Tuesday, 14 April 2020

Vol 5, APRIL 2020 - LOW AMH AND IVF-ICSI TREATMENT OUTCOMES: ANALYSIS OF 15YRS DATA



LOW AMH LEVELS AND FERTILITY TREATMENT OUTCOMES: ANALYSIS OF 15 YRS DATA


Authors:  Sarah Baker RM, Fertility Midwife, St Jude’s Women’s Hospital, Wolverhampton, UK.
R. Sriskandakumar, MSc, Senior Embryologist, St Jude's Women's Hospital, Wolverhampton, UK
J. Adeghe PhD, FRCOG, Consultant - Gynaecology/Reproductive Medicine.


Introduction

This audit looks at the relationship between patient AMH levels and associated fertility treatment outcomes. The audit includes 157 women, who had 296 treatment cycles over a 15 year period from 2003 to 2018. The vast majority of these cycles were carried out between 2010 and 2018 (98% of cycles), however data of all cycles for women included in the audit were completed hence the inclusion of cycles from earlier years.

St Jude’s Hospital has been routinely testing AMH levels in female patients undergoing fertility treatment for over ten years. The Doctors Laboratory processes these samples and formulates results. Bloods are tested for Anti-M├╝llerian Hormone (AMH), which is produced by developing follicles in the ovaries. AMH levels are low during childhood, increase during puberty and reach a peak in early adulthood. Levels then gradually decline in line with ovarian function as the number of follicles present in the ovaries decrease until levels are undetectable following menopause. AMH measurement is therefore used as an indication of ovarian reserve and is now used routinely to guide fertility practitioners. Aside from fertility, AMH has other diagnostic value in investigating abnormal sexual development in babies and children and monitoring response to treatment of ovarian tumors. (The Doctors Laboratory, 2017)

AMH is a relatively new diagnostic test, and was frequently practiced at St Jude’s Hospital before it became widely recognised as a diagnostic fertility test. Therefore the hospital has accumulated a vast data set which may be utilised to identify trends, inform practice and advise patients.

The demographic of women seen by St Jude’s Hospital differs from that seen at many other clinics, in particular NHS clinics. The majority of women seek treatment at the clinic because they are ineligible for NHS treatment. This may be due to factors such as increased maternal age <40 years, raised BMI <30, or low ovarian reserve/premature ovarian failure. It is important to factor this into conclusions made from the audit, in particular when making wider comparisons of success rates etc. Due to the volume of women seen by the clinic with a low AMH (<5pmol/L), there was a particular interest in this group to better advise them of their relative success rates for IVF treatment. 


Rationale

The purpose of the audit was to collect and utilise the vast data set accumulated by St Jude’s Hospital from testing patient AMH levels over a 15 year period, and analyse data to better inform patients of projected treatments outcomes and success rates based on data from women with a similar demographic to themselves. This will allow the clinic to give honest real estimates and better advise women to aid in their decision making process when undergoing fertility treatment. 


Prediction

 Expectations of results were based on clinical experience and theory as follows:

·        As AMH declines with age, the expectation is that number of eggs collected would also decline.

·        There would be an increase in the incidence of abandoned cycles, or cycles that do not proceed to ET

·        There would be an increase in the number of embryos transferred for cycles which did proceed to Embryo Transfer which decreasing AMH/increasing maternal age, in view of HFEA guidelines. (Guidelines state that a up to three embryos may be transferred for women over the age of 40, although this should be carefully considered and discussed with healthcare professionals in view of the risk of a multiple pregnancy)

·        The prediction is that pregnancy rates will increase with an increase in AMH up to a peak (estimated to be approximately 40pmol/L), beyond which point rates are likely to decrease in view of co-morbidities associated with a raised AMH such as PCOS.

·        It is expected that starting dose and total dose of Stimulation medication will decrease as AMH increases, as women with lower AMH levels need higher doses of medication to stimulate a good ovarian response, compared to those with higher AMH levels.

·        It is predicted that duration of stimulation may be longer for women with lower AMH levels or increased maternal age, as ovarian response may be less favourable and take longer compared to younger women with a higher AMH level.

·        Ongoing pregnancy rates and live birth rates may be lower as women’s age increases in view of the increased risk of miscarriage associated with advancing maternal age. 


Data Collection

TDL laboratory were contacted by the hospital’s Senior Clinical Embryologist, Rasiah Sriskandakumar to request data relating to patients of the clinic. A list of 163 lab results was obtained inclusive of a lab reference number, patient’s initials, date of birth and AMH levels.

This data was used to search the clinical accounting system, Midex. By searching for women’s date of birth and matching results by initials, registration numbers and full names were obtained, which enabled us to pull out current and archived records to audit and collect data.

However for six of the lab results, no match was found on searching the date of birth on Midex and women’s names or registration numbers could not be identified; therefore these AMH results could not be included in the audit. This may be explained by the fact that the Midex accounting system was not routinely used for some of the earlier cycles included in the audit. Some patients may have also had blood tests for AMH level done, and then not proceeded to have any treatment, again in which case in previous years all data may not have been entered onto the Midex system.

Hospital staff facilitated locating patient records from the filing system and archive room. Unfortunately a further 25 records could not be located in either the current patient note filing system or from archived files, and these results had to again be excluded from the audit as no data could be collected.

Data was then collected from patient notes to include name and registration number, date of birth, age at point of treatment, AMH, treatment type, clinical protocol used, start date and dose of stimulation and total dose, duration of stimulation, medication used, number of eggs collected, number of embryos transferred and clinical outcomes. 


Data Analysis

Data was separated into different sets and analysed. An initial overview of pregnancy rates was conducted, then data was grouped based on treatment typed, splitting into ICSI/IVF, IUI/IUDU/follicle tracking and FET cycles. Within each group data was ordered based first on AMH and then by age, and analysed for each to identify trends (see excel document). Demographics for each group were analysed, and a summary of mean dosage of medication, mean number of eggs collected and embryos transferred tabulated, and results collated to see how many cycles were abandoned/did not proceed to ET/had no outcome information recorded, and how many resulted in positive and negative pregnancy tests. Comparison of the percentages of the above parameters enabled the establishment of correlations and an estimate of the likelihood of different outcomes for each group.

Results of an AMH of less than 5 were then further disseminated into groups with an interval of 1pmol/L, as there was a particular interest in women with a lower AMH and their treatment outcomes.  Analysis was based on the same summary table templates and parameters outlined above. 


Results

Data was broken down into different sets and analysed in order to identify correlations and make conclusions. Data was initially separated by the nature of treatment, into IVF/ICSI, FET, IUI/IUDI and simple follicle tracking. Summary tables were assimilated for each set and then formulated into tables and also represented in graphical form. Data was then analysis in order of ascending AMH and in age order to identify trends.

IVF/ICSI Treatment

IVF and ICSI treatment cycles included in the audit were ordered on both AMH and Age to identify any potential correlations.

AMH

All IVF/ICSI cycles included in the audit were ordered according to ascending AMH level, the grouped in intervals of 5poml/L. Data was summarised for each group on average AMH, average age, average start dose and total dose of stimulation, average duration of stimulation, average number of eggs collected and number of embryos transferred, percentage of cycles  which were abandoned/did not proceed to Embryo Transfer or had no information recorded, and percentage of positive and negative pregnancy test results. The data was formulated into a table, then into a graphical format to identify emerging trends and relationships.

AMH
0-5
5-10
10-15
15-20
20-30
30-50
50+
Data in set
54
56
25
34
23
16
15
Avg age
38.4
38
35.7
34.2
33.4
35.1
31.7
Avg AMH
2.3
7.45
12.6
17.3
26.2
42
63.2
Avg start dose
403
315
294
249
232
225
185
Avg total dose
3359
2905
2433
2321
2123
2114
1745
Avg duration of stim
11.3
11.1
11.24
11.4
10.8
12
11.6
Ave no eggs
3.3
7.5
8.12
8.8
11.4
11.3
8.8
Avg embryos transferred
1.2
1.5
1.4
1.7
1.7
1.81
1.2
Abandoned cycles
5.6
5.4
4
2.9
0
0
6.7
No ET/failed fert
22.2
14.3
12
8.8
4.3
0
20
No information recorded
9.3
5.4
4
0
0
0
0
Positive test
20.4
33.9
40
23.5
43.5
43.75
26.7
Negative test
42.6
41.1
40
64.7
52.2
56.25
73.3
Pos test (of completed cycles)
32.4
45.2
50
26.7
45.5
43.75
36.4
Neg test (of completed cycles)
67.6
54.8
50
73.3
54.5
56.25
63.6



Findings from analysing data from IVF/ICSI cycles arranged and grouped in order of ascending AMH levels are as follows:

-         Mean age decreased with ascending AMH values. So generally older women had a lower AMH and younger women had a higher AMH level.

-         Mean start dose and mean total dose of stimulation medication decreased with increasing AMH values.

-         Mean number of eggs collected increased with increasing AMH levels up to the 20-30pmol/L group, after which point mean number of eggs was static in 30-50pmol/L group, then decreased with an AMH of >50pmol/L.

-         As AMH increased the number of abandoned cycles and cycles which did not proceed to ET decreased up to the point of 30-50pmol/L, again after which the incidence increased again with AMHs of >50pmol/L.

-         The proportion of positive pregnancy tests increased from AMH of 0pmol/L up to 30pmol/L, the 30-50pmol/L group was static at 43.8% and the >50pmol/L group had a lower proportion of positive tests at 26.7%. An anomaly was observed in the 15-20pmol/L group, with lower than expected positive test rate at just 23.5%.

These results would indicate that optimal AMH level for treatment outcomes would be approximately 30pmol/L.  A low AMH level or very high AMH level >50pmol/L are associated with poorer outcomes and lower success rates.

 





AMH 0-5pmol/L

All IVF/ICSI cycles included in the audit for women with an AMH of <5pmol/L were analysed further. Ordered according to ascending AMH level, these cycles were split down into smaller groups in intervals of 1pmol/L. Data was summarised for each group on average AMH, average age, average start dose and total dose of stimulation, average duration of stimulation, average number of eggs collected and number of embryos transferred, percentage of cycles  which were abandoned/did not proceed to Embryo Transfer or had no information recorded, and percentage of positive and negative pregnancy test results. The data was formulated into a table, then into a graphical format to identify emerging trends and relationships.

AMH
0-1
1-2
2-3
3-4
4-5
Data in set
18
8
20
5
10
Avg age
40.7
42.5
39.9
40.6
43.4
Avg AMH
0.7
1.2
2.3
3.6
4.5
Avg start dose
477
506.3
405
480
366.7
Avg total dose
3875.5
3909.4
3453.8
4005
3250
Avg duration of stim
12.2
11.5
12
12.6
12.8
Ave no eggs
2.3
3.6
3.8
3.6
3.6
Avg embryos transferred
0.9
1.5
1.2
1.8
1.2
Abandoned cycles
9.1
0
0
20
10
No ET/failed fert
45.5
25.0
15
0
20
No information recorded
0.0
25.0
5
20
10
Positive test
18.2
0.0
25
40
20
Negative test
27.3
50.0
55
20
40
Pos test (of completed cycles)
40.0
0.0
31.3
66.7
33.3
Neg test (of completed cycles)
60
100.0
68.7
33.3
66.7



Findings from analysing data from IVF/ICSI cycles arranged and grouped in order of ascending AMH levels <5pmol/L are summarised below. A total of 61 cycles were analysed for women with an AMH of between 0 and 5pmol/L, however sample sizes between sub-groups varied significantly, with just 5 treatment cycles in the 3-4pmol/L group up to a maximum of 20 cycles included in the 2-3pmol/L group.

-         There was no correlation between mean age in ascending AMH groups between 0 and 5pmol/L.

-         Mean start dose and mean total dose of stimulation medication showed a minimal decreasing trend with increasing AMH values between 0 and 5pmol/L.

-         Mean number of eggs collected increased from 2.3 in the 0-1pmol/L AMH group to 3.6 in the 1-2pmol/L AMH group, and then remained static for the remaining AMH groups up to 5pmol/L.

-         As AMH increased, the number of cycles which did not proceed to ET consistently decreased from 45.5% in the 0-1pmol/L group to 0% in the 3-4pmolL AMH group. An anomaly was observed in the 4-5pmol/L AMH group as number of cycles which did not proceed to ET increased up to 20%. No trends were identified in the number of abandoned cycles or cycles which had no outcome information recorded between the AMH groups 0-5pmol/L.

-         A general increase in the proportion of positive pregnancy tests was observed across the ascending AMH groups. The best pregnancy rate was observed in the 3-4pmol/L AMH group with 40% positive test rate; the 1-2pmol/L groups had a 0% positive pregnancy test rate (however this subgroup consisted of a sample size of only eight treatment cycles).

These results, whilst still very interesting to explore, are overall fairly inconclusive in identifying strong correlations between factors, which may be attributed to the fact that the sample sizes in the sub groups were too small, or due to the fact that splitting cycles according to AMH intervals of just 1pmol/L is too small, and insufficient to distinguish adequate differences in outcomes between one group and the next. For example an AMH of 1.9pmol/L is insignificantly different to an AMH of 2.1pmol/L, which would be split into separate groups, where treatment outcomes may be approximated to be the same.





Age

All IVF/ICSI cycles included in the audit were subsequently ordered according to ascending maternal age, and grouped in 5 years intervals between 20 and 50 years. Data was summarised for each group on average age, average AMH, average start dose and total dose of stimulation, average duration of stimulation, average number of eggs collected and number of embryos transferred, percentage of cycles  which were abandoned/did not proceed to Embryo Transfer or had no information recorded, and percentage of positive and negative pregnancy test results. The data was formulated into a table, then into a graphical format to identify emerging trends and relationships.

Age
20-25
25-30
30-35
35-40
40-45
45-50
Data in set
6.0
16.0
58.0
76.0
42.0
21.0
Avg age
24.0
28.0
32.7
37.0
42.0
46.2
Avg AMH
29.0
31.0
23.4
15.0
8.0
5.8
Avg start dose
138.0
202.0
252.2
311.0
375.0
439.3
Avg total dose
1750.0
1753.0
2250.0
2731.0
3213.0
3939.3
Avg duration of stim
13.2
10.9
11.3
11.2
11.7
12.4
Ave no eggs
11.0
8.7
9.6
7.3
5.6
5.0
Avg embryos transferred
1.3
1.7
1.5
1.4
1.7
1.4
Abandoned cycles
0.0
0.0
1.7
7.9
2.4
4.8
No ET/failed fert
33.3
6.3
10.3
13.2
7.1
23.8
No information recorded
0.0
0.0
6.9
1.3
9.5
0.0
Positive test
33.3
56.3
36.2
31.6
21.4
19.0
Negative test
33.3
37.5
44.8
46.1
60.0
52.4
Pos test (of completed cycles)
50.0
60.0
44.7
40.7
26.5
26.7
Neg test (of completed cycles)
50.0
40.0
55.3
59.3
73.5
73.3



Findings from analysing data from IVF/ICSI cycles arranged and grouped in order of ascending maternal age are as follows:

-         Mean AMH decreased with ascending maternal age after the age of 30. Between the ages of 20 and 30, mean AMH was relatively static with a mean of 29.0pmol/L in the 20-25 years age group and a mean of 31.0pmol/L in the 25-30 years age group. This gradually declined to a mean of just 5.8pmol/L in the 45-50 years age group (of women who had IVF/ICSI treatment).

-         Mean start dose and mean total dose of stimulation medication increased with increasing maternal age values.

-         There was a general decrease in the mean number of eggs collected with ascending age groups.

-         As maternal age increased, there was a slight correlation with an increase in the number of abandoned cycles. However no significant correlation was identified with cycles which did not proceed to ET or cycles where no outcome information was recorded.

-         The proportion of positive pregnancy tests increased up to a peak of 56.3% in the 25-30 years age group (from 33.3% in the 20-25 years age group), after which point there was a consistent general trend of decreasing pregnancy rates, down to 19% in the 45-50 years age group.

The volume of data in each set should be factored into conclusions when considering the reliability of any average values. There were only 6 women in the 20-25years age group, which may account for slightly lower than expected pregnancy rates etc compared to other groups, compared to 16 in the 25-30years age group, 58 in the 30-35years age group, 76 in the 35-40 years age group, 42 in the 40-45 years age group, and 21 in the 45-50years age group. The vast majority of women were therefore aged between 30 and 45 years and average values are therefore likely to be more reliable for these age groups given the larger sample size.







IUI/IUDI/Follicle Tracking Treatment

Data in this group was insufficient to split into smaller groups as the sample size would be too small to make accurate estimations and draw conclusions. Included in the audit were 15 IUI/IUDI treatment cycles; 10 IUI cycles and 5 IUDI cycles. The average age of the women undergoing theses treatment cycles was 35 years, ranging from a minimum of 26 years to a maximum of 47 years. The average start dose of medication was calculated, to include women who were stimulated with gonadatrophins only (13 women), as no comparisons can be made between doses of alternate medications such as clomifene. The average start dose for the 13 women stimulated with gonadotrophins was 95IU, and the average total dose 835IU. The average duration of stimulation was 12 days. Out of the total 15 insemination cycles, 14 had outcome information recorded. This equated to a 7% positive pregnancy test rate across the 15 treatment cycles.



An additional five follicle tracking cycles were recorded in the audit, and one Ovulation Induction treatment cycle.  The average age of these 6 women was 40, and average AMH level was 37pmol/L, however they ranged vastly from 0.83 to 67.9pmol/L and the small sample size make these average values relatively arbitrary. No outcome information was recorded for 4 of the 6 cycles; the 2 cycles which had outcome information recorded both resulted in negative pregnancy test results. This highlights a need for better follow up of women having less intensive treatments such as simple Follicle Tracking or Ovulation Induction Cycles due to the high incidence of a lack of information in patients’ notes for these treatments compared to IUI/IVF/ICSI. No mean values could be calculated for start dose or total dose of ovarian stimulation as medications used varied too greatly between patients, with the use of clomifene, letrozole and menopur.

FET Treatment

From the 157 women included in the audit, there were 55 FET cycles recorded. As well as looking at overall success rates relating to FET cycles, data was broken down into the same groups as for IVF and ICSI and ordered according to ascending AMH and Age groups. This enabled an analysis of the proportion of women in each group who went on to have FET treatment following fresh IVF/ICSI cycles.

AMH

AMH
0-5
5-10
10-15
15-20
20-30
30-50
50+
Data in set
5
13
6
11
7
8
5
Avg age
37.4
39.5
39
34.1
33.9
36.1
31.4
Avg AMH
1.43
7.6
11.4
18
25.9
40.1
59.3
% natural cycles
60
38.5
66.7
72.7
57.1
25
40
% programmed cycles
40
61.5
33.3
27.3
42.9
75
60
Avg embryos transferred
1
2.2
1.8
1.5
2
2
2
Abandoned cycles
20.0
0.0
0
9.1
0
0
0
No ET/failed fert
20.0
0.0
0
9.1
0
0
0
No information recorded
0.0
0.0
16.7
9.1
0
12.5
0
Positive test
20.0
15.4
16.7
9.1
28.6
12.5
40
Pos test (of completed cycles)
33.0
15.4
20
12.5
28.6
14.3
40
No FETS as proportion of fresh cycles
9.3
23.2
24
32.4
30.4
50
33.3

No great imbalance was observed in regards to sample sizes across the different AMH groups, however most of the groups relatively small sized, ranging from a minimum of just five cycles  to a maximum of 13.

Findings from analysing data from Frozen Embryo Transfer cycles arranged and grouped in order of ascending AMH levels are as follows:

-         Mean age decreased across the increasing AMH groups in line with the trends identified from the fresh IVF/ICSI cycles.

-         There was a general decrease in number of abandoned cycles and those which did not proceed to Embryo Transfer with increasing AMH groups. No correlation was observed in cycles which had no outcome information recorded.

-         The percentage of positive pregnancy tests increased as AMH levels increased, with the highest proportion of positive pregnancy tests recorded in the AMH group 50+pmol/L at 40%.

-         There was a strong positive correlation linking an increase in the number of FET cycles as a proportion of fresh IVF/ICSI cycles in the same AMH subgroup. The proportion of FET cycles completed increased consistently across AMH groups up to a peak in the 30-50pmol/L group, therefore as AMH increased up to this parameter, so did the likelihood of women undergoing fresh IVF or ICSI cycles going on to have subsequent FET cycles. This may be attributed to the fact that as AMH increases, we expect women to achieve a higher number of eggs collected, and therefore they are more likely to have surplus embryos to freeze and use in subsequent Frozen treatment cycles.







Age

The age groups, categorised in 5 year intervals as for the fresh cycles, had variable sample sizes, with the two smallest groups consisting of results from 5 treatment cycles only and the two largest groups with a sample size of 18. This makes the comparison of mean parameters more difficult across the different age groups, as the groups with considerably larger sample sized are more likely to result in valid mean results, compared to less accurate, more easily skewed averages obtained from the groups with smaller sample sizes.

Age
<30
30-35
35-40
40-45
45-50
Data in set
5
18
18
7
7
Avg age
27.2
32.8
36.4
41.7
45.6
Avg AMH
26.4
21.3
23.8
12.1
10.7
% natural cycles
40
33.3
72.2
42.9
57.1
% programmed cycles
60
66.7
27.8
57.1
42.9
Avg embryos transferred
1.8
1.7
1.8
1.6
2.3
Abandoned cycles
0.0
11.1
0
0
0
No ET/failed fert
0.0
0.0
5.6
14.3
0
No information recorded
0.0
0.0
11.1
14.3
0
Positive test
20.0
33.3
11.1
0
14.3
Pos test (of completed cycles)
20.0
37.5
13.3
0
14.3
No FETS as proportion of fresh cycles
20.8
31.0
23.7
16.7
33.3



Findings from analysing data from Frozen Embryo Transfer cycles arranged and grouped in order of ascending age groups are as follows:

-         Mean AMH decreased with ascending age groups, as expected in line with predictions and trends observed from fresh IVF/ICSI cycles.

-         No correlations were observed with incomplete treatment cycles across the age groups.

-         It is apparent from the summary tables, that women in the 45-50 years age group had a higher average number of embryos replaced (a mean of 2.3 compared to means of 1.6-1.8 in all other age groups)

-         The proportion of positive pregnancy tests decreased with advancing maternal age, a peak of 33.3% was observed in the 30-35 years age group and a the minimum pregnancy rate was observed in the 40-45 years age group with a 0% positive test rate. However it is important to note that this group had a sample size of just seven cycles.





Conclusion

To conclude, the aim of the audit to identify emerging trends between patient AMH levels and fertility treatment outcomes has been met. The audit has succeeded in providing estimates of relative success rates for different patients according to their demographics. In this way women may be advised and given real estimates of likely treatment outcomes and success rates, based on outcomes of treatments conducted at the hospital for previous patients of a similar age or with similar AMH hormone levels.

A clear link between advancing age and depleting AMH levels was established from the audit, which reflects the theoretical basis. This is also reflected in the trends identified relating to an increase in the number of eggs collected with increasing AMH levels up to the 30-50pmol/L group, and decreasing numbers of eggs collected with advancing age groups. No significant trends or correlations were identified in the duration of stimulation across the different age groups or AMH groups.

Based on AMH levels alone, irrespective of the nature of fertility treatment women underwent, pregnancy rates increased up to a peak of 42.9% within the 20-25pmol/L group, beyond which point they began to gradually decline. Similarly, considering age alone, irrespective of treatment, pregnancy rates consistently decreased with advancing age groups, from a peak of 42.9% positive pregnancy tests in the 20-25 age group down to a minimum rate of a still very impressive14.7% positive pregnancy test rate in the 45-50 age group. It must be acknowledged that positive pregnancy test rates were above national averages in almost all categories.

Cycle abandonment rates and the proportion of cycles which did not proceed to Embryo Transfer decreased with increasing AMH levels up to the 30-50pmol/L group, beyond which point they increased dramatically, likely due to co-morbidities associated with high AMH levels >50pmol/L. The number of abandoned cycles and those that did not result in an Embryo transfer procedure also increased consistently with advancing maternal age groups.

For most categories, there was no significant correlation between the number of embryos transferred and maternal age or AMH levels, however in the Frozen Embryo Transfer cycles, women over 45 years were noted to have a higher mean number of embryos transferred, which reflect the HFEA guidelines and restrictions in place on how many embryos may be replaced for women dependent on their age. Women with higher AMH levels were increasingly likely to go on to have subsequent Frozen Embryo Transfer cycles after fresh IVF/ICSI, therefore increasing their chances of achieving a pregnancy and reflecting the fact that higher AMH levels and associated higher number of eggs collected increase the chances of having surplus embryos to freeze and ultimately increase the likelihood of a successive positive pregnancy test. No links were established to connect advancing female age and the likely success of FET treatment cycles.

Whilst the audit has been very useful in establishing correlations and summarising data to inform clinical staff and patients of the hospital, it has also highlighted a need for further research on this topic. Unfortunately, due to the broad range of characteristics of women included in the audit, when data was categorised and split into smaller groups based on the type of fertility treatment or age/AMH level parameters, some of the sub-groups had a very small data set and sample size. This resulted in some of the calculated averages being easily skewed by more extreme results and therefore results vary in accuracy/validity for this reason, which can affect the ability to establish real trends. By obtaining more results and ensuring groups have larger and more evenly distributed sample size, analysis and averages are likely to be more accurate. More research would also be beneficial to look at the ongoing pregnancy rates, which were not considered in this audit, due to the fact that not information of medical history or co-morbidities was gathered and multiple cycles and pregnancies are ongoing therefore results would be incomplete. The focus of this audit was on AMH levels and treatment outcomes, rather than on ongoing pregnancy rates. Due to the extensive data set that was collected, there is scope for further auditing to be conducted based on this information, with different visions and aims in mind.






References

The Association for Clinical Biochemistry and Laboratory Medicine, 2017. Anti-Mullerian Hormone. (online). Available from: https://labtestsonline.org.uk/tests/anti-mullerian-hormone

Human Fertilisation and Embryology Authority, 2018. Decisions to make about your embryos. (online). Available from: https://www.hfea.gov.uk/treatments/explore-all-treatments/decisions-to-make-about-your-embryos/


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Vol.16, JUNE 2020, Recurrent IVF failure: What to Do

Recurrent IVF Failure - What to Do Mr J. Adeghe PhD, FRCOG.,  Consultant – Fertility & Gynaecology St Jude Hospitals & Clinics, ...