Anti-Mullerian hormone (AMH): what do we still need to know?

The value of Anti-Müllerian hormone in low and extremely low ovarian reserve in relation to live birth after in vitro fertilization

OBJECTIVE

To determine the relation of Anti-Müllerian hormone (AMH) with live birth after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in women with (extremely) low ovarian reserve.

STUDY DESIGN

This study was a retrospective cohort study in a Dutch tertiary fertility clinic. Between January 2009 and March 2012, AMH levels were measured in infertile women when ≥36 years of age or when showing clinical signs of diminished ovarian reserve, before they underwent IVF or ICSI treatment. Ultimately, 156 women with (extremely) low ovarian reserve were included and evaluated for cumulative live birth rates. Of each woman, only one treatment cycle was analyzed, either the one in which she became pregnant or her first treatment cycle if she did not reach pregnancy. The relation between AMH and live birth was evaluated with multivariable logistic regression analysis. A ROC curve was composed to evaluate the discriminative value of AMH in relation to live birth after IVF/ICSI.

RESULTS

Thirty-three out of 156 women (21.2%) gave live birth. Live birth was significantly lower in women with AMH ≤0.1ng/ml (4/37 women; 10.8%) or AMH >0.1-0.4ng/ml (7/42 women; 16.7%), compared to women with AMH >0.4-1.05ng/ml (22/77 women; 28.6%), p<0.001. Multivariable logistic regression revealed an association between the severity of low ovarian reserve and live birth (per 0.1ng/ml increase in AMH value, Odds ratio 1.21; 95% CI 1.07-1.36).

CONCLUSIONS

The level of AMH is related to live birth after IVF/ICSI in women with (extremely) low ovarian reserve. The live birth rate in women with AMH >0.4ng/ml was significantly higher than in women with AMH ≤0.4ng/ml. AMH could serve as a tool in the pre-treatment counseling for pregnancy and live birth chances in women with (extremely) low ovarian reserve.

Serum Anti-Müllerian Hormone Levels before Surgery in Patients with Ovarian Endometriomas Compared to Other Benign Ovarian Cysts

OBJECTIVES

To evaluate preoperative anti-Müllerian hormone (AMH) levels in women with endometrioma or other benign ovarian cysts and differences of AMH changes according to various characteristics.

METHODS

Ninety-seven patients aged 20 to 39 years who underwent surgery for benign ovarian cyst were enrolled retrospectively. Of these, 65 patients were diagnosed as endometriomas, and 32 had other benign cysts. Serum AMH, mean, maximum, and total diameter of ovarian cysts were measured. The AMH levels were compared according to pathology (endometrioma vs. other benign cyst), size of ovarian cyst, age-matched AMH quartile percentile and characteristics of endometrioma.

RESULTS

Preoperative serum AMH level was significantly lower in endometrioma group than other benign cyst group (4.12 ± 2.42 ng/mL vs. 6.02 ± 2.29 ng/mL, P < 0.001). Serum AMH level was significantly lower in endometrioma group, especially in patients aged 30 to 39 years. Dividing to age-matched AMH quartile percentile, there were significantly fewer patients with AMH level ≥ 75 percentile in endometrioma group (24.6% vs. 50.0%, P = 0.035). Among 4 subgroups of endometrioma, patients with AMH level ≥ 75 percentile were significantly decreased in multiple bilateral endometrioma group. Mean and total diameter of cysts were negatively correlated with preoperative serum AMH level in other benign cyst group.

CONCLUSION

We suggest that preoperative AMH level measurement might be considered in women with endometrioma, especially in 30 to 39 years old, multiple bilateral type, or big-sized other benign ovarian cyst to assess the diminished ovarian reserve.

Role of Anti-Müllerian Hormone in pathophysiology, diagnosis and treatment of Polycystic Ovary Syndrome: a review

Polycystic ovary syndrome (PCOS) is the most common cause of chronic anovulation and hyperandrogenism in young women. Excessive ovarian production of Anti-Müllerian Hormone, secreted by growing follicles in excess, is now considered as an important feature of PCOS. The aim of this review is first to update the current knowledge about the role of AMH in the pathophysiology of PCOS. Then, this review will discuss the improvement that serum AMH assay brings in the diagnosis of PCOS. Last, this review will explain the utility of serum AMH assay in the management of infertility in women with PCOS and its utility as a marker of treatment efficiency on PCOS symptoms. It must be emphasized however that the lack of an international standard for the serum AMH assay, mainly because of technical issues, makes it difficult to define consensual thresholds, and thus impairs the widespread use of this new ovarian marker. Hopefully, this should soon improve.

The anti-Müllerian hormone (AMH) acts as a gatekeeper of ovarian steroidogenesis inhibiting the granulosa cell response to both FSH and LH

PURPOSE

Anti Müllerian Hormone (AMH) has a negative and inhibitory role in many functions of human granulosa-lutein cells (hGCs) including notoriously the reduction of the aromatase CYP19A1 expression induced by follicle-stimulating hormone (FSH). No data have been provided on the possible role of AMH in modulating the response to luteinizing hormone (LH) (alone or combined with FSH) as well as its effect on other enzymes involved in steroidogenesis including aromatase P450scc. The aim of this study was to investigate the role of AMH as regulator of the basal and stimulated steroids production by hGCs.

METHODS

Primary culture of hGCs were incubated with hormones AMH, LH, and FSH, alone or in combination. The CYP19A1 and P450scc messenger RNA (mRNA) expression, normalized by housekeeping ribosomal protein S7 (RpS7) gene, was evaluated by reverse transcriptase quantitative PCR (RT-qPCR). Each reaction was repeated in triplicate. Negative controls using corresponding amount of vehicle control for each hormone treatment were performed.

RESULT

AMH did not modulate the basal mRNA expression of both aromatase genes at any of the concentrations tested. Meanwhile, the strong mRNA induction of CYP19A1 and P450scc generated by a 24-h gonadotropin treatment (alone and combined) was suppressed by 20 ng/ml AMH added to culture medium.

CONCLUSIONS

These findings contribute in clarifying the relationship between hormones regulating the early phase of steroidogenesis confirming that AMH is playing a suppressive role on CYP19A1 expression stimulated by gonadotropin in hGCs. Furthermore, a similar inhibitory effect for AMH was observed on P450scc gene expression when activated by gonadotropin treatment.

Age-related trends in anti-Mullerian hormone serum level in women with unilateral and bilateral ovarian endometriomas prior to surgery

BACKGROUND

Endometriosis is a well-known cause of infertility, and the anti-Mullerian hormone (AMH) is an accepted biomarker of ovarian reserve and response to artificial reproductive technology procedures. The present study was a prospective analysis of age-dependent AMH serum concentration in women with bilateral and unilateral ovarian endometriomas before therapy onset compared with healthy controls.

METHODS

This prospective cross-sectional study included 384 women aged 18-48 years. AMH serum concentration was assessed between days 3 and 6 of the menstrual cycle in 78 patients with bilateral and 157 patients with unilateral ovarian endometriomas and compared with 149 healthy controls. Ovarian endometriosis was confirmed histopathologically, and data were presented as medians with interquartile range (IQR).

RESULTS

Stage III endometriosis was diagnosed in 53.2 %, stage IV in 18.3 %, stage V in 23.4 % and stage VI in 5.4 % of the patients. Patients with bilateral ovarian endometriomas showed the lowest median AMH levels compared with patients suffering from unilateral ovarian endometriosis (0.55; IQR: 0.59 vs. 2.00; IQR: 2.80; p < 0.001) and the control group (0.55; IQR: 0.59 vs. 2.84; IQR: 3.2; p < 0.001). Median AMH concentration values were not significantly different between patients with unilateral ovarian endometriosis and the healthy controls (2.00; IQR: 2.80 vs. 2.84; IQR: 3.2; p = 0.182). A strongly negative correlation between AMH levels and age was confirmed in healthy individuals (R = -0.834; p < 0.001) and women with unilateral ovarian endometriomas (R = -0.774; p < 0.001). Patients with bilateral ovarian endometriosis showed a significantly negative but only moderate correlation between AMH levels and age (R = -0.633; p < 0.001), which was significantly lower than in the healthy controls (R = -0.633 vs. R = -0.834; p = 0.006) but not in the patients with unilateral ovarian endometriosis (R = -0.663 vs. R-0.774; p = 0.093). Based on a multivariate regression analysis, only bilateral localization of ovarian endometrial cysts (p = 0.003) and patient age (p < 0.001), but not left/right localization of unilateral cyst or cyst volume, were negatively associated with AMH serum concentration.

CONCLUSION

According to our data, unilateral ovarian endometriosis had a moderately negative and nonsignificant effect on AMH-based ovarian reserve evaluated prior to surgery, irrespective of age. In contrast, the ovarian reserve was significantly reduced in women with bilateral ovarian endometriomas.

The role of Amh signaling in teleost fish--Multiple functions not restricted to the gonads

This review summarizes the important role of Anti-Müllerian hormone (Amh) during gonad development in fishes. This Tgfβ-domain bearing hormone was named after one of its known functions, the induction of the regression of Müllerian ducts in male mammalian embryos. Later in development it is involved in male and female gonad differentiation and extragonadal expression has been reported in mammals as well. Teleosts lack Müllerian ducts, but they have amh orthologous genes. amh expression is reported from 21 fish species and possible regulatory interactions with further factors like sex steroids and gonadotropic hormones are discussed. The gonadotropin Fsh inhibits amh expression in all fish species studied. Sex steroids show no consistent influence on amh expression. Amh is produced in male Sertoli cells and female granulosa cells and inhibits germ cell proliferation and differentiation as well as steroidogenesis in both sexes. Therefore, Amh might be a central player in gonad development and a target of gonadotropic Fsh. Furthermore, there is evidence that an Amh-type II receptor is involved in germ cell regulation. Amh and its corresponding type II receptor are also present in brain and pituitary, at least in some teleosts, indicating additional roles of Amh effects in the brain-pituitary-gonadal axis. Unraveling Amh signaling is important in stem cell research and for reproduction as well as for aquaculture and in environmental science.

Comparison of two different methods for measuring anti-mullerian hormone in a clinical series

BACKGROUND

Anti Mullerian hormone (AMH) has previously been measured using a manual method, but a fully automated assay from Roche Diagnostics was recently introduced. The aim of this study was to compare the results from the AMH gen II ELISA and Elecsys Cobas AMH methods in a clinical setting to evaluate whether the assays achieve the goals of analytical performance. A prospective observational study with 23 women seeking laparoscopic sterilization was conducted. Blood samples were collected preoperatively as well as 1 week and 1, 3 and 6 months postoperatively; they were evaluated with the AMH gen II ELISA and Elecsys Cobas AMH methods. The assays were validated according to the optimal performance of biochemical assays: CV Analytical < 0.25* CV Within Biological Variation.

FINDINGS

We found a good correlation between the two methods; there was a bias of approximately 32 %. The total within-person biological variability ranged from approximately 21 to 32 %. The analytical variability of the AMH gen II ELISA and Elecsys Cobas methods ranged from 5.5 to 10.3 % and 2.8 to 3.3 %, respectively. Applying the goals for optimal assay performance, the Elecsys Cobas method achieved optimal performance throughout the measuring range, whereas the AMH Gen II only achieved optimal performance in the high end of the measuring range. Furthermore, the Elecsys Cobas assay had a low limit of quantitation of 0.5 pmol/l compared to 3.0 pmol/l for the AMH gen II ELISA.

CONCLUSIONS

In the clinical setting, the Elecsys Cobas AMH assay performs well according to the optimal standard for biochemical assays.

Anti-Mullerian-Hormone during pregnancy and peripartum using the new Beckman Coulter AMH Gen II Assay

BACKGROUND

AMH levels determined by the conventional AMH assay declined during pregnancy and postpartum. A new Beckman Coulter AMH Gen II assay removes the potentially assay-interfering complement which is activated in pregnancy. The aim of this study was to evaluate if the decline of AMH levels in the serum of pregnant women during the course of pregnancy and peripartum was assay-dependent and thus artificial.

METHODS

In this cross-sectional study prepartal blood samples were collected from 62 patients (median age 30.6 years [interquartile range: 25.6 - 34.5]) in the third trimester of pregnancy and again 1-4 days after delivery between 2011 and 2012. In another cohort of 11 patients (median age 34.1 years [interquartile range: 32.6 - 37.8]) blood samples were taken in different trimesters of pregnancy between 1995 and 2001. The conventional and the modified AMH assay were performed in the same patient serum samples. We used the conventional and the modified AMH-Gen-II ELISA (Beckman Coulter, Immunotech, Webster, USA) for the assessment of AMH levels. The Wilcoxon signed rank test was used for determining differences between AMH levels pre- and postpartum. The method of Bland and Altman was applied for analyzing the agreement of both methods for determining AMH levels.

RESULTS

AMH values peripartum were lower than those expected in fertile non-pregnant women of comparable age. An overall mean difference of 0.44 ng/ml was observed between the conventional and the modified assay. Measurements with the modified assay showed a significant decline of postpartal levels compared with prepartal levels which is consistent with values obtained using the conventional assay (both p < 0.00001). Compared to the longitudinal measurements of AMH levels determined using the conventional assay, AMH levels obtained using the modified assay suggest a steeper decline of values during the course of pregnancy.

CONCLUSION

By comparing the conventional assay for AMH determination with the modified assay the present study confirmed that AMH levels decline during the course of pregnancy and early after delivery.

Assessing ovarian response: antral follicle count versus anti-Müllerian hormone

Oocyte number and quality decline with age; however, fertility varies significantly even among women of the same age. Various measures have been developed to predict response to ovarian stimulation and reproductive potential. Evaluation of ovarian reserve can identify patients who may experience poor response or hyper-response to exogenous gonadotrophins and can aid in the personalization of treatment to achieve good response and minimize risks. In recent years, two key methods, antral follicle count (AFC), an ultrasound biomarker of follicle number, and the concentration of serum anti-Müllerian hormone (AMH), a hormone biomarker of follicle number, have emerged as preferred methods for assessing ovarian reserve. In this review, a live debate held at the American Society for Reproductive Medicine 2013 Annual Meeting is expanded upon to compare the predictive values, merits, and disadvantages of AFC and AMH level. An ovarian reserve measure without limitations has not yet been discovered, although both AFC and AMH have good predictive value. Published evidence, however, as well as the objectivity and potential standardization of AMH level and the convenience of testing any time throughout the menstrual cycle, leans towards AMH level becoming the gold-standard biomarker to evaluate ovarian reserve and predict ovarian response to stimulation.

Effect of Anti-Müllerian hormone (AMH) and bone morphogenetic protein 15 (BMP-15) on steroidogenesis in primary-cultured human luteinizing granulosa cells through Smad5 signalling

PURPOSE

To determine if there is any effect of AMH and BMP-15 on estradiol and progesterone production from primary-cultured human luteinizing granulosa cells, to delineate what is the effect of FSH on their actions and which are the possible mechanisms involved.

METHODS

Luteinizing granulosa cells (GCs), obtained from follicular fluid of 30 women undergoing in vitro fertilization, were cultured, after a short 24-h preincubation period, in serum-free medium for 24 or/and 48 h in the presence/absence of various concentrations of AMH, BMP-15 and FSH alone or in combinations. Estradiol and progesterone production, SMAD5 phosphorylation and StAR expression were studied in parallel. Steroids were measured in culture-supernatant using enzyme-immunoassays, while Smad5-signaling pathway activation and StAR protein expression were assessed immunocytochemically.

RESULT(S)

We found that the treatment of AMH in GCs for 24/48 h attenuated FSH-induced estradiol production (p < 0.001), had no effect on basal estradiol levels, decreased basal progesterone production (p < 0.001) and FSH-induced StAR expression (p < 0.001). On the other hand, BMP-15 decreased basal estradiol levels (p < 0.001) and attenuated FSH-induced estradiol production (p < 0.001). Furthermore, BMP-15 reduced progesterone basal secretion (p < 0.001), an effect that was partially reversed by FSH (p < 0.01), probably via increasing StAR expression (p < 0.001). FSH-induced StAR expression was also attenuated by BMP-15 (p < 0.001). FSH, AMH and BMP-15 activated Smad-signaling pathway, as confirmed by the increase of phospo-Smad5 protein levels (p < 0.001 compared to control).

CONCLUSION(S)

AMH and BMP-15 by interacting with FSH affect the production of estradiol and progesterone from cultured luteinizing-granulosa cells possibly via Smad5-protein phosphorylation.

Surgical diminished ovarian reserve after endometrioma cystectomy versus idiopathic DOR: comparison of in vitro fertilization outcome

STUDY QUESTION

Does the live birth rate after IVF depend on the etiology of diminished ovarian reserve (DOR)?

SUMMARY ANSWER

IVF outcome and live birth rate are significantly impaired in women with DOR caused by a previous cystectomy for endometrioma compared with women with idiopathic DOR.

WHAT IS KNOWN ALREADY

The safety of the surgical treatment of endometriomas is being discussed in terms of damage to ovarian reserve. Several studies have reported a poor response to controlled ovarian stimulation and a significantly impaired IVF outcome in women with DOR consecutive to an endometrioma cystectomy compared with women with tubal factor infertility.

STUDY DESIGN, SIZE, DURATION

Retrospective case-control study conducted in women aged under 40 treated in our Reproductive Medicine Center between January 2010 and January 2014 for a DOR defined by anti-Müllerian hormone level <2 ng/ml. Two groups of patients were selected: group A included patients with a DOR diagnosed after cystectomy(s) for endometrioma(s), group B included patients with an idiopathic DOR. In each group, subgroups of patients 'poor ovarian responders', based on the ESHRE criteria ('Bologna criteria'), have been established.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 51 patients in group A were matched to 116 patients in group B, representing respectively 125 and 243 IVF cycles. Among them, 39 patients in group A and 78 patients in group B validated strictly by the Bologna criteria, representing 99 and 189 IVF cycles, respectively. Each patient underwent a controlled ovarian hyperstimulation and IVF with fresh embryo transfer. Primary end-point was the live birth rate. Secondary end-points were the number of retrieved oocytes, fertilization rate, implantation rate, clinical pregnancy rate, spontaneous abortion rate and cycle cancelation rate.

MAIN RESULTS AND THE ROLE OF CHANCE

Significantly lower pregnancy (11.2% in group A versus 20.6% in group B, P = 0.02) and live birth (7.2 versus 16.9% respectively, P = 0.01) rates per cycle were assessed in women in group A compared with women in group B. The same results were obtained in the Bologna criteria subgroup analysis with a significantly lower pregnancy (9.1 versus 20.1%, P = 0.016) and live birth (5.1 versus 15.3%, P = 0.001) rates per cycle in women in subgroup A compared with women in subgroup B. Patients in group A required significantly higher gonadotrophins doses (2881 IU ± 1111 versus 2526 IU ± 795, P = 0.005), longer ovarian stimulation (10.6 Days ± 2.8 versus 9.9 Days ± 2.4, P = 0.019) and higher cancelation rate for poor response (12 versus 6.2%, P = 0.05). Despite a mean number of retrieved oocytes similar with the group B (5.4 ± 3.1 and 5.1 ± 3.2, NS), and a significantly higher fertilization rate (65.7 versus 47.2%, P < 0.001), women in group A showed a significantly lower implantation rate (7.2 versus 13.5%, P = 0.03). Abortion rate, ectopic pregnancy rate and multiple pregnancy rate were similar in both groups.

LIMITATIONS, REASONS FOR CAUTION

Data were collected retrospectively using the database of our Department. Sample size is relatively small but our study provides statistically significant evidence that the chances of IVF success are decreased in women with DOR after cystectomy for endometrioma. Further larger series are needed to confirm these findings.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study evaluating IVF outcome in patients with DOR after cystectomy(s) for endometrioma(s) versus in patients with an idiopathic DOR. In addition to the risk of damaging ovarian reserve, we hypothesize that endometrioma surgery would not have qualitative benefits on results in IVF in patients with DOR.

STUDY FUNDING/COMPETING INTERESTS

The authors have no competing interests to declare.

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.

First fully automated immunoassay for anti-Müllerian hormone

BACKGROUND

The increasing importance of anti-Müllerian hormone (AMH) for the assessment of ovarian reserve requires accurate AMH measurements. There have been conflicting results about the reliability of currently existing manual AMH assays.

METHODS

Development of a high sensitive, fast and fully automated AMH assay on the Elecsys®/cobas e electrochemiluminescence immunoassay platform.

RESULTS

Elecsys® AMH is a monoclonal two-site assay used to measure AMH in 50 µL of serum or lithium heparin plasma in about 18 min. Its measuring range is from 0.01 to 23 ng/mL. The assay detects primarily 140 kDa total AMH (proAMH and AMHN,C). Standardization was against the Beckman AMH Gen II. Recovery against the highly cited Immunotech calibration was about 90%. Within-run imprecision coefficient of variation (CV) calculated on 10 serum samples were between 0.5% and 1.8%. Repeatability and intermediate precision calculated on 14 serum samples ranged from 2.6% to 1.7% and 2.9% to 2.1%, respectively. Limit of detection (LoD) [limit of quantitation (LoQ)] was 0.01 ng/mL (0.03 ng/mL). Percent recovery in dilution studies was <10% and after mixing of high and low AMH pools 94% to 103%. Elecsys® AMH, when compared to revised AMH Gen II (or Ansh Labs ultrasensitive AMH ELISA) using 57 female serum samples yielded a correlation coefficient of 0.98 (0.97) and a slope of 0.81 (0.73). There was no evidence for sample instability or variability. Samples stored at 20-25 °C or 2-8 °C up to 7 days showed no significant storage issues. Freeze-thaw cycles or sample storage at -20 °C and -80 °C for up to 9 months was without any effect on measured AMH.

CONCLUSIONS

Availability of an automated Elecsys® AMH assay offers an attractive alternative to the current manual AMH assays.

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.

Serum estradiol level during withdrawal bleeding as a predictive factor for intermittent ovarian function in women with primary ovarian insufficiency

The objective of this study was to assess the potential predictive factors for follicle growth, ovulation, and pregnancy rate in patients with primary ovarian insufficiency/premature ovarian failure (POI/POF). We enrolled 25 POI patients with desired fertility who were treated and monitored for a minimum of 7 months between the years of 2000-2009 into this retrospective study. The clinical, endocrinologic, chromosomal, and autoimmunologic parameters of these patients were collected. Furthermore, hormonal backgrounds on each of 620 treatment cycles were investigated. The main outcome measures were follicle growth, ovulation, and pregnancy rate. Four of 25 patients (16%) conceived while being monitored and undergoing treatment. Follicle growth, ovulation, and pregnancy rate were not significantly different as a function of parity, iatrogenic history (e.g., chemotherapy), age of disease onset, serum estradiol (E(2))/follicle stimulating hormone (FSH) level at the time of diagnosis, chromosomal abnormality, and positive autoantibody titer. The serum E2 levels on days 1-5 of withdrawal bleeding (Day 1-5 E(2)) were significantly higher in the cycles with successful follicle growth and ovulation than unsuccessful cycles (P<0.05). Receiver-operator characteristic curve analysis revealed the cut-off value of the Day 1-5 E(2) to be 15.5 pg/mL, and an area under the curve (AUC) value of 0.674 for follicle growth and 0.752 for ovulation. The results suggest that cycles with a Day 1-5 E(2)≥15.5 pg/mL have a higher rate of follicle growth and ovulation in patients with POI.

The menstrual cycle regularization following D-chiro-inositol treatment in PCOS women: a retrospective study

Polycystic ovary syndrome is characterized by irregular cycles, hyperandrogenism, polycystic ovary at ultrasound and insulin resistance. The effectiveness of D-chiro-inositol (DCI) treatment in improving insulin resistance in PCOS patients has been confirmed in several reports. The objective of this study was to retrospectively analyze the effect of DCI on menstrual cycle regularity in PCOS women. This was a retrospective study of patients with irregular cycles who were treated with DCI. Of all PCOS women admitted to our centre, 47 were treated with DCI and had complete medical charts. The percentage of women reporting regular menstrual cycles significantly increased with increasing duration of DCI treatment (24% and 51.6% at a mean of 6 and 15 months of treatment, respectively). Serum AMH levels and indexes of insulin resistance significantly decreased during the treatment. Low AMH levels, high HOMA index, and the presence of oligomenorrhea at the first visit were the independent predictors of obtaining regular menstrual cycle with DCI. In conclusion, the use of DCI is associated to clinical benefits for many women affected by PCOS including the improvement in insulin resistance and menstrual cycle regularity. Responders to the treatment may be identified on the basis of menstrual irregularity and hormonal or metabolic markers.

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.

The role of anti-Mullerian and inhibin B hormones in the evaluation of 46,XY disorders of sex development

OBJECTIVE

To assess the sensitivity and specificity of anti-Mullerian hormone (AMH) and inhibin B for diagnosis of 46,XY disorders of sex development (DSD).

PATIENTS AND METHODS

The study included 43 patients of 46,XY DSD and compared them with 43 healthy, male, age matched controls. All patients underwent karyotyping, assessment of testosterone, dihydrotestosterone (DHT) and Δ4-androstendione (Δ4A) basal and after human chorionic gonadotropin (HCG) testing. Basal dehydroepiandrosterone (DHEA) was measured. Ultrasonograghy was also done and some cases underwent laparoscopy or gonadal biopsies. Basal AMH and inhibin B were measured in both cases and controls.

RESULTS

The mean age of patients was 5.16±4.24 years. There were significant correlations between basal AMH and HCG stimulated testosterone and DHT (r=0.64; p<0.001 and r=0.52; p<0.001, respectively). Also, significant positive correlations were found between inhibin B and HCG as well as stimulated testosterone and DHT (r=0.62; p<0.001 and r=0.44; p=0.003, respectively). A highly significant correlation was found between AMH and inhibin B (r=0.78; p<0.001). The sensitivity of AMH was (96.6%), specificity (60.7%), NPV (89.5%) and PPV (83.6%). Best cut-off value was (27.11 IU/mL) while overall accuracy was (85%). The sensitivity of inhibin B was (96.6%), specificity (67.9%), NPV (90.5%), PPV (86.2%), and best cut-off value was (41.9 IU/mL) with an overall accuracy (87%).

CONCLUSION

AMH and inhibin B are valuable, and reliable noninvasive parameters for the detection of functioning testicular tissues in prepubertal patients.

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.

Anti-Müllerian hormone is associated with extrauterine involvement and stage of disease in patients with endometrial cancer

Our aim was to evaluate serum levels of anti-Müllerian hormone (AMH) and also immunohistochemical (IHC) staining properties of AMH receptor type II (AMHRII) in patients with endometrial cancer (EC) and a control group. Preoperatively, serum levels of AMH were assessed and AMHRII expression was evaluated by immunohistochemistry in a benign and malignant group. AMH serum levels of the control group and EC patients were comparable. For EC patients, there was no difference with respect to the AMH levels and tumour stage; grade; histological type; deep myometrial invasion; lymphovascular space invasion or lymph node involvement. However, AMH levels in patients with extrauterine involvement were higher than patients with disease confined to the uterus. EC samples were more likely to be stained positive for AMHRII than benign lesions. Also, as the stage of the lesion worsens, the rate of IHC staining of AMHRII decreases. In conclusion, AMHRII is expressed in normal endometrial cells as well as endometrial cancer cells. AMH levels increase in EC, with extrauterine involvement at least in locally advanced disease. Also AMH expression decreases as the disease is staged-up.

Ovarian aging and premature ovarian failure

Physiological reproductive aging occurs as a result of a decrease in the number and quality of oocytes in ovarian cortex follicles. Although the reason for the decrease in the quality of the pool and follicular oocytes is not fully understood, endocrine, paracrine, genetic, and metabolic factors are thought to be effective. Nowadays, in order to understand the mechanisms of ovarian aging, genomic research has gained importance. The effect of co-factors, such as telomerase and ceramide, in the ovarian aging process is only getting ascertained with new research studies. The most important tests in the assessment of ovarian aging are antral follicle count and anti-Mullerian hormone.

[What's new in 2014 about anti-Müllerian hormone?]

The existence of the anti-Müllerian hormone (AMH) has been postulated by Professor Alfred Jost to explain the regression of the Müllerian ducts during male sexual differentiation. Since then, AMH has been purified, its gene and specific receptor, AMHR-II have been cloned. Further, the signaling pathways were identified and it has been observed that AMH was produced by the granulosa cells of growing follicles. From the 2000s, unexpected roles of AMH have been highlighted, reactivating international research on this hormone. It is now well established that AMH plays a key role in the follicular recruitment and development. Over the past years, serum AMH measurements have been proposed as a marker of the follicular ovarian status, and a predictor of assisted reproductive cycles. AMH is also useful to assess the effectiveness of treatment of some gynecological tumors. This article is a review of the past five years advances on the regulation of the expression of AMH and its specific receptor AMHR-II in female.

Anti-mullerian hormone is expressed by endometriosis tissues and induces cell cycle arrest and apoptosis in endometriosis cells

Background

The anti-mullerian hormone (AMH) is a member of the transforming growth factor β (TGF-β) superfamily, which is responsible of the regression of the mullerian duct. AMH is expressed in the normal endometrium, where, acting in a paracrine fashion, negatively regulates cellular viability. Our objective was to evaluate the in vitro effects of the treatment with AMH of endometriosic cells.

Methods

AMH expression in human endometriosis glands was evaluated by immunohistochemistry. RT-PCR has been used to quantify the expression levels of AMH and AMH RII isoforms, as well as of cytochrome P450 in both endometriosis epithelial and stromal cells Effects of AMH and AMH-cleaved treatment in endometriosis cells were evaluated by flow-cytometry analysis. Finally, it has been evaluated the effect of plasmin-digested AMH on cytochrome P450 activity.

Results

AMH and AMH RII isoforms, as well as cytochrome P450, were expressed in both endometriosis epithelial and stromal cells. Treatment of endometriosis stromal and epithelial cell growth with AMH was able to induce a decrease in the percentage of cells in S phase and increase percentage of cells in G1 and G2 phase; coherently, decreased cell viability and increased percentage of cells death fraction was observed. The plasmin-digested AMH was able to suppress most of the cytochrome P450 activity, causing an increase of pre-G1 phase and of apoptosis induction treating with plasmin-digested AMH in both cell lines, most marked in the epithelial cells.

Conclusions

The data produced suggest a possible use of AMH as therapeutic agents in endometriosis.

Long-term treatment with dehydroepiandrosterone may lead to follicular atresia through interaction with anti-Mullerian hormone

Background

Hyperandrogenism is the primary manifestation of polycystic ovary syndrome (PCOS), which appears to be caused by excess exposure to androgen. As such, androgenized animal models have been developed and investigated to study the etiology of PCOS. Anti-Mullerian hormone (AMH) is known to be associated with follicle growth, and its levels are two to three times higher in women with PCOS than in those with normal ovaries. We studied how duration of androgen administration affects folliculogenesis and AMH expression.

Methods

We divided 30 immature (3-week-old) Sprague Dawley rats into six groups. Three groups were injected each evening with dehydroepiandrosterone (DHEA) (6 mg/100 g body weight/0.2 ml sesame oil) for 7, 15 or 30 days, respectively. The three control groups were injected with 0.2 ml of sesame oil for the corresponding lengths of time. Resected ovaries were sectioned and examined to determine follicle numbers at each developmental stage, and immunostained to assess AMH expression.

Results

On day 7, follicle numbers and AMH expression levels at each developmental stage of follicle growth were similar in the respective control and DHEA groups. On day 15, the total follicle number (P = 0.041), the percentage of primordial follicles (P = 0.039) and AMH expression were significantly greater in the DHEA than the control group. On day 30, the percentages of primordial (P = 0.005), primary (P = 0.0002) and atretic (P = 0.03) follicles were significantly greater in the DHEA group, whereas the percentage of intermediary follicles (early pre-antral, late preantral, and early antral follicles) was significantly lower in the DHEA group (P = <0.0001). AMH expression in DHEA-treated rats on day 30 was seen exclusively in the primordial (P = 0.0413) and late antral follicles (p = 0.028).

Conclusions

Androgen administration increases AMH production in a process that regulates the growth of primordial follicles. That is, androgen-induced AMH expression provides local negative feedback to folliculogenesis augmented by androgen.

Anti-Müllerian hormone (AMH) is a strong predictor of live birth in women undergoing assisted reproductive technology

In the present study, we evaluated the clinical value of the following parameters: basal anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), inhibin B and antral follicle count (AFC) in predicting live birth outcomes. The study involved 603 women undergoing in vitro fertilization (IVF) using the long protocol for controlled ovarian hyperstimulation (COH). Serum levels of AMH, FSH and inhibin B as well as AFC were measured on the first three days of the menstrual cycle prior to the beginning of stimulation. AMH was the only independent parameter that correlated with the chance of live birth. We found that live birth rates of 46.2% (patient age <35 years), 44.7% (35-37 years), 32.1% (38-39) and 15.3% (>39) were associated with concentrations of AMH>1.4 ng/ml. For the AMH range 0.6-1.4 ng/ml, the live birth rates were 29.3%, 12.5%, 5.6% and 2.7%, respectively, and for AMH concentrations below 0.6 ng/ml the rates were 7.1%, 8.3%, 0% and 5.8%, respectively. Independently of other parameters affecting the chance of live birth, the success rate was the highest when the AMH level was >2 ng/ml, significantly lower when the AMH concentration was about 1 ng/ml, and 0% when the AMH concentration was ∼0.1 ng/ml. In conclusion, this is the first report to demonstrate that AMH level correlated better than age, FSH or inhibin B concentrations or AFC with live birth outcome. Therefore, the basal serum concentration of AMH may become a new, substantial prognostic factor regarding live birth above and beyond other currently available predictors of IVF outcome.

Serum AMH level as a marker of acute and long-term effects of chemotherapy on the ovarian follicular content: a systematic review

Anti-Müllerian hormone (AMH) is a very sensitive indicator of the ovarian follicular content. Chemotherapeutic agents are notoriously ovariotoxic in that they damage follicles. The aim of this systematic review was to investigate the interest of serum AMH variations in determining the acute and long-term effects of chemotherapy on the ovarian reserve. According to the PRISMA guidelines, searches were conducted on PubMed for all English language articles until December 2013. Fifteen articles that focused on dynamic variations of AMH levels before and after chemotherapy were selected. Cancer patients have significantly lower AMH after chemotherapy than age-matched controls. Longitudinal studies of AMH variations before, during and after chemotherapy provide information about the degree of follicle loss for each patient according to different chemotherapy regimens. Different patterns of AMH levels during the ovarian recovery phase make it possible to discriminate between high and low gonadotoxic chemotherapy protocols. In addition, pretreatment AMH levels are shown to predict the long-term ovarian function after the end of treatment. These results may help to better understand the ovarian toxicity mechanisms of chemotherapy and to predict the degree of the ovarian follicle loss. Therefore, it can be useful for fertility preservation strategies, fertility counseling and future family planning.

Surgical impact on serum anti-Müllerian hormone in women with benign ovarian cyst: A prospective study

OBJECTIVE

The aim of this study was to evaluate the surgical impact of benign ovarian mass on ovarian reserve as measured by serum follicle stimulating hormone (FSH), estradiol (E2) and anti-Müllerian hormone (AMH) levels, antral follicle count (AFC) and ovarian volumes. In addition, the differences in ovarian reserve impairment between endometrioma cystectomy and non-endometrioma cystectomy were investigated.

METHODS

In this prospective study, 22 patients of reproductive age (range, 18.35 years) with benign ovarian masses were enrolled to undergo laparoscopic cystectomy. Of whom 12 had endometriomas and 10 had non-endometriomas. On early follicular phase (day 3) of the cycle preceding the operation and three months after the laparoscopic cystectomy, serum levels of FSH, E2 and AMH, AFC and ovarian volumes were measured in all patients. Data were analyzed with Mann-Whitney U-test and Wilcoxon rank test using SPSS ver. 12.0 for statistic analysis.

RESULTS

Median level of serum AMH was significantly decreased from 5.48 ng/mL (interquartile range [IQR], 2.80-7.47) before cystectomy to 2.56 ng/mL (IQR, 1.74-4.32) 3 months postoperation (P<0.05). On the other hand, no significant differences in FSH, E2, AFC and ovarian volumes were found between the preoperative and three months postoperative levels. In a subgroup analysis of the pathologic type of the ovarian cyst, postoperative serum AMH levels were significantly decreased in the endometrioma group, but not in the non-endometrioma group.

CONCLUSION

Serum AMH levels were significantly decreased after laparoscopic cystectomy without any changes of other ovarian reserve tests.

Decreasing quality of the new generations of anti-Müllerian hormone assays

Anti-Müllerian hormone (AMH) measurements are widely used to optimize the stimulation protocols. First generation AMH kits correlated well with ovarian reserve and response to stimulation. In the present study we aimed to asses if the new generation kits share the same accurate correlations. Retrospective data were collected from 8323 blood samples. For comparison we used Immunotech I generation kit (ImI 4035 samples), Beckman Coulter II generation kit RUO (BCII RUO 3449, samples) and Beckman Coulter II generation kit with IVD certificate (BCII IVD 839 samples). We compared average AMH concentrations measured with different kits, as well as correlation between kits. We also compared average AMH concentrations in sera collected on different cycle days and samples of different quality of preservation. AMH serum concentrations differed for each kit, ranging 4.4 ± 4.12 (mean ± SD) for the ImI, 2.68 ± 3.15 for the BCII RUO, and 1.64 ± 2.85 for BCII IVD. The mean differences from an adjusted regression model were -48.7%, -40%, and -69.2%, respectively. In conclusion, the changes of the BC AMH kits are unpredictable; however, the improvement of them is still possible. It would be very dangerous to use elaborated stimulation protocol (based on the Ist generation AMH results) with the results from the IInd generation assays.

Anti-Müllerian hormone (AMH): a reliable biomarker of oocyte quality in IVF

PURPOSE

To evaluate the impact of serum AMH levels on stimulated IVF implantation and clinical pregnancy rates.

METHODS

•

DESIGN

Retrospective study with multivariate analysis. •

SETTING

Clinique ovo (Montreal University affiliated Center). •

PATIENT(S)

Six hundred and thirty seven patients undergoing a stimulated IVF protocol were included. Only non-polycystic ovary patients at their first IVF attempt were considered for the analysis. •

INTERVENTION(S)

None. •

MAIN OUTCOME MEASURES(S)

Implantation and ongoing pregnancy rates.

RESULT(S)

Cycle outcomes were analysed according to AMH percentiles based on the AMH normogram per patient's age of our infertile population. Multivariate analyses were done to adjust for potential confounding factors such as age, total exogenous FSH dosage and number of eggs retrieved. Compared to the reference population, a significant lower mean implantation rate (0.26 vs 0.45) was observed in patients under 35 years of age with AMH < 1 ng/ml. Women with AMH < 25th percentile had less chances of having an embryo transferred, lower chances of having an ongoing pregnancy per started IVF cycle and a lower embryo freezing rate compared to the reference population.

CONCLUSION(S)

Patients with AMH < 0.47 ng/ml should be advised before starting a stimulated IVF cycle of the poorer prognosis compared to our reference population independently of their age, total exogenous FSH dosage and number of eggs retrieved. Therefore, AMH could enable a more individualized number of embryo transfer policy based on oocyte quality.

Relation of antimullerian hormone with the clinical signs of hyperandrogenism and polycystic ovary morphology

The relation of antimullerian hormone (AMH) levels with the clinical and biochemical markers of polycystic ovary syndrome (PCOS) could be different. A total of 463 PCOS patients were evaluated in this cross-sectional study. Groups were constructed according to polycystic ovarian morphology (PCOM) and menstrual cycle-length. The relation of serum AMH with androgenic hormones, menstrual cycle-length and clinical signs of PCOS were investigated. A powerful positive relation was found between the PCOM and AMH levels (odds ratio = 2.49). There was a negative correlation between age and AMH level (p < 0.001, r[correlation coefficent] = -0.155). Positive correlations were found between luteinizing hormone (LH) and AMH (p < 0.001, r = 0.25) and also between cycle length and AMH (p < 0.01, r = 0.27). We found a negative week correlation between AMH and follicle-stimulating hormone (FSH) (p = 0.01, r = -0.19). After controlling main androgenic hormones, AMH was found to be correlated with the Ferriman-Gallway score (p = 0.03, r = 0.18). There was a positive relationship between hirsutism and AMH (odds ratio = 1.43), but no correlation between AMH and other parameters of clinical hyperandrogenism like hair-loss, acne and seborrhea were identified. The strongest relation was presented between the AMH levels and PCOM. Also, cycle-length correlated well with the AMH levels. The relationship between hirsutism and AMH is found to be independent from androgenic hormones.

Anti-Müllerian hormone levels in women with polycystic ovarian syndrome compared with normal women of reproductive age in China

OBJECTIVES

Aim was to evaluate anti-Müllerian-hormone (AMH) in women with polycystic ovary syndrome (PCOS) comparing with normo-ovulatory women, and to assess for the first time AMH levels across reproductive lifespan in Chinese women.

METHODS

Within the prospective cross-sectional study in PCOS cases and in normal subjects, AMH and other hormone levels were measured in early follicular phase in five age groups. Additionally ovarian ultrasound parameters were assessed.

RESULTS

A total of 437 PCOS patients and 150 normo-ovulatory women matched by age were included. AMH levels were 2- to 3-fold higher in PCOS cases. In both groups AMH decreased with age in a non-linear pattern. In normo-ovulatory women AMH levels were relatively constant from 18 to 25 years and then declined with age. In contrast, AMH in PCOS cases declined with an increasing rate from 18 to 45 years, narrowing the difference in older women.

CONCLUSIONS

AMH may be a useful parameter to assess the severity and prognosis of PCOS since certain differences exist to normo-ovulatory women. Further studies may improve the understanding of the relationship between AMH levels and age, providing more scientific basis for fertility counselling for both healthy women and PCOS cases.

Involvement of androgens in ovarian health and disease

In women, ovary and adrenal gland produce androgens. Androgens are essential drivers of the primordial to antral follicle development, prior to serving as substrate for estrogen production in the later stages of folliculogenesis. Androgens play a crucial role in the follicular-stromal intertalk by fine tuning the extracellular matrix and vessel content of the ovarian stroma. Local auto-and paracrine factors regulate androgen synthesis in the pre-antral follicle. Androgen excess is a hallmark of polycystic ovary syndrome and is a key contributor in the exaggerated antral follicle formation, stromal hyperplasia and hypervascularity. Hyperandrogenaemia overrides the follicular-stromal dialog, resulting in follicular arrest and disturbed ovulation. On the other hand, androgen deficiency is likely to have a negative impact on fertility as well, and further research is needed to examine the benefits of androgen-replacement therapy in subfertility.

Serum anti-Mullerian hormone (AMH) levels correlate with infrarenal aortic diameter in healthy older men: is AMH a cardiovascular hormone?

Anti-Müllerian hormone (AMH) is a gonadal hormone present in the blood in men and pre-menopausal women. AMH regulates male sexual differentiation but has no putative function in adulthood. In recent studies, high AMH levels are associated with absence of cardiovascular disease in men and smaller atherosclerotic burden in monkeys. Mechanistically, AMH has downstream convergence with known regulators of the cardiovascular system, while the specific receptor for AMH is present in murine aorta and the human heart. Our primary objective was to examine whether AMH levels in healthy men correlated with the physical characteristics of their aorta. Our secondary aim was to document whether men with distinct vascular disorders expressed different levels of AMH. Serum AMH assayed by ELISA in 153 men (54-93 years) free from vascular disease inversely correlated with the ultrasonographic diameters of the distal- (r=-0.22, P=0.006) and mid-infrarenal aorta (r=-0.26, P=0.008). This association was similar in magnitude but opposite to that of body surface area (largest known determinant of aortic diameter) and independent of known cardiovascular risk factors. This relationship is specific to AMH, as inhibin B, a Sertoli cell hormone-like AMH, did not correlate with aortic diameter (r=-0.04, P=0.66) despite partially correlating with AMH. Among men with known vascular disease, higher AMH levels were associated with varicose vein disease, while men with higher levels of AMH were under-represented in the abdominal aortic aneurysm relative to the healthy cohort. These findings identify AMH as a novel putative regulator of the cardiovascular system.

Chronological age vs biological age: an age-related normogram for antral follicle count, FSH and anti-Mullerian hormone

Objective

To evaluate the correlation between chronological and biological age by comparing the normograms of AFC, AMH, and FSH.

Design

Retrospective study

Setting

Data were taken from patients who visited the Infertility Clinic at Dr. Cipto Mangunkusumo General Hospital Jakarta, Indonesia, between January 2008 and December 2010.

Patient(s)

Infertile women who visited the Infertility Clinic.

Intervention(s)

None.

Main Outcome Measure(s)

Normogram of AFC (n = 366), AMH (n = 1616) and FSH (n = 415).

Result(s)

The correlations among AFC, AMH, FSH, and age are statistically significant. Normograms of AFC and AMH with 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles showed a decrease in age where FSH increased. A cut-off value of AFC, AMH, and FSH for poor responders was plotted at the 50th percentile of each normogram. Serum AMH and AFC started to decline in women between 34 and 35 years old. We found a relatively lower slope increase of FSH in older patients compared to that of AFC and AMH. FSH was observed to be a later predictor of biological age than AMH and AFC.

Conclusion(s)

AMH predicted biological age earlier than FSH or AFC. Normograms can provide a reference guide for physicians to counsel infertile women. However, future validation with longitudinal data is still needed.

Biomarkers of ovarian reserve

Although it is widely appreciated that age is the primary determinant of the number of primordial follicles remaining within the ovary, it is now also recognized that for any given age two women can have a 100-fold difference in their ovarian reserve. Consequently, age alone has relatively poor accuracy in determining the reproductive potential for young women, and this has led to the development of additional biomarkers that more accurately reflect the ovarian reserve. In this review we discuss the strengths and limitations of the classical and novel biomarkers and provide a rationale for the adoption of biomarkers to facilitate the individualization of reproductive health.

Anti-Mullerian-hormone levels during pregnancy and postpartum

BACKGROUND

The number of unintentionally childless couples is increasing as more couples seek to conceive for the first time in the third or fourth decade of the woman's life. Determination of ovarian reserve is an essential component of infertility assessment. The Anti-Müllerian-Hormone (AMH) seems to be the most reliable predictor of ovarian reserve. In this study we analyzed AMH in a cohort of pregnant women without fertility impairment to determine age-dependent decline and possible AMH fluctuations during pregnancy and postpartum.

METHODS

A total of 554 healthy women aged 16 to 47 years without history of infertility or previous surgery on the ovaries were enrolled in the study between 1995 and 2012. In 450 women, a single measurement of AMH was taken during pregnancy, allowing for cross sectional analysis of trimester- and age-related differences in AMH levels. For another 15 women longitudinal data on AMH levels for all trimesters was recorded. In addition, for 69 women AMH was measured at the time just before and after delivery, and for another 20 AMH was measured just before delivery and once on each of the first four days after delivery. We used AMH-Gen-II ELISA (Beckman Coulter, Immunotech, Webster, USA) for the assessment of AMH levels. Non-parametric statistical tests were used to compare AMH levels between age groups, trimesters and postpartum.

RESULTS

Comparison between the trimesters revealed a significant difference in AMH values at each trimester (first trimester: 1.69 ng/ml (IQR 0.71-3.10), second trimester: 0.8 ng/ml (IQR 0.48-1.41), third trimester: 0.5 ng/ml (IQR 0.18-1.00)). AMH significantly dropped during the course of pregnancy and immediately after delivery, whereas an increase was observed over the first four days postpartum. Women, greater than or equal to 35 years, showed significant lower AMH levels than those <35 years across all trimesters.

CONCLUSIONS

AMH levels decrease during pregnancy. The decline in AMH levels during pregnancy indicates ovarian suppression. AMH levels recover quickly after delivery. AMH levels assessed in pregnant women are not an accurate indicator of ovarian reserve, since AMH levels during pregnancy seem not to be independent of gestational age.