Technical and performance characteristics of anti-Müllerian hormone and antral follicle count as biomarkers of ovarian response.

BACKGROUND Stratified (individualized) medicine has been recognized as a key priority for policy makers and healthcare providers. The main principle of individualized care depends on utilizing patients' characteristics and biomarkers to predict prognosis, tailor intended treatment and predict treatment outcomes. In reproductive medicine a wide variety of biomarkers have been proposed as predictors of ovarian response; of these, anti-Müllerian hormone (AMH) and antral follicle count (AFC) are purported as exhibiting the most favourable analytical and performance characteristics. Previously AFC and AMH have been considered essentially interchangeable; however, recent trial data have questioned this postulation. The aim of this review is to present an analysis of the strengths and weaknesses of these biomarkers as predictors of ovarian response, using both physiological and technical perspectives. METHODS We have conducted a systematic search of the most recent (to May 2014) relevant literature and summarized the existing evidence. Articles written in a language other than English without an available English translation were excluded. RESULTS Both AMH values and AFC can be influenced by comparable technical, physiological and exogenous factors. AMH displays some variation within and between cycles, consistent with its physiological role in follicle development, and there are growing data on the impact of pharmacological treatments and pathological conditions but cycle-independent measurement is appropriate for clinical purposes. A range of issues with manual AMH assays may be resolving with the development of fully automated assays. Despite described standardization of its measurement technique, AFC is subject to marked inter- and intra-operator variability and the effects of external influences are likely to be comparable. Outwith some highly specialist centres, the intracyclic variation in AFC requires its measurement between Day 2 and 4 of the cycle. Observational studies suggest comparable performance characteristics for AMH and AFC in predicting poor and high ovarian response, but recent RCTs suggest markedly better performance for AMH. CONCLUSIONS The performance characteristics of both AMH and AFC for the prediction of ovarian response to exogenous gonadotrophins have been inflated by single site observational cohorts, resulting in the viewpoint that AMH and AFC exhibit equivalent performance characteristics. Large scale multicentre RCTs, with centralized assay performance, have demonstrated that AMH is substantially the more accurate and robust biomarker, probably reflecting difficulties with standardization of AFC determination. While AFC retains some advantages, particularly immediacy and accessibility, international standardization of AMH combined with a stable automated assay is likely to enhance its performance as the biomarker of choice in predicting the ovarian response in assisted conception.

[1]  S. Nelson,et al.  Predictive factors for ovarian response in a corifollitropin alfa/GnRH antagonist protocol for controlled ovarian stimulation in IVF/ICSI cycles , 2015, Reproductive Biology and Endocrinology.

[2]  A. Childs,et al.  Activation of the aryl hydrocarbon receptor by a component of cigarette smoke reduces germ cell proliferation in the human fetal ovary , 2015, Molecular human reproduction.

[3]  D. Gassner,et al.  First fully automated immunoassay for anti-Müllerian hormone , 2014, Clinical chemistry and laboratory medicine.

[4]  D. Dewailly,et al.  Toward a better follow-up of ovarian recovery in young women after chemotherapy with a hypersensitive antimüllerian hormone assay. , 2014, Fertility and sterility.

[5]  N. Perkins,et al.  Biological variability in serum anti-Müllerian hormone throughout the menstrual cycle in ovulatory and sporadic anovulatory cycles in eumenorrheic women. , 2014, Human reproduction.

[6]  M. Meseguer,et al.  Ethnicity as a determinant of ovarian reserve: differences in ovarian aging between Spanish and Indian women. , 2014, Fertility and sterility.

[7]  Zi-jiang Chen,et al.  Age-specific serum antimüllerian hormone levels in women with and without polycystic ovary syndrome. , 2014, Fertility and sterility.

[8]  S. Iliodromiti,et al.  The predictive accuracy of anti-Müllerian hormone for live birth after assisted conception: a systematic review and meta-analysis of the literature. , 2014, Human reproduction update.

[9]  M. Eijkemans,et al.  Prognostic models for high and low ovarian responses in controlled ovarian stimulation using a GnRH antagonist protocol , 2014, Human reproduction.

[10]  E. Stener-Victorin,et al.  Ovarian morphology assessed by magnetic resonance imaging in women with and without polycystic ovary syndrome and associations with antimüllerian hormone, free testosterone, and glucose disposal rate. , 2014, Fertility and sterility.

[11]  M. Sammel,et al.  Comparability of antimüllerian hormone levels among commercially available immunoassays. , 2014, Fertility and sterility.

[12]  R. Norman,et al.  Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. , 2014, Human reproduction update.

[13]  R. Fanchin,et al.  The physiology and clinical utility of anti-Mullerian hormone in women. , 2014, Human reproduction update.

[14]  P. Welsh,et al.  A single-centre evaluation of two new anti-Mullerian hormone assays and comparison with the current clinical standard assay. , 2014, Human reproduction.

[15]  W. Ledger,et al.  Pre-mixing serum samples with assay buffer is a prerequisite for reproducible anti-Mullerian hormone measurement using the Beckman Coulter Gen II assay. , 2014, Human reproduction.

[16]  D. Hougaard,et al.  The prevalence of polycystic ovary syndrome in a normal population according to the Rotterdam criteria versus revised criteria including anti-Mullerian hormone. , 2014, Human reproduction.

[17]  E. Stener-Victorin,et al.  Ovarian volume and antral follicle count assessed by MRI and transvaginal ultrasonography: a methodological study , 2014, Acta radiologica.

[18]  S. Harlow,et al.  Updated assays for inhibin B and AMH provide evidence for regular episodic secretion of inhibin B but not AMH in the follicular phase of the normal menstrual cycle. , 2014, Human reproduction.

[19]  S. Iliodromiti,et al.  Reference range for the antimüllerian hormone Generation II assay: a population study of 10,984 women, with comparison to the established Diagnostics Systems Laboratory nomogram. , 2014, Fertility and sterility.

[20]  R. Pieters,et al.  Decreased serum anti-Müllerian hormone levels in girls with newly diagnosed cancer. , 2014, Human reproduction.

[21]  P. Sluss,et al.  The impact of depot GnRH agonist on AMH levels in healthy reproductive-aged women. , 2013, The Journal of clinical endocrinology and metabolism.

[22]  J. Laven,et al.  Levels of Serum Anti–Müllerian Hormone, a Marker for Ovarian Reserve, in Women With Rheumatoid Arthritis , 2013, Arthritis care & research.

[23]  P. Matson,et al.  Within-laboratory and between-laboratory variability in the measurement of anti-müllerian hormone determined within an external quality assurance scheme. , 2013, Reproductive Biology.

[24]  Budi Wiweko,et al.  Chronological age vs biological age: an age-related normogram for antral follicle count, FSH and anti-Mullerian hormone , 2013, Journal of Assisted Reproduction and Genetics.

[25]  N. Raine-Fenning,et al.  Which follicles make the most anti-Mullerian hormone in humans? Evidence for an abrupt decline in AMH production at the time of follicle selection. , 2013, Molecular human reproduction.

[26]  C. Lewis,et al.  Antral follicle count predicts natural menopause in a population-based sample: the Coronary Artery Risk Development in Young Adults Women’s Study , 2013, Menopause.

[27]  P. Bossuyt,et al.  Prediction of an excessive response in in vitro fertilization from patient characteristics and ovarian reserve tests and comparison in subgroups: an individual patient data meta-analysis. , 2013, Fertility and sterility.

[28]  S. Iliodromiti,et al.  Can anti-Mullerian hormone predict the diagnosis of polycystic ovary syndrome? A systematic review and meta-analysis of extracted data. , 2013, The Journal of clinical endocrinology and metabolism.

[29]  A. Pontes,et al.  Evaluation of a new ovarian response prediction index (ORPI) for individualised controlled ovarian stimulation , 2013 .

[30]  D. Lawlor,et al.  Anti-Müllerian Hormone Is Not Associated with Cardiometabolic Risk Factors in Adolescent Females , 2013, PloS one.

[31]  N. Hadlow,et al.  Variation in antimüllerian hormone concentration during the menstrual cycle may change the clinical classification of the ovarian response. , 2013, Fertility and sterility.

[32]  A. Nyboe Andersen,et al.  Antimüllerian hormone in gonadotropin releasing-hormone antagonist cycles: prediction of ovarian response and cumulative treatment outcome in good-prognosis patients. , 2013, Fertility and sterility.

[33]  A. Ruokonen,et al.  Antimüllerian hormone levels decrease in women using combined contraception independently of administration route. , 2013, Fertility and sterility.

[34]  M. Eijkemans,et al.  Reproductive and lifestyle determinants of anti-Müllerian hormone in a large population-based study. , 2013, The Journal of clinical endocrinology and metabolism.

[35]  A. Erdem,et al.  Antral follicle count determines poor ovarian response better than anti-müllerian hormone but age is the only predictor for live birth in in vitro fertilization cycles , 2013, Journal of Assisted Reproduction and Genetics.

[36]  S. Nelson.  Biomarkers of ovarian response: current and future applications. , 2013, Fertility and sterility.

[37]  J. Forman,et al.  Ovarian antral follicle subclasses and anti-mullerian hormone during normal reproductive aging. , 2013, The Journal of clinical endocrinology and metabolism.

[38]  E. Erdem,et al.  Serum anti-Müllerian hormone levels are lower in reproductive-age women with Crohn's disease compared to healthy control women. , 2013, Journal of Crohn's & colitis.

[39]  E. Papaleo,et al.  Individualization of the FSH starting dose in IVF/ICSI cycles using the antral follicle count , 2013, Journal of Ovarian Research.

[40]  J. Clewes,et al.  Intracycle variation in number of antral follicles stratified by size and in endocrine markers of ovarian reserve in women with normal ovulatory menstrual cycles , 2013, Ultrasound in Obstetrics and Gynecology.

[41]  J. Forman,et al.  Ovarian reserve parameters: a comparison between users and non-users of hormonal contraception. , 2012, Reproductive biomedicine online.

[42]  A. Juul,et al.  Serum levels of antimüllerian hormone in early maturing girls before, during, and after suppression with GnRH agonist. , 2012, Fertility and sterility.

[43]  C. Argento,et al.  Development of a nomogram based on markers of ovarian reserve for the individualisation of the follicle‐stimulating hormone starting dose in in vitro fertilisation cycles , 2012, BJOG : an international journal of obstetrics and gynaecology.

[44]  A. Armeni,et al.  Sibutramine administration decreases serum anti-Müllerian hormone (AMH) levels in women with polycystic ovary syndrome. , 2012, European journal of obstetrics, gynecology, and reproductive biology.

[45]  T. Fehm,et al.  Reduced pretreatment ovarian reserve in premenopausal female patients with Hodgkin lymphoma or non-Hodgkin-lymphoma--evaluation by using antimüllerian hormone and retrieved oocytes. , 2012, Fertility and sterility.

[46]  C. Lambalk,et al.  Intra-cycle fluctuations of anti-Müllerian hormone in normal women with a regular cycle: a re-analysis. , 2012, Reproductive biomedicine online.

[47]  N. Raine-Fenning,et al.  Quantifying effect of combined oral contraceptive pill on functional ovarian reserve as measured by serum anti‐Müllerian hormone and small antral follicle count using three‐dimensional ultrasound , 2012, Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology.

[48]  P. Barrière,et al.  Ovarian reserve and in vitro fertilization cycles outcome according to women smoking status and stimulation regimen , 2012, Archives of Gynecology and Obstetrics.

[49]  Hui Lin,et al.  Anti-mullerian hormone as a predictor of time to menopause in late reproductive age women. , 2012, The Journal of clinical endocrinology and metabolism.

[50]  R. Anderson,et al.  Data-driven assessment of the human ovarian reserve. , 2012, Molecular human reproduction.

[51]  K. Gordon,et al.  Predictive factors of ovarian response and clinical outcome after IVF/ICSI following a rFSH/GnRH antagonist protocol with or without oral contraceptive pre-treatment. , 2011, Human reproduction.

[52]  A. Duhamel,et al.  Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. , 2011, Human reproduction.

[53]  M. Cedars,et al.  Reproductive aged women with cancer have a lower antral follicle count than expected , 2011 .

[54]  A. McConnachie,et al.  External validation of nomogram for the decline in serum anti-Müllerian hormone in women: a population study of 15,834 infertility patients. , 2011, Reproductive biomedicine online.

[55]  L. Gianaroli,et al.  ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria. , 2011, Human reproduction.

[56]  S. Nelson,et al.  A multicentre evaluation of the new Beckman Coulter anti-Müllerian hormone immunoassay (AMH Gen II) , 2011, Annals of clinical biochemistry.

[57]  Silvia Garagna,et al.  What does it take to make a developmentally competent mammalian egg? , 2011, Human reproduction update.

[58]  Richard A. Anderson,et al.  A Validated Model of Serum Anti-Müllerian Hormone from Conception to Menopause , 2011, PloS one.

[59]  C. Gnoth,et al.  Age-related normograms of serum antimüllerian hormone levels in a population of infertile women: a multicenter study. , 2011, Fertility and sterility.

[60]  A. Giwercman,et al.  Circadian variation in concentration of anti-Müllerian hormone in regularly menstruating females: relation to age, gonadotrophin and sex steroid levels. , 2011, Human reproduction.

[61]  H. Tunstall-Pedoe.  Cardiovascular Risk and Risk Scores: ASSIGN, Framingham, QRISK and others: how to choose , 2011, Heart.

[62]  A. Volpe,et al.  Age-specific nomogram for the decline in antral follicle count throughout the reproductive period. , 2011, Fertility and sterility.

[63]  Seang Tan,et al.  Age-related normogram for antral follicle count: McGill reference guide. , 2011, Fertility and sterility.

[64]  A. McConnachie,et al.  Nomogram for the decline in serum antimüllerian hormone: a population study of 9,601 infertility patients. , 2011, Fertility and sterility.

[65]  R. Rey,et al.  Elevated anti‐Müllerian hormone (AMH) and inhibin B levels in prepubertal girls with type 1 diabetes mellitus , 2011, Clinical endocrinology.

[66]  B. Kalra,et al.  Development of a second generation anti-Müllerian hormone (AMH) ELISA. , 2010, Journal of immunological methods.

[67]  Yun-Seok Yang,et al.  Correlation between sonographic and endocrine markers of ovarian aging as predictors for late menopausal transition , 2010, Menopause.

[68]  F. Broekmans,et al.  The antral follicle count: practical recommendations for better standardization. , 2010, Fertility and sterility.

[69]  F. Stewart,et al.  Longitudinal assessment of antimüllerian hormone during pregnancy-relationship with maternal adiposity, insulin, and adiponectin. , 2010, Fertility and sterility.

[70]  N. Raine-Fenning,et al.  A prospective, comparative analysis of anti-Müllerian hormone, inhibin-B, and three-dimensional ultrasound determinants of ovarian reserve in the prediction of poor response to controlled ovarian stimulation. , 2010, Fertility and sterility.

[71]  R. Rey,et al.  Anti-Mullerian hormone and inhibin B levels as markers of premature ovarian aging and transition to menopause in type 1 diabetes mellitus. , 2009, Human reproduction.

[72]  G. Brinkworth,et al.  The effect of weight loss on anti-Müllerian hormone levels in overweight and obese women with polycystic ovary syndrome and reproductive impairment. , 2009, Human reproduction.

[73]  A. Tuttle,et al.  Cigarette smoke causes follicle loss in mice ovaries at concentrations representative of human exposure. , 2009, Human reproduction.

[74]  Thomas W. Kelsey,et al.  Human Ovarian Reserve from Conception to the Menopause , 2009, PloS one.

[75]  N. Raine-Fenning,et al.  Intraobserver and interobserver reliability of automated antral follicle counts made using three‐dimensional ultrasound and SonoAVC , 2009, Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology.

[76]  B. Mol,et al.  The role of antimullerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. , 2009, Fertility and sterility.

[77]  S. Nelson,et al.  Anti-Müllerian hormone-based approach to controlled ovarian stimulation for assisted conception. , 2008, Human reproduction.

[78]  C. Lambalk,et al.  Evaluation of anti-Müllerian hormone as a test for the prediction of ovarian reserve. , 2008, Fertility and sterility.

[79]  M. Yosef,et al.  Anti-mullerian hormone and inhibin B in the definition of ovarian aging and the menopause transition. , 2008, The Journal of clinical endocrinology and metabolism.

[80]  P. Bischof,et al.  Serum antimüllerian hormone levels remain stable throughout the menstrual cycle and after oral or vaginal administration of synthetic sex steroids. , 2008, Fertility and sterility.

[81]  B. K. Campbell,et al.  Three‐dimensional ultrasound improves the interobserver reliability of antral follicle counts and facilitates increased clinical work flow , 2008, Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology.

[82]  S. Nelson,et al.  Serum anti-Müllerian hormone and FSH: prediction of live birth and extremes of response in stimulated cycles--implications for individualization of therapy. , 2007, Human reproduction.

[83]  Alain Gougeon,et al.  Estimating human ovarian non-growing follicle number: the application of modern stereology techniques to an old problem. , 2007, Human reproduction.

[84]  Y. Englert,et al.  Stable serum levels of anti-Müllerian hormone during the menstrual cycle: a prospective study in normo-ovulatory women. , 2007, Human reproduction.

[85]  N. Raine-Fenning,et al.  The interobserver reliability of off‐line antral follicle counts made from stored three‐dimensional ultrasound data: a comparative study of different measurement techniques , 2007, Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology.

[86]  J. Skull,et al.  Evaluation of the utility of multiple endocrine and ultrasound measures of ovarian reserve in the prediction of cycle cancellation in a high-risk IVF population. , 2007, Human reproduction.

[87]  L. Nardo,et al.  Anti-Müllerian hormone levels and antral follicle count in women enrolled in in vitro fertilization cycles: Relationship to lifestyle factors, chronological age and reproductive history , 2007, Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology.

[88]  A. Volpe,et al.  Serum anti-Mullerian hormone throughout the human menstrual cycle. , 2006, Human reproduction.

[89]  C. Lambalk,et al.  A systematic review of tests predicting ovarian reserve and IVF outcome. , 2006, Human reproduction update.

[90]  F. Broekmans,et al.  Anti-Müllerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation. , 2006, The Journal of clinical endocrinology and metabolism.

[91]  D. Cameron,et al.  The effects of chemotherapy and long-term gonadotrophin suppression on the ovarian reserve in premenopausal women with breast cancer. , 2006, Human reproduction.

[92]  T. Kutlu,et al.  Early follicular antimüllerian hormone as an indicator of ovarian reserve. , 2006, Fertility and sterility.

[93]  P. Serhal,et al.  Antral follicle count, anti‐mullerian hormone and inhibin B: predictors of ovarian response in assisted reproductive technology? , 2005, BJOG : an international journal of obstetrics and gynaecology.

[94]  L. Merce,et al.  Intraobserver and Interobserver Reproducibility of Ovarian Volume, Antral Follicle Count, and Vascularity Indices Obtained With Transvaginal 3‐Dimensional Ultrasonography, Power Doppler Angiography, and the Virtual Organ Computer‐Aided Analysis Imaging Program , 2005, Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine.

[95]  R. Fanchin,et al.  High reproducibility of serum anti-Mullerian hormone measurements suggests a multi-staged follicular secretion and strengthens its role in the assessment of ovarian follicular status. , 2005, Human reproduction.

[96]  F. Durmuşoǧlu,et al.  Intercycle variabilities of basal antral follicle count and ovarian volume in subfertile women and their relationship to reproductive aging: A prospective study , 2005, Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology.

[97]  M. Faddy,et al.  Antral follicle counts are related to age at natural fertility loss and age at menopause , 2004, Menopause.

[98]  D. Economides,et al.  Patient acceptance of transvaginal sonography in the early pregnancy unit setting , 2003, Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology.

[99]  M. Soules,et al.  Reproductive aging and variability in the ovarian antral follicle count: application in the clinical setting. , 2003, Fertility and sterility.

[100]  R. Fanchin,et al.  Serum anti-Müllerian hormone is more strongly related to ovarian follicular status than serum inhibin B, estradiol, FSH and LH on day 3. , 2003, Human reproduction.

[101]  F. Broekmans,et al.  Serum anti-Müllerian hormone levels: a novel measure of ovarian reserve. , 2002, Human reproduction.

[102]  S. Campbell,et al.  Investigation of the infertile couple: a one-stop ultrasound-based approach. , 2001, Human reproduction.

[103]  Y. Soong,et al.  Use of the antral follicle count to predict the outcome of assisted reproductive technologies. , 1998, Fertility and sterility.

[104]  P. Donahoe,et al.  An immunoassay to detect human müllerian inhibiting substance in males and females during normal development. , 1990, The Journal of clinical endocrinology and metabolism.

[105]  A. Gougeon.  Dynamics of follicular growth in the human: a model from preliminary results. , 1986, Human reproduction.

[106]  H. Peters,et al.  Follicular growth in fetal and prepubertal ovaries of humans and other primates. , 1978, Clinics in endocrinology and metabolism.

[107]  S. Gregorich,et al.  Race/ethnic disparities in reproductive age: an examination of ovarian reserve estimates across four race/ethnic groups of healthy, regularly cycling women. , 2014, Fertility and sterility.

[108]  S. Sunkara,et al.  Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: from theory to practice. , 2014, Human reproduction update.

[109]  P. Bossuyt,et al.  Added value of ovarian reserve testing on patient characteristics in the prediction of ovarian response and ongoing pregnancy: an individual patient data approach. , 2013, Human reproduction update.

[110]  R. Anderson,et al.  The ageing ovary and uterus: new biological insights. , 2013, Human reproduction update.

[111]  A. Dahan.  Reply from the authors. , 2013, British journal of anaesthesia.

[112]  S. Nelson,et al.  P-543 Predictive factors for ovarian response in a corifollitropin alfa/GnRH antagonist protocol for controlled ovarian stimulation , 2013 .

[113]  L. Natarajan,et al.  Impact of breast cancer on anti-mullerian hormone levels in young women , 2012, Breast Cancer Research and Treatment.

[114]  W. Foster,et al.  Cigarette smoke exposure leads to follicle loss via an alternative ovarian cell death pathway in a mouse model. , 2012, Toxicological sciences : an official journal of the Society of Toxicology.

[115]  A. Raziel,et al.  Ovarian response to stimulation for fertility preservation in women with malignant disease: a systematic review and meta-analysis. , 2012, Fertility and sterility.

[116]  S. Nelsonb,et al.  Measuring anti-Müllerian hormone for the assessment of ovarian reserve: when and for whom is it indicated? , 2012, Maturitas.

[117]  R. Pierson,et al.  Ovarian antral folliculogenesis during the human menstrual cycle: a review. , 2012, Human reproduction update.

[118]  N. Knowlton,et al.  Correlation of ovarian reserve tests with histologically determined primordial follicle number. , 2011, Fertility and sterility.

[119]  F. Broekmans,et al.  AMH and AFC as predictors of excessive response in controlled ovarian hyperstimulation: a meta-analysis. , 2011, Human reproduction update.

[120]  M. Eijkemans,et al.  Comparison of inter- and intra-cycle variability of anti-Mullerian hormone and antral follicle counts. , 2010, Human reproduction.

[121]  M. Meseguer,et al.  Antral follicle count (AFC) can be used in the prediction of ovarian response but cannot predict the oocyte/embryo quality or the in vitro fertilization outcome in an egg donation program. , 2009, Fertility and sterility.

[122]  P. Barrière,et al.  Active smoking compromises IVF outcome and affects ovarian reserve. , 2008, Reproductive biomedicine online.

[123]  A. Price,et al.  Women's perception of transvaginal sonography in the first trimester; in an early pregnancy assessment unit , 2004, Archives of Gynecology and Obstetrics.

[124]  C R Weinberg,et al.  Toward a clearer definition of confounding. , 1993, American journal of epidemiology.

[125]  J. Hutson,et al.  Serum levels of müllerian inhibiting substance in boys from birth to 18 years, as determined by enzyme immunoassay. , 1990, The Journal of clinical endocrinology and metabolism.

[126]  M. Forest,et al.  An enzyme linked immunoassay for anti-müllerian hormone: a new tool for the evaluation of testicular function in infants and children. , 1990, The Journal of clinical endocrinology and metabolism.