P-588 Evaluation of anti-Müllerian hormone levels as a predictor of pregnancy outcome following intrauterine insemination in infertile women
Authors: Romanski P , Bortoletto P , Malmsten J , Spandorfer S 
Published: June 2022

Abstract

Study question
Is a low anti-Müllerian hormone (AMH) level (&lt;1.0 ng/mL) negatively associated with pregnancy outcomes in intrauterine insemination (IUI) cycles?

Summary answer
Clinical pregnancy, spontaneous abortion, and ongoing pregnancy rates are comparable between patients with AMH levels &lt;1.0 and ≥1.0 in all age categories.

What is known already
Before ovarian stimulation for IVF treatment is recommended, many patients will first be treated with ovulation induction and IUI. Compared to IVF, intrauterine insemination has acceptable success rates, fewer risks, and is less expensive. However, in patients with diminished ovarian reserve, clinicians may be inclined to recommend that a patient proceed straight to IVF due to a concern that IUI cycles may yield unacceptable pregnancy and live birth rates, and that these cycles may waste valuable time for the patient.

Study design, size, duration
This was a retrospective cohort study of infertile patients at an academic center. The first ovulation induction/IUI cycle with oral medication (clomiphene or letrozole) between 2015-2019 was included. Patients that did not have an AMH level within 12 months of the treatment cycle were excluded. Spontaneous abortion was defined as the spontaneous demise of an intrauterine fetus before 8 weeks’ gestation. Ongoing pregnancy was defined as a viable intrauterine fetus at 8 weeks’ gestation.

Participants/materials, setting, methods
The primary outcome was ongoing pregnancy. Patients were stratified into two groups based on their AMH level: Group 1 (AMH &lt;1.0; n = 606) and Group 2 (AMH ≥1.0; n = 2518). Patients were further categorized by age to control for the association between age and low AMH level (&lt;35 years, 35-40 years, and &gt;40 years). Modified Poisson regression model with robust error variance adjusted a priori for patient age was used to estimate the RR (95% CI).

Main results and the role of chance
The mean age of patients with an AMH &lt;1.0 was 38.8 ± 3.8 years and with an AMH ≥1.0 was 35.2 ± 3.8 years. The mean AMH level of patients with an AMH &lt;1.0 was 0.6 ± 0.3 ng/mL and with an AMH ≥1.0 was 4.6 ± 4.7 ng/mL. Additional demographics including body mass index, race, use of clomiphene versus letrozole, number of follicles ≥14mm at trigger, endometrial thickness, and post-wash total motile sperm count were comparable between the two groups. Among the entire cohort, when patients with an AMH &lt;1.0 were compared to patients with an AMH ≥1.0, after adjusting for age, there were no significant differences in clinical pregnancy (11.6% versus 15.0%; RR 0.90 (0.70-1.17)), spontaneous abortion (2.6% versus 2.1%; RR 1.29 (0.71-2.32)), or ongoing pregnancy rates (8.9% versus 12.9%; RR 0.83 (0.62-1.11)). Similarly, when patients were stratified into age groups, there were no significant differences in any pregnancy outcomes with an ongoing pregnancy rate: for patients &lt;35 years (12.9% versus 15.0%; RR 0.84 (0.49-1.45), for patients 35-40 years (10.9% versus 12.1%; RR 0.95 (0.66-1.35)), and for patients &gt;40 years (3.3% versus 4.5%; RR 0.89 (0.32-2.45).

Limitations, reasons for caution
As this was a retrospective study, selection bias is possible given that treatment decisions could not be prospectively controlled. However, we attempted to control for this in the study design by restricting our analysis to the first initiated cycle per patient and by excluding natural cycle and gonadotropin treatment cycles.

Wider implications of the findings
Our observations provide reassurance that a low AMH level is not associated with the chance of success or failure in an ovulation induction/IUI. Ovulation induction/IUI is, therefore, a reasonable option to consider before proceeding to IVF in patients with an AMH level &lt;1.0 ng/mL.

Trial registration number
not applicable