Anti-Müllerian hormone (AMH) in female reproduction: is measurement of circulating AMH a useful tool?

Ovarian function in Duarte galactosemia

OBJECTIVE

To determine if girls with Duarte variant galactosemia (DG) have an increased risk of developing premature ovarian insufficiency based on prepubertal anti-Müllerian hormone (AMH) levels.

DESIGN

Cross-sectional study.

SETTING

University research laboratory.

PATIENT(S)

Study volunteers included 57 girls with DG, 89 girls with classic galactosemia (GG), and 64 control girls between the ages of <1 month and 10.5 years.

INTERVENTION(S)

Blood sampling.

MAIN OUTCOME MEASURE(S)

We determined AMH and FSH levels in study volunteers with and without Duarte variant or GG.

RESULT(S)

FSH levels were significantly higher and AMH levels significantly lower in girls with GG than in age-stratified control girls, but there was no significant difference between FSH and AMH levels in girls with DG and control girls.

CONCLUSION(S)

Although >80% of girls with GG in this study demonstrated low to undetectable AMH levels consistent with diminished ovarian reserve, 100% of girls with DG in our study demonstrated no apparent decrease in AMH levels or increase in FSH levels, suggesting that these girls are not at increased risk for premature ovarian insufficiency.

Animal age, weight and estrus cycle stage impact the quality of in vitro grown follicles

BACKGROUND

Ovarian tissue cryopreservation is an emerging fertility preservation option, and culturing follicles isolated from this tissue to obtain mature gametes may ultimately be the best solution for patients for whom transplantation is contraindicated. It is unclear, however, how patient-specific variables (including age, weight and menstrual cycle stage) impact follicle growth and quality during three-dimensional culture.

METHODS

We used a mouse model to systematically determine how these variables impact in vitro follicle growth. We characterized metabolic and hormonal profiles of mice at specific ages, weights and cycle stages and secondary follicles from these cohorts were isolated and cultured. We then assessed follicle survival, growth and function, as well as meiotic competence and spindle morphology of the resulting oocytes.

RESULTS

We found that older mice and mice with increased body weight had higher serum cholesterol, abnormal glucose tolerance and lower levels of circulating Anti-Müllerian hormone compared with younger and leaner controls. Secondary follicles isolated from different cohorts and grown in vitro had indistinguishable growth trajectories. However, the follicles isolated from older and heavier mice and those in diestrus had altered hormone profiles. These follicles contained oocytes with reduced meiotic competence and produced oocytes with greater spindle defects.

CONCLUSIONS

These results suggest that the original physical environment of the follicle within the ovary can impact its function when isolated and cultured. These findings are valuable as we begin to use in vitro follicle growth technology for a heterogeneous fertility preservation patient population.

Antimüllerian Hormone (AMH) Not Only a Marker for Prediction of Ovarian Reserve

The main characteristics of the Antimüllerian hormone from the points of view of biochemistry, molecular genetics, physiological functions and importance for diagnostics in reproductive endocrinology and related biomedical fields are reviewed. The role of the hormone in male and female development, its participation in oocyte maturation including selection of a dominant follicle are summarized, as well as its changes under various pathological situations in both sexes. The physiological changes of serum AMH leves in the life span in both sexes and their alterations under various pathological conditions are provided, too.

Ovarian function in girls and women with GALT-deficiency galactosemia

Primary or premature ovarian insufficiency (POI) is the most common long-term complication experienced by girls and women with classic galactosemia; more than 80% and perhaps more than 90% are affected despite neonatal diagnosis and careful lifelong dietary restriction of galactose. In this review we explore the complexities of timing and detection of galactosemia-associated POI and discuss potential underlying mechanisms. Finally, we offer recommendations for follow-up care with current options for intervention.

The effect of different hormone therapies on anti-müllerian hormone serum levels in anovulatory women of reproductive age

OBJECTIVE

To investigate the effect of oral contraceptives (OC), metformin and ovulation induction with gonadotropins on circulating anti-müllerian hormone (AMH).

DESIGN

Prospective clinical study.

PATIENTS

Thirty patients with PCOS (Group 1), 15 normogonadotropic anovulatory infertile women (WHO 2) (Group 2) and 15 normoovulatory control women (Group 3). Patients in Group 1 received OC (n = 12), metformin (n = 11) or no-treatment (n = 7) for 6 months. Ovulation induction with FSH or hMG was used in Group 2.

MAIN OUTCOME MEASURES

Total follicle number (TFN) and hormonal (fasting insulin and glucose, testosterone, SHBG, LH, androstenedione and AMH) measurements at baseline and during therapy.

RESULTS

Basal AMH and TFN were higher in Groups 1 and 2 than in controls. Only TFN was significantly related to AMH level in Groups 1 and 2. AMH level was significantly reduced during OC treatment, and there was a trend for AMH decrease during metformin therapy. No significant changes in AMH level were observed during ovulation induction. TFN was the only parameter showing a significant positive correlation with circulating AMH over the 6-month treatment period in patients in Group 2.

CONCLUSIONS

AMH is an accurate marker of the antral follicle pool in WHO-2/PCOS women but the measurement of AMH is not likely to be helpful in the management of those patients.

Does size matter in females? An overview of the impact of the high variation in the ovarian reserve on ovarian function and fertility, utility of anti-Müllerian hormone as a diagnostic marker for fertility and causes of variation in the ovarian reserve in cattle

The mechanism whereby the inherently high variation in ovary size and the total number of high-quality oocytes in ovaries (ovarian reserve) impact on ovarian function and fertility, diagnostics to measure the size of the ovarian reserve and the factors that cause variation in the ovarian reserve are unknown. Our results show that cattle can be phenotyped reliably based on the number of antral follicles growing during follicular waves (antral follicle count, AFC). Young adult cattle with a consistently low v. a high AFC have smaller gonads, a markedly diminished ovarian reserve and many other phenotypic characteristics usually associated with ovarian aging and infertility. A powerful new approach based on a single measurement of serum concentration of anti-Müllerian hormone (AMH) is described to test the longstanding hypothesis that the size of the ovarian reserve is positively associated with fertility. Also, new evidence shows that maternal environment has a critical role in regulation of the high variation in the ovarian reserve and perhaps fertility in offspring. These results support the conclusion that the inherently high variation in the ovarian reserve, potentially caused by alterations in the maternal environment, has a negative impact on ovarian function that may result in suboptimal fertility in young adult cattle, and a single AMH measurement can be used reliably in future studies to determine if fertility is suboptimal in young adult cattle with low circulating AMH concentrations and a correspondingly diminished ovarian reserve.

The reproducibility of serum anti-Müllerian hormone in subfertile women: within and between patient variability

Serum anti-Müllerian hormone concentrations vary significantly over time and this should be taken into account when tailoring treatment protocols for patients undergoing controlled ovarian hyperstimulation (COH). Compared with FSH, serum anti-Müllerian hormone may have greater discriminatory power because of its modest intrapatient variation and the larger interpatient variation.

Primary ovarian insufficiency: autoimmune causes

PURPOSE OF REVIEW

To review the pathogenesis of premature ovarian insufficiency due to steroid cell autoimmunity (SCA-POI).

RECENT FINDINGS

Autoimmune oophoritis is characterized by a selective mononuclear cell infiltration into the theca layer of large, antral follicles, with earlier stage follicles consistently free of lymphocytic infiltration. SCA-POI is caused by the selective autoimmune destruction of theca cells with preservation of granulosa cells that produce low amounts of estradiol because of lack of substrates. Typically, serum concentrations of inhibins are increased in women with SCA-POI, as compared to both healthy fertile women and women with other forms of ovarian insufficiency. Normal serum antimüllerian hormone (AMH) concentrations were detected in two-thirds of women with recently diagnosed SCA-POI, which demonstrates that this form of ovarian insufficiency is associated with a preserved pool of functioning follicles.

SUMMARY

The combined measurement of autoantibodies and markers of ovarian reserve (as inhibin B and AMH) may permit to identify women with POI due to steroid cell autoimmunity with a preserved proportion of primordial and primary follicles. In the future the development of techniques of in-vitro folliculogenesis may permit new treatment strategies for women with SCA-POI-related infertility.

Discordances between follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) in female infertility

BACKGROUND

Follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) represent the two most frequently utilized laboratory tests in determining ovarian reserve (OR). This study determined the clinical significance of their concordance and discordance in female infertility patients.

METHODS

We investigated 366 consecutive infertility patients (350 reached IVF), excluding women with polycystic ovarian syndrome (PCOS). They were considered to have normal FSH and AMH if values fell within age-specific (as-) 95% confidence intervals (CI), and to suffer from diminished ovarian reserve (DOR) if FSH exceeded and/or AMH fell below those. The two hormones, thus, could be concordant (Group I), both normal (IA) or abnormal (IB), show normal AMH/abnormal FSH (Group II) or normal FSH/abnormal AMH (Group III). Oocyte yields, stratified for age categories, were then studied in each group as reflection of OR.

RESULTS

Oocyte yields significantly decreased from groups IA to II to III and IB. Predictive values of as-FSH/AMH patterns changed, however, at different ages. Except at very young and very old ages, normal as-AMH better predicted higher oocytes yields than normal as-FSH, though above age 42 years normal as-FSH predicts good oocyte yields even with abnormally low AMH. Under age 42 discrepancies between as- FSH and as-AMH remain similarly predictive of oocyte yields at all ages.

DISCUSSION

Concordances and discordances between as-FSH and as-AMH improve OR assessments and predictability of oocyte yields in IVF.

Normal serum concentrations of anti-Müllerian hormone in women with regular menstrual cycles

Anti-Müllerian hormone (AMH) has become the 'molecule of the moment' in the field of reproductive endocrinology. Indeed, it is valuable as a means of increasing understanding of ovarian pathophysiology and for guiding clinical management across a broad range of conditions. However, no normative values have been established for circulating AMH in healthy women. In this cross-sectional study, 277 healthy females (aged 18-50 years) were included. AMH was measured by commercial enzyme-linked immunosorbent assay. Serum AMH concentrations show a progressive decline with female ageing. The age-related changes in AMH were best fitted by a polynomial function. Mean AMH concentrations were not modified by past use of oral contraceptive and were independent of parity of women. Age-specific normative values for circulating AMH concentration were established. AMH concentrations seem to be independent of the reproductive history of the patient.

Anti-mullerian hormone and cumulative pregnancy outcome in in-vitro fertilization

PURPOSE

To evaluate the role of Anti-mullerian hormone (AMH) in predicting cumulative pregnancy outcome during in-vitro fertilization (IVF) treatment.

METHODS

Serum AMH levels on day 6 of ovarian stimulation were taken from 180 women undergoing IVF with or without intracytoplasmic sperm injection (ICSI). The main outcome measures were ongoing pregnancy in the fresh cycle, cumulative ongoing pregnancy and ovarian response.

RESULTS

There was a trend of higher median AMH levels in subjects achieving ongoing pregnancy in the fresh IVF cycle. The median AMH levels were significantly higher in subjects attaining ongoing pregnancy cumulatively and in subjects showing ovarian hyper-response in the stimulated cycle. Areas under the ROC curves were 0.606 and 0.792 for the prediction of cumulative ongoing pregnancy and ovarian hyper-response respectively.

CONCLUSIONS

Serum AMH concentration on day 6 of stimulation was significantly higher in subjects who achieved cumulative ongoing pregnancy in IVF compared to those who did not. Serum AMH is a reasonably good predictor of ovarian hyper-response.

Fertility preservation in girls during childhood: is it feasible, efficient and safe and to whom should it be proposed?

BACKGROUND

In prepubertal and adolescent girls, fertility may be impaired by gonadotoxic treatments, repeat ovarian surgery or genetic disorders. Cryopreservation of ovarian cortex is an existing option to preserve fertility in these young girls at risk of premature ovarian failure (POF). The efficacy, feasibility and risks of ovarian cryopreservation in children must be assessed in order to validate the technique.

METHODS

Here, we conducted a review of ovarian cryopreservation in adults and, more specifically, in children using the PubMed databases. In addition, our own experience with ovarian cryopreservation in children was evaluated and compared with the literature.

RESULTS

Analysis of the literature and six published series on ovarian cryopreservation in children, as well as our own series of 58 cases, show that there is no reason to doubt its efficacy in this young population. However, no consensus has yet been reached on the indications for the technique. Indeed, with existing models, the real risk of POF may be over- or underestimated.

CONCLUSION

Our review suggests that ovarian cortex cryopreservation is feasible and as safe as comparable operative procedures in children. Although no births have yet resulted from freeze-thawing of prepubertal ovarian cortex, the results of this approach in adults are encouraging. However, the absence of consensus on the indications for fertility preservation, as well as the optimal timing and quantity of ovarian cortex for cryopreservation, should be taken into consideration when discussing fertility issues with girls at risk of POF and their parents.

Improvement in diminished ovarian reserve after dehydroepiandrosterone supplementation

Dehydroepiandrosterone (DHEA) has been reported to improve oocyte/embryo yields and oocyte/embryo quality in women with diminished ovarian reserve. Whether DHEA objectively improves ovarian reserve is, however, unknown. This study investigated 120 consecutive patients with diminished ovarian reserve, supplemented for 30-120 days (mean 73+/-27) with DHEA (25mg three times daily). Anti-Müllerian hormone (AMH) concentrations were determined in relationship to DHEA supplementation using linear regression and, longitudinally, by examining interaction between days of DHEA treatment and pregnancy success in respect to changes in AMH. AMH concentrations significantly improved after DHEA supplementation over time (P=0.002). Women under age 38 years demonstrated higher AMH concentrations and improved AMH concentrations more than older females. AMH improved longitudinally by approximately 60% (P<0.0002). Women reaching IVF experienced a 23.64% clinical pregnancy rate and conceiving women showed significantly improved AMH concentrations compared with those who did not (P=0.001). DHEA supplementation, thus, significantly improved ovarian reserve in parallel with longer DHEA use and was more pronounced in younger women.

Change in the ovarian environment after hysterectomy as assessed by ovarian arterial blood flow indices and serum anti-Müllerian hormone levels

OBJECTIVE

The aim of this prospective study was to evaluate the changes in the ovarian environment after hysterectomy based on ovarian arterial blood flow indices and serum anti-Müllerian hormone (AMH) levels.

STUDY DESIGN

Ovarian arterial blood flow indices (pulsatile and resistance indices) by Doppler ultrasonography and serum AMH levels were measured at baseline and 1 week, 1 month, and 3 months after hysterectomy in 32 women ranging in age from 38 to 49 years, or at the time of screening in 21 age-matched controls. The study subjects underwent hysterectomy with conservation of both ovaries for benign diseases of the uterus (laparoscopy-assisted vaginal hysterectomy [LAVH], n=26; and total abdominal hysterectomy [TAH], n=6). The study subjects and controls were analyzed using a t-test or one-way analysis of variance.

RESULTS

No differences existed in demographic profiles, ovarian arterial blood flow indices, and serum AMH levels at baseline between the hysterectomy and control groups. Ovarian arterial blood flow indices did not change before and after surgery, and there were no serial changes in the mean levels of serum AMH at each time point (1.80+/-1.81 ng/mL [pre-operatively], 1.69+/-1.62 ng/mL [1 week post-hysterectomy], 1.42+/-1.34 ng/mL [1 month post-hysterectomy], and 1.52+/-1.72 ng/mL [3 months post-hysterectomy]; p=0.805). In addition, no significant differences in ovarian arterial blood flow indices and serum AMH levels existed between the LAVH and TAH groups.

CONCLUSION

This preliminary study suggests that hysterectomy does not affect the ovarian environment for up to 3 months post-operatively, as assessed by ovarian arterial blood flow indices and serum AMH levels.

Evaluating the performance of serum antimullerian hormone concentration in predicting the live birth rate of controlled ovarian stimulation and intrauterine insemination

OBJECTIVE

To evaluate the role of serum antimullerian hormone (AMH) concentration in predicting live birth outcome in controlled ovarian stimulation and intrauterine insemination (IUI).

DESIGN

Retrospective analysis.

SETTING

Tertiary assisted reproduction unit.

PATIENTS

243 patients undergoing IUI treatment.

INTERVENTION(S)

Archived early follicular phase serum samples taken at the start of the first treatment cycle before ovarian stimulation were retrieved from patients undergoing IUI treatment.

MAIN OUTCOME MEASURE(S)

First-cycle and cumulative live birth rates.

RESULT(S)

Patients attaining a successful live birth, either in the first cycle or cumulatively after three cycles, had significantly higher serum AMH concentrations than those failing treatment. Serum AMH concentration correlated positively with antral follicle count (AFC) and duration of stimulation and inversely with maternal age, serum FSH concentration, and total dose of gonadotropin used. After controlling for age, body mass index, AFC, and FSH, AMH remained the only significant predictor of cumulative live birth. The area under the receiver operating characteristic curve was 0.668 in predicting cumulative live birth. Serum AMH concentration was significantly higher in overresponders.

CONCLUSION(S)

Serum AMH concentration was significantly higher in subjects with a live birth from the first cycle or after three cycles of stimulated IUI treatment compared with those failing treatment. Serum AMH concentration has a modest predictive value on ovarian overresponse.

A single test of antimullerian hormone in late reproductive-aged women is a good predictor of menopause

OBJECTIVE

The aim of this study was to assess the capability of a single measurement of antimullerian hormone (AMH) to predict menopause status in late reproductive-aged women.

METHODS

A group of 147 women, naturally fertile, aged 40 to 50 years with regular menstrual cycles were selected from the Tehran Lipid and Glucose Study cohort. Participants were assessed three times at 3-year intervals (T1-T3), and their blood levels of AMH were measured. The World Health Organization classification was used to define menopause status. The area under the receiver operating characteristics curve was calculated to assess the ability of AMH at T1 to discriminate between women who have reached menopause status and those who have not. Cutoff points and their relevant sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

Of 147 women, menopause occurred in 60. With use of the AMH level at T1, the probability of an accurate prediction of not reaching menopause status within the next 6 years for women aged 40 to 50 years was 88% (area under the receiver operating characteristics curve, 0.88; 95% CI, 0.83-0.94; P < 0.001). A threshold of 0.39 ng/mL for AMH had the optimal combined sensitivity and specificity for prediction with a positive predictive value of 0.90 (95% CI, 0.81-0.96) and negative predictive value of 0.76 (95% CI, 0.65-0.86). Results for a slightly lower (0.365 ng/mL) and higher (0.49 ng/mL) AMH threshold had negligible effect. Stratified analysis for women aged 40 to 44 and 45 to 49 years produced similar results.

CONCLUSIONS

Of every 10 women in late reproductive age with AMH levels greater than 0.39 ng/mL, only one will reach menopause status within the next 6 years. A single AMH measurement is a good predictor for the onset of menopause.

Primary ovarian insufficiency due to steroidogenic cell autoimmunity is associated with a preserved pool of functioning follicles

CONTEXT

Primary ovarian insufficiency (POI) is defined as hypergonadotropic amenorrhea before the age of 40 yr. In 4-5% of patients with POI, an ovarian autoimmune process is present.

DESIGN

Serum concentrations of antimüllerian hormone (AMH) have been determined in 26 women with POI due to steroidogenic cell autoimmunity (SCA-POI), 66 with nonautoimmune idiopathic POI (iPOI), 40 postmenopausal women (PMW), and 44 healthy fertile women (HW). SCA-POI was diagnosed according to presence of steroidogenic enzyme autoantibodies (17alpha-hydroxylase, side chain cleavage, and 21-hydroxylase autoantibodies).

RESULTS

AMH concentrations were significantly higher in women with SCA-POI than women with iPOI (P = 0.018) or PMW (P = 0.03) but significantly lower than HW (P < 0.0001). AMH was detected in 11 of 26 women with SCA-POI (42%) and seven of 66 with iPOI (11%) (P = 0.002). Serum concentrations above the fifth percentile of the normal range (0.6 ng/ml) were detected in nine of 26 women with SCA-POI (35%) and four of 66 with iPOI (6%) (P = 0.001). Eight of 12 women with SCA-POI with less than 5 yr (67%) and one of 14 with longer disease duration (7%) had AMH concentrations within the normal range (P = 0.003). AMH concentrations correlated inversely with disease duration in women with SCA-POI (rho = -0.563, P = 0.003) but not women with iPOI. AMH correlated inversely with FSH serum concentrations in HW (rho = -0.584, P < 0.001) but not PMW or women with POI.

CONCLUSIONS

Two thirds of women with recent-onset SCA-POI had normal AMH concentrations. Women with SCA-POI, differently from those with iPOI, present a preserved ovarian follicle pool for several years after diagnosis of ovarian insufficiency.

The antral follicle count: practical recommendations for better standardization

OBJECTIVE

To provide recommendations for the standardized use of the Antral follicle count (AFC) which is used to predict ovarian response to gonadotrophin stimulation during assisted reproductive technology treatment. However, the nature of the follicles that are visualized by ultrasound and the competence of the oocytes held within are largely unknown. In addition, there is considerable variability in the clinical definitions and technical methods used to count and measure antral follicles in both published studies and clinical practice.

DESIGN AND SETTING

In December 2007, specialist reproductive medicine clinicians and scientists attended a workshop in an effort to address these issues. Literature concerning the physiology and measurement of ovarian antral follicles was reviewed, clinical and technical considerations regarding antral follicle measurement were discussed, and an operational definition of AFC was developed.

PATIENT(S)

None.

INTERVENTION(S)

None.

OUTCOME MEASURES

Simple recommendations were established for the standardization of AFC assessment in routine clinical practice. The basic clinical and technical requirements required for AFC evaluation were agreed upon, and a systematic method of measuring and counting antral follicles in routine practice was proposed.

CONCLUSION(S)

The use of a standardized approach according to the practical recommendations for antral follicle counting as presented is encouraged in future clinical trials and routine practice. The authors also advocate a systematic evaluation of these recommendations as standardized study data become available.

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

In the ovary, Anti-Müllerian hormone (AMH) is produced by the granulosa cells of early developing follicles and inhibits the transition from the primordial to the primary follicular stage. AMH levels can be measured in serum and have been shown to be proportional to the number of small antral follicles. In women serum AMH levels decrease with age and are undetectable in the post-menopausal period. In patients with premature ovarian failure AMH is undetectable or greatly reduced depending of the number of antral follicles in the ovaries. In contrast, AMH levels have been shown to be increased in women with polycystic ovary syndrome (PCOS). AMH levels appear to represent the quantity of the ovarian follicle pool and may become a useful marker of ovarian reserve. AMH measurement could also be useful in the prediction of the extremes of ovarian response to gonadotrophin stimulation for in vitro fertilization, namely poor- and hyper-response. Although AMH has the potential to increase our understanding of ovarian pathophysiology, and to guide clinical management in a broad range of conditions, a number of important questions relating to both the basic physiology of AMH and its clinical implications need to be answered.

[Anti-Müllerian hormone--its role in management of involuntary infertility]

BACKGROUND

Although fertility in women decreases significantly after the age of 35 years, women in Norway - as in many other developed countries- postpone having children. It has long been recognised that there is a need for a better marker of ovarian function. This article provides an overview of physiological development of follicles in the ovaries and the special place Anti-Müllerian- hormone has in this process.

MATERIAL AND METHODS

Literature was retrieved from the databases PubMed, Athens and Embase by using the keywords Anti-Müllerian hormone, follicle, ovarian reserve, ovarian response and fertility. The reference lists of relevant articles were searched for additional information.

RESULTS AND INTERPRETATION

32 articles with relevant information were retrieved. The level of Anti-Müllerian hormone is relatively stable throughout the menstruation cycle. The hormone appears to be a reliable marker for ovarian reserve and ovarian response after controlled ovarian hyperstimulation during in vitro fertilisation. Determination of the hormone level will enable identification of women with high risk of deviating response upon ovarian hyperstimulation.

Anti-Mullerian hormone levels reflect severity of PCOS but are negatively influenced by obesity: relationship with increased luteinizing hormone levels

The objective of the study was the comparison of anti-Müllerian hormone (AMH) levels among obese or overweight and normal-weight women with the four different polycystic ovary syndrome (PCOS) phenotypes and healthy control subjects. AMH levels were evaluated in four age- and body mass index (BMI)-matched groups of 25 normal-weight and 25 obese or overweight women each, belonging to the four main subsets of the syndrome resulting from combinations of the three diagnostic criteria [group 1: oligo- and/or anovulation (ANOV), hyperandrogenemia (HA), and polycystic ovaries (PCO) on ultrasonographic evaluation; group 2: ANOV and HA; group 3: HA and PCO, group 4: ANOV and PCO], and in 50 (25 obese or overweight and 25 normal weight) age- and BMI-matched healthy control subjects. Age, BMI, waist circumference, FSH, LH, prolactin, testosterone, Delta(4)-androstenedione, dehydroepiandrosterone-sulfate, 17alpha-OH-progesterone, fasting insulin, glucose, AMH, free androgen index, and homeostasis model assessment for insulin resistance index were analyzed. AMH levels were significantly higher in PCOS groups 1 and 2 compared with groups 3 and 4 and the control group and higher in PCOS groups 3 and 4 compared with the control group. AMH levels were significantly increased in normal-weight compared with obese and overweight women. AMH concentrations were independently predicted, in order of significance, by LH and testosterone levels, BMI (negatively), and the total number of follicles 2-9 mm in diameter. The differences in circulating AMH levels between the main phenotypic groups of PCOS women appear to reflect the severity of the syndrome, but are negatively affected by obesity. Increased LH levels might be the most significant independent link between PCOS-associated disorders of ovulation and the observed increase in circulating AMH concentration.

Long-term follow-up of patients with polycystic ovary syndrome: reproductive outcome and ovarian reserve

BACKGROUND

The purpose of the present study was to examine long-term reproductive outcome and ovarian reserve in an unselected population of women with polycystic ovary syndrome (PCOS). METHODS A total of 91 patients with confirmed PCOS and 87 healthy controls were included in the study. Patients had been diagnosed between 1987 and 1995 and at the time of the follow-up, subjects were 35 years of age or older.

RESULTS

Among women who had attempted a pregnancy, 86.7% of PCOS patients and 91.6% of controls had given birth to at least one child. Among PCOS patients who had given birth, 73.6% had done so following a spontaneous conception. Mean ovarian volume and the number of antral follicles in PCOS patients were significantly greater than in control women (P < 0.001, respectively). PCOS patients also had higher serum concentrations of anti-Müllerian hormone and lower follicle-stimulating hormone levels.

CONCLUSIONS

Most women with PCOS had given birth, and the rate of spontaneous pregnancies was relatively high. Together with the ultrasound findings and the hormonal analyses, this finding could imply that PCOS patients have a good fecundity, and an ovarian reserve possibly superior to women with normal ovaries.

Fertility preservation in girls with turner syndrome: prognostic signs of the presence of ovarian follicles

CONTEXT

Many girls with Turner syndrome have follicles in their ovaries at adolescence.

OBJECTIVE

Our objective was to study which girls might benefit from ovarian tissue freezing for fertility preservation.

DESIGN

Clinical and laboratory parameters and ovarian follicle counts were analyzed among girls referred by 25 pediatric endocrinologists.

SUBJECTS AND SETTING

Fifty-seven girls with Turner syndrome, aged 8-19.8 yr, were studied at a university hospital.

INTERVENTIONS

Ovarian tissue was biopsied laparoscopically, studied for the presence of follicles, and cryopreserved. Blood samples were drawn for hormone measurements.

MAIN OUTCOME MEASURES

Presence of follicles in the biopsied tissue related to age, signs of spontaneous puberty, karyotype, and serum concentrations of gonadotropins and anti-Müllerian hormone were assessed.

RESULTS

Ovarian biopsy was feasible in 47 of the 57 girls. In 15 of the 57 girls (26%), there were follicles in the tissue piece analyzed histologically. Six of seven girls (86%) with mosaicism, six of 22 (27%) with structural chromosomal abnormalities, and three of 28 with karyotype 45X (10.7%) had follicles. Eight of the 13 girls (62%) with spontaneous menarche had follicles, and 11 of the 19 girls (58%) who had signs of spontaneous puberty had follicles. The age group 12-16 yr had the highest proportion of girls with follicles. Normal FSH and anti-Müllerian hormone concentrations for age and pubertal stage were more frequent in girls with follicles.

CONCLUSIONS

Signs of spontaneous puberty, mosaicism, and normal hormone concentrations were positive and statistically significant but not exclusive prognostic factors as regards finding follicles.

Assessment of ovarian reserve following ovarian tissue banking and/or GnRH-a co-treatment prior to chemotherapy in patients with Hodgkin's disease

PURPOSE

To examine ovarian reserve following chemotherapy in women with Hodgkin's disease.

METHODS

The study included nine patients who underwent ovarian tissue cryopreservation (OTCP) prior to chemotherapy consisting of the ABVD regimen (Adriamycin, bleomycin, vinblastine, and dacarbazine) and co-treatment with gonadotropin-releasing hormone agonist (GnRH-a) (Group A), and 13 patients treated by the ABVD protocol only without GnRH-a (Group B). The average age was 25.2 +/- 2.7 years for the women in Group A and 31.8 +/- 6.8 years for those in Group B.

RESULTS

Six months following the end of chemotherapy, the menstrual cycle resumed in all Group A patients and in four Group B patients who had amenorrhea. Eight Group B patients had regular menses during and after chemotherapy. None of the patients suffered from ovarian failure. Two Group A patients conceived in the first year after completing chemotherapy.

CONCLUSIONS

Co-treatment with GnRH-a has little effect on ovarian protection in women with Hodgkin's disease.

Increased gonadotrophin stimulation does not improve IVF outcomes in patients with predicted poor ovarian reserve

PURPOSE

This retrospective study was carried out to evaluate whether increasing the starting dose of FSH stimulation above the standard dose of 150 IU/day in patients with low predicted ovarian reserve can improve IVF outcomes.

METHOD

A total of 122 women aged less than 36 years in their first cycle of IVF were identified as having likely low ovarian reserve based on a serum AMH measurement below 14 pmol/l. Thirty five women were administered the standard dose of 150 IU/day FSH, while the remaining 87 received a higher starting dose (200-300 IU/day FSH). There were no significant differences in age, BMI, antral follicle count, serum AMH, FSH or aetiology of infertility between the two dose groups.

RESULTS

No significant improvement in oocyte and embryo yield or pregnancy rates was observed following an upward adjustment of FSH starting dose. While increasing the dose of FSH above 150 IU/day did not produce any adverse events such as OHSS, it did consume an extra 1,100 IU of FSH per IVF cycle.

CONCLUSION

The upward FSH dose adjustment in anticipation of low ovarian reserve can not be advocated as it is both expensive and of no proven clinical value.

Expression of anti-Müllerian hormone (AMH) in equine granulosa-cell tumors and in normal equine ovaries

Anti-Müllerian hormone (AMH), also known as Müllerian inhibiting substance (MIS), is expressed by granulosa cells in females of many mammalian species, and circulating AMH concentrations have been used to monitor granulosa-cell tumors (GCT) in women. The objective was to characterize expression of AMH in equine GCT, and in normal equine ovaries, based upon immunohistochemistry (IHC), using a polyclonal primary antibody directed against human AMH. Equine GCT (n=27) and normal equine ovaries (n=10) were examined by IHC. In addition, sera from four mares with GCT were characterized for AMH bioactivity, based upon suppression of Müllerian duct development in the fetal rat. Immunolabeling with alpha-AMH was localized to granulosa cells in equine GCT, as well as within antral follicles in normal ovaries. Expression of AMH first appeared in granulosa cells of small growing follicles and was most intense in small antral follicles; large antral or atretic follicles had reduced immunolabeling. Omission of the primary antibody or incubation of the primary antibody with the corresponding blocking peptide eliminated immunolabeling of granulosa cells in GCT and in normal antral follicles, confirming the specificity of the immunolabel. Sera from mares with GCT had increased AMH bioactivity compared to control sera. In conclusion, AMH was strongly expressed by granulosa cells in equine GCT and in normal antral follicles. Therefore, anti-Müllerian hormone may be a useful biomarker for detection of GCT in the horse.

Biomarkers of Ovarian Reserve

The primary function of the female ovary is the production of a mature and viable oocyte capable of fertilization and subsequent embryo development and implantation. At birth, the ovary contains a finite number of oocytes available for folliculogenesis. This finite number of available oocytes is termed "the ovarian reserve". The determination of ovarian reserve is important in the assessment and treatment of infertility. As the ovary ages, the ovarian reserve will decline. Infertility affects approximately 15%-20% of reproductive aged couples. The most commonly used biomarker assay to assess ovarian reserve is the measurement of follicle stimulating hormone (FSH) on day 3 of the menstrual cycle. However, anti-müllerian hormone and inhibin-B are other biomarkers of ovarian reserve that are gaining in popularity since they provide direct determination of ovarian status, whereas day 3 FSH is an indirect measurement. This review examines the physical tools and the hormone biomarkers used to evaluate ovarian reserve.

Undetectable serum anti-Müllerian hormone levels and occurrence of ongoing pregnancy

OBJECTIVE

To discuss, on the basis of the experience of two clinical cases and extensive literature review, the significance of extremely low levels of anti-Müllerian hormone (AMH), also known as Müllerian-inhibiting substance, in infertile women.

DESIGN

Case report.

SETTING

University-based infertility clinic at a medical center in Switzerland.

PATIENT(S)

Two women, 29 and 41 years of age and with a 2- and 4-year history of secondary infertility, respectively.

INTERVENTION(S)

Clinical, radiological, and biological investigation of infertility, including repeated measurements of the serum AMH with serial ELISA assays.

MAIN OUTCOME MEASURE(S)

Levels of AMH and development of ongoing pregnancy.

RESULT(S)

Both women had a spontaneous ongoing pregnancy despite undetectable AMH levels.

CONCLUSION(S)

Although it is helpful for day-to-day management of infertile patients, the predictive value of AMH for the occurrence of a spontaneous ongoing pregnancy has limits.

Superovulatory response in a bovine model of reproductive aging

Two experiments were done to test the hypotheses that aging in cattle is associated with a reduced number of follicles recruited into an ovarian follicular wave, and a reduction in the ovarian response to gonadotropin treatment. Older cows (13-16 years of age) and their daughters (3-6 years of age) were treated with FSH for ovarian superstimulation four times over two consecutive years (31 and 33 superstimulations in old and young cows, respectively, experiments and years combined). In Experiment 1, ovulation was induced using LH. In Experiment 2, cumulus-oocyte complexes were collected by ultrasonographic-guided follicle aspirations before expected ovulations. The ovarian follicular and ovulatory responses were monitored daily by ultrasonography. Fewer 2-5mm follicles (P<0.01) were detected at the expected time of follicular wave emergence in older cows than in their daughters. After superstimulation, older cows had fewer follicles >or=6mm (P<0.01), and tended (P=0.1) to have fewer ovulations than their daughters (32+/-4 versus 40+/-3, respectively). There was a positive correlation in the response of individual cows to successive superstimulatory treatments (r>0.8; P<0.0001) and the number of detected ovulations from one year to the next (r=0.6; P=0.04). In conclusion, aging was associated with fewer 2-5mm follicles at follicular wave emergence and a lesser follicular and ovulatory response after superstimulatory treatment. The follicular and ovulatory response after superstimulation was repeatable within individuals, regardless of age.

Endocrine features of menstrual cycles in middle and late reproductive age and the menopausal transition classified according to the Staging of Reproductive Aging Workshop (STRAW) staging system

CONTEXT

Female reproductive aging based on changes in menstrual cycle length and frequency progresses through a number of stages as defined by the Stages of Reproductive Aging Workshop (STRAW) staging criteria.

OBJECTIVE

This paper provides a comprehensive description of the endocrine features associated with the STRAW stages.

DESIGN

Healthy women aged 21-35 and 45-55 yr submitted three blood samples a week over a single menstrual cycle. They were classified as mid-reproductive age (n = 21), late-reproductive age (n = 16), early menopause transition (n = 16), and late menopause transition (n = 23).

RESULTS

There were nine, one, zero, and two anovulatory cycles identified in the late menopause transition, early menopause transition, late-reproductive age, and mid-reproductive age groups, respectively. Ovulatory cycle FSH, LH, and estradiol levels increased with progression of STRAW stage (P = 0.001, P < 0.01, and P < 0.05, respectively), and mean luteal phase serum progesterone decreased (P < 0.01). Early cycle (ovulatory and anovulatory) inhibin B decreased steadily across the STRAW stages (P < 0.01) and was largely undetectable during elongated ovulatory and anovulatory cycles in the menopause transition. Anti-Mullerian hormone decreased markedly (10- to 15-fold) and progressively across the STRAW stages (P < 0.01 and P < 0.001, respectively).

CONCLUSIONS

Progression through the STRAW stages is associated with elevations in serum FSH, LH, and estradiol and decreases in luteal phase progesterone. The marked fall in inhibin B and particularly anti-Mullerian hormone indicate that they may be useful in predicting STRAW stage but future analyses of early cycle measurements on larger cohorts are needed to draw predictive conclusions.

A review of hormonal changes during the menopausal transition: focus on findings from the Melbourne Women's Midlife Health Project

The menopause, defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity, marks the end of natural female reproductive life. It is preceded by a period of menstrual cycle irregularity, the menopausal transition, which usually begins in the mid-40s and is conventionally divided into early and late phases. The endocrine changes, which underlie the transition, are predominantly the consequence of a marked decline in ovarian follicle numbers. The most significant changes include a decrease in early cycle inhibin B and in anti-Mullerian hormone (AMH) levels. The decline in inhibin B results in an increase in FSH, which appears to be an important factor in the maintenance of estradiol (E2) concentrations until late in reproductive life. In the post-menopause, FSH levels are markedly raised, E2 levels are low, whereas inhibin B and AMH are undetectable. The menopausal transition is a time of marked hormonal instability. The Melbourne Women's Midlife Health Project has been an extremely productive study in which it has been possible to describe longitudinal changes in hormone levels throughout the menopause transition and to separate the effects of hormone change from the effects of ageing on a number of endpoints. This review provides the background for an accompanying manuscript in which a novel approach to modelling the hormonal changes during the transition is described.

The Anti-Mullerian hormone and ovarian cancer

The Anti-Mullerian hormone (AMH), which is produced by fetal Sertoli cells, is responsible for regression of Mullerian ducts, the anlagen for uterus and Fallopian tubes, during male sex differentiation. Ovarian granulosa cells also secrete AMH from late in fetal life. The patterns of expression of AMH and its type II receptor in the post-natal ovary indicate that AMH may play an important role in ovarian folliculogenesis. Recent advances in the physiological role of AMH has stimulated interest in the significance of AMH as a diagnostic marker and therapeutic agent for ovarian cancer. Currently, AMH has been shown to be a circulating marker specifically for granulosa cell tumour (GCT). Its diagnostic performance seems to be very good, with a sensitivity ranging between 76 and 93%. In patients treated for GCT, AMH may be used post-operatively as marker for the efficacy of surgery and for disease recurrence. Based on the physiological inhibitory role of AMH in the Mullerian ducts, it has been proposed that AMH may inhibit epithelial ovarian cancer cell both in vitro and in vivo. These observations will be the basis for future research aiming to investigate the possible clinical role of AMH as neo-adjuvant, or most probably adjuvant, therapy for ovarian cancer.

Anti-Müllerian hormone measurement on any day of the menstrual cycle strongly predicts ovarian response in assisted reproductive technology

BACKGROUND

Recently, a new marker, the anti-Müllerian hormone (AMH), has been evaluated as a marker of ovarian response. Serum AMH levels have been measured at frequent time-points during the menstrual cycle, suggesting the complete absence of fluctuation. The aim of this study was to evaluate whether serum AMH measurement on any day of the menstrual cycle could predict ovarian response in women undergoing assisted reproductive technology (ART).

METHODS

This study included 48 women attending the IVF/ICSI programme. Blood withdrawal for AMH measurement was performed in all the patients independently of the day of the menstrual cycle.

RESULTS

Women in the lowest AMH quartile (<0.4 ng/ml) were older and required a higher dose of recombinant FSH than women in the highest quartile (>7 ng/ml). All the cancelled cycles due to absent response were in the group of the lowest AMH quartile, whereas the cancelled cycles due to risk of ovarian hyperstimulation syndrome (OHSS) were in the group of the highest AMH quartile. This study demonstrated a strong correlation between serum AMH levels and ovarian response to gonadotrophin stimulation.

CONCLUSION

For the first time, clinicians may have a reliable serum marker of ovarian response that can be measured independently of the day of the menstrual cycle.

Serum anti-Mullerian hormone throughout the human menstrual cycle

BACKGROUND

The anti-Mullerian hormone (AMH) is a member of the transforming growth factor (TGF) superfamily. In women, AMH serum levels can be almost undetectable at birth, with a subtle increase noted after puberty. Data are lacking with regard to menstrual cycle day-to-day fluctuations. This longitudinal study was designed to investigate the pattern of secretion of AMH throughout the menstrual cycle in regularly cycling women.

METHODS

Twelve healthy female subjects aged 18-24 years participated in this study. Blood samples were taken every other day throughout one menstrual cycle. Serum FSH, LH, estradiol (E(2)), progesterone, inhibin B and AMH levels were assayed by double-antibody radioimmunoassay using commercial kits.

RESULTS

Serum AMH in the first days of the menstrual cycle (days -14 to -12) was 3.8 +/- 1.2 ng/ml (mean +/- SD). No significant changes were observed in serum AMH levels throughout the menstrual cycle. The highest value was 3.9 +/- 1.3 ng/ml at day -12 and the lowest value was 3.4 +/- 1.1 ng/ml at day 14, and the difference was not significant.

CONCLUSION

In this study, we demonstrated that serum AMH levels do not change significantly throughout the menstrual cycle. Hence, AMH exhibits a relatively stable expression during the menstrual cycle, making it an attractive determinant of ovarian activity.