The influence of depression, body mass index, and smoking on serum inhibin B levels in late reproductive-aged women

Smoking and Its Consequences on Male and Female Reproductive Health

Smoking contributes to the death of around one in 10 adults worldwide. Specifically, cigarettes are known to contain around 4000 toxins and chemicals that are hazardous in nature. The negative effects of smoking on human health and interest in smoking-related diseases have a long history. Among these concerns are the harmful effects of smoking on reproductive health. Thirteen percent of female infertility is due to smoking. Female smoking can lead to gamete mutagenesis, early loss of reproductive function, and thus advance the time to menopause. It has been also associated with ectopic pregnancy and spontaneous abortion. Even when it comes to assisted reproductive technologies cycles, smokers require more cycles, almost double the number of cycles needed to conceive as non-smokers. Male smoking is shown to be correlated with poorer semen parameters and sperm DNA fragmentation. Not only active smokers but also passive smokers, when excessively exposed to smoking, can have reproductive problems comparable to those seen in smokers. In this book chapter, we will approach the effect of tobacco, especially tobacco smoking, on male and female reproductive health. This aims to take a preventive approach to infertility by discouraging smoking and helping to eliminate exposure to tobacco smoke in both women and men.

Association of body mass index with serum anti-Müllerian hormone and inhibin B levels among 8323 women attending a reproductive medical center: a cross-sectional study

PURPOSE

To assess the association of body mass index (BMI) with serum anti-Müllerian hormone (AMH) and inhibin B (InB) levels among women attending a reproductive medical center.

METHODS

We conducted a cross-sectional study of 8323 women (96.4% were Han race) without polycystic ovary syndrome (PCOS) from the reproductive medical center of Tongji Hospital in Wuhan, China for assisted reproductive technology treatment between January 2016 and May 2018. For each participant, BMI and levels of serum AMH and InB were measured at entry by trained clinical technicians. Multivariate linear regression models were used to quantitatively estimate the associations of continuous and categorical BMI with serum AMH and InB levels.

RESULTS

Each 1 kg/m² increase in BMI was significantly associated with a 1.02% (95% CI: 0.40, 1.65%) and 3.59% (3.11, 4.06%) reduction in AMH and InB levels, respectively. No departure from linearity was observed for either AMH or InB (both P for nonlinear trend >0.05). Overweight and obesity were significantly associated with a 6.01% (0.70, 11.04%) and 18.64% (2.29, 32.26%) reduction in AMH level, and were significantly associated with a 18.80% (15.23, 22.23%) and a 35.44% (25.47, 44.08%) reduction in InB level, respectively. In addition, the association between BMI and AMH level was significantly stronger among women ≥32 years.

CONCLUSIONS

BMI was linearly and inversely associated with AMH and InB levels among women without PCOS. Both overweight and obesity were significantly associated with lower AMH and InB levels.

Association between a history of depression and anti-müllerian hormone among late-reproductive aged women: the Harvard study of moods and cycles

Background

There is conflicting evidence regarding the association between a history of depression and risk of early menopause. In a cohort of premenopausal women, we investigated the association between depression history and ovarian reserve, as measured by anti-müllerian hormone (AMH).

Methods

The Harvard Study of Moods and Cycles (HSMC) was a prospective cohort study of women living in the Boston, MA metropolitan-area (1995–1999). Women aged 36–45 years at cohort entry (1995) were sampled from seven Boston metropolitan-area communities using census directories. We measured serum AMH in early-follicular phase venous blood specimens from 141 women with a Structured Clinical Interview for DSM-IV (SCID)-confirmed history of depression and 228 without such a history. We calculated prevalence ratios (PR) for the association between characteristics of depression history and low AMH (≤1.4 ng/mL), adjusting for several potential confounders.

Results

The prevalence of low AMH was similar among depressed (57.5%) and non-depressed (57.9%) women (Adjusted [Adj] PR = 0.90, 95% CI: 0.75, 1.08). Among depressed women, results were not appreciably different among those who had ever used antidepressants and those with comorbid anxiety. Modest inverse associations between depression and low AMH were seen among women aged 36–40 years (Adj PR = 0.75, 95% CI: 0.52, 1.09) and nulliparous women (Adj PR = 0.77, 95% CI: 0.59, 1.00). No dose-response association with greater duration or length of depressive symptoms was observed.

Conclusions

Overall, the prevalence of low AMH was similar for depressed and non-depressed women 36–45 years of age. Surprisingly, among younger and nulliparous women, those with a history of depression had a slightly reduced prevalence of low AMH relative to those without such a history. These results do not indicate reduced ovarian reserve among women with a history of depression.

Does cigarette smoking really have a clinical effect on folliculogenesis and oocyte maturation?

Infertility is the most common issue in the field of reproductive medicine. Many factors affect fertility status, including life-style choices such as cigarette smoking or alcohol use. The aim of this study was to investigate the effects of cigarette smoking on oocyte quality as well the quantity in young fertile women. In total, 56 young fertile women who were undergoing oocyte donation programmes were included in this study. The effects of cigarette smoking on antral follicle count, number of follicles and oocytes retrieved and morphology were assessed by an expert embryologist. The results of this study showed that cigarette smoking did not have a significant effect on the follicle count or the number of oocytes retrieved from young and fertile women. However, a significant difference was observed in the morphological assessment. In conclusion, although cigarette smoking does not seem to affect oocyte development, it had an effect on cytoplasmic anomalies and therefore may lower pregnancy chance. Therefore, it is crucial to give proper counselling to patients who are trying to become pregnant both naturally and by in vitro fertilization.

Cigarette smoking and hormones

PURPOSE OF REVIEW

The purpose is to provide a summary of the effects of cigarette smoking on steroid hormone metabolism and how it affects female fertility.

RECENT FINDINGS

Components of tobacco smoke such as polycyclic aromatic hydrocarbons lead to transcriptional upregulation of a number of genes, including members of the cytochrome P450 (CYP) family, in particular CYP1B1 and CYP1A1. In humans, CYP1A1 and CYP1A2 are the primary enzymes catalyzing the 2-hydroxylation of estradiol. This pathway shunts available estrogen away from the more estrogenically potent 16α-hydroxylation to the production of catechol estrogens, mainly 2 and 4 hydroxyestradiol.

SUMMARY

Smoking has multiple effects on hormone secretion and metabolism. These effects are mainly mediated by the pharmacological action of tobacco alkaloids (nicotine and its metabolite cotinine). A strong body of evidence indicates that the negative effects of cigarette smoking on fertility compromises nearly every system involved in the reproductive process.

Levels of antimüllerian hormone in serum during the normal menstrual cycle

OBJECTIVE

To determine whether levels of antimüllerian hormone (AMH) in serum vary during the normal menstrual cycle, using the most recently developed immunoassay method.

DESIGN

Prospective cohort study.

SETTING

Local community.

PATIENT(S)

Women with normal menstrual cycles and between the ages of 18 and 45 years were recruited (n = 45). Blood samples were collected on 5 days within each cycle: two in the follicular phase and three after confirmed ovulation. Exclusion criteria were anovulatory cycles, incomplete sample collection, insufficient blood volume, or non-Caucasian ethnicity.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Serum samples were tested for levels of AMH using a new immunoassay method (Ansh Labs). The effects of body mass index (BMI) and smoking on serum AMH levels were considered.

RESULT(S)

Serum AMH levels varied significantly during the menstrual cycle, with the highest levels in the follicular phase. When the analysis was stratified by age, AMH variation during the menstrual cycle was significant only for women older than 30 years. Serum AMH levels were not significantly altered by BMI or smoking.

CONCLUSION(S)

The new AMH immunoassay revealed a follicular phase rise in serum levels, particularly in women over the age of 30 years. This is consistent with other reports finding an interaction of menstrual cycle variation in AMH and chronological age. Nonetheless, the extent of variation is small, and sampling on any day of the menstrual cycle is expected to adequately reflect ovarian reserve.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01337999.

Prenatal diethylstilbestrol exposure and reproductive hormones in premenopausal women

Diethylstilbestrol (DES), a synthetic estrogen widely prescribed to pregnant women in the mid-1900s, is a potent endocrine disruptor. Prenatal DES exposure has been associated with reproductive disorders in women, but little is known about its effects on endogenous hormones. We assessed the association between prenatal DES exposure and reproductive hormones among participants from the Harvard Study of Moods and Cycles (HSMC), a longitudinal study of premenopausal women aged 36–45 years from Massachusetts (1995–1999). Prenatal DES exposure was reported at baseline (43 DES exposed and 782 unexposed). Early follicular-phase concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol were measured at baseline and every 6 months during 36 months of follow-up. Inhibin B concentrations were measured through 18 months. We used multivariable logistic and repeated-measures linear regression to estimate odds ratios (OR) and percent differences in mean hormone values (β), respectively, comparing DES exposed with unexposed women, adjusted for potential confounders. DES-exposed women had lower mean concentrations of estradiol (pg/ml) (β=−15.6%, 95% confidence interval (CI): −26.5%, −3.2%) and inhibin B (pg/ml) (β=−20.3%, CI: −35.1%, −2.3%), and higher mean concentrations of FSH (IU/I) (β=12.2%, CI: −1.5%, 27.9%) and LH (IU/I) (β=10.4%, CI: −7.2%, 31.3%), than unexposed women. ORs for the association of DES with maximum FSH>10 IU/I and minimum inhibin B<45 pg/ml – indicators of low ovarian reserve – were 1.90 (CI: 0.86, 4.22) and 4.00 (CI: 0.88–18.1), respectively. Prenatal DES exposure was associated with variation in concentrations of FSH, estradiol and inhibin B among women of late reproductive age.

The impact of smoking on antimüllerian hormone levels in women aged 38 to 50 years

OBJECTIVE

Smoking is associated with increased follicle-stimulating hormone levels and early menopause. Smoking may directly accelerate ovarian follicular depletion or may act indirectly by increasing the pituitary production of follicle-stimulating hormone. Antimüllerian hormone (AMH), produced by ovarian follicles, is a more direct measure of ovarian reserve. The objective of our study was to determine the extent to which smoking influences ovarian reserve, as measured by AMH levels.

METHODS

A community sample of 284 women aged 38 to 50 years completed a self-administered questionnaire including a detailed smoking history. Serum AMH levels were measured on day 2, 3, or 4 of the menstrual cycle. The association between AMH and smoking was analyzed using linear regression, adjusting for age and body mass index.

RESULTS

Participants aged 38 to 42, 43 to 45, and 46 to 50 years had geometric mean AMH values of 6.7 pM (95% CI, 5.2-8.7 pM), 2.7 pM (95% CI, 1.9-3.8 pM), and 1.3 pM (95% CI, 1.0-1.7 pM), respectively. Current smokers, but not past smokers, had 44% lower AMH values than did the reference group (participants with neither active nor former or passive smoke exposure; P = 0.04). Passive smoking had no effect on AMH values when compared with the reference group (P = 0.55). The impact of smoking on AMH values was not dose dependent based on cigarettes per day (P = 0.08) or pack-years (P = 0.22). Finally, prenatal exposure to smoking (either maternal or paternal) had no impact on AMH levels (P = 0.47 and P = 0.89, respectively).

CONCLUSIONS

Active smoking, but not former smoking, is associated with decreased AMH values in late-reproductive-age and perimenopausal women, suggesting a possible direct effect of smoking on the depletion of the antral but not primordial follicles. The direct impact of active smoking on AMH levels in younger women requires further investigation.

Effect of cigarette smoking upon reproductive hormones in women of reproductive age: a retrospective analysis

There is continuing debate concerning the relationship between cigarette smoking and premature ovarian failure. The aim of this retrospective data analysis was to investigate whether smoking has a measurable effect on early follicular serum concentrations of inhibin B hormone, FSH and anti-Müllerian hormone (AMH) in women of reproductive age. A database containing data on age, smoking status and serum concentrations of inhibin B, FSH and AMH was analysed. Pearson's correlation coefficient was calculated to determine the correlation between hormone concentrations and age. One-way analysis of variance was used to determine any significant difference in age between smoking categories and a univariate general linear model was used to compare geometric means and geometric mean ratios of hormone concentrations in relation to smoking status. Serum concentrations of inhibin B were significantly lower in women who had ever smoked cigarettes: F(2,332) = 3.371, P = 0.036. There was no statistically significant difference in FSH or AMH concentrations although a trend towards lower AMH concentrations in smokers was observed. This analysis provides evidence of an advancement of ovarian ageing in women who smoke cigarettes and is relevant to women of childbearing age who wish to avoid premature decline in fertility.

Controlled clinical trial assessing the effect of laparoscopic uterine arterial occlusion on ovarian reserve

STUDY OBJECTIVE

To assess the effect on ovarian reserve function after laparoscopic uterine artery occlusion (LUAO) compared with laparoscopic surgery supracervical hysterectomy (LSH) and laparoscopic myomectomy (LM).

DESIGN

Prospective cohort study (Canadian Task Force classification II-1).

SETTING

Hospital with experience in gynecologic minimal access surgery.

PATIENTS

Ninety patients with uterine myomas operated on from August through December 2007.

INTERVENTION

Ninety patients were divided into 3 groups of 30 patients each: the study group underwent LUAO and myomectomy (LUAO-M), control group 1 underwent LSH, and control group 2 underwent LM only.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected before surgery and at 1, 3, and 6 months postoperatively. Concentrations of follicle-stimulating hormone (FSH), leuteinizing hormone (LH), and estradiol (EZ) were determined using an immunoassay, and serum inhibin B (INHB) concentration was evaluated using an enzyme-linked immunosorbent assay. No significant differences in preoperative hormone concentrations between the 3 groups were found (p>.05). In the LSH group, FSH, LH, and E2 concentrations were significantly increased, whereas the INHB concentration was significantly decreased at 1 month postoperatively (p<.05); after 3 months, only the INHB concentration was significantly decreased (p<.05). However, in the LOUA-M and LM groups, there were no significant differences between preoperative and postoperative hormone concentrations (p>.05). Serum concentrations of FSH, LH, and INHB in the LSH group were significantly different from those in the study group at 1 and 3 months postoperatively (p<.05); however, the differences in postoperative hormone concentrations between the study group and the LM group were not significant (p>.05).

CONCLUSION

At short-term follow-up, no significant effect on ovarian reserve in patients with myoma who underwent LUAO was found.

Pilot study of serum inhibin B as a potential marker of testosterone doping in weight lifting men

OBJECTIVE

The aim of this study was to explore effectors of the pituitary-testicular axis suitable as potential biochemical markers to screen for testosterone doping.

DESIGN

Pilot study with male bodybuilding athletes with a self-reported history of testosterone doping (repeated intramuscular administration of testosterone preparations, last injection 8 weeks or less ago) compared with an equal sized control group matched for sex, age, and body mass index.

SETTING

Endocrine outpatients.

PARTICIPANTS

Fifteen healthy young men of white background.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Inhibin B, testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH).

RESULTS

Although the levels of testosterone, LH, and FSH did not differ between the 2 groups, the serum concentrations of inhibin B in individuals with a history of testosterone doping were exclusively at or below the lower limit of the normal range for adult men (100-400 pg/mL). Inhibin B was significantly lower in those men who used testosterone for weight lifting (76.1 +/- 36.3 ng/L [mean +/- SD]) than in controls (182.1 +/- 35.4 ng/L).

CONCLUSION

A low concentration of serum inhibin B may reflect the application of exogenous testosterone and appears to be a potential marker associated with anabolic androgenic steroid doping.

Clinical implications of ovarian reserve testing

Serum and urinary markers of ovarian reserve, follicular phase inhibin B, follicle stimulating hormone, and antimullerian hormone levels, are physiologically associated with ovarian aging, decline with chronologic age, and appear to predict later stages of reproductive aging including the menopause transition and menopause. In infertile women, they can be used to predict low oocyte yield and treatment failure in women undergoing in vitro fertilization. These markers seem to be affected by common ovarian toxicants, such as smoking, which advance the age at menopause. Although available for commercial use, home test kits have not been shown to predict fertility or infertility in the general population. Clinical use of these markers is limited by the variety of assays, lack of definitive thresholds, and their intercycle variability in older women. Results should be conveyed with caution when highly discrepant with age, in the obese, and in women with irregular menstrual cycles. Further research is needed to assess their predictive value for determining fertility in the general population.

In vitro fertilization, embryo development, and cell lineage segregation after pre- and/or postnatal exposure of female mice to ambient fine particulate matter

OBJECTIVE

To evaluate effects of pre- and/or postnatal exposure to ambient fine particulate matter on fertilization, embryo development, and cell lineage segregation in preimplantation blastocysts using the IVF mouse model.

DESIGN

Animal model.

SETTING

Academic institution.

ANIMAL(S)

Six-week-old, superovulated mice.

INTERVENTION(S)

Pre- and postnatal exposure to filtered air (FA-FA), filtered-ambient air (FA-AA), or ambient air (AA-AA) in exposure chambers 24 hours a day for 9 weeks.

MAIN OUTCOME MEASURE(S)

Gestation length, litter size, sex ratio, ovarian response to superovulation, fertilization rate, embryo development, blastocyst and hatching rates, total cell count, and proportion of cell allocation to inner-cell mass (ICM) and trophectoderm (TE).

RESULT(S)

Gestation length, litter size and birth weight, live-birth index, and sex ratio were similar among exposure groups. Ovarian response was not affected by the exposure protocol. A multivariate effect for pre- and/or postnatal exposure to ambient fine particulate matter on IVF, embryo development, and blastocyst differential staining was found. Cell counts in ICM and ICM/TE ratios in blastocysts produced in the FA-FA protocol were significantly higher than in blastocysts produced in the FA-AA and AA-AA protocols. No difference in total cell count was observed among groups.

CONCLUSION(S)

Our study suggests that exposure to ambient fine particulate matter may negatively affect female reproductive health by disrupting the lineage specification at the blastocyst stage without interfering in early development of the mouse embryo.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial

OBJECTIVE

To compare among women with menorrhagia the effect of hysterectomy or levonorgestrel-releasing intrauterine system (LNG-IUS) on sexual functioning.

DESIGN

A randomised controlled trial.

SETTING

Five university hospitals in Finland.

SAMPLE

A total of 236 women, aged 35-49 years.

METHODS

Of the women, 117 were treated by hysterectomy and 119 by LNG-IUS.

MAIN OUTCOME MEASURES

Sexual functioning was evaluated by modified McCoy sexual scale at baseline and at 6 months, 12 months, and 5 years after initiation of treatment (hysterectomy or application of LNG-IUS).

RESULTS

Among women treated by hysterectomy, sexual satisfaction increased and sexual problems decreased. Among LNG-IUS users, satisfaction with partner decreased. In addition to treatment modality (P = 0.02), estrogen therapy (P = 0.01), smoking (P = 0.001), night sweats (P = 0.03), vaginal dryness (P = 0.04), hot flushes (P = 0.01), and having someone to ask for advice (P = 0.03) and to share worries (P = 0.01) explained changes in sexual functioning.

CONCLUSIONS

Among women with menorrhagia, hysterectomy improves sexual functioning, whereas LNG-IUS does not have such a positive effect.

Effect of hysterectomy or LNG-IUS on serum inhibin B levels and ovarian blood flow

OBJECTIVES

Nearly one third of women complain of heavy menstrual bleeding during their reproductive years. Hysterectomy and levonorgestrel-releasing intrauterine system (LNG-IUS) are effective treatment options for menorrhagia. However, the influence of these two treatment modalities on ovarian function remains unclear. The aim of the study was to evaluate the effect of hysterectomy or LNG-IUS on ovarian function.

METHODS

Of 107 women, aged 35-49 years, referred for menorrhagia to the University of Helsinki, Finland, 54 were randomised to hysterectomy group and 53 to LNG-IUS group. Serum concentrations of inhibin B were measured at baseline, at 6-month, and at 12-month follow-up visits. The pulsatility indeces (PI) of ovarian and intraovarian arteries were measured by transvaginal ultrasound on the same visits. Changes in outcome measures between the groups were tested by Student's t-test for independent samples and within the group by Wilcoxon signed rank test. To test association between outcome variables and explaining factors a multiple linear regression model was used.

RESULTS

Serum inhibin B concentrations decreased after the first 6 months in both groups (P<0.05). No change was observed in PI of the ovarian arteries in either group. PI of the intraovarian arteries decreased at 6 and 12 months (P<0.05) in the hysterectomy group, which was not seen among LNG-IUS users. Change in PIs between the treatment arms was also significant (P<0.05). In multiple linear regression model treatment modality explained the change in serum inhibin B concentration and the change in PI of intraovarian artery (P<0.05).

CONCLUSIONS

Hysterectomy but not LNG-IUS alters intraovarian blood flow and may impair ovarian function.

Smoking, alcohol and caffeine in relation to ovarian age during the reproductive years

BACKGROUND

We sought to determine whether smoking, alcohol and caffeine are related to four indicators of ovarian age: antral follicle count (AFC), follicle stimulating hormone (FSH), inhibin B and estradiol.

METHODS

Analyses drew on ultrasound scans and sera from 188 women, aged 22-49. We used least squares regression to estimate differences in AFC and hormone levels for women who smoke cigarettes or who drink alcohol or caffeine.

RESULTS

Current smoking is related to elevated FSH (beta for ln(FSH) = 0.21, 95% CI 0.04, 0.39), but not to AFC, inhibin B or estradiol. Neither alcohol nor caffeine is related to any ovarian age indicator. Exploratory analyses suggest that the association of current smoking with FSH varies with age: comparing current with never smokers, at ages 30, 35, 40 and 45, estimated differences in mean FSH are 0.3, 1.3, 3.2 and 6.9 mIU/ml.

CONCLUSIONS

The association of current smoking with FSH may reflect accelerated oocyte atresia, impaired follicle quality or dysregulation of the hypothalamic-pituitary-ovarian axis. Identification of the causal mechanism has implications for prevention or treatment of conception delay, infertility and morbidity associated with early menopause.