We read with interest the review by Quinn et al regarding the use and limitations of AMH measurement in reproductive medicine. We strongly agree with many of their conclusions; however we feel that the section on measuring AMH in cancer survivors does not fully reflect the available evidence resulting in an incorrect headline conclusion. Specifically, there are robust data from prospective studies supporting the use of post-treatment AMH for the prediction of recovery of ovarian function for specific oncological disease states and their associated therapeutic strategies.  

In women following recovery from treatment for breast cancer, AMH (using an ultrasensitive assay) accurately predicted those with or without ovarian function at 5 years (1). Subsequent analyses have refined this, confirming that an undetectable AMH at 2 years from treatment is a highly accurate diagnostic test for premature ovarian insufficiency and that in women aged 40 or more, an undetectable AMH level at the end of chemotherapy has a very high predictive value for subsequent non-recovery of ovarian function, with 91% sensitivity and 82% specificity (2).  This is a clinically important timepoint as it may inform optimal choice of adjuvant endocrine therapy, but importantly this level of accuracy was not observed in younger women, who were more likely to show recovery of ovarian function even with an initially undetectable AMH level.  Data from a 3rd independant cohort of women treated for breast cancer aged 40-44 has recently confirmed this, with positive predictive value of undetectable AMH 6 months after chemotherapy for non-recovery of ovarian function of 92.1% when women were known to have been treated with a taxane (3).

These data therefore support refinement of Quinn et al’s recommendation, similar to their discussion of the value of AMH in predicting menopause, that age is an important modifier, and in women aged 40 or more, AMH is in fact of value in identifying those women where ovarian recovery is highly unlikely to recover after chemotherapy. We acknowledge that space limitations may have precluded Quinn and colleagues from a more detailed and nuanced analysis: the interested reader may find our systematic review of AMH in cancer patients (Ninety-two publications (N=9,183 patients)) currently in press in Human Reproduction Update of value.

References

1. Chai J, Howie AF, Cameron DA, Anderson RA. A highly-sensitive anti-Mullerian hormone assay improves analysis of ovarian function following chemotherapy for early breast cancer. Eur J Cancer 2014;50:2367-74.
2. Anderson RA, Mansi J, Coleman RE, Adamson DJA, Leonard RCF. The utility of anti-Mullerian hormone in the diagnosis and prediction of loss of ovarian function following chemotherapy for early breast cancer. Eur J Cancer 2017;87:58-64.
3. Anderson RA, Kelsey TW, Perdrix A, Olympios N, Duhamel O, Lambertini M et al. Diagnostic and predictive accuracy of anti-mullerian hormone for ovarian function after chemotherapy in premenopausal women with early breast cancer. Breast Cancer Res Treat 2022;doi: 10.1007/s10549-021-06508-w.

Professor Richard A Anderson

Elsie Inglis Professor of Clinical Reproductive Science

Acting Co-Director MRC Centre for Reproductive Health

University of Edinburgh

Edinburgh, UK

Professor Scott Nelson

Muirhead Professor of Obsetrics & Gynaecology

University of Glasgow

Glasgow, UK.