JBRA Assist. Reprod. 2026;30(2):282-285
ORIGINAL ARTICLE
doi: 10.5935/1518-0557.20260002

Anti-Mullerian Hormone As A Predictor Of Live Birth For Patients With Unexplained Recurrent Pregnancy Loss

Edward R. McClellan^1,2, Yael Eliner³, Hillary Pearson¹, Timothy J. Rafael⁴, Ji Yoon Lee⁵, Randi Goldman¹, Mary Rausch¹

¹Northwell, New Hyde Park, NY; Department of Obstetrics and Gynecology, Division of Human Reproduction, Manhasset, NY; USA, Zucker School of Medicine, Uniondale, NY, USA
²AMEDD Student Detachment, 187th Medical Battalion, 32nd Medical Brigade, Fort Sam Houston, TX, USA
³Northwell, New Hyde Park, NY; Lenox Hospital Obstetrics and Gynecology Residency Program, New York, NY, USA
⁴Northwell, New Hyde Park, NY; Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Manhasset, NY; Zucker School of Medicine, Uniondale, NY, USA
⁵Northwell, New Hyde Park, NY; Department of Biostatistics, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA

Received June 04, 2025
Accepted December 31, 2025

Corresponding author:
Edward R. McClellan, Zucker School of Medicine, Uniondale, NY, Email: mccer@gwu.edu

COMPETING INTERESTS

The authors have no competing interests to declare.

ABSTRACT
Objective:To determine whether anti-mullerian hormone (AMH) levels were associated with live birth and miscarriage rates following the first euploid frozen embryo transfer (FET) cycle for patients with unexplained recurrent pregnancy loss (URPL).
Methods:This retrospective cohort study included all patients (n=63) at an academic medical center in New York undergoing their first euploid FET with a sole diagnosis of URPL between October 2019 and October 2023. URPL was defined as a history of two or more spontaneous abortions (SAB) after a pregnancy (defined as a positive home pregnancy test or serum hCG > 2mIU/mL) and before 20 weeks of gestation without a known cause. Patient demographic data was obtained, and the primary outcomes of live birth and miscarriage were assessed while controlling for relevant clinical variables (obesity, prior number of spontaneous abortions, and aneuploidy). Significance was set at p<0.05.
Results:Lower AMH (<1 ng/mL) was associated with having fewer total blastocysts from prior IVF cycles (p=0.02). Patients with lower AMH also had fewer euploid blastocysts from prior IVF cycles, although this difference was not statistically significant (p=0.08). There were no significant differences based on AMH, and the overall miscarriage rate was 21.3%. Adjusting for obesity and prior number of SABs, AMH was not associated with live birth (aOR 1.12 (95% CI 0.93-1.35), p=0.23) or miscarriage (aOR 0.88 (95% CI 0.64-1.19), p=0.40).
Conclusions:These results suggest that once a euploid embryo is created, AMH is not associated with subsequent transfer outcomes among women with URPL.

Keywords:AMH, RPL, euploid FET, unexplained recurrent pregnancy loss, URPL

INTRODUCTION
AMH is not associated with reduced fecundability among women without a history of infertility (Steiner et al., 2017), nor is AMH associated with fecundability among women with a history of one or two prior spontaneous abortions (Zarek et al., 2015). However, lower AMH is a possible risk factor for miscarriage in naturally conceived pregnancies (Lyttle Schumacher et al., 2018) and has also been associated with lower implantation and clinical pregnancy rates among women undergoing In-Vitro Fertilization (IVF) cycles (Tal et al., 2015).
While low anti-mullerian hormone (AMH) levels have been associated with recurrent pregnancy loss (RPL) among women with RPL (Bunnewell et al., 2020), this association has been confounded by age and unknown ploidy status (Murugappan et al., 2019; Bunnewell et al., 2020). It has been hypothesized that the reported association between AMH and RPL may be due to AMH’s role as a putative marker of oocyte quality, perhaps independent of aneuploidy (Murugappan et al., 2019; Bunnewell et al., 2020); however, others argue that AMH is a marker only of quantity, not quality, of oocytes (Tal & Seifer, 2017). Because prior studies have not assessed the association between AMH and RPL among patients using PGT-A tested embryos, the role of AMH as a prognosticator of pregnancy outcomes has thus far been confounded by unknown ploidy status, and the relevance of AMH for women with RPL transferring PGT-A tested euploid embryos remains unknown (Murugappan et al., 2019).
Despite insufficient evidence that PGT-A increases live birth rates for patients with unexplained recurrent pregnancy loss (URPL), this treatment is pursued by some with URPL because aneuploidy is the major cause of all miscarriages (Practice Committee of the American Society for Reproductive Medicine, 2012). Prior research has noted similar IVF and pregnancy outcomes among patients with RPL compared to patients with other infertility diagnoses (Kornfield et al., 2022). This previous study controlled for AMH; however, it reported neither the outcomes of the first euploid frozen embryo transfer (FET) in their RPL cohort nor their pregnancy rates per transfer (Kornfield et al., 2022).
Our study aimed to determine whether AMH levels were associated with live birth and miscarriage following the first euploid frozen embryo transfer (FET) cycle for patients with URPL.

MATERIAL AND METHODS
This is a retrospective cohort study of all patients (n=63) at an academic institution undergoing their first autologous, euploid FET with a sole diagnosis of URPL between October 2019 and October 2023. URPL was defined as a history of two or more spontaneous abortions (SAB) after a pregnancy (defined as a positive home pregnancy test or serum hCG > 2mIU/mL) and before 20 weeks of gestation without a known cause (Practice Committee of the American Society for Reproductive Medicine, 2012). A complete RPL workup included completing all of the following: parental karyotypic evaluation, serum screening for antiphospholipid antibody syndrome, either sonohysterogram or hysterosalpingogram, and serum screening for thyroid and prolactin disorders (Practice Committee of the American Society for Reproductive Medicine, 2012). Patients were excluded from analysis if a known etiology for their losses was present or if they did not have a completed evaluation performed before their first euploid FET.
This study was approved by the Feinstein Institute for Medical Research Institutional Review Board (22-1015). Fisher’s Exact test and Kruskal-Wallis test were performed with p<0.05 considered statistically significant. For significant Kruskal-Wallis test results, pairwise Wilcoxon rank-sum tests were conducted with Bonferroni correction for multiple comparisons. Multivariate logistic regression models were examined, and adjusted odds ratios were calculated, controlling for two clinically relevant variables (obesity and prior number of spontaneous abortions), to maintain an acceptable events-per-variable ratio. Aneuploidy was inherently controlled for by the study design.

RESULTS
Table 1 reports cycle characteristics with additional information provided in Supplementary Table 1. A lower AMH level was associated with having fewer total blastocysts from prior IVF cycles (p=0.02). Patients with lower AMH also had fewer euploid blastocysts from prior IVF cycles, although this difference was not statistically significant (p=0.08). Pregnancy outcomes are reported in Table 2. There were no significant differences based on AMH, and the overall miscarriage rate was 21.3%. Adjusting for obesity and prior number of spontaneous abortions, AMH was not associated with live birth (aOR 1.12 (95% CI 0.93-1.35), p=0.23) or miscarriage (aOR 0.88 (95% CI 0.64-1.19), p=0.40).

 

Table 1. Cycle Characteristics.
*After obtaining significant differences in the total number of blastocysts with the Kruskal-Wallis test, pairwise Wilcoxon rank-sum tests with Bonferroni correction were performed (significance level: 0.05/3 = 0.0167). A significant difference was observed between patients with AMH<1 ng/mL and AMH > 3.5 ng/mL (p=0.007). However, no significant differences were observed between patients with AMH<1 ng/mL and AMH 1-3.5 ng/mL (p=0.03) or between patients with AMH 1-3.5 ng/mL and AMH > 3.5 ng/mL (p=0.16).

 

Table 2. Transfer Outcomes.
*The miscarriage rate was calculated for 47 patients with a positive pregnancy test.
^One patient with an AMH > 3.5 had an ectopic pregnancy

DISCUSSION
This is the first known study to assess whether AMH levels are associated with live birth and miscarriage following the first euploid FET cycle for patients with URPL. A prior systematic review and meta-analysis showed that low AMH is associated with subsequent pregnancy loss among patients with RPL; however, the authors were unable to adjust for age (Bunnewell et al., 2020). Age is known to affect both AMH and euploid rates, and there is evidence that AMH may be associated with euploid rates even when adjusting for age (Jaswa et al., 2021). Our results showed no association between AMH and either live birth or miscarriage rates among patients with URPL. Lower AMH was associated with having fewer total blastocysts although the number of euploid blastocysts from prior IVF cycles was not significantly different among groups.
These results of no association between AMH and subsequent FET outcomes suggest that prior associations between AMH and RPL noted by some authors may have been confounded by age and aneuploidy, because in our study, once a euploid embryo was created, AMH was not associated with subsequent transfer outcomes among women with URPL.
The study’s major limitations include our small sample size, the small number of patients with an AMH<1ng/mL, and our retrospective study design. The study’s main strengths are the strict inclusion criteria utilized for defining URPL and novelty. Additionally, this manuscript can inform future research into this important, understudied area of reproductive medicine. Based on the estimates of this study, a sample size of 241 patients in each of the three AMH level groups would be needed to achieve 80% power using a Chi-square test with a significance level of p<0.05.

CONCLUSION
These results suggest that AMH is not associated with live birth or miscarriage rates among patients with URPL undergoing their first euploid FET cycle. Future research is needed to determine if this finding remains true for patients with URPL and an AMH<1ng/mL.

Preliminary results were presented at the 2023 American Society for Reproductive Medicine Annual Meeting in New Orleans, LA.

Disclosure Statement
The views and information presented are those of the authors and do not represent the official position of the U.S. Army Medical Center of Excellence, the U.S. Army Training and Doctrine Command, or the Department of the Army, Department of Defense, or U.S. Government.

 

Supplementary Table 1.
Fisher's Exact Test.

REFERENCES

Bunnewell SJ, Honess ER, Karia AM, Keay SD, Al Wattar BH, Quenby S. Diminished ovarian reserve in recurrent pregnancy loss: a systematic review and meta-analysis. Fertil Steril. 2020;113:818-27.e3. PMID: 32145928 DOI: 10.1016/j.fertnstert.2019.11.014 Medline

Jaswa EG, McCulloch CE, Simbulan R, Cedars MI, Rosen MP. Diminished ovarian reserve is associated with reduced euploid rates via preimplantation genetic testing for aneuploidy independently from age: evidence for concomitant reduction in oocyte quality with quantity. Fertil Steril. 2021;115:966-73. PMID: 33583594 DOI: 10.1016/j.fertnstert.2020.10.051 Medline

Kornfield MS, Parker P, Rubin E, Garg B, O’Leary T, Amato P, Lee D, Wu D, Krieg S. Patients with Recurrent Pregnancy Loss Have Similar Embryonic Preimplantation Genetic Testing Aneuploidy Rates and In Vitro Fertilization Outcomes to Infertility Patients. F S Rep. 2022;3:342-8. PMID: 36568927 DOI: 10.1016/j.xfre.2022.10.002 Medline

Lyttle Schumacher BM, Jukic AMZ, Steiner AZ. Antimüllerian hormone as a risk factor for miscarriage in naturally conceived pregnancies. Fertil Steril. 2018;109:1065-71.e1. PMID: 29871793 DOI: 10.1016/j.fertnstert.2018.01.039 Medline

Murugappan G, Shahine L, Lathi RB. Antimullerian hormone is a predictor of live birth in patients with recurrent pregnancy loss. Fertil Res Pract. 2019;5:2. PMID: 30923623 DOI: 10.1186/s40738-019-0054-z Medline

Practice Committee of the American Society for Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril. 2012;98:1103-11. PMID: 22835448 DOI: 10.1016/j.fertnstert.2012.06.048 Medline

Steiner AZ, Pritchard D, Stanczyk FZ, Kesner JS, Meadows JW, Herring AH, Baird DD. Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age. JAMA. 2017;318:1367-76. PMID: 29049585 DOI: 10.1001/jama.2017.14588 Medline

Tal R, Seifer DB. Ovarian reserve testing: a user’s guide. Am J Obstet Gynecol. 2017;217:129-40. PMID: 28235465 DOI: 10.1016/j.ajog.2017.02.027 Medline

Tal R, Tal O, Seifer BJ, Seifer DB. Antimüllerian hormone as predictor of implantation and clinical pregnancy after assisted conception: a systematic review and meta-analysis. Fertil Steril. 2015;103:119-30.e3. PMID: 25450298 DOI: 10.1016/j.fertnstert.2014.09.041 Medline

Zarek SM, Mitchell EM, Sjaarda LA, Mumford SL, Silver RM, Stanford JB, Galai N, White MV, Schliep KC, DeCherney AH, Schisterman EF. Is Anti-Müllerian Hormone Associated With Fecundability? Findings From the EAGeR Trial. J Clin Endocrinol Metab. 2015;100:4215-21. PMID: 26406293 DOI: 10.1210/jc.2015-2474 Medline