The dynamics of serum anti-Mullerian-hormone levels during controlled ovarian hyperstimulation with GnRH-antagonist short protocol in polycystic ovary syndrome and low responders

Fetal hypoxia exposure induces Hif1a activation and autophagy in adult ovarian granulosa cells†

Environmental hypoxia adversely impacts the reproduction of humans and animals. Previously, we showed that fetal hypoxia exposure led to granulosa cell (GC) autophagic cell death via the Foxo1/Pi3k/Akt pathway. However, the upstream regulatory mechanisms underlying GC dysfunction remain largely unexplored. Here, we tested the hypothesis that fetal hypoxia exposure altered gene expression programs in adult GCs and impaired ovarian function. We established a fetal hypoxia model in which pregnant mice were maintained in a high-plateau hypoxic environment from gestation day (E) 0-16.5 to study the impact of hypoxia exposure on the ovarian development and subsequent fertility of offspring. Compared with the unexposed control, fetal hypoxia impaired fertility by disordering ovarian function. Specifically, fetal hypoxia caused mitochondrial dysfunction, oxidant stress, and autophagy in GCs in the adult ovary. RNA sequencing analysis revealed that 437 genes were differentially expressed in the adult GCs of exposed animals. Western blotting results also revealed that fetal exposure induced high levels of hypoxia-inducible factor 1-alpha (Hif1a) expression in adult GCs. We then treated granulosa cells isolated from exposed mice with PX-478, a specific pharmacological inhibitor of Hif1a, and found that autophagy and apoptosis were effectively alleviated. Finally, by using a human ovarian granulosa-like tumor cell line (KGN) to simulate hypoxia in vitro, we showed that Hif1a regulated autophagic cell death in GCs through the Pi3k/Akt pathway. Together, these findings suggest that fetal hypoxia exposure induced persistent Hif1a expression, which impaired mitochondrial function and led to autophagic cell death in the GCs of the adult ovary.

Protective effects of melatonin on female rat ovary treated with nonylphenol

We investigated using histochemistry and immunohistochemistry ovarian damage caused by nonylphenol (NP) and the protective effect of melatonin treatment of NP induced ovarian damage. We used 21 female rats divided randomly into three groups: control, NP and melatonin + NP. Histopathological examination of the ovaries, and counting and classification of follicles were performed using Masson's trichrome staining. Expression of anti-Mullerian hormone (AMH), Bax, Bcl-2 and caspase-3 was detected in the ovaries using immunohistochemistry. Melatonin had an ameliorative effect on NP induced follicular atresia and absence of corpora lutea. More follicles were observed in the ovaries of animals treated with melatonin prior to treatment with NP. AMH immunoreactivity was significantly lower in the NP group than in the melatonin + NP group. NP increased immunostaining for Bax, Bcl-2 and caspase-3. Melatonin significantly reduced the increased expression of Bax, Bcl-2 and caspase-3 due to NP exposure. We found that pretreatment with melatonin is beneficial for protecting the ovaries from damage by NP.

Interactions between serum FSH, inhibin B and antral follicle count in the decline of serum AMH during the menstrual cycle in late reproductive age

Objective

To investigate the hormonal interrelationships during the menstrual cycle in women of late reproductive age with suppressed serum AMH and antral follicle count (AFC).

Methods

Serum hormones (AMH, FSH, LH, estradiol, progesterone, inhibin A, inhibin B), AFC (2-10 mm) and AMH/AFC ratio (an estimate of AMH/follicle) were assessed every 2-3 days across the menstrual cycle in 26 healthy ovulatory women aged 18-50 years.

Results

An 11-fold fall in AMH/AFC was observed in women aged ≥45 years compared to those 18-45 years (P < .001). Although women ≥45 years exhibited normal menstrual cycle patterns of serum estradiol, progesterone, LH and inhibin A, FSH was elevated (P < .001) and inhibin B suppressed (P < .001) compared to the younger group. Overall FSH was inversely correlated (r = .55, P < .05) and AMH directly correlated (r = .88, P < .01) with AFC; however, these relationships were curvilinear and more pronounced when AFC was low. Inhibin B was directly linearly correlated (r = .70, P < .01) with AFC across both high and low AMH/follicle groups.

Conclusions

It is hypothesized that the marked fall in AMH/follicle in late reproductive age is attributed to the change in the hormonal interplay between the pituitary and ovary. The fall in AFC leads to a decrease in inhibin B and a concomitant increase in FSH by a recognized feedback mechanism. It is postulated the elevated FSH suppresses AMH either directly or indirectly through oocyte-specific growth factors leading to a marked fall in AMH/follicle. We propose that pituitary-ovarian and intra-ovarian regulatory systems underpin the accelerated fall in AMH/follicle during the transition to menopause.

Contribution of recruitable follicles to circulating anti-Müllerian hormone levels following maximal gonadotrophin stimulation in patients with limited ovarian reserve

In women, the majority of anti-Müllerian hormone (AMH) measured in serum originate from small antral follicles measuring 2-10 mm. In gonadotrophin-stimulated cycles prior to assisted reproductive technology (ART), most of the recruitable follicles develop beyond 10 mm in size and thus lose their AMH secretion capacity causing declining serum AMH levels. The aim of this study was to define the residual serum AMH level after elimination of the AMH producing recruitable follicles following maximal gonadotrophin stimulation. We measured serum AMH and number of follicles according to size at several time points during a cycle of maximal gonadotrophin stimulation (fixed dose of 300 IE HP-hMG) in 107 women with low AMH (median AMH 5 pmol/L, interquartile range (IQR) 3.3-8.3). We found that AMH decreased gradually and reached a minimum level of -55.4% (95% CI -59.6; -50.7) of the baseline value four days after ovulation trigger. Our findings suggest that the residual AMH production origins from pre-antral and small antral follicles not visible by sonography and that they account for up to 40% of the circulating AMH.

Comparison of Automated Anti-Müllerian Hormone Assays and Antral Follicle Count in Predicting Ovarian Response During Ovarian Stimulation

Objective: Various parameters had been used to predict ovarian response. Among them, Anti-Müllerian Hormone (AMH) and antral follicle count (AFC) demonstrate the most favourable analytical and performance characteristics. In this pilot study, we aim to determine the cut-off levels of AMH using automated AMH assays and AFC in the prediction of poor and high responders.

Study Design: Prospective study of 43 women between 21 to 45 years old scheduled for assisted reproduction. AMH levels on day 3 of menstruation were analysed using two immunoassay kits, namely the Beckman Coulter Access AMH and the Roche Elecsys AMH on the two automated analysers Beckman Coulter DxI 800 and Roche Cobas e602 respectively. AFC was also assessed on day 3 of menstruation prior to in vitro fertilization (IVF). These were compared with the number of oocytes retrieved after controlled ovarian stimulation.

Results: AMH (Beckman Coulter Access AMH and Roche Elecsys AMH) highly correlated with AFC and the number of oocytes retrieved after ovarian stimulation. Beckman Coulter Access AMH was the better predictor for poor ovarian response with ROC [Formula: see text] of 0.83. For the prediction of a high response, AFC had a higher ROC [Formula: see text] of 0.95. Through ROC, the AMH cut-off level for poor ovarian response was 2.23 ng/ml with Beckman Coulter Access AMH and 2.02 ng/ml with Roche Elecsys AMH, while the AMH cut-off for a high ovarian response was 5.19 ng/ml with Beckman Coulter Access AMH and 4.60 ng/ml with Roche Elecsys AMH. For AFC, the cut-off for poor ovarian response was 18 and for high response was 34.

Conclusion: AMH and AFC are reliable predictors of ovarian response. Establishment of specific levels may improve individualised controlled ovarian stimulation and optimise the oocyte yield. Larger studies are required to establish these findings.

A Microfluidic Device for Culturing an Encapsulated Ovarian Follicle

Microfluidic chips have been proved effective in mimicking different organs of human body. Simulating human ovarian follicles by microfluidic device will be useful in exploring the mechanism of folliculogenesis and related diseases. In this paper, a microfluidic chip was designed to culture a single human pre-antral follicle. Ovarian follicles were first encapsulated in 3D calcium alginate hydrogel beads and then cultured on chip and in dish under same conditions. The diameters of cultured ovarian follicles were measured, and the same amount of medium was collected from microfluidic device or dish per two days for measuring the estradiol and androgen concentrations. The results confirmed the successful growth of ovarian follicles on chip with their hormonal trends and diameters increase, which were similar to ovarian follicles cultured in dish. It is concluded that this microfluidic chip can be used to culture a single human ovarian follicle, which provides a useful tool to explore the hormonal changes and their interactions during folliculogenesis.

Dysregulation of the Anti-Müllerian Hormone System by Steroids in Women With Polycystic Ovary Syndrome

CONTEXT

Anti-Müllerian hormone (AMH) and AMH type II receptor (AMHR2) are overexpressed in granulosa cells (GCs) from women with polycystic ovary syndrome (PCOS), the most common cause of female infertility.

OBJECTIVE

The aim of the study was to compare the regulation of the AMH/AMHR2 system by 5α-dihydrotestosterone (5α-DHT) and estradiol (E2) in GCs from control subjects and women with PCOS.

DESIGN, SETTING, PATIENTS

Experiments were performed on follicular fluids (FF) and GCs from women undergoing in vitro fertilization.

MAIN OUTCOME MEASURES

FF steroid levels were measured by mass spectrometry, and messenger RNA (mRNA) accumulation was quantified by reverse transcription real-time polymerase chain reaction.

RESULTS

Total testosterone (T), free T, and 5α-DHT FF levels were significantly higher (P < 0.001) in women with PCOS than in controls. However, E2 and sex hormone-binding globulin concentrations were comparable between the two groups. In GCs from control women, the AMH and AMHR2 expression were not affected by 5α-DHT treatment, whereas AMH mRNA levels were upregulated by 5α-DHT in GCs from patients with PCOS (2.3-fold, P < 0.01) overexpressing the androgen receptor (1.4-fold, P < 0.05). E2 downregulated the AMH and AMHR2 expression in GCs from control women (1.4-fold, P < 0.001 and 1.8-fold, P < 0.01, respectively) but had no effect on these genes in GCs from women with PCOS. This differential effect of E2 was associated with a higher estrogen receptor 1 expression in GCs from women with PCOS (1.9-fold, P < 0.05).

CONCLUSIONS

In GCs from women with PCOS, the regulation of AMH and AMHR2 expression is altered in a way that promotes the overexpression of the AMH/AMHR2 system, and could contribute to the follicular arrest observed in these patients.

Interactions between androgens, FSH, anti-Müllerian hormone and estradiol during folliculogenesis in the human normal and polycystic ovary

BACKGROUND

Androgens, FSH, anti-Müllerian hormone (AMH) and estradiol (E2) are essential in human ovarian folliculogenesis. However, the interactions between these four players is not fully understood.

OBJECTIVES AND RATIONALE

The purpose of this review is to highlight the chronological sequence of the appearance and function of androgens, FSH, AMH and E2 and to discuss controversies in the relationship between FSH and AMH. A better understanding of this interaction could supplement our current knowledge about the pathophysiology of the polycystic ovary syndrome (PCOS).

SEARCH METHODS

A literature review was performed using the following search terms: androgens, FSH, FSH receptor, anti-Mullerian hormone, AMHRII, estradiol, follicle, ovary, PCOS, aromatase, granulosa cell, oocyte. The time period searched was 1980-2015 and the databases interrogated were PubMed and Web of Science.

OUTCOMES

During the pre-antral ('gonadotropin-independent') follicle growth, FSH is already active and promotes follicle growth in synergy with theca cell-derived androgens. Conversely, AMH is inhibitory by counteracting FSH. We challenge the hypothesis that AMH is regulated by androgens and propose rather an indirect effect through an androgen-dependent amplification of FSH action on granulosa cells (GCs) from small growing follicles. This hypothesis implies that FSH stimulates AMH expression. During the antral ('gonadotropin-dependent') follicle growth, E2 production results from FSH-dependent activation of aromatase. Conversely, AMH is inhibitory but the decline of its expression, amplified by E2, allows full expression of aromatase, characteristic of the large antral follicles. We propose a theoretical scheme made up of two triangles that follow each other chronologically. In PCOS, pre-antral follicle growth is excessive (triangle 1) because of intrinsic androgen excess that renders GCs hypersensitive to FSH, with consequently excessive AMH expression. Antral follicle growth and differentiation are disturbed (triangle 2) because of the abnormally persisting inhibition of FSH effects by AMH that blocks aromatase. Beside anovulation, this scenario may also serve to explain the higher receptiveness to gonadotropin therapy and the increased risk of ovarian hyperstimulation syndrome (OHSS) in patients with PCOS.

WIDER IMPLICATIONS

Within GCs, the balance between FSH and AMH effects is pivotal in the shift from androgen- to oestrogen-driven follicles. Our two triangles hypothesis, based on updated data from the literature, offers a pedagogic template for the understanding of folliculogenesis in the normal and polycystic ovary. It opens new avenues for the treatment of anovulation due to PCOS.

Is the suppressive effect of cyproterone acetate on serum anti-Müllerian-hormone levels in women with polycystic ovary syndrome stronger than under oral contraceptive pill?

OBJECTIVE

To compare the suppressive effect of anti-androgen therapy by cyproterone acetate (CPA) and by oral contraceptive pill (OCP) on anti-müllerian hormone (AMH) levels in women with polycystic ovary syndrome (PCOS) in order to detect a putative direct anti-androgen effect on AMH excess.

METHODS

This is a prospective longitudinal study including 58 women with PCOS between January 2010 and April 2014 at the Lille University Hospital. A total of 47 women with clinical hyperandrogenism were treated by CPA (50 mg/d was administered 20 days out of 28) and 11 women with PCOS but without clinical hyperandrogenism received OCP.

RESULT(S)

Serum AHM levels at baseline were similar in CPA and OCP groups (median [5-95th percentiles]: 60.4 pmol/l [25.1-200.2] versus 58 pmol/l [27.6-100], respectively, p = 0.39). After 3 months of treatment, serum AMH levels decreased significantly by 28% ± 20% and by 22% ± 27% in CPA and OCP groups, respectively. The decrease under both treatments was similar (p = 0.48).

CONCLUSION(S)

That any anti-androgen effect could be observed on AMH in our CPA group in addition to the gonadotropin-suppressing effect suggests that either androgens are not involved in AMH regulation or that they act by interfering with gonadotropin effects on granulosa cells.

Dynamic antimüllerian hormone levels during controlled ovarian hyperstimulation predict in vitro fertilization response and pregnancy outcomes

OBJECTIVE

To evaluate the patterns of change in serum antimüllerian hormone (AMH) during controlled ovarian hyperstimulation (COH) and their relation to concurrent response and in vitro fertilization (IVF) pregnancy outcomes.

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

A total of 113 consecutive fresh IVF embryo transfer cycles from September 1, 2012 through January 1, 2013.

INTERVENTION(S)

Serial serum AMH measurements were analyzed on each day that serum estradiol (E2) was drawn during COH.

MAIN OUTCOME MEASURE(S)

Relationship between the rate of COH AMH change [Δ ng/mL per day] (stratified into tertiles), and ovarian response, and pregnancy outcomes.

RESULT(S)

During COH, AMH declined. Age and ovarian reserve testing were associated with the rate of AMH decline (RAD). Women with intermediate and minimal RAD had statistically significantly fewer follicles ≥ 12 mm, lower peak serum E2, fewer oocytes, and inferior early embryo development compared with women with the greatest RAD. Compared with patients with the lowest RAD, clinical pregnancy was more likely in patients with the greatest RAD in the total population (adjusted odds ratio 3.51; 95% confidence interval, 1.03, 11.94) and among patients older than 35 years (adjusted odds ratio 6.95; 95% confidence interval, 1.09, 44.1).

CONCLUSION(S)

The rate of COH AMH decline was associated with ovarian reserve testing, oocyte yield, embryo progression, and clinical pregnancy rates, particularly in women older than 35 years. These results suggest that dynamic AMH levels may provide a novel intracycle approach to predict response and treatment outcomes after IVF.

Maximizing the clinical utility of antimüllerian hormone testing in women's health

Purpose of review

To provide an update on the latest clinical applications of serum antimüllerian hormone (AMH) testing with practical approaches to mitigate the impact of significant variability in AMH results.

Recent findings

Recent studies continue to demonstrate that AMH is the best single serum test for ovarian response management with, at most, a weak-to-moderate age-independent association with live-birth rate and time to conception. Data confirm serum AMH levels improve menopause prediction, monitoring of ovarian damage, and identification of women at risk for several ovary-related disorders such as polycystic ovary syndrome and premature or primary ovarian insufficiency. However, it is now recognized that serum AMH results can have dramatic variability due to common, biologic fluctuations within some individuals, use of hormonal contraceptives or other medications, certain surgical procedures, specimen treatment, assay changes, and laboratory calibration differences. Practical guidelines are provided to minimize the impact of variability in AMH results and maximize the accuracy of clinical decision-making.

Summary

AMH is an ovarian biomarker of central importance which improves the clinical management of women's health. However, with the simultaneous rapid expansion of AMH clinical applications and recognition of variability in AMH results, consensus regarding the clinical cutpoints is increasingly difficult. Therefore, a careful approach to AMH measurement and interpretation in clinical care is essential.