Fertility preservation in women with malignancies: the accuracy of AFC collected randomly during the menstrual cycle in predicting the number of mature oocytes retrieved

Study question: Is Antral Follicle Count collected at any time during the menstrual
cycle (random AFC) reliable in predicting the number of collected mature
oocytes?
Summary answer: Random AFC is as reliable as serum AMH in predicting
ovarian responsiveness to treatment.
What is known already: In young women with cancer who are scheduled
for chemotherapy, there is the need to provide prompt counseling on future
fertility issues including a reliable estimate of the possible benefits of fertility
preservation techniques. Unfortunately, hormonal assessments such as serum
FSH or AMH take time to be available and FSH needs to be taken in a particular
menstrual phase. AFC is conversely immediately available but its use is claimed
to be reliable only if collected in the early follicular phase (day 3-5 of the cycle).
Study design, size, duration: Retrospective case series of young women
with malignancies undergoing ovarian hyperstimulation aimed at oocytes cryopreservation
between July 2014 to December 2016. Random AFC and serum
AMH was systematically recorded prior to initiate the therapy. All women
received a standardized “random start” regimen of ovarian hyperstimulation.
Participants/materials, setting, methods: Seventy-two women were
ultimately included. The total number of retrieved mature oocytes was the primary
outcome. A good response was defined as ≥ 10 retrieved mature
oocytes. The predictive capacity of AFC was evaluated using receiver operating
characteristic (ROC) curves.
Main results and the role of chance: Indication to oocytes cryopreservation
was breast cancer in 42 women (58%), lymphoma in 20 (28%) and other
malignancies in the remaining 10 (14%). The mean ± SD age and AFC of the
selected women was 31.4 ± 5.6 years and 18.7 ± 10.7, respectively. The
median (interquartile range) serum AMH was 3.2 (1.3 - 4.2) ng/ml. Thirty-four
women (47%) were in the follicular phase, 32 (45%) in the luteal phase and the
remaining six (8%) were assuming oral contraceptives. Three cycles were cancelled
for poor response. The mean ± SD number of mature oocytes retrieved
in the remaining 69 women was 11.2 ± 7.7. Thirty-five women collected ≥10
oocytes (49% of the whole cohort).
The c-statistics for the prediction of ≥10 mature oocytes using AFC and serum
AMH were similar. Specifically, the area under the curve (AUC) was 0.76
(95%CI: 0.66-0.87; p<0.001) and 0.82 (95%CI: 0.72-0.92; p<0.001), respectively.
Similarly, when considering the subgroup of women who were not assuming
oral contraceptives and who were recruited after day 5 of the cycle (proper
random start, n = 49), the AUC resulted 0.77 (95%CI: 0.64-0.89; p = 0.001)
and 0.83 (95%CI: 0.72-0.95; p<0.001), respectively.
Limitations, reasons for caution: Even if the accuracy of serum AMH and
AFC resulted similar, larger series are required to rule out mild but potentially
clinically relevant differences.
Wider implications of the findings: Random AFC should be systematically
performed prior to counsel women with malignancies. It is a simple assessment
and can be obtained rapidly. Moreover, one may even question whether random
AFC may become a standard also in women without malignancies who
need ovarian reserve assessment.
Trial registration number: not applicable.