Anti-Müllerian hormone does not predict cumulative pregnancy rate in non-infertile women following four IUI cycles with donor sperm.

45 46 Author contributions and acknowledgements 47 48 2 MAC conceived the idea and directed the study. SGL participated in the study design as well 49 as in the research plan and coordination, collected data and wrote the manuscript. JMS and JSA 50 collected data, participated in the literature review, performed statistics and prepared the 51 figures. MPO and ARC collected data. All authors had access to the data in the study and take 52 responsibility for its integrity. All authors made significant contributions to this manuscript, 53 reviewed its final version and approved of this submission. We thank Ana Badia, nurse and 54 clinical coordinator, for their patient work and technical assistance. 55 56 Statements and declarations 57 58 Competing interests and funding: The authors have no conflicts of interest to disclose. 59 60 61 62 3 Anti-Müllerian hormone does not predict cumulative pregnancy rate in non-63 infertile women following four IUI cycles with donor sperm 64 65 66 Capsule Summary (40 words) 67 The cumulative clinical pregnancy rate after 4 cycles of ds -IUI in non-infertile women is not 68 correlated with AMH levels. Decreased AMH levels do not seem to reduce pregnancy rates 69 following ds-IUI and should not limit patient access to this treatment. 70 71 72 73

(250 words) 74 75 Purpose: To evaluate the predictive value of serum AMH for clinical pregnancy in non -76 infertile population undergoing intrauterine insemination with donor sperm (ds-IUI). 77 78

This multicenter prospective study (ClinicalTrials.gov ID: NCT06263192) recruited 79 all non-infertile women undergoing ds-IUI from June 2020 to December 2022 in three different 80 fertility clinics in Spain and Chile. Indications for ds -IUI included severe 81 oligoasthenoteratozoospermia, female partner, or single status. Clinical pregnancy rates were 82 compared between women with AMH ≥1.1 and <1.1 ng/mL. The main outcome measure was 83 the cumulative clinical pregnancy rate after up to 4 ds-IUI cycles. 84 85

A total of 458 ds -IUI cycles were performed amongst 245 patients, of whom 108 86 (44.08%) achieved clinical pregnancy within 4 cycles, 60.2% of these occurring in the first 87 attempt and 84.2% after two attempts. We found no significant differences in AMH levels or 88 other parameters (such as age, BMI, FSH, AFC) between women who became pregnant and 89 those who did not. Cumulative pregnancy rates and logistic regression analysis revealed that 90 AMH ≥1.1 ng/mL was not predictive of ds-IUI success. While a high positive correlation was 91 observed between AFC and AMH (r=0.67, p<0.001), ROC curve analyses indicated that neither 92 of these ovarian reserve markers accurately forecasts cumulative ds -IUI outcomes in non -93 infertile women. 94 95

The findings of this multicenter study suggest that AMH is not a reliable 96 predictor of pregnancy in non-infertile women undergoing ds-IUI. Even women with low AMH 97 levels can achieve successful pregnancy outcomes, supporting the notion that diminished 98 ovarian reserve should not restrict access to ds-IUI treatments in eligible non-infertile women. 99 100 101

102 anti-Müllerian hormone, AMH, intrauterine insemination, IUI, predictive value, cumulative 103 pregnancy rate 104 105 4

106 107 Anti-Müllerian hormone (AMH) is secreted by the granulosa cells of preantral and antral 108 ovarian follicles. Its serum levels peak at 20-25 years of age and gradually decrease after that, 109 along with antral follicle counts (AFC), due to the decrease in ovarian reserve [1-4]. This age-110 related follicle loss accelerates from 35 and furthermore from 37 and 40 years of age, while 111 serum levels of AMH becomes undetectable and follicle -stimulating hormone (FSH) increase 112 until reaching menopausal ranges [5,6]. 113 114 Serum AMH level is a widely used marker of ovarian reserve and predictor of follicular 115 response to controlled ovarian stimulation (COS) [1,7-9], being <1.1 ng/ml a well-established 116 cut-off point for poor ovarian response (POR) [10]. AMH levels have been correlated with the 117 ovarian sensitivity index [9], the number of oocytes retrieved [7], and live birth rates following 118 ovarian stimulation and In Vitro Fertilization (IVF) by the most comprehensive and recent 119 meta-analysis by Peigne et al [11]. However, the authors highlighted that data for AMH 120 predictive value is lacking after IUI or in women trying to conceive without ART [11]. Indeed, 121 despite occasional references, it is important to avoid misusing AMH as a "fertility test" since 122 the likelihood of becoming pregnant depends on many factors, with age being the most reliable 123 predictor [12-15]. 124 125 Particularly, pregnancy rates significantly decrease with advancing maternal age from 35 years 126 due to oocyte quality deterioration related to impaired DNA integrity and meiosis competence, 127 oxidative stress, and early apoptosis [16-27]. Based on this rationale, some authors raise doubt 128 about the predictive value of AMH for natural conception and intrauterine insemination (IUI) 129 [28-33]. This skepticism arises from the fact that in these predominantly monofollicular cycles, 130 the critical factor for achieving pregnancy is the quality of the ovulated oocyte rather than the 131 quantity of oocytes remaining in the ovary. In contrast, other authors report better pregnancy 132 rates following IUI in patients with high AMH levels [34-38], while observing poorer outcomes 133 in those with low AMH levels [39]. In fact, all the published studies to date are retrospective 134 and methodologically heterogeneous, and the only available meta -analysis is focused on 135 assessing the association between AMH and spontaneous pregnancy [40]. After IUI with donor 136 sperm (ds-IUI), it has been reported that the cumulative pregnancy rate can reach up to 60% in 137 appropriately selected, non-infertile women without advanced maternal age [41], remaining the 138 impact of low AMH uncertain in this group. However, despite the lack of conclusive evidence, 139 presenting low AMH level is a common exclusion criterion for women to access this treatment 140 in several fertility centers. This often results in more complex and invasive treatments such as 141 IVF. 142 143 The objective of this study is to assess the predictive value of AMH for clinical pregnancy in 144 non-infertile population undergoing ds -IUI. Determining this would allow clinicians to 145 establish a more accurate prognosis of IUI cycles and optimize the indication of assisted 146 reproductive techniques (ART). 147 148 149 5

150 151 This multicenter prospective observational study evaluated the correlation between AMH 152 levels and pregnancy rates in non -infertile women undergoing ds -IUI. Participants were 153 recruited from June 2020 to December 2022 from three centers: Hospital del Mar and Fertty 154 Clinic (Barcelona, Spain) and Women's Reproductive Medicine Clinic (Viña del Mar, Chile). 155 The study includes women aged 25 -42 years undergoing ds -IUI due to partner’s severe 156 oligoasthenoteratozoospermia, female partner or single status, were eligible for the study. 157 Patients with a BMI ≥ 30 kg/m2, ovarian cysts, endometriosis, or ovulation dysfunction were 158 excluded. In all participants, baseline measures included: age (years), pregnancy history, AMH 159 (ng/mL), cycle day -2-5 FSH (IU/L), and cycle day -2-5 AFC by transvaginal ultrasound 160 (TVUS). Patients underwent ovulation induction with low doses of gonadotropins (from 37.5 161 to 75 IU/day) from the second to the fifth day of the cycle until the follicles reached a diameter 162 of 17 to 20 mm. Follicle growth was monitored by transvaginal ultrasound (TVUS) every 2 -3 163 days, and ds-IUI was performed 36 hours after triggering ovulation with subcutaneous injection 164 of 250 µg of HCG (Ovitrelle®, Merk). Skilled Gynecologists specialized in Reproductive 165 Endocrinology and Infertility from each center managed patient care and performed the ds -166 IUIs. Patients repeated subsequent ds -IUI cycles until achieving a live birth or up to 4 cycles 167 when IVF was indicated. 168 169 In all cases, serum AMH levels were determined using the commercial automated 170 immunoassay Elecsys® test on a Cobas measurement system by Roche Diagnostics. This test 171 offers a measurement interval of 0.01 -23 ng/mL and an inter -day imprecision of <5%, which 172 is remarkably more accurate than preceding ELISA tests. 173 174 Sperm for the Spanish centers was supplied by the CEFER Reproduction Institute sperm bank 175 (Spain), while at Women's Reproductive Medicine Clinic, it was obtained from the National 176 Sperm Bank of Chile via California Cryobank (USA). 177 178 Per each complete ds-IUI cycle, total number of follicles reaching at least 17 mm in diameter 179 on the trigger day and clinical pregnancy rate were registered. Reproductive outcomes were 180 compared between women with AMH ≥1.1 ng/mL and <1.1 ng/mL. The main outcome 181 measure was the cumulative clinical pregnancy rate after up to 4 consecutive ds -IUI. Clinical 182 pregnancy was defined according to the latest version of the international ART terminology 183 consensus [42]. 184 185 Statistical analysis 186 187 Participant demographics, clinical characteristics, and outcomes were summarized using 188 descriptive statistics. Quantitative variables were reported as means and range or standard 189 deviation (SD). 190 191 Cumulative clinical pregnancy rates of patients presenting AMH ≥1.1 and <1.1 ng/mL were 192 represented using Kaplan-Meier, and both curves were compared by means of the log-rank test 193 or the model of Cox regression. A sub-analysis was also conducted comparing pregnancy rates 194 6 with AMH ≥1.1 and <1.1 ng/mL in patients in different age groups using the Chi -square test. 195 Statistical significance was established for p-value <0.05. 196 197 Multivariate logistic regression analysis was performed, including age, BMI, FSH, AFC and 198 AMH, and correlation coefficients, adjusted odds ratio (OR) with 95% CI and receiver 199 operating characteristic (ROC) curve analysis were estimated. 200 201 T-student test was performed to assess differences between patients who achieved clinical 202 pregnancy in a ds-IUI cycle and those who did not. 203 204 The STATA software package version 18.0 (SPSS, Chicago, IL) was used for statistical 205 analysis. Statistical significance was set at p<0.05. 206 207 Ethics 208 209 This project was approved by the Institutional Review Board and Ethics Committee at Hospital 210 del Mar in Barcelona (Spain) (IRB Protocol ID 2020/9445) and registered at ClinicalTrials.gov 211 (ID NCT06263192 ). 212 213 Neither the data collection, its analysis nor its results implied any change in the clinical 214 management of ds-IUI for the patients included in the study. 215 216 217

218 219 A total of 458 ds -IUI cycles were performed amongst 245 patients, of whom 108 (44.08%) 220 achieved a clinical pregnancy within 4 ds-IUI cycles. Patient baseline characteristics are shown 221 in Table 1. 222 223 Noteworthy, out of the 108 clinical pregnancies achieved through ds -IUI, 91 occurred within 224 the first two ds -IUI cycles (84.2%), with 65 of them occurring after the first ds -IUI attempt 225 (60.2%). The number of clinical pregnancies remarkably decreased after the third and fourth 226 cycles of ds-IUI (12 cases and 5 pregnancies, respectively). 227 228 Patients who achieved clinical pregnancy did not exhibit statistically significant differences in 229 AMH levels compared to those who did not become pregnant (Figure 1), nor did they show 230 differences in other parameters such as age, BMI, FSH, and AFC (Table 2). 231 232 The cumulative clinical pregnancy rates for women with AMH ≥1.1 and <1.1 ng/mL are 233 presented through the Kaplan -Meier estimator (Figure 2). The log -rank test (Mantel -Cox) 234 shows no statistically significant differences in cumulative clinical pregnancy rate between both 235 groups (1.06; p-value 0.302). Sub-analyses of patients in different age groups with AMH ≥1.1 236 ng/mL and <1.1 ng/mL revealed similar findings, with no significant differences in pregnancy 237 rates (Supplemental Tables 1 and 2). 238 239 7 Pearson correlation determined that there was a high positive correlation between AFC and 240 AMH (r= 0.67; p.value <0.001). 241 242 Logistic regression analysis examining the influence of age, BMI, FSH, AFC, and AMH on 243 cumulative clinical pregnancy rates is presented in Table 3. The comprehensive model was 244 reliable, being significantly correlated to pregnancy outcomes in the study population (Chi2= 245 12.45, p-value 0.029). 246 247 ROC curve analyses for AMH and AFC predicting ds -IUI pregnancy outcomes demonstrate 248 areas under the curve (AUC) of 0.554 and 0.562, respectively (Figure 3 and Supplemental 249 Figure 1), indicating that using AMH or AFC to predict ds-IUI success in non-infertile women 250 would not provide accurate guidance. Additional ROC curve analyses revealed that neither age, 251 FSH or BMI predict pregnancy following ds-IUI in the study population (Supplemental Figures 252 2 to 4). 253 254 The rates of clinical pregnancy and treatment failure in women with AMH ≥1.1 ng/mL were 255 45.1% and 54.8%, respectively. In contrast, these rates were 40.6% and 59.3% in women with 256 AMH <1.1 ng/mL. Logistic regression analysis examining the influence of serum AMH on 257 pregnancy rates showed that AMH ≥1.1 ng/mL is not a definitive predictive factor for clinical 258 pregnancy following ds-IUI in non-infertile women (OR 0.83; 0.46-1.51) (Table 4). 259 260 261

262 263 This multicenter study showed for the first time that AMH levels do not predict cumulative 264 pregnancy rates following multiple ds -IUI cycles in non -infertile women. Additionally, we 265 found that ovarian reserve markers were comparable between non -infertile women who 266 achieved pregnancy following ds-IUI and those who did not. 267 268 Our comprehensive logistic regression model was globally significant, indicating that the 269 variables of age, BMI, FSH, AFC, and AMH have a collective impact on the probability of 270 pregnancy. However, none of the studied variables proved to be an independent predictor of 271 cumulative clinical pregnancy rate in non-infertile women undergoing ds-IUI. This result may 272 be due to several reasons, including the size of the sample or the variability of the data. While 273 we identified a correlation between AMH and AFC in our study cohort, we observed a non -274 significant trend suggesting higher AFC, but not AMH, in women who obtained pregnancy 275 compared to those who did not. This contrast may be attributed to inter -observer variations in 276 AFC measurements or perhaps to a potentially higher incidence of favorable bifollicular cycles 277 in patients with higher AFC prior to IUI. Nonetheless, no significant differences in pregnancy 278 outcomes based on ovarian reserve were found and, therefore, none of these plausible 279 hypothetical effects seem remarkable, if present. 280 281 The selection of women without anatomical -functional ovarian abnormalities or diagnosis of 282 female infertility along with the use of donor semen allowed us to adequately assess the effect 283 8 of ovarian reserve on the probability of pregnancy after IUI in non -infertile populations. The 284 prospective nature of the study provided a longitudinal perspective for cumulative effects of 285 exposures, controlled data collection and the ability to measure incidence and multiple 286 outcomes, without recall bias from participants. Being performed at centers in different 287 continents, the study included patients from different ethnic backgrounds and socioeconomic 288 levels, granting robustness and a greater external validity. 289 290

of the study included the potential influence of undiagnosed polycystic ovary 291 syndrome (PCOS) in women with exceptionally high AMH values [43]. However, this effect 292 seems minimal, if any, given the exclusion of patients with menstrual irregularities and the 293 presence of 11 participants with AFC >25, and only 4 among them >30. Another limitation is 294 the limited representation of women with low AMH levels (<1.1 ng/mL, 43 patients; <0.5 295 ng/mL, 15 patients), which may be attributed to the general practice in our centers of not 296 offering IUI to women with low ovarian reserve or those over the age of 42. In addition, the 297 variability in length and total dosage of rFSH exposure before ds-IUI could have influenced the 298 outcomes, although this seems unlikely. Only exposure to excessively high gonadotropin levels 299 has been reported to decrease oocyte quality and pregnancy likelihood with IVF treatments [44-300 46], but low daily doses were used in all cases in our study. 301 302 There is still extensive controversy regarding the relationship between ovarian reserve and 303 fertility, while the association between AMH levels and success rates in natural conception and 304 IUI varies greatly across published studies. Although no studies assessed cumulative pregnancy 305 after ds-IUI in non -infertile population to date, some authors have reported poor predictive 306 value of AMH for natural pregnancy and IUI outcome [12,28 -34], in line with our findings. 307 This is also supported by the recent meta-analysis by Lin et al., which included eleven studies 308 (n=4,388 women) and was aimed to study the utility of AMH in predicting pregnancy. The 309 authors found low AMH levels not to be associated with reduced fertility following IUI in 310 different age groups [40], demonstrating the limited capability of AMH to predict fertility when 311 no COS is needed. Yet, a few authors reported better pregnancy rates after IUI in patients with 312 high AMH levels [34-38], and worse outcomes in patients with low AMH levels [39]. However, 313 these works present several limitations. Many only consider the first attempt of IUI and are 314 heterogeneous in its methods, lacking accurate control of confounding variables, especially 315 regarding the study populations, which include male factor or different infertility diagnoses 316 and/or treatment indications. In comparison, our study presents less risk of bias by being 317 prospectively monitored and strictly including women not older than 42 years, without female 318 infertility factors and using sperm from donors for their IUIs. Additionally, in most studies, low 319 AMH levels were strongly associated with advanced and very advanced maternal age, hence 320 the poorer pregnancy rates could have been due to age and not necessarily to AMH. In fact, 321 advanced maternal age is an established independent negative prognostic factor for clinical 322 pregnancy and live birth [47,48], including the following IUI [49]. While our results did not 323 demonstrate significantly higher cumulative clinical pregnancy rates in younger patients, it’s 324 noteworthy that the women who conceived following ds -IUI tended to be younger (p=0.057). 325 Hence, increasing our sample size could potentially lead to achieving statistical significance. 326 327 9 On the other hand, diminished ovarian reserve (DOR) does not necessarily correlate with poor 328 reproductive outcomes, despite the numerous controversial theories attempting to explain 329 possible oocyte quality impairment associated with DOR [50 -52]. These hypotheses suggest 330 potential underlying mechanisms such as ovulation of higher -quality oocytes earlier in life, 331 decreased ovarian support for folliculogenesis during IVF and reduced euploidy rates in DOR. 332 Yet, these theories remain unproven and are currently debated, with our findings not supporting 333 them. Instead, extensive research suggests that coexisting factors with DOR, rather than the 334 condition itself, impact oocyte performance and embryo quality. Extensive studies by the 335 POSEIDON group and others show how reproductive outcomes are not directly affected by 336 low ovarian reserve but by a range of possible coexisting factors [53 -56]. Even young women 337 who have undergone chemotherapy, experiencing DOR due to a gonadotoxic insult, seem to 338 maintain age -appropriate oocyte competence [57 -58]. Therefore, current evidence does not 339 support the existence of specific biochemical or molecular mechanisms in DOR compromising 340 oocyte quality. 341 342 Our study emphasizes the inappropriateness of directly inferring a poor pregnancy prognosis 343 to women with low ovarian reserve and therefore automatically dismissing the potential 344 effectiveness of IUI in selected cases, indicating IVF at the outset given its high success rates 345 in fertility clinics. In fact, DOR is a criterion for exclusion for access to IUI in many public 346 programs over the world. However, in practice, many other factors must be taken into account 347 when indicating ART techniques on an individual basis. IVF presents greater reproductive 348 efficiency per cycle than IUI in infertile and elderly maternal populations and has the advantage 349 of being able to freeze additional embryos. However, non-infertile women younger than 38-40 350 years of age with a male, female or single infertile partner can benefit from starting ART with 351 IUIs regardless of their ovarian reserve, as these treatments are less complex, less invasive, and 352 less expensive. As these are essentially monofollicular cycles, the prognosis of this technique 353 will depend on oocyte quality, and therefore presenting low AMH should not be used as an 354 exclusion criterion for non -infertile women seeking ds -IUI. Indeed, conversely, it could be 355 argued that in women with a low ovarian reserve (AFC 2 -3 or poor response criteria), the 356 indication for IUI becomes more advisable because IVF would offer little probability of 357 obtaining additional embryos for freezing, providing limited added benefit. Especially in 358 younger patients without female infertility factors, whose oocyte quality is anticipated to be 359 high, IUI should not be dismissed solely based on DOR since their outcomes may be 360 comparable to those with normal ovarian reserve. 361 362 Further studies are essential to validate our findings, ensuring a comprehensive interpretation 363 of ovarian markers and a consequent accurate prognosis and indications of ART in each clinical 364 case. Moreover, notably, prospects for a novel trend in ART centered around oocyte -based 365 approaches are emerging [59]. It seems crucial to investigate the influence of aging and 366 molecular environment on oocyte quality, potentially being the main predictor for pregnancy 367 success in the absence of COS. While clinicians should consider the results of this study when 368 indicating ds-IUI, we believe that a deeper understanding of the mechanisms underlying oocyte 369 competence will enhance overall reproductive outcomes in the future. 370 371 10 372

373 374 AMH is not a reliable predictor of pregnancy in non-infertile women undergoing ds-IUI. Even 375 women with significantly low ovarian reserve can achieve successful outcomes after ds -IUI, 376 which may be primarily influenced by oocyte quality. The findings of this multicenter study 377 support the idea that low AMH levels should not limit access of non-infertile women to ds-IUI. 378 379 380 381 11

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Description of baseline patient characteristics 612 613 Patients (n) 245 ds-IUI cycles (n) 458 Age (years) 34.28 ± 3.86 BMI (kg/m2) 25.01 ± 4.26 FSH (IU/L) 7.23 ± 3.03 AFC (n) 13.23 ± 7.06 AMH (ng/mL) 2.6 ± 2.09 Monofollicular cycles (n) 353 Bifollicular cycles (n) 105 1st ds-IUI cycle (n) 245 2nd ds-IUI cycle (n) 123 3rd ds-IUI cycle (n) 57 4th ds-IUI cycle (n) 34 614 Values expressed as total number (n) or as mean ± SD. 615 ds-IUI= donor sperm intrauterine insemination; BMI= Body Mass Index; FSH= follicle -616 stimulating hormone; AFC= antral follicle count; AMH= Anti-Müllerian hormone. 617 618 619 Table 2. Differences in clinical parameters among patients who achieved pregnancy after 620 up to 4 ds-IUI compared to those who did not 621 622 Pregnancy (n= 108) No Pregnancy (n= 137) p-value Age (years) 33.78 ± 3.85 34.67 ± 3.83 0.057 BMI (kg/m2) 25.12 ± 4.15 24.93 ± 4.35 0.768 FSH (UI/L) 7.02 ± 2.54 7.41 ± 3.41 0.48 AFC (n) 14.22 ± 7.7 12.42 ± 6.42 0.071 AMH (ng/mL) 2.67 ± 1.83 2.55 ± 2.28 0.649 623 Values expressed as mean ± SD. 624 ds-IUI= donor sperm intrauterine insemination; BMI= Body Mass Index; FSH= follicle -625 stimulating hormone; AFC= antral follicle count; AMH= Anti-Müllerian hormone. 626 627 628 17 Table 3. Logistic regression analysis examining the association between patient 629 characteristics and cumulative clinical pregnancy outcome 630 631 Univariate logistic regression Multivariate logistic regression OR 95% CI p-value Adjusted OR 95% CI p-value Age (years) 0.94 0.88 - 1.00 0.059 0.87 0.75 - 1.01 0.068 BMI (kg/m2) 1.01 0.94 - 1.08 0.767 1.11 0.98 - 1.25 0.102 FSH (UI/L) 0.96 0.85 - 1.08 0.478 1.19 0.96- 1.46 0.107 AFC (n) 1.04 1.00 - 1.08 0.074 1.07 0.98 - 1.17 0.142 AMH (ng/ml) 1.03 0.91 - 1.16 0.648 0.77 0.53 - 1.12 0.177 632 OR= Odds Ratio; 95% CI= 95% Confidence Interval. 633 BMI= Body Mass Index; FSH= follicle -stimulating hormone; AFC= antral follicle count; 634 AMH= Anti-Müllerian hormone; ds-IUI= donor sperm intrauterine insemination. 635 636 637 Table 4. Cumulative pregnancy outcome after up to 4 ds -IUI in patients with AMH ≥1.1 638 ng/mL vs AMH <1.1 ng/mL 639 640 AMH ≥1.1 ng/mL (n= 186) AMH <1.1 ng/mL (n= 59) OR (95% CI, p-value) No Pregnancy 102 35 0.83 (0.46 - 1.51, 0.546) Pregnancy 84 24 641 OR= Odds Ratio; 95% CI= 95% Confidence Interval. 642 AMH= Anti-Müllerian hormone; ds-IUI= donor sperm intrauterine insemination. 643 644 645 646 18 Figures 647 648 Figure 1. Association between AMH and cumulative clinical pregnancy outcome after up 649 to 4 ds-IUI 650 651 652 p-value=0.62. 653 654 AMH= Anti-Müllerian hormone; ds-IUI= donor sperm intrauterine insemination. 655 656 657 Figure 2. Cumulative clinical pregnancy rate up to 4 ds -IUI in women with serum AMH 658 levels ≥1.1 and <1.1 ng/mL 659 660 661 662 Log-rank test (Mantel-Cox)= 1.06; p-value 0.302. 663 19 664 AMH= Anti-Müllerian hormone; ds-IUI= donor sperm intrauterine insemination. 665 666 667 Figure 3. ROC curve analysis of AMH for cumulative clinical pregnancy rate after up to 668 4 ds-IUI 669 670 AUC= 0.554 671 672 ROC= Receiving Operating Characteristic; AUC= Area Under the Curve. 673 AMH= Anti-Müllerian hormone; ds-IUI= donor sperm intrauterine insemination. 674 675 676 20 Supplemental Material 677 678 Supplemental Table 1. Comparison of cumulative pregnancy rate up to 4 ds-IUI in women 679 with AMH ≥1.1 and <1.1 ng/mL in different age groups 680 681 Women aged <35 years AMH ≥1.1 (n=18) AMH <1.1 (n=109) Chi2 (df, p-value) No Pregnancy 10 53 0.3, (1, 0.586) Pregnancy 8 56 682 Women aged ≥35 years AMH ≥1.1 (n=41) AMH <1.1 (n=77) Chi2 (df, p-value) No Pregnancy 25 49 0.08, (1, 0.776) Pregnancy 16 28 683 Women aged <38 years AMH ≥1.1 (n=36) AMH <1.1 (n=149) Chi2 (df, p-value) No Pregnancy 17 81 0.59, (1, 0.441) Pregnancy 19 68 684 Women aged ≥38 years AMH ≥1.1 (n=23) AMH <1.1 (n=37) Chi2 (df, p-value) No Pregnancy 18 21 02.88, (1, 0.09) Pregnancy 5 16 685 Chi2= Chi square; df= degrees of freedom. 686 ds-IUI= donor sperm intrauterine insemination; AMH= Anti-Müllerian hormone. 687 21 Supplemental Figure 1. ROC curve analysis of AFC for the cumulative pregnancy rate 688 after up to 4 ds-IUI 689 690 AUC= 0.562 691 692 ROC= Receiving Operating Characteristic; AUC= Area Under the Curve. 693 AFC= antral follicle count; ds-IUI= donor sperm intrauterine insemination. 694 695 696 Supplemental Figure 2. ROC curve analysis of age for cumulative pregnancy rate after 697 up to 4 ds-IUI 698 699 22 AUC= 0.578 700 701 ROC= Receiving Operating Characteristic; AUC= Area Under the Curve. 702 ds-IUI= donor sperm intrauterine insemination. 703 704 705 Supplemental Figure 3. ROC curve analysis of FSH for cumulative pregnancy rate after 706 up to 4 ds-IUI 707 708 AUC= 0.509 709 710 ROC= Receiving Operating Characteristic; AUC= Area Under the Curve. 711 FSH= follicle-stimulating hormone; ds-IUI= donor sperm intrauterine insemination. 712 713 714 23 Supplemental Figure 4. ROC curve analysis of BMI for cumulative pregnancy rate after 715 up to 4 ds-IUI 716 717 AUC= 0.536 718 719 ROC= Receiving Operating Characteristic; AUC= Area Under the Curve. 720 BMI= Body Mass Index; ds-IUI= donor sperm intrauterine insemination. 721