# Undetectable Serum Level of Anti-Müllerian Hormone (AMH) in a Woman with an Unpredictable Hyper-Response During Controlled Ovarian Stimulation for an IVF-ICSI Program: Case Report

## TL;DR

A woman with undetectable AMH levels unexpectedly had a strong ovarian response during IVF, showing AMH alone may not predict treatment outcomes.

## Contribution

This case report highlights the limitations of using AMH as a sole predictor of ovarian response in IVF and suggests the need for a multidimensional approach.

## Key findings

- A patient with undetectable AMH exhibited an unpredictable hyperresponse during ovarian stimulation.
- Successful IVF-ICSI and embryo transfer did not result in a successful pregnancy.
- Alternative regulatory mechanisms may explain the paradoxical ovarian response.

## Abstract

Background/Objectives: A decrease in serum AMH is generally associated with low ovarian response in assisted reproductive procedures, whether or not in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) is performed. Methods: We report a case involving a 31-year-old woman who had never been pregnant and with irregular menstrual cycles. An ultrasound scan performed on the second day of the cycle showed several annular follicles, a high luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratio suggesting polycystic ovary syndrome (PCOS), and an undetectable serum level of AMH. Results: Despite these observations, she exhibited an unpredictable hyperresponse during controlled ovarian stimulation, followed by a failed pregnancy despite successful in vitro fertilization with ICSI and a good-quality thawed embryo transfer (4AA). Conclusions: This case highlights the challenges of relying solely on AMH as a predictive marker of ovarian response. Although AMH is widely used for assessing ovarian reserve and stimulation outcomes, its limitations become evident in atypical cases. The paradoxical hyperresponse observed here may result from alternative regulatory mechanisms influenced by elevated LH levels, enhanced gonadotropin receptor sensitivity, or local ovarian factors. This report underscores the need for a personalized, multidimensional approach combining hormonal profiles, ultrasound assessments, and clinical history to optimize stimulation protocols and mitigate risks such as ovarian hyperstimulation syndrome (OHSS). Such tailored protocols are essential for managing patients with complex profiles, particularly those with undetectable AMH levels. Further research is needed to explore the mechanisms behind these atypical ovarian responses, including the roles of genetic polymorphisms, inflammatory markers, and environmental factors. This case demonstrates the importance of cautious interpretation of AMH results and emphasizes the value of comprehensive evaluations in assisted reproductive technologies.