Serum anti-Müllerian hormone dynamics during controlled ovarian hyperstimulation

Role of the mitophagy-apoptosis axis in the pathogenesis of polycystic ovarian syndrome

AIM

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by menstrual irregularities, androgen excess, and polycystic ovarian morphology, but its pathogenesis remains largely unknown. This review focuses on how androgen excess influences the molecular basis of energy metabolism, mitochondrial function, and mitophagy in granulosa cells and oocytes, summarizes our current understanding of the pathogenesis of PCOS, and discuss perspectives on future research directions.

METHODS

A search of PubMed and Google Scholar databases were used to identify relevant studies for this narrative literature review.

RESULTS

Female offspring born of pregnant animals exposed to androgens recapitulates the PCOS phenotype. Abnormal mitochondrial morphology, altered expression of genes related to glycolysis, mitochondrial biogenesis, fission/fusion dynamics, and mitophagy have been identified in PCOS patients and androgenic animal models. Androgen excess causes uncoupling of the electron transport chain and depletion of the cellular adenosine 5'-triphosphate pool, indicating further impairment of mitochondrial function. A shift toward mitochondrial fission restores mitochondrial quality control mechanisms. However, prolonged mitochondrial fission disrupts autophagy/mitophagy induction due to loss of compensatory reserve for mitochondrial biogenesis. Disruption of compensatory mechanisms that mediate the quality control switch from mitophagy to apoptosis may cause a disease phenotype. Furthermore, genetic predisposition, altered expression of genes related to glycolysis and oxidative phosphorylation, or a combination of these factors may also contribute to the development of PCOS.

CONCLUSION

In conclusion, fetuses exposed to a hyperandrogenemic intrauterine environment may cause the PCOS phenotype possibly through disruption of the compensatory regulation of the mitophagy-apoptosis axis.

Hypothalamic neuroglial plasticity is regulated by anti-Müllerian hormone and disrupted in polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common reproductive-endocrine disorder affecting between 5 and 18% of women worldwide. An elevated frequency of pulsatile luteinizing hormone (LH) secretion and higher serum levels of anti-Müllerian hormone (AMH) are frequently observed in women with PCOS. The origin of these abnormalities is, however, not well understood.

METHODS

We studied brain structure and function in women with and without PCOS using proton magnetic resonance spectroscopy (MRS) and diffusion tensor imaging combined with fiber tractography. Then, using a mouse model of PCOS, we investigated by electron microscopy whether AMH played a role on the regulation of hypothalamic structural plasticity.

FINDINGS

Increased AMH serum levels are associated with increased hypothalamic activity/axonal-glial signalling in PCOS patients. Furthermore, we demonstrate that AMH promotes profound micro-structural changes in the murine hypothalamic median eminence (ME), creating a permissive environment for GnRH secretion. These include the retraction of the processes of specialized AMH-sensitive ependymo-glial cells called tanycytes, allowing more GnRH neuron terminals to approach ME blood capillaries both during the run-up to ovulation and in a mouse model of PCOS.

INTERPRETATION

We uncovered a central function for AMH in the regulation of fertility by remodeling GnRH terminals and their tanycytic sheaths, and provided insights into the pivotal role of the brain in the establishment and maintenance of neuroendocrine dysfunction in PCOS.

FUNDING

INSERM (U1172), European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (grant agreement n° 725149), CHU de Lille, France (Bonus H).

An online tool for predicting ovarian responses in unselected patients using dynamic inhibin B and basal antimüllerian hormone levels

BACKGROUND

Reliable predictive models for predicting excessive and poor ovarian response in controlled ovarian stimulation (COS) is currently lacking. The dynamic (Δ) inhibin B, which refers to increment of inhibin B responding to exogenous gonadotropin, has been indicated as a potential predictor of ovarian response.

OBJECTIVE

To establish mathematical models to predict ovarian response at the early phase of COS using Δinhibin B and other biomarkers.

MATERIALS AND METHODS

Prospective cohort study in a tertiary teaching hospital, including 669 cycles underwent standard gonadotropin releasing hormone (GnRH) antagonist ovarian stimulation between April 2020 and September 2020. Early Δinhibin B was defined as an increment in inhibin B from menstrual day 2 to day 6 through to the day of COS. Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression with 5-fold cross-validation was applied to construct ovarian response prediction models. The area under the receiver operating characteristic curve (AUC), prevalence, sensitivity, and specificity were used for evaluating model performance.

RESULTS

Early Δinhibin B and basal antimüllerian hormone (AMH) levels were the best measures in building models for predicting ovarian hypo- or hyper-responses, with AUCs and ranges of 0.948 (0.887-0.976) and 0.904 (0.836-0.945) in the validation set, respectively. The contribution of the early Δinhibin B was 67.7% in the poor response prediction model and 56.4% in the excessive response prediction model. The basal AMH level contributed 16.0% in the poor response prediction model and 25.0% in the excessive response prediction model. An online website-based tool (http://121.43.113.123:8001/) has been developed to make these complex algorithms available in clinical practice.

CONCLUSION

Early Δinhibin B might be a novel biomarker for predicting ovarian response in IVF cycles. Limiting the two prediction models to the high and the very-low risk groups would achieve satisfactory performances and clinical significance. These novel models might help in counseling patients on their estimated ovarian response and reduce iatrogenic poor or excessive ovarian responses.

Age-related changes in Folliculogenesis and potential modifiers to improve fertility outcomes - A narrative review

Reproductive aging is characterized by a decline in oocyte quantity and quality, which is directly associated with a decline in reproductive potential, as well as poorer reproductive success and obstetrical outcomes. As women delay childbearing, understanding the mechanisms of ovarian aging and follicular depletion have become increasingly more relevant. Age-related meiotic errors in oocytes are well established. In addition, it is also important to understand how intraovarian regulators change with aging and how certain treatments can mitigate the impact of aging. Individual studies have demonstrated that reproductive pathways involving antimullerian hormone (AMH), vascular endothelial growth factor (VEGF), neurotropins, insulin-like growth factor 1 (IGF1), and mitochondrial function are pivotal for healthy oocyte and cumulus cell development and are altered with increasing age. We provide a comprehensive review of these individual studies and explain how these factors change in oocytes, cumulus cells, and follicular fluid. We also summarize how modifiers of folliculogenesis, such as vitamin D, coenzyme Q, and dehydroepiandrosterone (DHEA) may be used to potentially overcome age-related changes and enhance fertility outcomes of aged follicles, as evidenced by human and rodent studies.

Anti-Mullerian Hormone as a Marker of Ovarian Reserve and Function

Background: Ovarian reserve tests are required to screen women with a diminished ovarian reserve so that women who are more likely to exhibit poor response to ovarian stimulation and a lower likelihood of becoming pregnant with treatment can be identified.

Aim and Objectives: This study aimed to determine whether serum anti-Mullerian hormone (AMH) level is a better predictor of ovarian reserve and function than other biochemical tests for ovarian reserve. The primary objective of this study was to find out the correlations of day 3 serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, inhibin B, AMH, ovarian volume, and antral follicle count (AFC) with advancing age; and a secondary objective was to find out the correlations between day 3 serum AMH, LH, FSH, estradiol, and inhibin B levels with AFC.

Methods: This was a prospective, single-center, observational study. A total of 100 infertile women who attended the Gynecology outpatient department over a period of two years and met the inclusion criteria were included in the study. History, clinical examination, routine investigations, hysterosalpingography for tubal patency, estimation of day 3 serum AMH, LH, FSH, estradiol and inhibin B, measurement of ovarian volume, and AFC were done. Correlations of different parameters with advancing age and with AFC were found using Spearman’s rho correlations. p-value < 0.05 was considered significant.

Results: The maximum infertile women were in the age group of 21-30 years (58 of 100). Serum AMH showed the strongest negative correlation (r=-0.931) with age, followed by AFC (r=-0.884), ovarian volume (r=-0.876), and inhibin B (r=-0.878), whereas serum LH, FSH, and estradiol showed a positive correlation (r=0.589, 0.408, and 0.638 respectively). Serum AMH also showed a strong positive correlation (r=0.972) with AFC followed by ovarian volume (r=0.919) and inhibin B (r=0.769), whereas serum LH, FSH, and estradiol showed a negative correlation (r=-0.504, -0.663, and -0.543 respectively) with AFC. 

Conclusion: Among all the different tests of ovarian reserve, serum AMH was the most reliable indicator of reproductive aging and decline in the ovarian pool as well as very closely related to AFC, which is one of the best predictors of ovarian reserve.

The effect of medication on serum anti-müllerian hormone (AMH) levels in women of reproductive age: a meta-analysis

OBJECTIVE

The study aims to address whether serum anti-müllerian hormone (AMH) levels fluctuate in the short term after medication application, including oral contraceptives (OCs), metformin (MET), Gonadotropin-releasing hormone agonist (GnRH-a), dehydroepiandrosterone (DHEA), vitamin D (VD), clomiphene citrate (CC), and letrozole (LET).

METHODS

Published literature from PubMed, Embase, and Cochrane central was retrieved up until 19 September 2021. A total of 51 self-control studies with an average Newcastle-Ottawa quality assessment scale (NOS) score of 6.90 were analyzed. The extracted data were entered into Stata software, and the weighted mean difference/standardized mean difference (WMD/SMD) and 95% confidence interval (CI) were used for data analysis.

RESULTS

After OCs treatment the AMH level showed a significant decline in women with normal ovarian function, which was significant within 3 months (WMD = -1.43, 95% CI: -2.05 to -0.80, P < 0.00001). After MET treatment, the serum AMH decreased in polycystic ovary syndrome (PCOS) patients (WMD = -1.79, 95% CI: -2.32 to -1.26, P < 0.00001), in both obese and non-obese patients. GnRH-a treatment in endometriosis patients led to dynamic changes in the serum AMH levels, that is, ascent at 1 month (P = 0.05), and descent at 3 months (P = 0.02). After DHEA treatment the serum AMH increased in diminished ovarian reserve (DOR) / poor ovarian response (POR) patients (WMD = 0.18, 95% CI: 0.09 to 0.27, P < 0.0001). After VD treatment the serum AMH increased, and it was obvious in non-PCOS patients (WMD = 0.78, 95% CI: 0.34 to 1.21, P = 0.0004). After CC treatment the serum AMH decreased significantly in PCOS patients, specifically in non-obese patients (WMD = -1.24, 95% CI: -1.87 to -0.61, P = 0.0001).

CONCLUSIONS

Serum AMH levels may be affected in the short term after drug application. Specifically, OC, MET and CC lead to decreased AMH level, DHEA and VD lead to increased AMH level, and GnRH-a leads to dynamic variation, which is correlated with PCOS, obesity, age, and duration of medication. The impacts of these medications should be taken into consideration when AMH is used as a marker of ovarian reserve.

Regulation of antral follicular growth by an interplay between gonadotropins and their receptors

Knowledge of the growth and maturation of human antral follicles is based mainly on concepts and deductions from clinical observations and animal models. To date, new experimental approaches and in vitro data contributed to a deep comprehension of gonadotropin receptors' functioning and may provide new insights into the mechanisms regulating still unclear physiological events. Among these, the production of androgen in the absence of proper LH levels, the programming of follicular atresia and dominance are some of the most intriguing. Starting from evolutionary issues at the basis of the gonadotropin receptor signal specificity, we draw a new hypothesis explaining the molecular mechanisms of the antral follicular growth, based on the modulation of endocrine signals by receptor-receptor interactions. The "heteromer hypothesis" explains how opposite death and life signals are delivered by gonadotropin receptors and other membrane partners, mediating steroidogenesis, apoptotic events, and the maturation of the dominant follicle.

The association of parity and breastfeeding with anti-Müllerian hormone levels at two time points

OBJECTIVE

To evaluate the association between parity and breastfeeding and anti-Müllerian hormone levels (AMH) and change in AMH levels over time. Furthermore, we examined whether AMH levels mediate the relation of parity and breastfeeding with age at menopause.

STUDY DESIGN

Observational, prospective cohort study.

MAIN OUTCOME MEASURES

AMH levels were assessed in a subset of premenopausal participants in the Nurses' Health Study II, including 1619 women who provided a blood sample in 1996-1999 and an additional 800 women who provided a second premenopausal sample in 2010-2012.

RESULTS

In multivariable linear regression models adjusted for parity, body mass index, smoking, and other factors, mean log AMH levels in 1996-1999 were 39% higher in women reporting ≥25 months of total breastfeeding vs. <1 month (P for trend = 0.009). Parity was not associated with AMH levels after adjustment for breastfeeding. Neither parity nor breastfeeding was associated with decline in AMH levels over 11 to 15 years. Breastfeeding duration was positively associated with age at menopause (P for trend = 0.01), with evidence that the association was mediated via AMH.

CONCLUSIONS

Our results suggest that breastfeeding is associated with higher AMH levels and later onset of menopause, and support the hypothesis that observed relations of parity with AMH levels and menopause timing may be largely attributable to breastfeeding.

The putative roles of FSH and AMH in the regulation of oocyte developmental competence: from fertility prognosis to mechanisms underlying age-related subfertility

BACKGROUND

Fertility loss during female ageing is associated with increasing basal FSH and decreasing anti-Müllerian hormone (AMH) concentrations, together with compromised oocyte quality, presumably due to increased oxidative stress (OS) and DNA damage, as well as reduced metabolic and meiotic competences. Basal FSH and AMH circulatory concentrations have been broadly utilized as IVF success predictors, regardless of fluctuations in prognostic accuracy; basal FSH and AMH perform better in pre-advanced maternal age (AMA: >35 years) and AMA patients, respectively. The relationships between FSH and AMH intrafollicular levels and IVF outcomes suggest, nevertheless, that both hormones regulate oocyte competence, supporting the hypothesis that changes in FSH/AMH levels cause, at least in part, oocyte quality degradation during ageing. To understand the reasons behind the fluctuations in FSH and AMH prognostic accuracies and to clarify their participation in mechanisms determining oocyte competence and age-related subfertility, a deeper knowledge of the regulation of FSH and AMH intrafollicular signalling during the female reproductive lifespan, and of their effects on the cumulus-oocyte complex, is required.

OBJECTIVE AND RATIONALE

An extensive body of information on the regulation of FSH and AMH intrafollicular availability and signalling, as well as on the control of folliculogenesis and oocyte metabolism, has been accumulated. However, these datasets have been explored within the relatively narrow boundaries of their specific subjects. Given the aforementioned gaps in knowledge and their clinical relevance, herein we integrate clinical and basic data, within a wide biological perspective, aiming to shed light on (i) the reasons for the variability in the accuracy of serum FSH and AMH as fertility markers, and on (ii) the potential roles of these hormones in mechanisms regulating oocyte quality, particularly those associated with ageing.

SEARCH METHODS

The PubMed database encompassing the period between 1960 and 2021 was searched. Principal search terms were FSH, FSH receptor, AMH, oocyte, maternal age, cumulus, transzonal projections (TZPs), actin, OS, redox, reactive oxygen species, mitochondria, DNA damage, DNA repair, aneuploidy, spindle, meiosis, gene expression, transcription, translation, oocyte secreted factors (OSFs), cAMP, cyclic guanosine monophosphate, natriuretic peptide C, growth differentiation factor 9, bone morphogenetic protein 15 and fibroblast growth factor.

OUTCOMES

Our analysis suggests that variations in the accuracy of fertility prognosis reflect a modest association between circulatory AMH levels and oocyte quality as well as increasing basal FSH inter-cycle variability with age. In addition, the basic and clinical data articulated herein support the hypothesis that increased intrafollicular FSH levels, as maternal age advances, may override the physiological protective influences of AMH and OSFs against excessive FSH signalling in cumulus cells. This would result in the disruption of oocyte homeostasis via reduced TZP-mediated transfer of cumulus-derived molecules essential for meiotic competence, gene expression, redox activity and DNA repair.

WIDER IMPLICATIONS

In-depth data analysis, encompassing a wide biological perspective has revealed potential causative mechanisms of age-related subfertility triggered by alterations in FSH/AMH signalling during the female reproductive life. Insights from new mechanistic models arising from this analysis should contribute to advancing our comprehension of oocyte biology in humans and serve as a valuable reference for novel AMA subfertility treatments aimed at improving oocyte quality through the modulation of AMH/FSH action.

Anti-Müllerian Hormone in Female Reproduction

Anti-Müllerian hormone (AMH), also called Müllerian inhibiting substance, was shown to be synthesized by the ovary in the 1980s. This article reviews the main findings of the past 20 years on the regulation of the expression of AMH and its specific receptor AMHR2 by granulosa cells, the mechanism of action of AMH, the different roles it plays in the reproductive organs, its clinical utility, and its involvement in the principal pathological conditions affecting women. The findings in respect of regulation tell us that AMH and AMHR2 expression is mainly regulated by bone morphogenetic proteins, gonadotropins, and estrogens. It has now been established that AMH regulates the different steps of folliculogenesis and that it has neuroendocrine effects. On the other hand, the importance of serum AMH as a reliable marker of ovarian reserve and as a useful tool in the prediction of the polycystic ovary syndrome (PCOS) and primary ovarian failure has also been acknowledged. Last but not least, a large body of evidence points to the involvement of AMH in the pathogenesis of PCOS.

Contribution of recruitable follicles to circulating anti-Müllerian hormone levels following maximal gonadotrophin stimulation in patients with limited ovarian reserve

In women, the majority of anti-Müllerian hormone (AMH) measured in serum originate from small antral follicles measuring 2-10 mm. In gonadotrophin-stimulated cycles prior to assisted reproductive technology (ART), most of the recruitable follicles develop beyond 10 mm in size and thus lose their AMH secretion capacity causing declining serum AMH levels. The aim of this study was to define the residual serum AMH level after elimination of the AMH producing recruitable follicles following maximal gonadotrophin stimulation. We measured serum AMH and number of follicles according to size at several time points during a cycle of maximal gonadotrophin stimulation (fixed dose of 300 IE HP-hMG) in 107 women with low AMH (median AMH 5 pmol/L, interquartile range (IQR) 3.3-8.3). We found that AMH decreased gradually and reached a minimum level of -55.4% (95% CI -59.6; -50.7) of the baseline value four days after ovulation trigger. Our findings suggest that the residual AMH production origins from pre-antral and small antral follicles not visible by sonography and that they account for up to 40% of the circulating AMH.

Live birth rate comparison of three controlled ovarian stimulation protocols for in vitro fertilization-embryo transfer in patients with diminished ovarian reserve after endometrioma cystectomy: a retrospective study

Background

Women with endometriosis and previous cystectomy may respond less well to gonadotropin stimulation, which results in fewer oocytes retrieved and poor pregnancy outcomes. Choosing an appropriate protocol for such populations is essential. This study involved an analysis of the effect of different controlled ovarian stimulation (COS) protocols on the clinical outcomes of in vitro fertilization-embryo transfer (IVF-ET) in women with diminished ovarian reserve (DOR) who underwent ovarian endometrioma cystectomy.

Methods

A total of 342 patients that underwent IVF-ET treatment at the Beijing Obstetrics and Gynecology Hospital from January 1, 2013 to April 30, 2018 were included in this retrospective study. The patients were distributed into three groups according to the COS protocols, namely prolonged GnRH-agonist (Group A, n = 113), GnRH-antagonist (Group B, n = 121), and long GnRH-agonist (Group C, n = 108). The clinical and laboratory parameters of the three protocols were analyzed and a logistic regression of clinical pregnancy and live births was conducted.

Results

There were no significant differences in the age, infertility duration, basic follicle stimulation hormone (FSH), luteinizing hormone (LH), or estradiol (E₂) levels as well as other baseline characteristics among groups (P > 0.05). The total gonadotrophin (Gn) dosage and duration tended to be less in the GnRH-antagonist group than in the others (P < 0.05). No significant differences were found in the implantation rate and clinical pregnancy rate among the groups, but the prolonged GnRH-agonist group showed the highest rates. In addition, no significant differences were present in the number of retrieved oocytes, oocyte fertilization rate, embryo utilization rate, live birth rate, abortion rate, ectopic pregnancy rate, or multiple pregnancy rate in the three groups (P > 0.05). Age had a significant effect on both clinical pregnancy and live birth.

Conclusion

For those DOR patients who had undergone ovarian endometriosis cystectomy, the prolonged GnRH-agonist protocol may achieve better clinical IVF-ET outcomes, but there were no significant differences from the other groups. The GnRH-antagonist protocol may reduce the cost and time of drug treatment. Age should be considered for its influence on pregnancy outcome. However, a larger sample size may be needed for further study.

Clinical Application of AMH Measurement in Assisted Reproduction

Anti-Müllerian hormone reflects the continuum of the functional ovarian reserve, and as such can predict ovarian response to gonadotropin stimulation and be used to individualize treatment pathways to improve efficacy and safety. However, consistent with other biomarkers and age-based prediction models it has limited ability to predict live birth and should not be used to refuse treatment, but rather to inform counselling and shared decision making. The use of absolute clinical thresholds to stratify patient phenotypes, assess discordance and individualize treatment protocols in non-validated algorithms combined with the lack of standardization of assays may result in inappropriate classification and sub-optimal clinical decision making. We propose that holistic baseline phenotyping, incorporating antral follicle count and other patient characteristics is critical. Treatment decisions driven by validated algorithms that use ovarian reserve biomarkers as continuous measures, reducing the risk of misclassification, are likely to improve overall outcomes for our patients.

Genes for anti-Müllerian hormone and androgen receptor are underexpressed in human cumulus cells surrounding morphologically highly graded oocytes

Objectives:

The aim of this study was to investigate the expression of genes crucial for the quality of the oocyte and whether expression levels of these genes in cumulus cells can be biological markers for the quality of the oocyte, zygote or embryo, or even for achievement of pregnancy after the assisted reproductive technology procedure. We examined the expression profile of the anti-Müllerian hormone (AMH) gene and its respective receptors: anti-Müllerian hormone receptor type 2 (AMHR2), follicle-stimulating hormone receptor (FSHR) and androgen receptor (AR) in cumulus cells (CCs) surrounding the oocyte, as well as AMH concentrations in follicular fluid of the associated follicle. The obtained gene expression levels were correlated with the morphological quality of the associated oocyte, zygote and embryo as well as with assisted reproductive technology outcome following the intracytoplasmic sperm injection procedure.

Methods:

This study involved 129 cumulus cells and 35 follicular fluid samples, taken from 58 patients undergoing the intracytoplasmic sperm injection procedure. Oocytes, zygotes and embryos were assessed for morphological quality. The relative gene expression of AMH, AMHR2, FSHR and AR was calculated using the delta–delta Ct method. Anti-Müllerian hormone concentrations in follicular fluids were measured by enzyme-linked immunosorbent assay.

Results:

The results yielded suggest a relationship between AMH, AR and oocyte morphology: AMH and AR gene expression levels in CCs surrounding morphologically optimal oocytes were significantly lower than in CCs surrounding oocytes with suboptimal morphology (p = 0.011 and p = 0.008, respectively). Statistically significant positive correlation was found between mRNA expression levels of AMH and FSHR (p < 0.001), AMH and AR (p = 0.001), AMHR2 and FSHR (p < 0.001), AMHR2 and AR (p < 0.001), as well as between FSHR and AR (p < 0.001).

Conclusion:

Assessed results point to AMH and AR relation with oocyte maturity, but not with its fertilization potential, or with embryo quality.

Comparison of Automated Anti-Müllerian Hormone Assays and Antral Follicle Count in Predicting Ovarian Response During Ovarian Stimulation

Objective: Various parameters had been used to predict ovarian response. Among them, Anti-Müllerian Hormone (AMH) and antral follicle count (AFC) demonstrate the most favourable analytical and performance characteristics. In this pilot study, we aim to determine the cut-off levels of AMH using automated AMH assays and AFC in the prediction of poor and high responders.

Study Design: Prospective study of 43 women between 21 to 45 years old scheduled for assisted reproduction. AMH levels on day 3 of menstruation were analysed using two immunoassay kits, namely the Beckman Coulter Access AMH and the Roche Elecsys AMH on the two automated analysers Beckman Coulter DxI 800 and Roche Cobas e602 respectively. AFC was also assessed on day 3 of menstruation prior to in vitro fertilization (IVF). These were compared with the number of oocytes retrieved after controlled ovarian stimulation.

Results: AMH (Beckman Coulter Access AMH and Roche Elecsys AMH) highly correlated with AFC and the number of oocytes retrieved after ovarian stimulation. Beckman Coulter Access AMH was the better predictor for poor ovarian response with ROC [Formula: see text] of 0.83. For the prediction of a high response, AFC had a higher ROC [Formula: see text] of 0.95. Through ROC, the AMH cut-off level for poor ovarian response was 2.23 ng/ml with Beckman Coulter Access AMH and 2.02 ng/ml with Roche Elecsys AMH, while the AMH cut-off for a high ovarian response was 5.19 ng/ml with Beckman Coulter Access AMH and 4.60 ng/ml with Roche Elecsys AMH. For AFC, the cut-off for poor ovarian response was 18 and for high response was 34.

Conclusion: AMH and AFC are reliable predictors of ovarian response. Establishment of specific levels may improve individualised controlled ovarian stimulation and optimise the oocyte yield. Larger studies are required to establish these findings.

Oocyte-Derived Factors (GDF9 and BMP15) and FSH Regulate AMH Expression Via Modulation of H3K27AC in Granulosa Cells

Anti-Müllerian hormone (AMH) produced by ovarian granulosa cells (GCs) plays a crucial role in ovarian function. It is used as a diagnostic and/or prognostic marker of fertility as well as for pathophysiological conditions in women. In this study, we investigated the underlying mechanism for regulation of AMH expression in GCs using primary mouse GCs and a human GC tumor-derived KGN cell line. We find that growth differentiation factor 9 (GDF9) and bone morphogenetic factor 15 (BMP15) together (GDF9 + BMP15), but not when tested separately, significantly induce AMH expression in vitro and in vivo (serum AMH). Our results show that GDF9 + BMP15 through the PI3K/Akt and Smad2/3 pathways synergistically recruit the coactivator p300 on the AMH promoter region that promotes acetylation of histone 3 lysine 27 (H3K27ac), facilitating AMH/Amh expression. Intriguingly, we also find that FSH inhibits GDF9 + BMP15-induced increase of AMH/Amh expression. This inhibition occurs through FSH-induced protein kinase A/SF1-mediated expression of gonadotropin inducible ovarian transcription factor 1, a transcriptional repressor, that recruits histone deacetylase 2 to deacetylate H3K27ac, resulting in the suppression of AMH/Amh expression. Furthermore, we report that ovarian Amh mRNA levels are significantly higher in Fshβ-null mice (Fshβ-/-) compared with those in wild-type (WT) mice. In addition, ovarian Amh mRNA levels are restored in Fshβ-null mice expressing a human WT FSHβ transgene (FSHβ-/-hFSHβWT). Our study provides a mechanistic insight into the regulation of AMH expression that has many implications in female reproduction/fertility.

Novel insights into the pathophysiology of chemotherapy-induced damage to the ovary

Cancer is the second leading cause of death in the USA and is considered a public health issue worldwide. Early diagnosis and advancement of treatment modalities contributed to declining mortality rates. Consequently, survival rates increased, leading to a greater interest in maintaining the quality of life after cancer treatment. Overall survival and disease-free survival rates are improved with the use of adjuvant chemotherapy. However, chemotherapy treatment might cause short and long-term side effects for cancer survivors. A special concern of young women diagnosed with cancer is their reproductive potential after chemotherapy. Chemotherapy drugs act by distinct mechanisms in the ovaries. DNA damage of primordial follicle oocytes, leading to chemotherapy-induced apoptosis, was recognized as the principal mechanism responsible for the irreversible decline of the ovarian reserve. The oocyte first attempts to repair DNA damage via the DNA damage repair pathway mediated by ataxia-telangiectasia mutated. Elimination through apoptosis occurs in cells in which DNA damage could not be repaired. In this review, the clinical impact and the major mechanisms of ovarian damage from chemotherapy treatment will be briefly described.

Serum anti-Müllerian hormone dynamics in mares following immunocontraception with anti-zona pellucida or -GnRH vaccines

Circulating anti-Müllerian hormone concentration (AMH) is positively correlated to the number of small growing follicles in the mare and may reflect ovarian function. Dynamics of AMH during immunocontraception have not previously been investigated. This study aimed to compare serum AMH in mares following treatment with native porcine zona pellucida (pZP), recombinant pZP3 and pZP4 (reZP) or gonadotrophin releasing hormone (GnRH) vaccines, and saline-treated controls. Stored sera collected during two previous studies examining ovarian activity in mares during zona pellucida (ZP) or GnRH immunocontraception were analysed for serum AMH. Data were compared among treatment groups using mixed-effects linear regression and one-way ANOVA with post hoc testing. Correlations between AMH and previously reported clinical variables were estimated using Spearman's rho. Mares immunized against GnRH showed variable but detectable AMH throughout successive breeding and non-breeding seasons that were not significantly different to unvaccinated control mares. Mares treated with pZP demonstrated marked, reversible suppression of AMH. Mares immunized using reZP showed an intermediate effect. In the ZP study, AMH was positively correlated to serum progesterone concentrations, mean ovarian volumes and antral follicle counts, whereas no correlations between AMH and serum progesterone concentrations, mean ovarian volumes, or the presence of one or more follicles ≥20 mm in diameter were detected in the GnRH study. In conclusion, marked suppression of AMH during pZP immunocontraception, but not during GnRH immunocontraception, suggested enhanced suppression of ovarian follicular development and, or follicular function during pZP immunocontraception. Serum AMH concentrations may provide a novel tool for the assessment of ovarian function during ZP-based immunocontraception.

Anti-Mullerian Hormone in Premenopausal Women and After Spontaneous or Surgically Induced Menopause

OBJECTIVE

The objectives of this study were: (1) to determine anti-Mullerian hormone (AMH) levels in menopausal women, and (2) to confirm the source of AMH in cycling women and its disappearance after the removal of the source.

METHODS

An observational and prospective study was conducted.

RESULTS

A total of 47 women were recruited for the study. The study population consisted of the following groups of patients: (A) women of late reproductive age (n = 24; mean age +/- SD, 44 +/- 2.8 years); (B) menopausal women (n =14; mean age, 56 +/- 4 years); and (C) regularly cycling women undergoing surgical menopause (n = 9; mean age, 43 +/- 4 years). Blood samples were obtained from all patients. In patients undergoing surgery, blood samples were obtained before and after surgery. AMH was undetectable in 13 of 14 postmenopausal women, whereas it was undetectable in only two of 24 women of late reproductive age. A significant negative correlation has been found between AMH and age or follicle-stimulating hormone (FSH) in women of late reproductive age. In women who were candidates for oophorectomy, samples were obtained 3-5 days after surgery. AMH was undetectable after the surgery in all women.

CONCLUSIONS

We found that AMH levels decreased in women in the late reproductive period and that menopause and ovariectomy in regularly cycling women are associated to undetectable AMH in serum. These observations confirm that the ovary could be the only source of AMH in women and that it is a novel marker for ovarian aging.

Interactions between androgens, FSH, anti-Müllerian hormone and estradiol during folliculogenesis in the human normal and polycystic ovary

BACKGROUND

Androgens, FSH, anti-Müllerian hormone (AMH) and estradiol (E2) are essential in human ovarian folliculogenesis. However, the interactions between these four players is not fully understood.

OBJECTIVES AND RATIONALE

The purpose of this review is to highlight the chronological sequence of the appearance and function of androgens, FSH, AMH and E2 and to discuss controversies in the relationship between FSH and AMH. A better understanding of this interaction could supplement our current knowledge about the pathophysiology of the polycystic ovary syndrome (PCOS).

SEARCH METHODS

A literature review was performed using the following search terms: androgens, FSH, FSH receptor, anti-Mullerian hormone, AMHRII, estradiol, follicle, ovary, PCOS, aromatase, granulosa cell, oocyte. The time period searched was 1980-2015 and the databases interrogated were PubMed and Web of Science.

OUTCOMES

During the pre-antral ('gonadotropin-independent') follicle growth, FSH is already active and promotes follicle growth in synergy with theca cell-derived androgens. Conversely, AMH is inhibitory by counteracting FSH. We challenge the hypothesis that AMH is regulated by androgens and propose rather an indirect effect through an androgen-dependent amplification of FSH action on granulosa cells (GCs) from small growing follicles. This hypothesis implies that FSH stimulates AMH expression. During the antral ('gonadotropin-dependent') follicle growth, E2 production results from FSH-dependent activation of aromatase. Conversely, AMH is inhibitory but the decline of its expression, amplified by E2, allows full expression of aromatase, characteristic of the large antral follicles. We propose a theoretical scheme made up of two triangles that follow each other chronologically. In PCOS, pre-antral follicle growth is excessive (triangle 1) because of intrinsic androgen excess that renders GCs hypersensitive to FSH, with consequently excessive AMH expression. Antral follicle growth and differentiation are disturbed (triangle 2) because of the abnormally persisting inhibition of FSH effects by AMH that blocks aromatase. Beside anovulation, this scenario may also serve to explain the higher receptiveness to gonadotropin therapy and the increased risk of ovarian hyperstimulation syndrome (OHSS) in patients with PCOS.

WIDER IMPLICATIONS

Within GCs, the balance between FSH and AMH effects is pivotal in the shift from androgen- to oestrogen-driven follicles. Our two triangles hypothesis, based on updated data from the literature, offers a pedagogic template for the understanding of folliculogenesis in the normal and polycystic ovary. It opens new avenues for the treatment of anovulation due to PCOS.

Maternal antimullerian hormone as a predictor of fetal aneuploidy occurring in an early pregnancy loss

Objective

The purpose of the study was to examine the relationship between the parameter representing ovarian reserve and the fetal aneuploidy in early spontaneous miscarriage.

Methods

A multicenter retrospective cohort study was performed in patients who were diagnosed with early pregnancy loss (≤13 gestational weeks) and examined for fetal karyotype at the CHA Gangnam Medical Center, CHA Bundang Medical Center, and CHA Gumi Medical Center between January 2011 and December 2012. Karyotyping was performed by the Genetic Laboratory of the Fertility Center of CHA Gangnam Medical Center. Medical records were reviewed for demographics, karyotype analysis and hormonal assay of ovarian reserve including antimullerian hormone (AMH) and follicle stimulating hormone. Statistical analysis was performed using SPSS software.

Results

A total 462 patients were included in this study. The mean age of the patients was 35.31±4.12 years and the mean AMH level was 3.88±3.50 ng/mL (n=195). Two hundred eleven conceptuses (45.7%) of patients showed the euploid and 251 (54.3%) showed the aneuploid. There are significant differences in maternal age, AMH and gestational age between fetal euploid and aneuploid groups (34.46±4.35 vs. 36.04±3.78 years, P<0.001; 4.60±3.86 vs. 3.43±3.18 ng/mL, P=0.022; 7.67±1.54 vs. 8.27±1.46 weeks, P<0.001, respectively). Multivariate analysis revealed that low AMH level and early gestational age were maternal age-independent markers for fetal aneuploid (P<0.001 and P=0.045, respectively).

Conclusion

Low maternal AMH level might be a predicting marker for fetal aneuploid in early pregnancy loss.

AMH levels at central precocious puberty and premature thelarche: is it a parameter?

BACKGROUND

The possible difference of antimüllerian hormone (AMH) levels at central precocious puberty (CPP) and premature thelarche (PT) has not been properly evaluated.

OBJECTIVE/HYPOTHESIS

By evaluating AMH levels in girls with diagnosed CPP and PT, we aim to show the change of AMH levels at the pubertal onset.

SUBJECTS

Sixty-five girls who have breast development before the age of 8 years and 25 healthy girls were enrolled in the study.

METHODS

The subjects were divided into two groups as CPP and PT, according to results of GnRH test. AMH levels were determined in the two groups.

RESULTS

The mean AMH levels of the CPP group were significantly lower than those in the PT group (13.57±9.85 pmol/L and 58.42±12.78 pmol/L, respectively, p=0.022).

CONCLUSION

These results suggest that the AMH levels decrease in the duration of the hypothalamus-pituitary-ovarian axis activation. We thought that AMH might/may be a marker for distinguishing between CPP and PT.

Anti-Mullerian hormone as a predictor of ovarian reserve in ART protocols: the hidden role of thyroid autoimmunity

BACKGROUND

Protocols of controlled ovarian hyper-stimulation (COH) require, as a crucial step, the identification of reliable predictors of ovarian reserve. Anti-Mullerian hormone (AMH) is one of the most reliable predictors of ovarian reserve but other factors including autoimmune thyroid diseases (ATD) have been associated with reduced fertility and poor COH outcome. Aim of the present study was to evaluate the relationship between ATD and AMH, and their role on the outcome of COH.

METHODS

The study group included 288 sub-fertile euthyroid women aged less than 40 years attending a single center for Reproductive Medicine. Among them, 55 were ATD-positive and 233 ATD-negative. The serum levels of AMH, FSH, LH, estradiol (E2), and TSH were measured before COH. The ratio between serum E2 concentration on the day of oocytes pick-up and the total dose of administered recombinant FSH (r-FSH) (E2/r-FSH ratio) was calculated.

RESULTS

The serum levels of AMH were significantly related to E2/r-FSH ratio, total dose of r-FSH and number of M II oocytes, both in ATD-positive and ATD-negative women. Within the low stratum of AMH levels, the presence of ATD did not further affect the outcome of COH. When the serum levels of AMH were in the high stratum, the presence of ATD significantly affected the E2/rFSH ratio, the total dose of r-FSH and the number of M II oocytes.

CONCLUSIONS

The probability of a poor response to COH is high, and independent from ATD, in women with low AMH serum levels. In women with a good ovarian reserve, as assessed by high AMH serum levels, the presence of ATD impairs the outcome of COH.

Effects of GnRH agonists on the expression of developmental follicular anti-mullerian hormone in varying follicular stages in cyclic mice in vivo

Gonadotrophin‑releasing hormone (GnRH) agonists (GnRHa) have been widely used to induce a state of downregulation for in vitro fertilization, and its direct effects on the pituitary are well known. However, the effects of GnRHa on the expression of anti‑mullerian hormone (AMH) by follicles in varying stages in vivo remain to be fully elucidated. In the present study 84 cyclic mice were randomly divided equally into four GnRHa groups and three cyclic mice were used as a control group. The expression levels of AMH in follicles of varying stages between days 0 and 7 following GnRHa administration were quantified using immunohistochemistry. The expression of AMH in follicles at various stages revealed dynamic changes during the process of downregulation. AMH in primary follicles initially increased and then decreased gradually. In small and large preantral follicles and in granulosa cells (GCs) surrounding the oocyte of small antral follicles, the expression of AMH began to increase on day 1, was attenuated on day 2, and then increased to a peak. The expression levels of AMH in the GCs surrounding the basement membrane, in contrast to the GCs surrounding the oocyte, were significantly lower and did not increase on day 1. In all stages of follicles, the expression of AMH declined gradually between the peak level and last day of downregulation. On day 7, the varying follicular stages all expressed lower levels of AMH than on day 0. This decrease was more prominent in the higher dose groups, compared with the lower dose groups. In conclusion, GnRHa was observed to induce time‑dependent changes in the expression of AMH at varying follicular stages, which occurred in a dose‑dependent manner.

Cut-Off Levels of Anti-Mullerian Hormone for The Prediction of Ovarian Response, In Vitro Fertilization Outcome and Ovarian Hyperstimulation Syndrome

Background

Evaluation of anti-mullerian hormone (AMH) cut-off levels in as- sisted reproductive technology (ART) as predictive factor for individualization of stimulation protocols and to avoid ovarian hyperstimulation syndrome (OHSS).

Materials and Methods

In a retrospective study, 177 infertile patients were as- sessed for AMH in serum and follicular fluid (FF) on the day of follicular puncture (FP), between 2012 and 2013 in Kiel, Germany. AMH levels and pregnancy rates were compared between low, moderate and high responders and cut-off levels of low and high responders. AMH cut-off levels in pathological cases were evaluated in analysis 1 (OHSS) and in analysis 2 [polycystic ovarian syndrome, (PCOS)] and compared in analysis 3 to normal endocrinological parameters.

Results

AMH levels in FF were higher than in serum (P<0.001). AMH levels in serum and FF increased from low through moderate to high responders (P<0.001). Pregnancy rates were 14.7, 23.3 and 44.9% (P=0.009), respectively. AMH cut-off level for poor responders was 0.61 ng/ml in serum with a pregnancy rate of 13.8 and 37.1% for below and above of this level, respectively. For FF, it was 1.43 ng/ml. AMH levels in analysis 1 and 2 were significantly higher than in analysis 3 (P=0.001). AMH cut-off level for OHSS was 1.5 ng/ml in serum with OHSS rates of 80.8 and 19.2 % for above and below of the level, respectively. For FF, it was 2.7 ng/ml. PCOS patients had an AMH cut-off level of 3.9 ng/ml in serum and 6.8 ng/ml in FF, resulting in a PCOS rate of 100% above this level.

Conclusion

AMH levels can help to assess ovarian response potential and guide ovarian stimulation while avoiding OHSS.

Circulating anti-Müllerian hormone levels in relation to nutritional status and selected adipokines levels in polycystic ovary syndrome

OBJECTIVE

The aim of the study was to analyse the relationship between nutritional status, selected adipokines and plasma anti-Müllerian hormone (AMH) levels in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN PATIENTS AND MEASUREMENTS

A prospective, cross-sectional study, involving 87 PCOS (48 obese) women and 67 non-PCOS women (36 obese). Anthropometric parameters were measured, and body composition was determined by the bioimpedance method. Fasting serum glucose, androgens, FSH, LH, SHBG, insulin, AMH, apelin-36, adiponectin, leptin and omentin-1 were measured.

RESULTS

Plasma AMH levels were significantly higher in PCOS compared to the non-PCOS group (7.8 ± 4.3 ng/ml vs 44 ± 2.4 ng/ml; P < 0.001). Furthermore, AMH levels were higher in both PCOS and non-PCOS normal weight than in obese subgroups (8.9 ± 4.4 ng/ml vs 7.0 ± 4.0 ng/ml; P < 0.05 and 5.1 ± 2.4 ng/ml vs 3.9 ± 2.3 ng/ml; P < 0.05). There were negative correlations between AMH levels and anthropometric parameters (body mass, BMI, fat mass and percentage, as well as waist circumference) and plasma omentin-1 concentrations (R = -0.28, P < 0.001; R = -0.30, P < 0.001; R = -0.36, P < 0.001; R = -0.34, P < 0.001; R = -0.23, P < 0.01; and R = -0.20, P < 0.05, respectively) in all study groups. In multiple regression analysis, circulating AMH level variability was explained by omentin-1 levels and anthropometric parameters (excluding waist circumference).

CONCLUSIONS

In this observational study, nutritional status appears to be the main factor influencing circulating AMH levels independent of PCOS. The observed AMH association with omentin-1 levels suggests that this adipokine may be a link between hormonal dysfunction of adipose tissue related to obesity and decreased AMH secretion.

The dynamic changes of anti-Mullerian hormone and inhibin B during controlled ovarian hyperstimulation in decreased ovarian reserve women and the effect on clinical outcome

OBJECTIVE

To investigate the dynamics of anti-Mullerian hormone (AMH) and inhibin B (INHB) levels during controlled ovarian hyperstimulation (COH) in women with decreased ovarian reserve (DOR), and assess the effect of these dynamic changes on the prediction of clinical outcome in in-vitro fertilization (IVF).

METHODS

A total of 124 women undergoing IVF cycles were divided into normal ovarian reserve (NOR) and DOR groups. AMH and INHB levels were measured in serum on menstrual cycle day 2 or 3 (D2/3), day 5 of stimulation (D5), hCG day (D-hCG) and follicular fluid (FF) on oocyte retrieval day.

RESULTS

Serum AMH levels were gradually decreased while INHB levels were gradually increased from D2/3 to D-hCG during the COH in both groups. Serum AMH, INHB levels on D2/3 and FF AMH, INHB levels were highly positively correlated with AFC and oocytes retrieval. Multivariate logistic regression analysis revealed that clinical pregnancy did not directly correlate with serum and FF AMH and INHB levels.

CONCLUSION

Serum AMH and INHB levels were not directly related to clinical pregnancy, dynamic serum AMH and IHNB levels were positively correlated with COH outcomes.

The correlations of anti-mullerian hormone, follicle-stimulating hormone and antral follicle count in different age groups of infertile women

Background

The objective of our study was to identify the correlations between the tests currently used in ovarian reserve assessment: anti-Mullerian hormone (AMH), follicle stimulating hormone (FSH) and antral follicle count (AFC) and to distinguish the most reliable markers for ovarian reserve in order to select an adequate strategy for the initial stages of infertility treatment.

Materials and Methods

In this prospective study, 112 infertile women were assessed. Subjects were divided into three age groups: group I <35 years (n=39), group II 35-40 years (n=31), and group III 41-46 years (n=42). AMH, FSH and AFC were determined on days 2-3 of the patients’ menstrual cycles.

Results

There was a significantly elevated negative correlation between age and AMH level (r_s=-0.67, p<0.0001) and AFC (r_s=-0.55, p<0.0001). We observed a significantly positive correlation between age and FSH (r_s=0.38, p<0.0001). AMH negatively correlated with FSH (r_s=-0.48, p<0.0001) and positively with AFC (r=-0.71, p=0.0001). There was a moderate negative relation between FSH and AFC (r=-0.41, p=0.0001) and moderate positive relation between age and FSH (r_s=0.38, p<0.0001). The correlation analysis performed in separate groups showed that AMH and AFC showed a statistically significant positive correlation for group I (r=0.57, p<0.0001), group II (r=0.69, p<0.0001) and group III (r=0.47, p<0.002). A statistically significant correlation between FSH and AMH was detected only in groups I (r=-0.41, p<0.02) and II (r=-0.55, p<0.0001). A statistically significant correlation existed between FSH and AFC only in group III (r=-0.42, p<0.006), as well as between age and AFC only in group I (r=-0.35, p<0.03).

Conclusion

Currently, AMH should be considered as the more reliable of the ovarian reserve assessments tests compared to FSH. There is a strong positive correlation between serum AMH level and AFC. The use of AMH combined with AFC may improve ovarian reserve evaluation.

Change of anti-Mullerian-hormone levels during follicular phase in PCOS patients

Anti-Mullerian-hormone (AMH) does not seem to fluctuate significantly during the menstrual cycle in healthy women. However, little is known about cycle fluctuations of AMH levels in patients with polycystic ovarian syndrome (PCOS). The purpose of this study was to examine AMH fluctuations during the follicular phase in PCOS patients receiving antiestrogens or recombinant follicle-stimulating hormone (FSH). About 40 PCOS patients diagnosed according to Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group 2003 and 19 controls were prospectively enrolled. PCOS patients received either antiestrogens or recombinant FSH for monoovulation induction and controls received antiestrogens. AMH levels were determined (1) between the 2nd and the 5th day of follicular phase and (2) when a single large dominant follicle ≥18 mm had appeared. Our study shows that AMH levels do not change during follicular development in controls as well as in PCOS patients with AMH levels < 5 ng/ml, irrespective of antiestrogen or FSH therapy. However, in PCOS patients with AMH levels ≥5 ng/ml, AMH declines significantly during follicular development (p < 0.01). We conclude that AMH levels should be determined in the early follicular phase in PCOS patients without the influence of antiestrogens or exogenous FSH, because these interventions may lower AMH values in patients with high levels.

Single nucleotide polymorphisms in the Anti-Müllerian hormone (AMH Ile(49)Ser) and Anti-Müllerian hormone type II receptor (AMHRII -482 A>G) as genetic markers in assisted reproduction technology

PURPOSE

The aim of the study was to evaluate whether the presence Antimullerian hormone (AMH) and Antimullerian hormone type II receptor (AMHRII) single nucleotide polymorphisms (SNPs) Ile(49)Ser and -482A>G respectively are related to the assisted reproduction outcome.

METHODS

A prospective cross-sectional observational study was conducted in order to assess the distribution of AMH and AMHRII SNPs in two cohorts, one of healthy women (N = 100) and the control group and the IVF/ICSI group (N = 151) consisted of women undergoing IVF/ICSI treatment for infertility. Furthermore, a prospective longitudinal observational study was performed on the latter group to assess possible associations of these SNPs with patients' characteristics and controlled ovarian stimulation (COS) and pregnancy outcome.

RESULTS

Among non-carriers of the AMH (Ile(49)Ser) polymorphism, basal FSH levels were lower in those with more than two of previous IVF attempts and fertilization rate was statistically higher in those with peak serum E2 levels below 1500 pg/ml, whereas among non-carriers of the AMHRII (-482 A>G) polymorphism, number of follicles was higher in those with more than two previous IVF attempts and total dose of gonadotropins was lower in those with peak serum E2 levels above 1500 pg/ml.

CONCLUSIONS

There was evidence that in specific subgroups of women undergoing IVF/ICSI, AMH and AMHRII SNPs may be related to patients' characteristics and controlled ovarian stimulation and pregnancy outcome and thus may provide a means for the prediction of ovarian response in specific subgroups of women entering an IVF/ICSI program.

Clinical pregnancy in a woman with idiopathic hypogonadotropic hypogonadism and low AMH: utility of ovarian reserve markers in IHH

OBJECTIVE

Serum anti-mullerian hormone (AMH) has been proposed as a useful marker of ovarian reserve that is cycle-independent and predictive of outcome in assisted reproduction cycles. However, there is evidence that AMH production is gonadotropin-dependent, and that under the influence of FSH, growing follicles contribute to circulating AMH levels. Therefore, AMH testing may not be universally reflective of the primordial follicle pool in certain conditions. We demonstrate that in patients with idiopathic hypogonadotropic hypogonadism (IHH) and deficient gonadotropin production, AMH and antral follicle count (AFC) may not be reliable markers of ovarian reserve.

DESIGN

Case report.

SETTING

Fertility clinic at a tertiary academic hospital.

PATIENT

A 30-year-old nulligravid patient with IHH who presented for fertility treatment with low FSH (0.3 IU/L), LH (0.1 IU/L), estradiol (77 pmol/L) and AMH levels (0.65 pmol/L), and an unmeasurable AFC.

INTERVENTION

A three-month course of priming with oral micronized 17β-estradiol, followed by daily injections of human menopausal gonadotropins (hMG).

MAIN OUTCOME MEASURE

AMH level and follicular development.

RESULTS

After 60 days of stimulation with hMG, the patient's AMH level increased to a peak of 1.27 pmol/L. After 102 days of stimulation, her estradiol level rose to 480 pmol/L and a 19 mm dominant follicle was detected. The patient successfully conceived with intrauterine insemination.

CONCLUSION

Ovarian reserve testing in patients with IHH can be challenging due to the contracted appearance of the ovaries and deficient FSH production. In these patients, AMH levels may underestimate ovarian reserve due to the lack of FSH-dependent growing follicles. When treated with a long course of hMG, these patients may exhibit increased AMH levels and demonstrate adequate follicular development.

The hormonal composition of follicular fluid and its implications for ovarian cancer pathogenesis

Ovulation has long been associated with an increased risk in ovarian cancer, yet the underlying molecular mechanisms remain obscure. Two aspects of ovulation have been linked to ovarian cancer pathogenesis. The first is the impact of repetitive tissue injury and repair that occurs with each ovulatory event. The second is the release of follicular fluid that accompanies the follicular rupture and its effect on the ovarian and fallopian tube epithelial cells. Hormones are an important component of follicular fluid, which transiently bathes the ovarian surface and fallopian tube epithelium during ovulation. Much work has been done exploring the role of hormones in fertility, but some, such as estrogen, have also been implicated in the pathogenesis of ovarian and other cancers. Understanding the role of hormones within follicular fluid, as well as how they are altered in disorders which increase ovarian cancer risk, will enhance our ability to assess risk and develop preventative strategies. This review provides an in depth discussion of the logistics of using and studying follicular fluid in ovarian cancer research, and discusses the fluctuations in follicular fluid hormone levels during normal physiological processes versus conditions that increase ovarian cancer risk.

Comparability of antimüllerian hormone levels among commercially available immunoassays

OBJECTIVE

To compare antimüllerian hormone (AMH) levels among three commercially available AMH immunoassays: AMH Gen II (Beckman Coulter), Ultrasensitive AMH (Ansh Labs), and picoAMH (Ansh Labs).

DESIGN

Cross-sectional.

SETTING

Academic reproductive endocrinology program.

PATIENT(S)

90 newly diagnosed breast cancer patients before cancer treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Proportion of detectable AMH levels by immunoassay, and comparability among assays.

RESULT(S)

At a mean age of 38.1 years, the median (interquartile range) AMH level for the cohort was 0.92 [1.35] ng/mL for the Gen II assay, 1.68 [2.30] ng/mL for the Ultrasensitive assay, and 1.52 [2.41] ng/mL for the picoAMH assay. Significantly higher proportions of detectable AMH levels were observed with the picoAMH kit (97%) compared with both the Gen II (84%) and Ultrasensitive (92%) assays. Although the AMH results were highly correlated among the assays (r = 0.92-0.99), the Gen II AMH levels were consistently lower than both Ultrasensitive and picoAMH levels. Moreover, as AMH levels increased, the magnitude of difference grew larger between Gen II and each of the other two assays.

CONCLUSION(S)

Measurement of AMH levels with the picoAMH kit maximized detection at very low levels, particularly in contrast with the Gen II kit. Conversion of AMH levels from different immunoassays using regression equations is potentially highly inaccurate.

The effect of ovarian puncture on the endocrine profile of PCOS patients who undergo IVM

BACKGROUND

To examine whether ovarian puncture for immature oocyte retrieval and in-vitro maturation (IVM) has an effect on the endocrine profile of patients with polycystic ovary syndrome (PCOS).

METHODS

Twenty-two consecutive patients with PCOS undergoing IVM treatment were included. Serum anti-Müllerian hormone (AMH), sex hormone-binding globulin (SHBG), total testosterone (TT) and luteinized hormone (LH) levels were analyzed at the start of the cycle, on the day of immature oocyte retrieval (OR) and at fixed intervals thereafter, for up to three months after OR.

RESULTS

Five days after OR circulating AMH, TT, calculated free testosterone (FTc), and LH levels were significantly reduced and circulating SHBG was significantly increased. Two weeks after OR, TT, FTc and LH remained reduced, whereas circulating AMH and SHBG levels recovered to pre-puncture values. Three months after OR, all circulating hormone levels had recovered to baseline values.

CONCLUSION

Ovarian puncture for the retrieval of immature oocytes and IVM in patients with PCOS has a significant impact on the ovarian endocrine profile, but this impact is brief and transient.

Dynamics of anti-Müllerian hormone during controlled ovarian stimulation

AIM

To evaluate the dynamics of anti-Müllerian hormone (AMH) during controlled ovarian stimulation (COH) and to correlate changes in AMH to age, estradiol (E2) levels, and the presence of polycystic ovary syndrome (PCOS).

METHODS

Data were retrospectively collected from women presenting for COH in the outpatient clinic of a university hospital between January and July 2011. Concentrations of AMH and E2 during COH with gonadotropins for in vitro fertilization (IVF) (n = 68) and clomiphene or low-dose gonadotropin stimulation cycles (n = 27) for intrauterine insemination were evaluated. Percentage change in AMH and E2 from pre-stimulation values was calculated. Dynamics of hormonal changes were analyzed using non-parametric tests. Correlations between changes in AMH and E2 were analyzed with Spearman correlation.

RESULTS

During IVF stimulation, AMH declined steadily from pre-stimulation values. No significant change in AMH dynamics was observed during clomiphene or low-dose stimulation cycles. Percentage decline in AMH during IVF stimulation correlated with rise in E2 at all time points.

CONCLUSIONS

The observed phenomena contribute to an improved understanding of AMH expression and its role in the follicular development. Our data support the concept that AMH is produced by secondary, preantral and small antral follicles in the early part of stimulation and declines as these follicles are recruited into dominant growing follicles.

The impact of depot GnRH agonist on AMH levels in healthy reproductive-aged women

CONTEXT

GnRH agonists (GnRHa) are being used experimentally in an attempt to preserve fertility in young female cancer patients undergoing chemotherapy. Anti-Müllerian hormone (AMH) produced by ovarian granulosa cells may serve as a marker of ovarian reserve, but it is not clear whether this marker is useful during GnRHa treatment.

OBJECTIVE

The purpose of this study was to determine the effect of a depot GnRHa on AMH levels.

DESIGN

Depot leuprolide (3.75 mg) was administered in the midluteal phase (MLP) in healthy women. Assessments of AMH, FSH, LH, estradiol, and progesterone were performed in the early follicular phase (EFP) and MLP before GnRHa treatment and approximately 7, 14, and 30 days after GnRHa administration.

SETTING

The study was conducted in a university research center.

PATIENTS

Participants were 33 healthy, premenopausal women aged 18 to 45 years old with regular menses.

RESULTS

EFP and MLP AMH levels were similar before GnRHa administration. Relative to MLP AMH levels, AMH decreased 7 days after GnRHa administration by a median of 24% (P < .001) and then increased above pretreatment levels 14 and 30 days after GnRHa by 13% and 32%, respectively (P < .001). Changes in AMH levels did not correlate with changes in gonadotropins, estradiol, or progesterone.

CONCLUSIONS

Significant changes in AMH levels occur in the first 4 weeks after depot leuprolide administration, suggesting that AMH may not be a reliable marker of ovarian reserve during this interval. Changes in AMH occurred independent of gonadotropin levels, supporting a direct effect of GnRHa on granulosa cell expression of AMH or an indirect effect of GnRHa on the development and/or dynamics of the follicle pool.