The use of anti-Müllerian hormone for controlled ovarian stimulation in assisted reproductive technology, fertility assessment and -counseling

Utility of Serum Anti-Müllerian Hormone Measurement as Part of Polycystic Ovary Syndrome Diagnosis

The 2023 international evidence-based guideline update for the assessment and management of polycystic ovary syndrome (PCOS) recommends using the Rotterdam criteria for the diagnosis of PCOS. The updated guideline has evidence-based recommendation for the diagnosis, and it now also includes serum anti-Müllerian hormone (AMH) measurement as an alternative tool for gynecological ultrasound to diagnose polycystic ovary morphology (PCOM). The aim of this new recommendation was to facilitate PCOS diagnostic workup in primary care and other disciplines, as currently most diagnosing is done in gynecology and infertility clinics. Here, we review factors affecting AMH levels as well as the utility of AMH in PCOS diagnosis. We identified relevant studies that report different cut-offs for AMH to diagnose PCOM as part of PCOS diagnosis. There are, however, some limitations when using AMH that should be acknowledged. These include physiological aspects like age, ethnicity, and obesity and iatrogenic causes like hormonal medication and ovarian surgery. Also reference ranges are different depending on AMH assay used. As a summary, we conclude that AMH is a usable tool in PCOM diagnostics, but it does not have a single cut-off. Therefore, further studies are needed to establish age and assay-based reference ranges.

Oocyte cryopreservation with in vitro maturation for fertility preservation in girls at risk for ovarian insufficiency

PURPOSE

To assess the feasibility and outcomes of oocyte cryopreservation with in vitro maturation (IVM) in post-pubertal girls undergoing fertility preservation (FP) for primary ovarian insufficiency (POI) risk.

METHODS

Ovarian stimulation was performed with an antagonist protocol or progesterone priming. Ultrasound monitoring was performed transabdominally. Oocytes were retrieved transvaginally under IV sedation. Immature oocytes were subjected to IVM for up to 36 h. All MII oocytes were vitrified. The main outcome measure was the total number of mature oocytes cryopreserved. The secondary outcome was the increase in the mature oocyte yield after IVM.

RESULTS

Indications for FP included mosaic Turner syndrome (mTS; n = 10), malignancy (n = 3), and POI risk (n = 2). The mean ± SD age, antral follicle count (AFC), and AMH levels were 14.2 ± 1.4 years, 8 ± 5.2 and 1.3 ± 1.3 ng/mL. In girls with mTS, the ovarian reserve was low for age (AFC 7.4 ± 4.7 and AMH 1.4 ± 1.6 ng/mL). Oocyte cryopreservation was possible in all girls with a range of 1-27 mature oocytes obtained, even in those who were previously exposed to chemotherapy or with low ovarian reserve, and no surgical complications were encountered. After IVM, the median mature oocyte yield increased significantly from 7.5 to 10.5 (p = 0.001).

CONCLUSIONS

Oocyte cryopreservation appears to be feasible and safe in girls as young as 12 years of age at risk for POI The utility of IVM increases the yield of cryopreserved mature oocytes. Prior exposure to chemotherapy or low ovarian reserve should not be an automatic reason to exclude these girls from FP consideration.

Predicting the total number of retrieved oocytes following double ovarian stimulation (DuoStim)

STUDY QUESTION

Can anti-Müllerian hormone (AMH) help predict how many oocytes will be retrieved following double stimulation (DuoStim)?

SUMMARY ANSWER

A simple clinical tool can use serum AMH values to predict ovarian response following DuoStim in IVF cycles.

WHAT IS ALREADY KNOWN

The knowledge that multiple follicular waves arise during a single ovarian cycle has led to the introduction of unconventional ovarian stimulation protocols. The DuoStim protocol involves two successive ovarian stimulations performed during a single ovarian cycle and has been proposed as an approach for patients with poor ovarian response and for medical fertility preservation. As AMH has been used as a marker of ovarian reserve and stimulation response, the current study aimed to investigate the diagnostic performance of AMH in predicting the number of retrieved oocytes following DuoStim.

STUDY DESIGN, SIZE, DURATION

This is a retrospective observational study involving 116 patients who received IVF treatment from January 2021 to September 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a private IVF centre. Only patients who had their AMH measured prior to treatment and had complete patient records regarding their clinical and IVF/ICSI cycle characteristics were included. The primary outcome was the correlation between AMH values and the number of oocytes retrieved following DuoStim. Parametric and non-parametric tests were used to compare baseline characteristics and outcomes. Spearman's R was used to analyse correlations between variables, while the C statistic was used to calculate the diagnostic performance of AMH.

MAIN RESULTS AND THE ROLE OF CHANCE

AMH levels were significantly correlated with the total number of oocytes retrieved after the DuoStim (R 0.61; CI 0.44-0.70; P < 0.0001). The difference in the total number of oocytes retrieved between the first (median 4 oocytes, interquartile range (IQR) 2-6) and second (median 6 oocytes, IQR 3.2-8) stimulation was statistically significant (P < 0.0001). However, there was no significant difference in the number of mature oocytes that were retrieved (median of 3 and 4 in the first and second stimulations, respectively). After the first stimulation, 68% of patients had at least one blastocyst available, while after the second stimulation, 74% did (NS). Based on linear regression, each 0.25 ng/ml increase in basal AMH corresponds to one additional oocyte recovered at the end of both stimulations (R2: 0.32, P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

The results are limited owing to the observational nature of the study and the number of participants.

WIDER IMPLICATIONS OF THE FINDINGS

Counselling infertile couples regarding the intermediate outcome of IVF (i.e. number of retrieved oocytes) is one of the most demanding tasks that clinicians face. To our knowledge, this is the first study that provides an easy-to-use clinical tool that enables the quantitative prediction of ovarian response following DuoStim, based on serum AMH values.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Clinical Efficacy of Assisted Reproductive Technology Combined with Progesterone Capsules in the Treatment of Infertility Caused by Diminished Ovarian Reserve and Its Influence on Serum FSH, E2, and LH Levels of Patients

Objective

To explore the clinical efficacy of assisted reproductive technology (ART) combined with progesterone capsules in the treatment of infertility caused by the diminished ovarian reserve (DOR) and its influence on serum FSH, E2, and LH levels of patients.

Methods

In the manner of retrospective study, the data of 120 patients with infertility caused by DOR admitted to our hospital (February 2019-February 2020) were retrospectively analyzed, and the patients were equally divided into the experimental group and the control group according to the order of admission. All patients underwent in vitro fertilization and embryo transfer (IVF-ET), and the experimental group was received progesterone capsules at the same time. Ovarian-related indexes, follicular development, serum hormone levels, and pregnancy outcomes were compared between both groups.

Results

After treatment, compared with the control group, ovarian-related indexes and follicular development in the experimental group were conspicuously better (P < 0.001). In the experimental group, the FSH level was (5.99 ± 1.20) U/L, the E₂ level was (540.12 ± 3.54) ng/L, and the LH level was (3.10 ± 0.35) U/L after treatment, which was significantly better than those of the control group (P < 0.001). After treatment, compared with the control group, the clinical pregnancy rate in the experimental group was conspicuously higher (P < 0.05), and the abortion rate in the experimental group was conspicuously lower (P < 0.05). No obvious difference was observed in multiple births rate between the two groups (P > 0.05).

Conclusion

ART combined with progesterone capsules can improve serum hormone levels, ovarian function, follicular development, and clinical pregnancy rate for patients with infertility caused by DOR, which should be applied in practice.

An Individualized Recommendation for Controlled Ovary Stimulation Protocol in Women Who Received the GnRH Agonist Long-Acting Protocol or the GnRH Antagonist Protocol: A Retrospective Cohort Study

BACKGROUND

The GnRH agonist long-acting protocol and GnRH antagonist protocol are widely used in ovarian stimulation. Which protocol eliciting higher live birth rate for IVF/ICSI patients with different ages, different ovarian reserves and different body mass index (BMI) has not been studied. However, among these protocols, the one that elicits higher live birth in IVF/ICSI patients with different ages, ovarian reserves and body mass indexes (BMI) has not been identified.

METHODS

This was a retrospective cohort study about 8579 women who underwent the first IVF-ET from January, 2018 to August, 2021. Propensity Score Matching (PSM) was used to improve the comparability between two protocols.

RESULTS

After PSM, significant higher live birth rates were found in the GnRH agonist long-acting protocol compared to GnRH antagonist protocol (44.04% vs. 38.32%) (p<0.001). Stratified analysis showed that for those with AMH levels between 3 ng/ml and 6 ng/ml, with BMI ≥ 24 kg/m² and were aged ≥ 30 years old, and for those women with BMI < 24kg/m² and were aged ≥30 years whose AMH levels were ≤ 3ng/ml, the GnRH agonist long-acting protocol was more likely to elicit live births [OR (95%CI), 2.13(1.19,3.80)], [OR (95%CI), 1.41(1.05,1.91)]. However, among women with BMI ≥ 24kg/m² and were aged ≥30 years whose AMH levels were ≤ 3ng/ml, the GnRH agonist long-acting protocol had a lower possibility of eliciting live births [OR (95%CI), 0.54(0.32,0.90)]. Also, among women with AMH levels between 3 ng/ml and 6 ng/ml, with BMI ≥ 24 kg/m² and with age < 30 years and for those with AMH levels between 3 ng/ml and 6 ng/ml, regardless of age, and with BMI<24kg/m2,, the possibility of live births was similar between the two protocols [OR (95%CI), 1.06(0.60,1.89)], [OR (95%CI), 1.38(0.97,1.97)], [OR (95%CI), 0.99(0.72,1.37)]. Among the women with AMH levels ≤ 3 ng/ml and with were aged < 30years, regardless of BMI, the possibility of live birth was similar between the two protocols [OR (95%CI), 1.02(0.68,1.54)], [OR (95%CI), 1.43(0.68,2.98)]. Moreover, among women with AMH levels ≥ 6ng/ml, the possibility of live birth was similar between the two protocols [OR (95%CI),1.42(0.75,2.69)], [OR (95%CI),1.02(0.19,5.35)], [OR (95%CI), 1.68(0.81,3.51)], [OR (95%CI), 0.51(0.10,2.55)].

CONCLUSIONS

The suitability of the GnRH agonist long-acting protocol or GnRH antagonist protocol to infertility patients is dependent on specific biological characteristics of the patients.

Development and Validation of Prediction Model for High Ovarian Response in In Vitro Fertilization-Embryo Transfer: A Longitudinal Study

Objective

To develop and validate a prediction model for high ovarian response in in vitro fertilization-embryo transfer (IVF-ET) cycles.

Methods

Totally, 480 eligible outpatients with infertility who underwent IVF-ET were selected and randomly divided into the training set for developing the prediction model and the testing set for validating the model. Univariate and multivariate logistic regressions were carried out to explore the predictive factors of high ovarian response, and then, the prediction model was constructed. Nomogram was plotted for visualizing the model. Area under the receiver-operating characteristic (ROC) curve, Hosmer-Lemeshow test and calibration curve were used to evaluate the performance of the prediction model.

Results

Antral follicle count (AFC), anti-Müllerian hormone (AMH) at menstrual cycle day 3 (MC3), and progesterone (P) level on human chorionic gonadotropin (HCG) day were identified as the independent predictors of high ovarian response. The value of area under the curve (AUC) for our multivariate model reached 0.958 (95% CI: 0.936-0.981) with the sensitivity of 0.916 (95% CI: 0.863-0.953) and the specificity of 0.911 (95% CI: 0.858-0.949), suggesting the good discrimination of the prediction model. The Hosmer-Lemeshow test and the calibration curve both suggested model's good calibration.

Conclusion

The developed prediction model had good discrimination and accuracy via internal validation, which could help clinicians efficiently identify patients with high ovarian response, thereby improving the pregnancy rates and clinical outcomes in IVF-ET cycles. However, the conclusion needs to be confirmed by more related studies.

Are ovarian reserve tests reliable in predicting ovarian response? Results from a prospective, cross-sectional, single-center analysis

OBJETIVE

Several biomarkers of ovarian reserve have been proposed as possible predictors of the response to controlled ovarian stimulation (COS). We aimed to evaluate age, FSH, AMH, antral follicle count (AFC), and ovarian response prediction index (ORPI), as potential predictors of response to COS.

METHODS

Cross-sectional study enrolling of 188 infertile women who underwent the first cycle of IVF/ICSI. AFC was evaluated; serum FSH and AMH levels were measured by ELISA. ORPI was calculated as AMH x AFC/patient´s age.

RESULTS

As expected, hypo-responder group had less retrieved oocytes, MII, and embryos compared to the good responders. The hyper-response patients were younger, with lower FSH, increased AMH, AFC, and ORPI values. Regarding the assessment of the predictive capacity of ovarian reserve tests, none of them individually or combined showed a good predictive capacity for hypo-response. With respect to the hyper-responder group, individually AMH was the best predictor, while in the multivariable model, ORPI demonstrated the best predictive capacity. Furthermore, patients with serum AMH < 2.09 ng/mL (p25) had fewer AFC than patients with higher AMH values.

CONCLUSIONS

Our findings suggest that none of the ovarian reserve tests showed a good predictive capacity for hypo-response, while the ORPI was the strongest predictor of hyper-response in normovulatory infertile women.

Anti-Müllerian hormone in African-American women with systemic lupus erythematosus

OBJECTIVE

Women with SLE may experience ovarian insufficiency or dysfunction due to treatment or disease effects. Anti-Müllerian hormone (AMH), a marker of ovarian reserve, has been examined in small populations of women with SLE with conflicting results. To date, these studies have included very few African-American women, the racial/ethnic group at greatest risk of SLE.

METHODS

We enrolled African-American women aged 22-40 years diagnosed with SLE after age 17 from the Atlanta Metropolitan area. Women without SLE from the same area were recruited from a marketing list for comparison. AMH was measured in serum using the Ansh Labs assay (Webster, Texas, USA). We considered AMH levels <1.0 ng/mL and AMH <25th percentile of comparison women as separate dichotomous outcomes. Log-binomial regression models estimating prevalence ratios were adjusted for age, body mass index and hormonal contraception use in the previous year.

RESULTS

Our sample included 83 comparison women without SLE, 68 women with SLE and no history of cyclophosphamide (SLE/CYC-) and 11 women with SLE and a history of cyclophosphamide treatment (SLE/CYC+). SLE/CYC+ women had a greater prevalence of AMH <1.0 ng/mL compared with women without SLE (prevalence ratio (PR): 2.90, 95% CI: 1.29 to 6.51). SLE/CYC- women were also slightly more likely to have AMH <1.0 ng/mL (PR: 1.62, 95% CI: 0.93 to 2.82) than comparison women. Results were similar when considering AMH <25th percentile by age of comparison women.

CONCLUSIONS

Treatment with CYC is associated with low AMH in African-American women with SLE. SLE itself may also be associated with reduced AMH, but to a lesser extent.

Relationship Between Anti-Müllerian Hormone and In Vitro Fertilization-Embryo Transfer in Clinical Pregnancy

OBJECTIVES

To retrospectively analyze the correlation between anti-Müllerian hormone (AMH) and the number of oocytes obtained by controlled ovarian hyperstimulation (COH) in women of different ages and explore the factors affecting in vitro fertilization and embryo transfer (IVF-ET) in clinical pregnancy of infertile women to provide evidence for infertile women to choose assisted reproduction strategies.

METHODS

Infertile women who received IVF-ET or intracytoplasmic sperm injection and embryo transfer (ICSI-ET) treatment in the reproductive center of XX hospital between October 2018 and September 2019 were included. Patient data on medical records, age, body mass index (BMI), years of infertility, basic follicle-stimulating hormone (FSH), basic luteinizing hormone (LH), basic estradiol (E₂), anti-Müllerian hormone level (AMH), antral follicle count (AFC), gonadotropins (Gn) medication days, Gn dosage, endometrial thickness on transplantation day, the number of retrieved oocytes, the number of mature oocytes obtained, the number of embryos transferred, clinical pregnancy status, etc., were collected.

RESULTS

A total of 314 patients were enrolled in this study, with an average age of 31.0 ± 4.5 years. The infertility period ranged from 0-21 years. The AMH level showed a downward trend with increasing age. Overall, the AMH level of women of all ages was positively correlated with the number of retrieved oocytes (r = 0.335, p < 0.001). The AMH level of women between 22 and 28 years old was positively correlated with the number of retrieved oocytes (r = 0.164, p < 0.061) but it was not statistically significant. Similarly, the AMH level of women aged 29-35 and 36-43 was positively correlated with the number of retrieved oocytes (r = 0.356, p < 0.001; r = 0.461, p < 0.001). The average age of the pregnant group (30.6 ± 4.4 years) was lower than that of the non-pregnant group (32.2 ± 4.6 years) (p < 0.001). The number of oocytes obtained (9.8 ± 4.5) and the number of embryos transferred (1.9 ± 0.4) in the pregnant group was significantly higher than that in the non-pregnant group (9.2 ± 4.5; 1.7 ± 0.5); the difference was statistically significant. The multivariate logistic regression model showed that age (OR = 0.574 95% CI: 0.350-0.940), AMH (OR = 1.430 95% CI: 1.130-1.820) and the number of oocytes obtained (OR = 1.360 95% CI: 1.030-1.790) were factors affecting clinical pregnancy.

CONCLUSION

We found that the level of AMH in infertile women decreased with age and the number of oocytes obtained in infertile women was positively correlated with AMH. Moreover, the number of oocytes and embryo transferred in the pregnant group was significantly higher than those in the non-pregnant group. Furthermore, age, AMH and the number of oocytes affected the clinical pregnancy.

Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review

BACKGROUND

The incidence of colorectal cancer among reproductive-aged women is increasing. Concerns regarding future fertility are secondary only to concerns regarding survival and may significantly impact quality of life among reproductive-aged female cancer survivors. Fertility preservation counseling reduces long-term regret and dissatisfaction among cancer survivors. Health care providers counseling patients with colorectal cancer must understand the impact of cancer treatment on future reproductive potential.

OBJECTIVE

This review aims to examine the effects that colorectal cancer treatments have on female fertility and summarize existing and emerging options for fertility preservation.

DATA SOURCES

EMBASE, National Library of Medicine (MEDLINE)/PubMed, Cochrane Review Library were the data sources for this review.

STUDY SELECTION

A systematic literature review was performed using exploded MeSH terms to identify articles examining the effect of surgery, chemotherapy, and radiation, as well as fertility preservation options for colorectal cancer on female fertility. Relevant studies were included.

MAIN OUTCOME MEASURES

The primary outcome was the effect of colorectal cancer treatment on fertility.

RESULTS

There are limited data regarding the impact of colorectal surgery on fertility. The gonadotoxic effects of chemotherapy on reproductive capacity depend on age at the time of chemotherapy administration, cumulative chemotherapy, radiation dose, type of agent, and baseline fertility status. Chemotherapy-induced risks for colorectal cancers are considered low to moderate, whereas pelvic radiation with a dose of 45 to 50 Gray induces premature menopause in greater than 90% of patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. Embryo and oocyte cryopreservation are considered standard of care for women desiring fertility preservation, with oocyte cryopreservation no longer being considered experimental. Ovarian tissue cryopreservation remains experimental but may be an option for select patients. The use of gonadotropin-releasing hormone agonists remains controversial and has not been definitively shown to preserve fertility.

LIMITATIONS

The limitations of this review are the lack of randomized controlled trials and high-quality studies, as well as the small sample sizes and the use of surrogate fertility markers.

CONCLUSION

Reproductive-aged women with colorectal cancer benefit from fertility preservation counseling before the initiation of cancer treatment.

Anti-Müllerian Hormone Expression in Endometrial Cancer Tissue

Anti-Müllerian hormone (AMH) is a commonly known factor secreted by Sertoli cells, responsible for regression of the Müllerian ducts in male fetuses. AMH has also other functions in humans. In vivo and in vitro studies have shown that AMH inhibits cell cycle and induces apoptosis in cancers with AMH receptors. The aim of the study was to assess whether the tissue of pre-cancerous states of endometrium (PCS) and various histopathologic types of endometrial cancer (EC) exhibit the presence of AMH. We aimed to investigate whether the potential presence of the protein concerns menopausal women or those regularly menstruating, and whether is related to cancers with a good or a bad prognosis, as well as what other factors may influence AMH expression. The undertaken analysis was carried out on tissues retrieved from 232 women who underwent surgical treatment for PCS and EC. Tissues were prepared for immunohistochemical assessment with the use of a tissue microarrays method. AMH expression was confirmed in 23 patients with well differentiated endometrioid adenocarcinoma (G1), moderately differentiated endometrioid adenocarcinoma (G2), clear cell carcinoma (CCA) and nonatypical hyperplasia. AMH was not found in EC tissues in regularly menstruating women. An appropriately long mean period of breastfeeding in line with a prolonged period of hormonal activity had a positive effect on AMH expression. Our results may suggest that AMH is a factor which protects the organism against cancer, and should be further investigated as a potential prognosis marker and a therapeutic agent.