Antibodies to the acetylcholine receptor (AChR) added to AChR-bearing muscle cells cross-link the receptors, thus increasing their internalization and degradation rate (antigenic modulation). This mechanism contributes to AChR loss in myasthenia gravis. Until recently, antigenic modulation has been studied in animal tissues, where only a small fraction of human anti-AChR antibodies bind. In the present study, we examined the antigenic modulation of AChR by using patients' sera and cultures of human muscle cells. We aimed to see whether antigenic modulation correlates better with disease severity or with antibody titer. Antibody-containing sera from 29 myasthenic patients in various states of the disease and with different antibody titers against AChR were tested. Control sera from six healthy individuals were also tested. Our experiments showed that all myasthenic sera affected the overall AChR content on the human myotube surface, causing a 49 to 82% loss, whereas control sera had no effect. Although at fixed serum volumes there was some correlation between disease severity and AChR loss, this effect was clearly due to differences in antibody titers. In fact, the antigenic modulation depended mainly on the final concentration of the antibody present. Thus, intrinsic factors other than antibodies to AChR may determine or influence the patients' susceptibility to the disease.