age,
body mass index, basal FSH level, and antral follicle count were
35.7  4.9 years, 21.7  3.3 kg/m2, 6.3  4.8 mIU/mL, and 10.6 
7.5, respectively. Mean duration of COH, total gonadotropin dose,
and number of retrieved oocytes were 9.8  1.8 days, 2,265.0 
980.0 IU, and 10.2  7.4, respectively. Clinical and ongoing preg-
nancy rates were 20.3% (35/172) and 18.6% (32/172), respectively.
AMH levels measured by the two kits were similar and signifi-
cantly correlated with each other (r 0.967; P<.001; regression
equation: BC 1.102  DSL
0.042). Concentrations of
AMH measured by both kits were significantly correlated with
age, basal FSH levels, antral follicle count, and COH outcomes
such as gonadotropin dose, serum E2 level on hCG day, number
of mature follicles on hCG day, numbers of retrieved and fertilized
oocytes, and cumulative embryo score. The coefficient for each
correlation was similar in both kits. The AMH levels measured
by both kits showed good performance with similar cutoff levels
in the prediction of poor response, cycle cancellation, clinical
pregnancy, and ongoing pregnancy (Table 1).
Many studies, including the present study, have shown the sig-
nificant correlation of AMH with COH outcomes, but these studies
suggested various cutoff values for prediction of poor and high re-
sponse and pregnancy. The suggested causes of this discrepancy
are the different criteria for poor and high responses and different
study populations. The difference of measurement kit could also
cause this discrepancy if there is a difference of AMH levels
according to kit.
The results of studies that compared the AMH levels measured
using the two kits have been controversial. Freour et al. showed
Fertility and Sterility
Specificity (%) AUC (95% CI) P value
76.5 0.881 (0.8120.951) < .001
80.4 0.901 (0.8370.965) < .001
75.7 0.922 (0.8530.991) < .001
86.5 0.948 (0.8921.004) < .001
67.9 0.683 (0.5890.776) .001
73.0 0.692 (0.6000.783) < .001
67.9 0.694 (0.5990.789) .001
72.9 0.708 (0.6160.799) < .001
that there was significant correlation between the AMH levels
measured by the two kits, but the AMH levels measured by the
DSL kit were 4.6-fold lower than those measured by the BC kit (re-
gression equation: BC 4.01  DSL 0.98) (16). Bersinger et al.
also showed that the AMH levels measured by the DSL kit were
significantly lower than those measured by the BC kit (regression
equation: BC 3.08  DSL
0.733) (17). Whereas a more re-
cent study by Streuli et al. showed that AMH levels measured by
both kits were similar (regression equation: BC 1.074  DSL

0.291) (18).
The possible causes of discrepancy among the previous studies
and the present study are differences in populations, sampling
days, and simultaneousness of the measurements. In the present
study and some other previous studies (16, 17), women with
infertility who underwent COH were included, and the
sampling day was before gonadotropin administration or on the
day of oocyte retrieval. In contrast, the study by Streuli et al.
included women in three different populations with various
sampling days (18). Even within one study, the correlations be-
tween the AMH levels measured by the two kits differed accord-
ing to differences in populations and sampling days. In the study
by Streuli et al., the results of regression analysis were different
for samples from 24 young women and for those from 58 hetero-
geneous women who underwent infertility work-ups (y 0.79x
3.24 vs. y 1.17x 0.57). In addition, for comparison of
levels measured by different kits, simultaneous assays of the
same sample are important to exclude possible biases stemming
from sequential measurement of frozen-stored samples and dif-
ferences in laboratory environment and measurement conditions.
Only one previous study (16) and the present study simulta-
neously measured AMH levels in the samples using two different
kits.
The authors of previous studies suggested that the causes of the
differences between the findings obtained by the two kits are the
lack of an international standard and residual matrix effects (16,
17). However, Streuli et al. claim that the residual matrix effects
have been addressed and solved by the assay manufacturers
2603
recently, although there were differences in some population
groups in their study (18). In the present study, the AMH levels
in all of the samples were simultaneously measured using recent
commercially available kits, and the AMH levels measured by
the two kits were very similar. La Marca et al. suggested that the
methodologic problems mentioned in the previous studies should
have been addressed and solved by the manufacturers (20).
To date, there is no consensus on cutoff values to predict poor or
high response to COH, and various cutoff levels of AMH have
been reported. One of the possible causes of this variation was
the kit-dependent difference in the AMH levels, which was ob-
served in earlier studies. However, in the present study, we demon-
strated that there is no difference between the levels measured by
the two kits, and that both kits are suitable for predicting the re-
sponse to COH with very similar cutoff levels. Therefore, at least
in recent analyses, the differences in the measurement kits are not
the cause of different AMH cutoff values.
According to a recent review, discrepancies between AMH cut-
off values have reduced in the recent studies. In the studies published
in and after 2007, the cutoff levels for poor response were 0.991.4 ng/
mL in four out of six studies (2124), and the cutoff levels for high
response were 3.363.5 ng/mL in three out of four studies (2527).
The cutoff values for poor response and cycle cancellation by the
two kits are not different in the present study, and they are also
similar to those of recent studies with the same criteria.
In conclusion, the two commercial assays available for AMH
measurement provide similar results. Serum AMH levels mea-
sured by both kits could be used as COH outcome predictors
with similar reference values.

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2604 Lee et al. Correspondence Vol. 95, No. 8, June 30, 2011