Ovarian cysts are common in reproductive age women, and laparoscopic ovarian cystectomy is a recommended treatment for benign cysts . There is reduction in the ovarian reserve after ovarian cystectomy as evidenced by a fall in AMH [34,35] and partial recovery in AMH is observed in some women from 3 to 12 months after excision of endometrioma [34,36–38]. The proposed mechanisms for ovarian damage after cystectomy include inadvertent damage to or removal of underlying healthy ovarian tissue during stripping of the ovarian cyst wall  and two recent systematic reviews and meta-analyses suggested that the use of bipolar diathermy is associated with a greater decline of AMH when compared with nonthermal haemostatic methods including suturing or haemostatic sealant [40,41▪]. The risk of ovarian damage and fall in AMH after cystectomy for endometrioma is greater than after surgery for other benign ovarian cysts in some studies. However, a recent meta-analysis reported a similar magnitude of reduction in AMH (38%) after both types of cystectomy .
There is an increased likelihood for a healthy woman to reach menopause before the median age of 51 years if AMH is low for her age . Conversely, if her AMH level is more than 0.02 ng/ml (0.14 pmol/l), there is minimal chance of menopause within 5 years regardless of women's age . The application of a low AMH to predict the probability of menopause is more sensitive in late than in young reproductive age women, but an undetectable AMH level (using a high-sensitivity assay) is predictive of menopause within 5 years in only 60% of healthy women aged more than 45 years . The difficulty of predicting menopause accurately by using AMH seems because of the differences in decline trajectory between different women , as well as other modifiers such as smoking, and at present it remains impossible to predict age at menopause accurately in healthy women.
The value of AMH for prediction of amenorrhoea after gonadotoxic treatment largely derives from studies in women receiving chemotherapy for breast cancer. The risk of amenorrhoea can be predicted by pretreatment AMH with the risk of persistent amenorrhoea higher with a lower pretreatment AMH. Younger age and higher pretreatment AMH are two important favourable prognostic factors for ovarian recovery [19,52,53]. Women with pretreatment AMH of less than 7.3 pmol/l were 9.3 times more likely to develop POI 2 years after chemotherapy [22▪▪]. A mosaic chart incorporating both age and pretreatment AMH level for postrecovery menstruation prediction indicates that, for all premenopausal women, an AMH level less than 3.8 pmol/l predicts amenorrhoea, whereas AMH more than 20.3 pmol/l predicts continuing menstruation at 2 years (Fig. 3). For intermediate values, age also becomes an important factor : larger studies are needed to validate and refine this analysis. In women older than 40 years, an undetectable AMH (using a highly sensitive assay) immediately post-treatment can predict POI at 2 years with good accuracy [22▪▪], whereas younger women showed recovery of AMH, including from undetectable levels. In older women this may be a potential guide to post-treatment endocrine therapy, but it may not be sufficiently reliable in younger women. Whether this can be improved with further improvements to the sensitivity of AMH assays is unclear, as it will also be determined by whether there are sufficient remaining nongrowing follicles (that do not produce AMH) to support development of antral follicles that do produce AMH. There is likely to be a combination of assay sensitivity and time as chemotherapy (perhaps combined with pretreatment AMH, age and an index relating to the chemotherapy regimen) that will reliably be able to predict ovarian recovery versus permanent ovarian failure.
Current evidence clearly demonstrates that AMH is not a ‘fertility test’, predicting neither natural conception in healthy women [55,56,57▪▪] nor live birth after assisted reproduction . Prospective cohort studies involving healthy women predominantly in their 20s  or 30s [57▪▪] showed no difference in fecundability between women with low and normal ovarian reserve and between older and younger women with DOR.
Childhood and adult cancer survivors have reduced fertility depending on diagnosis/treatment given [58,59], and AMH in cancer survivors is also lower when compared with healthy women [14,30,60]. However, there is no direct evidence demonstrating that a lower AMH is predictive of reduced chance to conceive naturally after cancer treatment. A retrospective study reported that there was no difference in pregnancy occurrence with detectable or undetectable post-treatment AMH in 134 women treated with breast cancer . Natural pregnancy has been reported even when AMH was undetectable after cancer treatment [17,62,63], although the assays used were less sensitive than current ones.
The implications of low AMH for fertility after ovarian cystectomy for benign ovarian cyst on pregnancy are similarly unclear. Women with low preoperative AMH have higher risk of DOR diagnosed 6 months after operation, and a lower cumulative spontaneous pregnancy rate at 24 months after ovarian cystectomy for endometrioma in women with DOR than non-DOR women (14.4 versus 59.2%) has been reported . A prospective study found that postoperative AMH level at 6 months after ovarian cystectomy for benign ovarian cyst was not different between pregnant and non-pregnant groups . It is difficult to draw any conclusion on the predictive value of low AMH after ovarian cystectomy on fertility outcome as most studies do not include pregnancy as an outcome. Interpretation of results from studies reporting pregnancy needs to be cautious as we need to know whether those women included in the studies sought to become pregnant, and the studies usually only report pregnancy as a secondary outcome.
AMH GenII ELISA assay by Beckman Coulter (Brea, CA, USA) was the most commonly used assay until recently, but is increasingly being replaced by automated assays. The lower limit of detection is valuable for analysis of the very low AMH levels often found after chemotherapy. There is still a difference in calibration between assays  which should be taken into account if comparing studies, until an international standard to unify the calibration between different assays is available.
A decrease in ovarian reserve with a fall in AMH can occur after treatments including chemotherapy, radiotherapy and ovarian surgery. In some women, depending on age, preexisting ovarian reserve/AMH and treatment administered, POI may result with undetectable AMH after treatment and without recovery. Clinicians should be aware of such effect and include discussion of the possible implications of decreased AMH on ovarian reserve and fertility with women before undergoing treatment. The accurate interpretation of post-treatment AMH level on reproductive lifespan and fertility prediction needs larger prospective studies with longer follow-up.
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