AMH is a hormone produced by the granulosa cells, which acts as a follicular gatekeeper. It acts to limit follicle growth and estradiol production from small antral follicles prior to selection. In childhood and adolescence, there is a complex rise in AMH level, which likely reflects the different stages of follicle development. It then peaks in a woman’s early 20s before declining to menopause, correlating positively with non-growing follicle recruitment.

Figure 1. A validated model of serum AMH from conception to menopause [12]

In women treated with mechlorethamine, vincristine, procarbazine and prednisone (MOPP) chemotherapy for Hodgkin lymphoma during childhood, AMH was noted to be lower compared with healthy women and women treated without MOPP.[13] In a larger series of 185 childhood cancer survivors, although the cohort’s median AMH concentration was no different from controls, the AMH levels were lower than the 10th percentile of normal values in 27% of the survivors and subgroups at risk for decreased fertility or premature ovarian failure were identified.[14]  In adult women with cancer, AMH declines during treatment followed by recovery in some patients, with the rate of recovery determined by the pretreatment AMH level.[15] 

Interest in the use of AMH as a measure of ovarian reserve to measure the gonadotoxic effect of chemotherapy/radiotherapy is growing, especially for children in whom FSH and inhibin B are not useful. When compared with other ovarian reserve markers, AMH levels reflect changes in ovarian function earlier and there is no significant fluctuation of AMH during the menstrual cycle and it is highly predictive for timing of menopause [16-18], suggesting that it may be the most useful marker for monitoring the decline of reproductive capacity. Moreover, serum AMH levels are detectable in healthy females from birth to menopause [19, 20], making it suitable as a marker even in prepubertal girls. It should be noted, however, that there are limited data correlating AMH and natural fertility at different stages of reproductive life and especially in children and adolescents. In addition, AMH assays continue to evolve and there are no international standards. Therefore, more long term data is needed to ascertain the use of AMH to evaluate fertility preservation strategies as well as predict long term ovarian function after cancer therapy.