By Rebecca H. Allen, MD, MPH, Editor
SYNOPSIS: In this randomized, controlled, online questionnaire trial, participants who received evidence-based information about anti-Müllerian hormone (AMH) testing had lower interest in getting an AMH test (mean difference, 1.05; 95% confidence interval, 0.83-1.30) than individuals who viewed the control information from a direct-to-consumer website.
SOURCE: Copp T, van Nieuwenhoven T, McCaffery KJ, et al. Women’s interest, knowledge, and attitudes relating to anti-Mullerian hormone testing: A randomized controlled trial. Human Reprod 2024; Jul 28. doi: 10.1093/humrep/deae147. [Online ahead of print].
Anti-Müllerian hormone (AMH) testing has become more popular among patients and consumers. The AMH level indicates the number of oocytes remaining in the ovaries and is used in assisted reproductive technology to estimate the number of oocytes potentially retrievable for in vitro fertilization (IVF) or egg freezing. However, the lay public often mistakenly interprets the test as a prediction of how fertile an individual with ovaries may be or how close they are to menopause. The authors of this study sought to design an educational instrument regarding AMH for patients and test its effect on patients’ desire for and knowledge about the test.
This was a randomized controlled trial conducted online in English and Dutch that compared an evidence-based information pamphlet about the AMH test (intervention group) to a pamphlet that contained information taken from an existing direct-to-consumer website promoting the AMH test (control group). The evidence-based pamphlet was created by the authors and a team of researchers and patients and went through pilot testing. The information sheet was low-literacy and contained information on the AMH test, including its limitations and testing risks and benefits. Eligibility criteria included nulliparous females aged 25 to 40 years living in Australia or the Netherlands who were not pregnant but desired a child now or in the future and had never had an AMH test before. Participants were recruited via an online social research company, were randomized after initial screening, and filled out the questionnaire online. The primary outcome was interest in having an AMH test. Secondary outcomes included intentions to discuss the test with their doctor; intentions to get the test; and attitudes, knowledge, and other measures of emotional response to the questions and information presented. Sociodemographic and health characteristics data also were collected.
A total of 4,072 individuals were assessed for eligibility and 1,004 were randomized, of which 37 were excluded for being repeat participants or failing the attention check during the survey, leaving 967 patients for analysis. The sample had a mean age of 30 years, 70% were in a relationship, and 80% had adequate health literacy. Overall, 11% had heard of the AMH test and 16% reported having infertility. On a scale of 1 being definitely not interested and 7 being definitely interested, individuals in the evidence-based information arm were less interested in getting a test (3.87 vs. 4.93, P < 0.001). More participants in the control group planned to talk to their doctor about the test (53% vs. 36%, P < 0.001) and intention to get the test was higher on a scale from 1 to 5, with 5 being “I definitely will get an AMH test” (3.36 vs. 2.84, P < 0.001). In addition, participants who viewed the evidence-based pamphlet had fewer positive attitudes toward the test and increased knowledge scores about AMH. In terms of the free-text responses to the participants’ interpretation of the take-home message of the pamphlet, the top three codes from the content analysis in the intervention group were that the AMH test was not helpful or reliable, that it provides information about the quantity of eggs, and that it was only useful during fertility treatments. The control arm’s top three codes were that the AMH test provides information about the chances of getting pregnant, that it provides information about the quantity of eggs, and that it was important to take the test.
COMMENTARY
AMH is one way to assess ovarian reserve and is used in infertility care to estimate the number of eggs in the ovaries that could be retrieved through ovulation induction. The test cannot predict a person’s chances of conceiving or when a patient will be menopausal. The American College of Obstetricians and Gynecologists discourages use of the test outside of infertility care.1 However, there is a lot of false information on the internet claiming that AMH can predict a person’s fertility status, and direct-to-consumer companies now are marketing the test for that purpose. A quick Google search showed that one website claims AMH “measures your ovulatory egg supply and provides information about what that means for your personal pregnancy journey” and sells the test for $135.2 Patients who obtain the test outside the medical setting and without counseling may be falsely reassured regarding their fertility or falsely worried about their ability to conceive.
The authors of this study sought to show that patients could be educated about the limitations of AMH testing through an evidence-based pamphlet. By all measures, the authors succeeded in showing that participants in the intervention group had increased knowledge about the test and its limitations and, therefore, less interest in obtaining the test or asking their doctor about it. The study was performed among Australian and Dutch women and, therefore, may have limited generalizability to other countries. In addition, the online sample may not be representative of all women who may consider AMH testing.
According to the American Society for Reproductive Medicine (ASRM), female age is the most important factor in fertility, with declines in fertility starting at age 35 years. ASRM further states, “The goal of using ovarian reserve testing is to identify women who may be poor responders to gonadotropin stimulation in efforts to tailor treatment and discuss realistic expectations of response to treatment. Poor ovarian reserve testing does not necessarily imply an inability to conceive or subfertility.”3 We should be counseling our patients regarding the role for AMH testing and its proper interpretation.
REFERENCES
- American College of Obstetricians and Gynecologists. The use of antimüllerian hormone in women not seeking fertility care. Committee Opinion No. 773. April 2019. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/the-use-of-antimullerian-hormone-in-women-not-seeking-fertility-care
- Quest Health. Ovarian Reserve Assessment Marker AMH test. https://www.questhealth.com/product/ovarian-reserve-assessment-marker-amh-test-37227M.html
- American Society for Reproductive Medicine. Fertility evaluation of infertile women: A committee opinion (2021). https://www.asrm.org/practice-guidance/practice-committee-documents/fertility-evaluation-of-infertile-women-a-committee-opinion-2021/