Anti-Müllerian hormone as a marker of ovarian reserve: What have we learned, and what should we know?

Anti-Müllerian hormone for screening, diagnosis, evaluation, and prediction: A systematic review and expert opinions

AIM

To present evidence-based recommendations for anti-Müllerian hormone (AMH) measurement as an ovarian reserve test.

METHODS

A systematic literature search for the clinical utility of AMH was conducted in PubMed from its inception to August 2022 to identify studies, including meta-analyses, reviews, randomized controlled trials, and clinical trials, followed by an additional systematic search using keywords. Based on this evidence, an expert panel developed clinical questions (CQs).

RESULTS

A total of 1895 studies were identified and 95 articles were included to establish expert opinions subdivided into general population, infertility treatment, primary ovarian insufficiency, polycystic ovary syndrome, surgery, and oncofertility. We developed 13 CQs and 1 future research question with levels of evidence and recommendations.

CONCLUSION

The findings of the current systematic review covered the clinical utility of AMH including its screening, diagnosis, evaluation, and prediction. Although some clinical implications of AMH remain debatable, these expert opinions may help promote a better understanding of AMH and establish its clinical significance.

Characterization of the molecular mechanisms that govern anti-Müllerian hormone synthesis and activity

The roles of anti-Müllerian hormone (AMH) continue to expand, from its discovery as a critical factor in sex determination, through its identification as a regulator of ovarian folliculogenesis, its use in fertility clinics as a measure of ovarian reserve, and its emerging role in hypothalamic-pituitary function. In light of these actions, AMH is considered an attractive therapeutic target to address diverse reproductive needs, including fertility preservation. Here, we set out to characterize the molecular mechanisms that govern AMH synthesis and activity. First, we enhanced the processing of the AMH precursor to >90% by introducing more efficient proprotein convertase cleavage sites (RKKR or ISSRKKRSVSS [SCUT]). Importantly, enhanced processing corresponded with a dramatic increase in secreted AMH activity. Next, based on species differences across the AMH type II receptor-binding interface, we generated a series of human AMH variants and assessed bioactivity. AMHSCUT potency (EC50 4 ng/mL) was increased 5- or 10-fold by incorporating Gln484 Met/Leu535 Thr (EC50 0.8 ng/mL) or Gln484 Met/Gly533 Ser (EC50 0.4 ng/mL) mutations, respectively. Furthermore, the Gln484 Met/Leu535 Thr double mutant displayed enhanced efficacy, relative to AMHSCUT . Finally, we identified residues within the wrist pre-helix of AMH (Trp494 , Gln496 , Ser497 , and Asp498 ) that likely mediate type I receptor binding. Mutagenesis of these residues generated gain- (Trp494 Phe or Gln496 Leu) or loss- (Ser497 Ala) of function AMH variants. Surprisingly, combining activating type I and type II receptor mutations only led to modest additive increases in AMH potency/efficacy. Our study is the first to characterize AMH residues involved in type I receptor binding and suggests a step-wise receptor-complex assembly mechanism, in which enhancement in the affinity of the ligand for either receptor can increase AMH activity beyond the natural level.

Elevated Thyroglobulin Antibody Level is Associated with Decreased Anti-Müllerian Hormone in Women of Reproductive Age

Purpose

Women with Hashimoto's thyroiditis (HT) have an increased risk of ovarian insufficiency. However, whether thyroid antibodies affect the ovarian reserve remains controversial. The aim of this study was to explore the possible relationship between anti-Müllerian hormone (AMH) and thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb) levels in women of reproductive age.

Methods

A total of 483 women between 18 and 45 years old who had their TPOAb, TgAb, thyroid-stimulating hormone (TSH), free thyroxine (FT4), and AMH levels measured on the same day were enrolled in this study. The levels of TSH, FT4, TPOAb, and TgAb, the prevalence of overt and subclinical hypothyroidism, and the positive rate of TPOAb and TgAb were compared between patients with low (below the 10th percentile), normal (10th to 90th percentile), and high (higher than the 90th percentile) AMH levels.

Results

The median AMH level was 1.72 (0.33-4.27) ng/mL. A total of 9.9% of patients had low AMH levels. The TgAb levels and the prevalence of TgAb positivity were higher in the low AMH group (37.62 (13.10-232.68) IU/mL, 35.42%) than in the normal (12.46 (10.0-67.04) IU/mL, 19.59%) and high (13.61 (10.0-95.74) IU/mL, 23.4%) AMH groups (p=0.001, p=0.040, respectively). Serum AMH levels were inversely correlated with TgAb levels (r = -0.114, p=0.013).

Conclusion

The AMH of women of reproductive age is affected by HT. Furthermore, women with the lowest AMH level had higher levels of TgAb and a positive rate of TgAb, and high TgAb levels may cause autoimmune damage to the ovaries.

A hybrid artificial intelligence model leverages multi-centric clinical data to improve fetal heart rate pregnancy prediction across time-lapse systems

STUDY QUESTION

Can artificial intelligence (AI) algorithms developed to assist embryologists in evaluating embryo morphokinetics be enriched with multi-centric clinical data to better predict clinical pregnancy outcome?

SUMMARY ANSWER

Training algorithms on multi-centric clinical data significantly increased AUC compared to algorithms that only analyzed the time-lapse system (TLS) videos.

WHAT IS KNOWN ALREADY

Several AI-based algorithms have been developed to predict pregnancy, most of them based only on analysis of the time-lapse recording of embryo development. It remains unclear, however, whether considering numerous clinical features can improve the predictive performances of time-lapse based embryo evaluation.

STUDY DESIGN, SIZE, DURATION

A dataset of 9986 embryos (95.60% known clinical pregnancy outcome, 32.47% frozen transfers) from 5226 patients from 14 European fertility centers (in two countries) recorded with three different TLS was used to train and validate the algorithms. A total of 31 clinical factors were collected. A separate test set (447 videos) was used to compare performances between embryologists and the algorithm.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Clinical pregnancy (defined as a pregnancy leading to a fetal heartbeat) outcome was first predicted using a 3D convolutional neural network that analyzed videos of the embryonic development up to 2 or 3 days of development (33% of the database) or up to 5 or 6 days of development (67% of the database). The output video score was then fed as input alongside clinical features to a gradient boosting algorithm that generated a second score corresponding to the hybrid model. AUC was computed across 7-fold of the validation dataset for both models. These predictions were compared to those of 13 senior embryologists made on the test dataset.

MAIN RESULTS AND THE ROLE OF CHANCE

The average AUC of the hybrid model across all 7-fold was significantly higher than that of the video model (0.727 versus 0.684, respectively, P = 0.015; Wilcoxon test). A SHapley Additive exPlanations (SHAP) analysis of the hybrid model showed that the six first most important features to predict pregnancy were morphokinetics of the embryo (video score), oocyte age, total gonadotrophin dose intake, number of embryos generated, number of oocytes retrieved, and endometrium thickness. The hybrid model was shown to be superior to embryologists with respect to different metrics, including the balanced accuracy (P ≤ 0.003; Wilcoxon test). The likelihood of pregnancy was linearly linked to the hybrid score, with increasing odds ratio (maximum P-value = 0.001), demonstrating the ranking capacity of the model. Training individual hybrid models did not improve predictive performance. A clinic hold-out experiment was conducted and resulted in AUCs ranging between 0.63 and 0.73. Performance of the hybrid model did not vary between TLS or between subgroups of embryos transferred at different days of embryonic development. The hybrid model did fare better for patients older than 35 years (P < 0.001; Mann-Whitney test), and for fresh transfers (P < 0.001; Mann-Whitney test).

LIMITATIONS, REASONS FOR CAUTION

Participant centers were located in two countries, thus limiting the generalization of our conclusion to wider subpopulations of patients. Not all clinical features were available for all embryos, thus limiting the performances of the hybrid model in some instances.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that considering clinical data improves pregnancy predictive performances and that there is no need to retrain algorithms at the clinic level unless they follow strikingly different practices. This study characterizes a versatile AI algorithm with similar performance on different time-lapse microscopes and on embryos transferred at different development stages. It can also help with patients of different ages and protocols used but with varying performances, presumably because the task of predicting fetal heartbeat becomes more or less hard depending on the clinical context. This AI model can be made widely available and can help embryologists in a wide range of clinical scenarios to standardize their practices.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for the study was provided by ImVitro with grant funding received in part from BPIFrance (Bourse French Tech Emergence (DOS0106572/00), Paris Innovation Amorçage (DOS0132841/00), and Aide au Développement DeepTech (DOS0152872/00)). A.B.-C. is a co-owner of, and holds stocks in, ImVitro SAS. A.B.-C. and F.D.M. hold a patent for 'Devices and processes for machine learning prediction of in vitro fertilization' (EP20305914.2). A.D., N.D., M.M.F., and F.D.M. are or have been employees of ImVitro and have been granted stock options. X.P.-V. has been paid as a consultant to ImVitro and has been granted stocks options of ImVitro. L.C.-D. and C.G.-S. have undertaken paid consultancy for ImVitro SAS. The remaining authors have no conflicts to declare.

TRIAL REGISTRATION NUMBER

N/A.

Follicle development and its prediction in patients with primary ovarian insufficiency: Possible treatments and markers to maximize the ability to conceive with residual follicles

Background

Primary ovarian insufficiency (POI) is characterized by the development of hypergonadotropic hypogonadism before 40 years of age and leads to intractable infertility. Although in vitro fertilization and embryo transfer with donated eggs enables pregnancy, not a few patients desire pregnancy using their oocytes. However, follicular development is rare and unpredictable in patients with POI. Thus, there is a need for treatments that promote the development of residual follicles and methods to accurately predict infrequent ovulation.

Methods

This review discusses the effects of various treatments for obtaining eggs from POI patients. Furthermore, this study focused a potential marker for predicting follicular growth in patients with POI.

Main Findings

Different treatments such as hormone-replacement therapy, dehydroepiandrosterone supplementation, platelet-rich plasma injection, and in vitro activation have shown varying degrees of effectiveness in retrieving oocytes from patients with POI. To predict follicle development in the cycle, elevated serum estradiol and reduced follicle-stimulating hormone (FSH) levels are important. However, these markers are not always reliable under continuous estradiol-replacement therapy. As a novel marker for predicting follicle growth, serum anti-Müllerian hormone (AMH) levels, measured using the picoAMH enzyme-linked immunosorbent assay, were found to predict follicle growth in patients and the cycle.

Conclusion

This review highlights the challenges and available interventions for achieving pregnancy using a patient's oocytes in cases of POI. We believe that a combination of currently available treatments and prediction methods is the best strategy to enable patients with POI to conceive using their own eggs. Although AMH levels may predict follicle growth, further research is necessary to improve the chances of successful follicular development and conception in patients with POI.

Influence of Diminished Ovarian Reserve on Early Embryo Morphokinetics during In Vitro Fertilization: A Time-Lapse Study

There is great controversy as to whether women with Diminished Ovarian Reserve (DOR) exhibit only a quantitative decrease in ovarian reserve or also impaired oocyte and embryo quality. In this retrospective study, we aimed to evaluate the impact of DOR on embryo morphokinetic parameters with a time-lapse system. 1314 embryos were obtained from 256 couples undergoing IVF or ICSI cycles, with 242 embryos in the DOR group as classified by the Bologna and POSEIDON criteria and 1072 embryos derived from the Normal Ovarian Reserve (NOR) group. For each morphokinetic parameter (t2, t3, t4, t5, t8, tB, ECC2, cc2a, ECC3, s2, s3), a generalized linear mixed model was created to control for female age, BMI, smoking status, method of insemination and correlation between oocytes from a same cohort. No significant association was found between DOR and any of the morphokinetic parameters studied. In a secondary analysis, we evaluated the influence of maternal aging, comparing morphokinetic characteristics between two age groups (<37 and ≥37 years). In the univariate analysis, we found that embryos from older women displayed a slower embryo development (in particular for t3, t4, t5, tB, and ECC2), although without statistical significance in the multivariate analysis. In conclusion, our study did not reveal any substantial impact of ovarian aging on early morphokinetic parameters and suggested potential biases that may be a source of controversy in the literature.

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

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

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

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

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

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

Association of AMH and AMHR2 gene polymorphisms with ovarian response and pregnancy outcomes in Indian women

PURPOSE

To evaluate the association of single-nucleotide polymorphisms (SNPs) in the anti-Müllerian hormone (AMH) and AMH type II receptor (AMHR2) genes with ovarian response and clinical pregnancy outcomes in women undergoing controlled ovarian hyperstimulation.

METHODS

In this prospective study, we genotyped AMH polymorphisms (c. -649 T > C, c. 146 T > G, c. 252 G > A, and c. 303 G > A) in 365 women and AMHR2 polymorphisms (c. -482 A > G, c. 622-6 C > T, c. 4952 G > A, c. 10 A > G) in 80 women undergoing controlled ovarian hyperstimulation for IVF.

RESULTS

Higher doses of exogenous FSH and lower numbers of preovulatory follicles were noted in women having AMH c. -649 T > C and AMH c. -146 T > G polymorphisms, respectively. Overall, we found that the presence of a polymorphic genotype (homozygous or heterozygous) at positions c. -649 T > C, c. 146 T > G, c. 252 G > A, and c. 303 G > A in the AMH gene was associated with higher doses of FSH for ovulation induction (p < 0.001). Interestingly, a higher live birth rate was noted in women with a homozygous polymorphic genotype for all four AMH SNPs investigated while none of the women showing a homozygous polymorphic genotype at all AMHR2 SNPs investigated in this study had a live birth.

CONCLUSION

Our results show that presence of AMHR2 SNPs (c. 482 A > G, c. 622-6 C > T, c. 4952 G > A, and c. 10 A > G) negatively correlate with live birth rate. However, these findings need to be validated by using larger sample size.

Maternal Exposure to D-galactose Reduces Ovarian Reserve in Female Rat Offspring Later in Life

BACKGROUND

Embryonic life is critical for the formation of ovaries in mammals, and the intrauterine environment may affect ovarian reserve.

OBJECTIVES

The present study aimed to investigate the impact of prenatal D-galactose exposure on ovarian reserve in female rat offspring in their later lives.

METHODS

Ten pregnant Wistar rats were randomly divided into two groups. In one group, rats were fed with 35% D-galactose-enriched food from the third day to the end of pregnancy, and in the other group, rats were fed with a standard diet throughout pregnancy. Female offspring (prenatally galactose-exposed rats and non-exposed control rats) were examined in terms of hormonal levels [anti-Mullerian hormones (AMH), follicle-stimulating hormone (FSH), and estradiol (E2)] and ovarian histology at 45 - 50, 105 - 110, and 180 - 185 days of their age.

RESULTS

The number of primordial follicles significantly decreased time-dependently in prenatally galactose-exposed rats compared to controls (P-value = 0.002). In addition, decreases in AMH (3.25 vs. 7.5 ng/mL; P = 0.000) and E2 (7.9 vs. 19.5 pg/mL; P = 0.000) and increases in FSH (6.5 vs. 0.8 mIU/mL; P < 0.007) were observed in galactose-exposed rats compared to controls at 45 - 50 days of age.

CONCLUSIONS

Prenatal exposure to D-galactose negatively affects ovarian reserve in female rats in their later lives. However, further investigation is needed to confirm our findings and explore underlying mechanisms.

The effect of micronutrient supplementation on serum anti-Mullerian hormone levels: a retrospective pilot study

BACKGROUND

The anti-Müllerian-hormone (AMH) is secreted by the granulosa cells of the oocytes and can be used as a marker of the ovarian reserve; helpful to estimate female fertility or the menopause onset. Although various factors may influence AMH levels, the correlation with nutritional factors needs more research.

OBJECTIVE

To evaluate the effect of a micronutrient supplementation on female AMH levels.

METHODS

This retrospective analysis includes a total of 244 women, who attended the Karl Landsteiner Institute, Korneuburg, Austria from January 2013 to June 2019 due to an unfulfilled desire for a child. All women were treated with an oral micronutrient preparation consisting the dosage of one soft capsule and one tablet per day for 3 months. The soft capsule contains omega-3 fatty acids and the tablet is a standardized combination of coenzyme Q₁₀, vitamin E, folic acid, selenium, catechins from green tea extract, and glycyrrhizin from licorice extract. Serum AMH levels before and after 3 months were compared. In addition, available clinical data such as ovulation frequency, endometrium thickness, and luteal phase duration were analyzed.

RESULTS

The mean age of the women was 37.3 ± 1.8 years, the mean body mass index of 24.3 ± 4.6 k/m². The mean serum AMH levels and endometrial thickness values were significantly higher after micronutrient supplementation as compared to baseline (1.42 ± 0.86 versus 1.86 ± 0.82 ng/mL and 6.10 ± 1.76 versus 7.29 ± 1.65 mm, respectively). In addition, ovulation frequency and luteal phase duration significantly improved in more than 60%.

CONCLUSION

Proposed micronutrient supplementation had a positive effect on serum AMH levels, endometrial thickness, ovulation frequency, and luteal phase duration. It could be a simple, risk-free therapeutic option to improve female fertility. More research is warranted to prove this effect.

Reproductive Health in Chronic Kidney Disease: The Implications of Sex and Gender

Chronic kidney disease (CKD) is frequently accompanied by reproductive health challenges in females and males alike. Progression of CKD is associated with escalating impairment of the hypothalamic-pituitary-gonadal axis, which facilitates evolving ovarian, testicular, and sexual dysfunction. Common clinical reproductive health complications in CKD include abnormal menstruation, impaired sexual health, and reduced fertility. Though sex-specific factors, such as sex hormones and gonadal function, have a strong influence on reproductive health outcomes in CKD, a person's gender and gendered experience also have important implications. Institutionalized gender, gendered perceptions of health, and health care-seeking behaviors, as well as adherence to medical care, all have critical effects on reproductive health in CKD. This review endeavors to explore the implications of both sex and gender on overall reproductive health in individuals living with CKD.

COVID-19 disease does not cause ovarian injury in women of reproductive period: An observational before-and-after COVID-19 study

Research question

Design

Results

Conclusion

GnRH Analogues as a Co-Treatment to Therapy in Women of Reproductive Age with Cancer and Fertility Preservation

In this review, we analyzed existing literature regarding the use of Gonadotropin-releasing Hormone (GnRH) analogues (agonists, antagonists) as a co-treatment to chemotherapy and radiotherapy. There is a growing interest in their application as a prophylaxis to gonadotoxicity caused by chemotherapy and/or radiotherapy due to their ovarian suppressive effects, making them a potential option to treat infertility caused by such chemotherapy and/or radiotherapy. They could be used in conjunction with other fertility preservation options to synergistically maximize their effects. GnRH analogues may be a valuable prophylactic agent against chemotherapeutic infertility by inhibiting rapid cellular turnover on growing follicles that contain types of cells unintentionally targeted during anti-cancer treatments. These could create a prepubertal-like effect in adult women, limiting the gonadotoxicity to the lower levels that young girls have. The use of GnRH agonists was found to be effective in hematological and breast cancer treatment whereas for ovarian endometrial and cervical cancers the evidence is still limited. Studies on GnRH antagonists, as well as the combination of both agonists and antagonists, were limited. GnRH antagonists have a similar protective effect to that of agonists as they preserve or at least alleviate the follicle degradation during chemo-radiation treatment. Their use may be preferred in cases where treatment is imminent (as their effects are almost immediate) and whenever the GnRH agonist-induced flare-up effect may be contra-indicated. The combination treatment of agonists and antagonists has primarily been studied in animal models so far, especially rats. Factors that may play a role in determining their efficacy as a chemoprotective agent that limits gonadal damage, include the type and stage of cancer, the use of alkylating agents, age of patient and prior ovarian reserve. The data for the use of GnRH antagonist alone or in combination with GnRH agonist is still very limited. Moreover, studies evaluating the impact of this treatment on the ovarian reserve as measured by Anti-Müllerian Hormone (AMH) levels are still sparse. Further studies with strict criteria regarding ovarian reserve and fertility outcomes are needed to confirm or reject their role as a gonadal protecting agent during chemo-radiation treatments.

Impact of perioperative use of GnRH agonist or dienogest on ovarian reserve after cystectomy for endometriomas: a randomized controlled trial

BACKGROUND

Ovarian endometrioma is a common gynecological disease that is often treated with surgery or hormonal treatment. Ovarian cystectomy, a surgical procedure for ovarian endometrioma, can result in impaired ovarian reserve.

METHODS

We conducted a randomized controlled trial to evaluate the efficacy of hormonal treatment [gonadotropin-releasing hormone agonist (GnRHa) or dienogest (DNG)] for preserving ovarian reserve after cystectomy for ovarian endometrioma. The primary endpoint was the level of serum Anti-Müllerian hormone (AMH) as a marker of ovarian reserve.

RESULTS

Before and after laparoscopic surgery, 22 patients in the GnRHa group and 27 patients in the DNG group were administered hormonal treatment for a total of 4 months. After 1-year follow-up, >60% of the patients in the DNG group retained over 70% of their pretreatment AMH levels, whereas no patient in the GnRHa group retained their AMH levels after cystectomy (P < 0.01). Interleukin-6 (IL-6) is a key cytokine involved in inflammation. Compared with the GnRHa group, patients in the DNG group had lower IL-6 levels at the end of treatment.

CONCLUSIONS

Our data revealed that DNG is more effective than GnRHa in preserving ovarian reserve after cystectomy of ovarian endometrioma. This is achieved through the reduction of the inflammatory response during the perioperative period and other endometriosis-related inflammatory reactions.

TRIAL REGISTRATION

The registration number of this trial is UMIN-CTR, UMIN000018569, registered 6 August 2015, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000021492 , and Japan Registry of Clinical Trials, jRCTs041180140, registered 29 March 2019, https://jrct.niph.go.jp/en-latest-detail/jRCTs041180140 . This randomized controlled trial was conducted in accordance with the CONSORT guidelines.

Pregnancy outcome of freeze thaw cycles of polycystic ovary syndrome patients regarding the anti-Müllerian hormone percentile

Patients with polycystic ovary syndrome display increased levels of anti-Müllerian hormone. Frozen-thawed embryo transfer (FET) prevents ovarian hyperstimulation and results in better pregnancy outcome in PCOS patients. Therefore, we aimed to evaluate the effect of serum AMH levels on the pregnancy outcome of FET cycles in PCOS patients. 110 infertile women with PCOS who were recommended for embryo cryopreservation followed by FET. The patients' AMH levels were evaluated, and the age-related AMH percentiles were determined. The patients were then grouped according to AMH percentiles, namely, 75th-90th percentile (Group 1) and higher than the 90th percentile (Group 2).A total of 110 PCOS patients who conceived in Frozen Embryo Transfer (FET)-In-vitro Fertilisation (IVF) cycles were included in this study. The preterm delivery rates in FET cycles were higher in the group of PCOS patients with AMH levels greater than the 90th percentile than in patients in the 75th-90th percentile group (50% vs 28.8%, p = .024). In conclusion, PCOS patients with AMH levels higher than the 90^th percentile had substantially higher preterm delivery rates than those with AMH levels at the 75^th-90^th percentile, suggesting the need for closer follow-up. Further studies are needed to elucidate the underlying mechanisms behind this correlation.IMPACT STATEMENTWhat is already known on this subject? The association of AMH levels with the risk of adverse pregnancy outcomes has been previously investigated. In women with PCOS, substantially elevated AMH levels were significantly associated with preterm birth.What do the results of this study add? Results showed that the PCOS patients with higher AMH levels and underwent assisted reproductive treatment demonstrated an increased risk of preterm labour than the PCOS patients with lower AMH levels.What are the implications of these findings for clinical practice and/or further research? In women with PCOS, substantially elevated AMH levels were significantly related to preterm birth, suggesting the need for closer follow-up in this population and the need for further studies to elucidate the underlying mechanisms behind this correlation.

Impact of age and menopausal stage on serum anti-Müllerian hormone levels in middle-aged women

OBJECTIVE

This study aimed to evaluate the association between age, menopausal stage and serum anti-Müllerian hormone (AMH) levels in middle-aged women.

METHODS

In this cross-sectional study, the serum AMH levels of 288 healthy women aged 40-55 years (divided into age groups: 40-44, 45-49 and 50-55 years) were evaluated. Stages of Reproductive Aging Workshop + 10 criteria were used to categorize these women into menopausal stages: late reproductive, menopausal transition and early postmenopausal stages. The impact of age, menopausal stage and hormone replacement therapy on serum AMH levels was analyzed using multi-factor analysis of variance. Effects of body mass index, smoking status and oral contraceptive use were simultaneously considered.

RESULTS

The median AMH level was 0.140 ng/ml. Log-AMH levels varied according to age group (variance = 20.113, F = 88.538, p < 0.001) and menopausal stage (variance = 5.543, F = 24.501, p < 0.001). An exponential model defined as AMH = 227,421.757 × e^{(-0.301 × age)} was fit to describe the decline in AMH level with age. The 5th-95th percentiles of the AMH levels ranged from less than 0.020 to 3.150, less than 0.020 to 1.944 and less than 0.020 to 0.030 ng/ml in the aforementioned menopausal stages, respectively.

CONCLUSION

Age and menopausal stage were associated with AMH levels; age had a greater impact on AMH than menopausal stage in middle-aged women.

Demographic, lifestyle, and reproductive determinants of serum anti-Müllerian hormone levels in adult women of reproductive age in Ilorin, North-Central Nigeria

Background

Anti-Müllerian hormone is a dimeric glycoprotein produced by the granulosa cells of preantral and small antral follicles of the ovaries. It is a reliable biomarker of ovarian reserve, ageing, and response in the management of women with infertility. However, there are few studies on the determinants of serum anti-Müllerian hormone in Nigerian women. This study aimed to investigate determinants of serum anti-Müllerian hormone among adult women of reproductive age. The study was a hospital-based cross-sectional study involving 161 women of reproductive age attending the gynaecology clinic and immunisation clinic of a Nigerian tertiary hospital. Baseline characteristics were collected using a semi-structured questionnaire. Serum anti-Müllerian hormone was quantified using enzyme-linked immunosorbent assay.

Results

In univariate analysis, age (B = − 0.035, P = 0.000), parity (B = − 0.080, P = 0.001), and infertility duration (B = − 0.050, P = 0.011) had a negative relationship with serum anti-Müllerian hormone, while ethnicity (B = 0.180, P = 0.040), body mass index (B = 0.015, P = 0.010), and cycle length (B = 0.042, P = 0.000) had a positive relationship with serum anti-Müllerian hormone. In multivariable analysis, all relationships except infertility duration persisted.

Conclusion

We found that age, ethnicity, parity, infertility duration, body mass index, and cycle length were associated with serum anti-Müllerian hormone. A large prospective population-based study is required to better understand factors that are associated with serum anti-Müllerian hormone in an ethnically diverse country like Nigeria.

Correlations among anti-Müllerian hormone levels, body mass index and lipid profile in reproductive-aged women: The Korea Nurses' Health Study

Aim

This study aimed to evaluate the correlations among anti‐Müllerian hormone levels, body mass index and lipid profile in female nurses of reproductive age.

Design

This is a descriptive cross‐sectional study that used data from the Korea Nurses' Health Study, based on Nurses' Health Study 3 in the United States.

Methods

Participants included 448 female nurses of reproductive age. They provided details about their work experience, shift work, body mass index and history of polycystic ovary syndrome. Serum anti‐Müllerian hormone levels and lipid profile were measured using blood samples. Statistical analysis included quantile regression analysis using STATA 13.0. Data were collected between November 2016 and March 2017 from Module 5 of the Korean Nurses' Health Study.

Results

Approximately 12% of the participants were underweight, and roughly one‐tenth were either overweight or obese. Although linear regression showed no relationship between anti‐Müllerian hormone levels and body mass index, quantile regression showed that body mass index, total cholesterol levels and low‐density lipoprotein levels were negatively correlated with anti‐Müllerian hormone levels at the lower tails of the dependent variable. Meanwhile, high‐density lipoprotein levels were positively correlated with anti‐Müllerian hormone at the higher percentiles of anti‐Müllerian hormone levels.

Conclusion

These findings suggest the possibility that changes in the lipid profile may influence anti‐Müllerian hormone levels in women with diminished ovarian function, rather than obesity itself.

Machine Learning-Based Approach Highlights the Use of a Genomic Variant Profile for Precision Medicine in Ovarian Failure

Ovarian failure (OF) is a common cause of infertility usually diagnosed as idiopathic, with genetic causes accounting for 10-25% of cases. Whole-exome sequencing (WES) may enable identifying contributing genes and variant profiles to stratify the population into subtypes of OF. This study sought to identify a blood-based gene variant profile using accumulation of rare variants to promote precision medicine in fertility preservation programs. A case-control (n = 118, n = 32, respectively) WES study was performed in which only non-synonymous rare variants <5% minor allele frequency (MAF; in the IGSR) and coverage ≥ 100× were considered. A profile of 66 variants of uncertain significance was used for training an unsupervised machine learning model to separate cases from controls (97.2% sensitivity, 99.2% specificity) and stratify the population into two subtypes of OF (A and B) (93.31% sensitivity, 96.67% specificity). Model testing within the IGSR female population predicted 0.5% of women as subtype A and 2.4% as subtype B. This is the first study linking OF to the accumulation of rare variants and generates a new potential taxonomy supporting application of this approach for precision medicine in fertility preservation.

Low Anti-Mullerian Hormone Levels Are Associated with the Severity of Anxiety Experienced by Healthcare Professionals During the COVID-19 Pandemic

The objective of this study is to investigate a possible correlation between anxiety status and anti-Mullerian hormone (AMH) levels among healthcare professionals who provide medical care directly to COVID-19-positive patients during the recent pandemic. Fifty-two healthcare professionals (nurses, midwives, and residents) who provide medical care directly to COVID-19-positive patients in inpatient clinics or intensive care units were enrolled in this study. Serum AMH levels were analyzed to reflect ovarian reserve. The Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI-S and STAI-T, respectively) were completed by participants to assess their anxiety status. A linear regression model with participant age as the constant variable was applied to analyze the relationship between inventory scale scores and AMH levels. P-values less than 0.05 were considered statistically significant. The mean AMH value was significantly lower for the participants in the moderate/severe anxiety group compared to the minimal/mild anxiety group (p = 0.007). A linear regression analysis revealed a significant negative correlation between AMH levels and both BAI (B = -0.030, standard error = 0.010, p = 0.004) and STAI-S and STAI-T scores when age was controlled (both p = 0.003). The severity of anxiety experienced during the recent COVID-19 pandemic among healthcare professionals, who provide medical care directly to COVID-19-positive patients, is found to be related to low AMH levels.

Urinary vitamin D-binding protein as a marker of ovarian reserve

BACKGROUND

Ovarian reserve reflects the quality and quantity of available oocytes and has become an indispensable measure for the better understanding of reproductive potential. Proteomic approaches are especially helpful in discerning differential protein expression patterns associated with normal and diseased states and, thus, proteomic analyses are increasingly used to identify clinically useful biomarkers. The aim of this study was to investigate proteins secreted in the urine of patients with different ovarian reserve by proteomic techniques to identify potential markers for assessing ovarian reserve.

METHODS

Urine samples were obtained from patients with polycystic ovary syndrome (PCOS) and diminished ovarian reserve (DOR), and from normal control (NC)participants. We used isobaric tags for relative and absolute quantification (iTRAQ) technology combined with mass spectrometry analysis to identify candidate urinary proteins in the three groups. The selected proteins were confirmed using western blot analysis and enzyme-linked immunosorbent assay (ELISA). Diagnostic performance of the selected proteins was assessed using receiver operating characteristic analysis.

RESULTS

When Compared with NC samples, 285 differentially expressed proteins (DEPs) were identified in the DOR samples and 372 in the PCOS samples. By analyzing the intersection of the two groups of DEPs, we found 26 proteins with different expression trends in the DOR and PCOS groups. Vitamin D-binding protein (VDBP) was the key protein for the protein-protein interaction network. ELISA quantification of urinary VDBP revealed the highest levels in the PCOS group, followed by the NC group and the lowest levels in the DOR group (115.90 ± 26.02, 81.86 ± 23.92 and 52.84 ± 21.37 ng/ml, respectively; P < 0.05). As a diagnostic marker, VDBP had a sensitivity of 67.4% and a specificity of 91.8% for DOR, and a sensitivity of 93.8% and a specificity of 77.6% for PCOS.

CONCLUSIONS

Urinary VDBP is closely associated with ovarian reserve and can be considered as a novel noninvasive biomarker of ovarian reserve. However, studies including large sample sizes are needed to validate these results.

Ovarian transposition in patients with cervical cancer prior to pelvic radiotherapy: a systematic review

Ovarian transposition aims to minimize ovarian exposure and damage during pelvic radiotherapy. One or both ovaries are separated from the uterus and mobilized away from the area where the radiation will be administered. A review of the available literature was conducted to evaluate the efficacy and safety of ovarian transposition among pre-menopausal women diagnosed with cervical cancer and eligible for pelvic radiotherapy. Outcomes evaluated were ovarian function preservation and complication rates. We also searched for information on pregnancy/live birth rates after ovarian transposition. Our search yielded a total of 635 manuscripts, of which 33 were considered eligible. A total of 28 full texts were selected for the current review, including 1377 patients who underwent ovarian transposition. The median or mean follow-up ranged between 7 and 87 months. Ovarian function preservation after ovarian transposition and pelvic radiotherapy, with or without chemotherapy, was 61.7% (431/699 patients), ranging from 16.6% to 100%. A total of 12 studies reported on 117 complications, accounting for 8.5%. Ovarian metastases were described in 5 (0.4%). Data about fertility preservation after ovarian transposition are scarce and definitive conclusions cannot be drawn. Based on the available data, ovarian transposition could be performed on young patients with tumors smaller than 4 cm, and it should be avoided in those with bulky tumors. A risk/benefit assessment should be carefully evaluated by a multidisciplinary team, and the decision regarding ovarian transposition should be always guided by the values and informed preferences of the patient.

Fertility Preservation and Long-Term Monitoring of Gonadotoxicity in Girls, Adolescents and Young Adults Undergoing Cancer Treatment

Chemo- and radio-therapy can often affect reproductive organs impairing hormonal regulation, fertility, and sexual function. As cancer treatments become more effective and many patients have long term survival, concerns related to patient's quality of life and reproductive health become relevant. It is especially important for girls and young females facing cancer therapy who have not yet started family planning. Chemotherapy protocols using alkylating agents and abdominal radiotherapy, which are frequently used in the treatment of childhood and adolescent cancer, can cause gonadal injury. The most common clinical manifests are ovarian hormone insufficiency, premature ovarian insufficiency, early menopause and infertility. In this review we assess current literature and summarize current recommendations on the reproductive function of girls and young females undergoing cancer treatment and their follow-up. Fertility preservation methods are discussed, including psychological and ethical considerations and barriers. Improvement of reproductive health and quality of life of adolescents and young adults (AYA) undergoing cancer treatment is an important issue. Further research should be continued to develop efficient and accessible methods for fertility preservation in young patients. An expert panel including oncologists, radiation oncologists, endocrinologists and gynecologists should always consider fertility preservation in pediatric, adolescent and AYA cancer patients, minding patients' medical condition, cancer staging and potential risk of treatment-related gonadotoxicity.

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

Background

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

Methods

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

Results

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

Conclusions

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

Very Low Levels of Serum Anti-Müllerian Hormone as a Possible Marker for Follicle Growth in Patients with Primary Ovarian Insufficiency Under Hormone Replacement Therapy

Patients with primary ovarian insufficiency (POI) occasionally present with follicle growth; however, accurately predicting cycles accompanied by follicle growth is challenging. Early-stage follicles produce serum anti-Müllerian hormone (AMH), a useful marker of ovarian reserve. Therefore, serum AMH levels indicate growth of small follicles (which are difficult to detect ultrasonographically) and may predict follicle growth in patients with POI. Using an ultrasensitive enzyme-linked immunosorbent assay (ELISA) kit, we observed very low serum AMH levels in patients with POI. We further evaluated follicle growth in each patient during each cycle to determine the usefulness of measuring serum AMH levels as a predictor of follicle growth in patients with POI who receive hormone replacement therapy (HRT). We investigated 19 patients with POI in whom we analyzed 91 cycles; 14 cycles showed positive and 77 cycles showed negative results on serum AMH testing. The rate of cycles showing follicle growth in AMH-positive cycles was higher than that in AMH-negative cycles (64.3% vs. 6.5%, p = 0.0001). The median serum AMH level (7.7 pg/mL [25th and 75th percentiles 4.6 pg/mL and 22.3 pg/mL, respectively]) in AMH-positive cycles was lower than the lower limit of detection of conventional AMH ELISA kits. The positive predictive value of positive serum AMH levels for follicle growth was higher than that of follicle-stimulating hormone (< 10 mIU/mL). These results indicate that a very low level of serum AMH detected using picoAMH assays is a useful predictor of follicle growth in patients with POI receiving HRT.

Perceived stress, psychological distress and serum anti-Müllerian hormone levels among infertile and fertile women in North-central Nigeria

Background

Previous studies reported that self-reported stress, stressful life events, and psychological distress influence ovarian ageing and response. However, there are limited, yet conflicting findings on the effect of stress and psychological distress on serum anti-Müllerian hormone (AMH) as a biomarker of ovarian reserve, response, and ageing. This case-control study aimed to determine if stress and psychological distress levels were associated with serum anti-Müllerian hormone levels among 81 infertile and 109 fertile women of reproductive age attending the gynaecology and immunization clinics of a tertiary hospital in North-central Nigeria, respectively. Stress and psychological distress were measured using the Perceived Stress scale-10 and Kessler Psychological Distress Scale-10, respectively. The serum concentration of AMH was determined using enzyme-linked immunosorbent assays.

Results

There was a significantly higher stress (p = 0.001) and psychological distress (p = 0.005) levels among infertile women; however, there was no difference in serum anti-Müllerian hormone levels between the two groups (p = 0.409). There was no significant correlation found between perceived stress and serum anti-Müllerian hormone in both infertile (r = 0.041, p = 0.719) and fertile (r = − 0.090, p = 0.353) women. There was also no correlation between psychological distress and serum anti-Müllerian hormone in the infertile (r = − 0.020, p = 0.860) and fertile (r = − 0.049, p = 0.636) groups. Controlling for age and body mass index in multivariate linear regression; stress and psychological distress were not significantly associated with serum anti-Müllerian hormone (B = − 0.005; p = 0.370 and B = − 0.001; p = 0.811).

Conclusion

Self-reported stress and psychological distress are not associated with serum anti-Müllerian hormone levels in infertile and fertile women of reproductive age. Also, ovarian ageing was accelerated in infertile women when compared to fertile women; however, this does not appear to be related to stress or psychological distress. More research is needed to understand factors that may contribute to this accelerated decline.

The effects of salpingectomy on the serum level of anti-Müllerian hormone: A single-blind randomized controlled trial

OBJECTIVES

Concerns exist over the effects of salpingectomy on ovarian function. This study aimed to assess the effects of salpingectomy on the serum level of anti-Müllerian hormone.

MATERIALS AND METHODS

This single-blind randomized controlled trial was conducted in 2017-2018 on 86 candidates for hysterectomy. Participants were randomly allocated to undergo either hysterectomy without salpingectomy (control group) or hysterectomy with salpingectomy (intervention group). Serum anti-Müllerian hormone level was measured both before and three months after surgery. Data were analyzed through the Mann-Whitney U test, the Chi-square test, the analysis of covariance, and the linear regression analysis.

RESULTS

The mean value of Serum anti-Müllerian hormone level did not significantly change in the study groups (P>0.05). After removing the effects of confounders, study groups did not significantly differ from each other respecting the posttest mean value of serum anti-Müllerian hormone level (P=0.868).

CONCLUSION

Salpingectomy does not significantly affect serum anti-Müllerian hormone level and ovarian function.

A case of premature ovarian insufficiency in Nijmegen breakage syndrome patient and review of literature. From gene mutation to clinical management

Background: Nijmegen breakage syndrome (NBS) is an autosomal recessive disorder leading to chromosomal instability and an array of symptoms, including characteristic facial features (bird-like face), predisposition to malignancies, as well as hypergonadotropic hypogonadism. This case report discusses the diagnostic process and management of a 23-year-old Polish female patient who was admitted to hospital with symptoms of secondary amenorrhea and clinical features corresponding to NBS. Methods: Clinical examination, per-rectal ultrasound, laboratory diagnostics (including serum concentrations of FSH, LH, estradiol, testosterone, and TSH), as well as SSCP analysis and classic karyotyping were performed. Results: During hormonal evaluation elevated serum concentration of FSH and LH and decreased serum concentration of estradiol were measured. The genetic testing revealed translocation 7;14 (t(7;14)) and inversion 7 in 22% of examined cells which confirmed the initial hypothesis of NBS. The diagnosis was finally verified by identifying a Slavic founder mutation, c.657_661del5, on both allels of the NBN gene. Furthermore, hormonal serum evaluation conducted after four weeks allowed the patient to be diagnosed with premature ovarian insufficiency (POI) suspected earlier on the grounds of preliminary examinations (ultrasound imaging and laboratory tests). Conclusions: Chromosomal instability resulting from a mutation present in Nijmegen breakage syndrome patients might be a causative factor of premature ovarian insufficiency. Therefore, females diagnosed with NBS should undergo additional diagnostic procedures in order to determine further management and treatment.

Management of Primary Ovarian Insufficiency Symptoms in Survivors of Childhood and Adolescent Cancer

Cancer treatments can damage the ovaries, causing primary ovarian insufficiency (POI), a condition associated with numerous sequelae that impact long-term quality of life. This article systematically reviews the literature on the prevalence, surveillance, and treatment of POI in survivors of pediatric and adolescent and young adult (AYA) cancers. A systematic review of the literature was conducted in January 2018 through a search of Medline, Embase, Web of Science, and SCOPUS, alongside the screening of relevant reference lists. An initial search identified 746 potentially relevant studies. A total of 36 studies were included in the final review. Studies were categorized into one of the following categories: incidence/prevalence of POI, measurement of ovarian reserve, and other. Depending on patient characteristics, cancer diagnosis, and treatment, the prevalence of POI ranged from 2.1% to 82.2%. Risk factors for POI included exposure to alkylating agents and abdominal/pelvic radiation. POI may be associated with a number of complications, including low bone mineral density and poor cardiovascular health. Radiotherapy and chemotherapy are known to cause gonadal damage in female survivors of pediatric and AYA cancers. Acute or chronic effects depend on the dose of treatment, age of the individual, radiotherapy field, and ovarian reserve of the individual. Some women experience short-term loss of reproductive function and then may resume menstrual cycles, months or even years later. Although protecting fertility through banking of mature eggs, embryos, and tissue samples has become standard of care, additional steps need to be taken to ensure that patients have adequate hormone levels to maintain whole-body health, including life expectancy, bone health, cardiovascular health, quality of life, sexual and genitourinary function, and neurologic function. Surveillance and management of each of these comorbidities is critically important to survivor health.

Triclosan exposure and ovarian reserve

The objective of the current analysis was to investigate the associations of urinary triclosan concentrations with parameters of ovarian reserve. Five hundred eleven female aged 25-39 years who attended the infertility clinic for diagnostic purposes were recruited. Urinary concentrations of triclosan were measured by a validated gas chromatograohy ion-tap mass spectrometry method. Parameters of ovarian reserve were: antral follicle count (AFC), anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH) and estradiol (E₂) levels. Urinary concentrations of triclosan decrease antral follicle count. There were no statistically significant associations between other parameters of ovarian reserve (estradiol, FSH and AMH levels) and triclosan concentrations. Triclosan exposure may negatively affect antral follicle count, a marker of ovarian reserve. As the data on triclosan exposure and ovarian reserve are scarce additional study is needed to confirm the results.

Ovarian reserve parameters and response to controlled ovarian stimulation in infertile patients

Objective:

To determine the ovarian reserve parameters in patients presenting for IVF and intracytoplasmic sperm injection (ICSI) treatment and its association with the number of follicles retrieved and number of oocyte retrieved and fertilized.

Methods:

A retrospective cross sectional study was conducted at Australian Concept Infertility Medical Centre from January 2017 to August 2017. Around 120 couples presenting to infertility clinics selected for IVF and ICSI with Females (25-45) had their FSH, AMH and AFC done. After ovulation induction, its response was determined by number of follicles retrieved, quality of oocytes retrieved or fertilized and inseminated. SPSS version 20 was used for the purpose of data analysis.

Results:

The median age of the patients was 34 (29-38) years. A moderate negative correlation of age and FSH levels was observed with quality of oocytes, Number of oocyte inseminated, number of oocyte fertilized and number of follicle restored. However, a positive correlation of AMH and AFC levels were found with quality of oocytes, Number of oocyte inseminated, number of oocyte fertilized and number of follicle restored. The correlation of AMH levels with number of oocyte inseminated (rho 0.729, p-value <0.001), number of oocyte fertilized (rho 0.721, <0.001) and number of follicle restored (rho 0.723, p-value <0.001) were found strongly correlated.

Conclusion:

Our study concluded that AMH and AFC have a strong correlation with number of follicles restored and number of oocytes retrieved whereas FSH and age has a weak correlation with the number of follicles restored and number of oocytes retrieved.

Anti-Müllerian Hormone in Fertility Preservation: Clinical and Therapeutic Applications

Anti-Müllerian hormone (AMH) is a member of the transforming growth factor (TGF)-beta family and a key regulator of sexual differentiation and folliculogenesis. While the serum AMH level has been used in reproductive medicine as a biomarker of quantitative ovarian reserve for more than 20 years, new potential therapeutic applications of recombinant AMH are emerging, notably in the field of oncofertility. Indeed, it is well known that chemotherapy, used to treat cancer, induces ovarian follicular depletion and subsequent infertility. Animal models have been used widely to understand the effects of different cytotoxic agents on ovarian function, and several hypotheses regarding chemotherapy gonadotoxicity have been proposed, that is, it might have a direct detrimental effect on the primordial follicles constituting the ovarian reserve and/or on the pool of growing follicles secreting AMH. Recently, a new mechanism of chemotherapy-induced follicular depletion, called the “burn-out effect,” has been proposed. According to this theory, chemotherapeutic agents may lead to a massive growth of dormant follicles which are then destroyed. As AMH is one of the factors regulating the recruitment of primordial follicles from the ovarian reserve, recombinant AMH administration concomitant with chemotherapy might limit follicular depletion, therefore representing a promising option for preserving fertility in women suffering from cancer. This review reports on the potential usefulness of AMH measurement as well as AMH’s role as a therapeutic agent in the field of female fertility preservation.

Effect of laparoscopic endometrioma cystectomy on anti-Müllerian hormone (AMH) levels

OBJECTIVE

To investigate temporary or long-term changes of AMH after laparoscopic endometrioma cystectomy and its dependency on characteristics of endometriomas.

METHODS

One hundred and seventy-one women, open-labeled prospective study; five groups divided according age ≤/> 35, uni-/bilateral, cyst ≤/> 7 cm, coagulation/suture surgery, stage III/IV; between- and within-group analyses after 1, 3, 6, and 12 months.

RESULTS

After 12 months, compared to pretreament, AMH decreased significantly for patients with bilateral cysts, cyst size >7 cm and endometriosis stage IV. In the between-group analysis all comparisons were significant, with exception of the surgery type. However, this was different performing the multiple linear regression analysis suggesting lower postoperative decrease using suturing technique. This analysis also showed higher age at pretreatment and bilateral cysts as risk factor for AMH decline.

CONCLUSIONS

Effects of endometrioma cystectomy on AMH are dependent on characteristics of the endometrioma, showing long-term a decrease in patients with larger, bilateral cysts and in stage IV endometriosis, but only short-time decrease in smaller, unilateral cysts and stage III which sometimes also can fully recover in AMH production within one year. In our study suture compared to coagulation surgery was protective, i.e. may lead to lower postoperative AMH decline.

Anti-Müllerian hormone level is associated with vitamin D receptor polymorphisms in women with polycystic ovary syndrome

Objective

Our study aimed to investigate the relationship between polymorphisms (Apa1, Bsm1, Fok1, and Cdx2) in the VDR gene as well as AMH and AMHR2 genes and their influence on AMH and 25(OH)D levels in PCOS women.

Study design

Seventy-five patients with PCOS and 23 control women were included. Serum AMH and 25(OH)D levels in patients and controls were measured by enzyme-linked immunosorbent assay (ELISA). Polymorphisms in VDR gene Fok1 C/T (rs2228587), Bsm1 A/G (rs1544410), Apa1 A/C (rs7975232), and Cdx2 A/G (rs11568820) polymorphisms as well as AMH G/T (rs10407022) and AMHR2 A/G (rs2002555) were analyzed using real-time PCR.

Results

Analysis of the VDR Cdx2 polymorphism showed a significantly higher frequency of the homozygous GG (mutant) genotype in the PCOS group as compared with the control group (p < 0.05). The analysis revealed a statistically significant correlation between the presence of FokI and ApaI polymorphisms and AMH levels in PCOS women (p < 0.05). The presence of mutant genotypes (CT, TT) in the Fok1 and (CA, CC) in the Apa1 polymorphisms were associated with higher AMH level in PCOS women (p < 0.05). No statistically significant correlations between AMH and AMHR2 polymorphisms and AMH level were found. Moreover, there was no correlation between AMH and 25(OH)D levels in the PCOS or in the control group.

Conclusion

It seems that the elevated AMH level is associated with VDR Fokl and Apal polymorphisms, but not with 25(OH)D levels in PCOS women. Further research is needed to determine the role of VDR polymorphism in AMH level in PCOS.

Ovarian dysfunction following prenatal exposure to an insecticide, chlordecone, associates with altered epigenetic features

Chlordecone (CD) is an insecticide that was used in the French West Indies for several years to control the banana root borer pest. Given its nonsignificant degradation, it persists in the environment. CD is a carcinogenic compound with reproductive and developmental toxicity and is a recognized endocrine-disrupting chemical. In this study, we examined the effects of CD on female reproductive system of mice with the focus on epigenetic features in ovary. Our data show that gestational exposure to low dose of CD affects meiotic double-strand breaks repair in female embryos. In adult mice derived from CD-treated pregnant females, we observed delayed puberty, decreased number of primordial and increased number of atretic follicles. Gene expression analysis revealed that Rcbtb2 and Rbpms genes were not expressed in embryonic gonads. Estrogen signaling- and oocyte maturation-associated genes were downregulated in adult ovaries. The morphological changes were associated with altered epigenetic features: increased H2Aub and increased H3K27me3 and decreased H4ac and H3K4me3 in embryonic oocytes. The DNA damage-associated, γH2AX marks were detected in the follicles of treated but not control adult ovaries. We also found reduced H3K4me3 and H4ac in fully grown oocytes of the treated ovaries. The ChIP-seq analysis of H3K4me3 in adult ovaries showed that target genes of ZFP57 and TRIM28, which regulate pluripotency and imprinting, were significantly enriched in altered regions. Our study clearly demonstrates that gestational exposure to a low dose of CD impairs the function of female reproductive system and the changes are associated with altered epigenetic features.

The impact of repetitive oocyte retrieval on the ovarian reserve: a retrospective cohort study

PURPOSE

To investigate a possible influence of repetitive micro-traumata on the ovaries in the course of oocyte retrieval during IVF/ICSI treatment on serum anti-Müllerian hormone (AMH) levels.

METHODS

The study included retrospectively collected data from women who underwent three or more consecutive IVF/ICSI treatments between 2007 and 2017. The primary endpoint of the study was to evaluate changes in serum AMH levels on cycle days 1-3 during the course of repetitive IVF/ICSI treatments.

RESULTS

A total of 125 patients were included in this study. Median AMH levels before the first, second and third IVF/ICSI cycles were 3.8 ng/mL (IQR 1.8-7.1), 3.3 ng/mL (IQR 1.8-6.1) and 3.0 ng/mL (IQR 1.6-5.3), respectively (p = n.s.). In patients who underwent IVF/ICSI due to polycystic ovary syndrome (PCOS), we found a significant decrease in AMH serum levels between the first [AMH 9.7 ng/mL (IQR 7.4-14.4)] and the third [AMH 5.3 ng/mL (IQR 3.3-10.4)] IVF/ICSI cycles (p = 0.026). When performing a generalized linear model, we found PCOS to be an independent predictor for serum AMH decrease during the course of three oocyte retrievals (p < 0.001).

CONCLUSIONS

When comparing the indications for IVF/ICSI, we observed a significant decrease in AMH serum levels after repetitive oocyte retrievals only in women with PCOS, while the decrease in AMH was not significant in patients with tubal factor, endometriosis, male factor and unexplained infertility. This finding leads us to hypothesize that repetitive micro-traumata on the ovarian cortex might diminish/normalize functional ovarian reserve in women with PCOS. Further prospective studies are highly warranted to allow firm conclusions.

Fertility and reproductive care in chronic kidney disease

In both women and men, chronic kidney disease (CKD) is associated with decreased fertility. Though a multitude of factors contribute to the reduction in fertility in this population, progressively impaired function of the hypothalamic-pituitary-gonadal axis appears to play a key role in the pathophysiology. There is limited research on strategies to manage infertility in the CKD population, but intensive hemodialysis, kidney transplantation, medication management and assisted reproductive technologies (ART) have all been proposed. Though fertility and reproductive care are reported as important elements of care by CKD patients themselves, few nephrology clinicians routinely address fertility and reproductive care in clinical interactions. Globally, the average age of parenthood is increasing, with concurrent growth and expansion in the use of ART. Coupled with an increasing prevalence of CKD in women and men of reproductive age, the importance of understanding fertility and reproductive technologies in this population is highlighted. This review endeavors to explore the female and male factors that affect fertility in the CKD population, as well as the evidence supporting strategies for reproductive care.

Ovarian reserve after uterine artery embolization in women with morbidly adherent placenta: A cohort study

Objective

To evaluate ovarian reserve in women after preservative cesarean delivery using uterine artery embolization due to morbidly adherent placenta.

Study design

A historical cohort study including all women admitted to a single tertiary care center, with morbidly adherent placenta that had preservative cesarean delivery with bilateral uterine artery embolization. Inclusion criteria included gestational age >24 weeks, singleton pregnancy and placenta increta / percreta. Exclusion criteria included maternal age > 43 years old and cesarean hysterectomy. Control group included women attending the infertility clinic due to male factor or single women conceiving via sperm donation, matched by age. Blood samples were collected on day 2–5 of menstruations for hormonal profile and Anti Mullarian Hormone (AMH) levels. Primary outcome was ovarian reserve evaluated by the levels of AMH.

Results

59 women underwent preservative cesarean delivery using uterine artery embolization during the study period. 21 women met inclusion criteria (33.9%) and were matched controls (n = 40). Circulating levels of E2 and FSH did not differ significantly between the two groups (p = 0.665, p = 0.396, respectively). AMH was lower in the study group (median 0.8 IQR 0.44–1.80) compared to the controls (median 2.08 IQR 1.68–3.71) (p = 0.001). This finding was consistent in linear multivariate regression analysis where the group of cesarean delivery using bilateral artery embolization due to placenta accrete was significantly predictive for the levels of AMH (B = -1.308, p = 0.012).

Conclusion

Women post preservative cesarean delivery using uterine artery embolization due to placenta accrete have lower ovarian reserve compare to controls matched by age.

Micro-RNAs involved in cellular proliferation have altered expression profiles in granulosa of young women with diminished ovarian reserve

PURPOSE

The study aims to determine differences in micro-RNA (miRNA) expression in granulosa (GC) and cumulus cells (CC) between young women with diminished ovarian reserve (DOR) or normal ovarian reserve (NOR). Secondary objective was to identify downstream signaling pathways that could ultimately indicate causes of lower developmental competence of oocytes from young women with DOR.

METHODS

The method of the study is prospective cohort study.

RESULTS

Of the miRNA, 125 are differentially expressed in GC between DOR and NOR. Only nine miRNA were different in CC; therefore, we focused analysis on GC. In DOR GC, miR-100-5p, miR-16-5p, miR-30a-3p, and miR-193a-3p were significantly downregulated, while miR-155-5p, miR-192-5p, miR-128-3p, miR-486-5p, miR130a-3p, miR-92a-3p, miR-17-3p, miR-221-3p, and miR-175p were increased. This pattern predicted higher cell proliferation in the DOR GC. The primary pathways include MAPK, Wnt, and TGFbeta.

CONCLUSIONS

The miRNA pattern identified critical functions in cell proliferation and survival associated with DOR. GC in women with DOR seems to respond differently to the LH surge.

Influence of body mass index in anti-Müllerian hormone levels in 951 non-polycystic ovarian syndrome women followed at a reproductive medicine unit

PURPOSE

Anti-Müllerian hormone (AMH) is a useful marker of ovarian reserve. Obesity/overweight are increasing and may affect the reproductive health. Previous studies regarding the effect of body mass index (BMI) on AMH levels are discordant. Our main goal was to evaluate the influence of BMI on AMH levels in women without polycystic ovarian syndrome.

METHODS

Revision of medical records of 951 women who performed AMH determinations as part of their fertility workup, between 2011 and 2016.

RESULTS

Median AMH concentration was 1.75 [interquartile range (IQR) 2] ng/mL (12.9 pmol/mL) and median age at AMH determination was 35 (IQR 6) years. These women evidenced a median BMI of 23 (IQR 5) kg/m². Caucasian women were more represented [889(89.3%)]. Smoking habits (present/past) were present in 359(36.1%), and 147(14.8%) harboured a history of ovarian surgery. On univariable analysis AMH was not correlated with BMI (r = 0.048/p = 0.135); the only factors influencing AMH were age (p < 0.001), ethnicity (p = 0.004), and previous ovarian surgery (p < 0.001). On multivariable analysis, age was the only variable significantly associated with AMH, evidencing a reduction of 6.2% for each additional year (p < 0.0001). Furthermore, we verified a trend suggesting an AMH reduction of 22% (p = 0.08) in black patients comparing with the caucasian ones, when controlling for the other variables.

CONCLUSION

We report one of the largest series evaluating the influence of BMI on AMH levels and, consequently, on ovarian reserve. BMI does not seem to affect AMH levels. The reported concerns on infertility in overweight and obese women may be related to follicular development/oocyte maturation or endometrial disorders, rather than decreased ovarian reserve.

Clinical application of serum anti-Müllerian hormone as an ovarian reserve marker: A review of recent studies

It has been more than 15 years since the measurement of serum anti-Müllerian hormone (AMH) first allowed the quantitative assessment of ovarian reserve. Meanwhile, the clinical implication of serum AMH has been expanding. The measurement of serum AMH has been applied in various clinical fields, including assisted reproduction, menopause, reproductive disorders and assessment of ovarian damage/toxicity. Well-known findings about the usefulness of serum AMH revealed by numerous studies executed in the early era include decline with aging, a good correlation with oocyte yield in assisted reproduction, upregulation in polycystic ovarian syndrome and a decrease on ovarian surgery and toxic treatment. More intensive research, including a meta-analysis, cutting-edge clinical trial and advances in AMH assays, has yielded newer findings and firmer clinical interpretations in serum AMH in the past few years. Variations in the AMH decline trajectory in the general population do not support the accurate prediction of menopause. The ability to predict pregnancy in infertility treatment and natural conception is poor, while a nomogram integrating serum AMH as a stimulation protocol is useful for avoiding poor and/or hyper-responses. On the other hand, improvements in measuring very low concentrations of serum AMH may be capable of distinguishing women with poor ovarian function. Age-independent standardization of AMH values may be helpful for comparing ovarian reserves among women at different ages.

Relationship between serum anti-Mullerian hormone and clinical parameters in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is an ovulatory disorder that affects 6-10% of women of reproductive age. Serum AMH level may be an additional factor, or surrogate of PCOM, in the diagnostic criteria of PCOS. We evaluated the correlations between the serum AMH level and various endocrine and metabolic features in PCOS using the latest fully automated assay. Serum AMH level was compared between 114 PCOS patient (PCOS group) and 95 normal menstrual cycle women (Control group). Correlations between serum AMH level and various endocrine and metabolic factors were analysed in PCOS group. The serum AMH level was significantly higher in the PCOS group (8.35±8.19 ng/mL) than in the Control group (4.99±3.23 ng/mL). The serum AMH level was independently affected by age and the presence of PCOS on multiple regression analysis. Ovarian volume per ovary (OPVO) showed the strongest positive correlation (r=0.62) with the serum AMH level among related factors. On receiver operating characteristic (ROC) curve analysis, the cut-off value of AMH for the diagnosis of PCOS was 7.33 ng/mL, but this value did not have high efficacy (sensitivity 44.7%, specificity 76.8%). A cut-off value of 10 ng/mL had a high specificity of 92.6%, although the sensitivity was low (24.6%). The serum AMH level was elevated and reflected ovarian size in PCOS patients. The serum AMH level could be a surrogate for ultrasound findings of the ovaries in PCOS and might be useful for estimating ovarian findings without transvaginal ultrasound in the diagnosis of PCOS.

Involvement of mesosalpinx in endometrioma is a possible risk factor for decrease of ovarian reserve after cystectomy: a retrospective cohort study

BACKGROUND

Serum anti-Müllerian hormone (AMH) concentration has been used to assess ovarian reserve in patients with endometriosis, especially when endometrioma surgery is involved. Previously, we reported that decreased serum AMH levels after cystectomy for endometriomas can recover to preoperative levels in some cases. In this present study, we assessed the sequential changes in serum AMH levels before and after cystectomy in terms of the state of the mesosalpinx prior to surgery.

METHODS

The retrospective cohort study recruited 53 patients from a series of prospective studies conducted from 2009 to 2015. All patients underwent laparoscopic cystectomy for endometriomas. If either mesosalpinx was involved in the endometrioma or adnexal adhesion before cystectomy, the case was defined as 'involved mesosalpinx' (n = 14). If both mesosalpinx remained anatomically correct, the case was classified as 'intact mesosalpinx' (n = 39). Blood samples were obtained from the patients 2 weeks before surgery, and at 1 month and 1 year after surgery to assess serum AMH levels.

RESULTS

The serum AMH levels (the involved group vs. the intact group) were 1.92 vs. 0.98 (P = 0.552) preoperatively, 0.59 vs. 1.99 (P = 0.049) at 1 month postoperatively, and 0.48 vs. 2.37 ng/mL (P = 0.007) at 1 year postoperatively. The involved mesosalpinx group showed a further decrease in serum AMH levels at 1 year postoperatively, while serum AMH levels in the intact mesosalpinx group tended to recover.

CONCLUSION

These results suggest that pre-existing mesosalpinx disturbance, in combination with adhesiolysis, may be involved in the medium- and long-term decrease in ovarian reserve after endometrioma surgery. A disturbance in ovarian blood supply via the mesosalpinx may underlie this.

TRIAL REGISTRATION

UMIN-CTR UMIN000019369 . Retrospectively registered October 15, 2015.