The role of antimullerian hormone in assessing ovarian damage from chemotherapy, radiotherapy and surgery

Abstract

Purpose of review: Iatrogenic ovarian damage can occur after chemotherapy, radiotherapy and surgery for cancer as well as for non-malignant conditions. This review describes the effects of such treatment on antimullerian hormone (AMH) and the implications of the fall in AMH in relation to ovarian function and fertility, especially in the era of improved fertility preservation strategies.

Recent findings: The risk of gonadotoxicity differs between chemotherapy regimens. There is growing evidence that pretreatment AMH has prognostic significance for the degree of fall in AMH after treatment, the reversibility of ovarian damage and risk of premature ovarian insufficiency. The accuracy of prediction increases when age is coupled with AMH. The adverse effect of removal of endometriomas is increasingly clear, and AMH pre and post surgery useful is assessing the degree of damage to the ovary. The implications of low AMH after such treatment on natural fertility and reproductive lifespan are less clear. Apart from treatment effects, there are other coexisting conditions that can affect AMH which needs to be taken into consideration during interpretation of AMH before and after treatment.

Summary: A fall in AMH in women after gonadotoxic treatment has been consistently described, with variable recovery, the accurate interpretation and clinical application of post-treatment AMH level on reproductive lifespan and fertility prediction needs to be studied in future larger prospective studies with longer follow-up.

Box 1

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FIGURE 1

Schematic of the effect of gonadotoxic cancer treatment on ovarian function. The three lines represent women with high, average and low ovarian reserve (as, e.g. reflected in AMH concentrations). Treatment results in a rapid fall in all women. Those with low ovarian reserve (red line) are more likely to develop POI during treatment, and for that to persist thereafter. Conversely, those with higher ovarian reserve will show a variable recovery, some going on to develop early POI (blue line) with others, at the highest level of ovarian reserve (green line) showing more prolonged ovarian activity, with later the normal age-related decline. POI, premature ovarian insufficiency. Reproduced with permission [26].

FIGURE 2

AMH concentrations at prechemotherapy, after two cycles of Doxorubicin, (Bleomycin), Vinblastine, Dacarbazine [A(B)VD], at end of treatment and at 1, 2 and 3 years after chemotherapy. Blue, women treated with A(B)VD throughout; red, women treated with BEACOPP after 2 cycles of A(B)VD. Mean ± sem. A(B)VD, Doxorubicin, (Bleomycin), Vinblastine, Dacarbazine; AMH, antimullerian hormone. Adapted from [28].

FIGURE 3

Mosaic chart for ongoing menses (M) or chemotherapy-related amenorrhoea (A) using serum AMH and chronological age as predictor variables. AMH, antimullerian hormone. Reproduced with permission [19].