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Vale-Fernandes E, Moreira MV, Rodrigues B, Pereira SS, Leal C, Barreiro M, Tomé A, Monteiro MP. Anti-Müllerian hormone a surrogate of follicular fluid oxidative stress in polycystic ovary syndrome? Front Cell Dev Biol 2024; 12:1408879. [PMID: 39011395 PMCID: PMC11246868 DOI: 10.3389/fcell.2024.1408879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/11/2024] [Indexed: 07/17/2024] Open
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women at childbearing age. Anti-Müllerian hormone (AMH) is a widely accepted sensitive marker of ovarian reserve, which has been suggested that could also act as biomarker of ovarian morphology for PCOS diagnosis. Oxidative stress (OS) is known to be associated and have a negative impact factor in several reproductive conditions, including PCOS. However, the relationship between circulating AMH and OS within the follicular fluid (FF), and its potential impact on in vitro fertilization (IVF) outcomes of women with PCOS, remains largely unexplored. A total of 84 women, with PCOS (n = 30) or ovulatory controls (n = 54), were enrolled in this study. Women underwent individualized controlled ovarian stimulation for oocyte retrieval. Blood and FF obtained from mature follicles were collected at the time of oocyte retrieval, for measuring total testosterone, ∆4-androstenedione, progesterone, sex hormone binding globulin (SHBG) and AMH. OS in the FF was assessed by measuring total antioxidant capacity (TAC) through the ferric reducing antioxidant power (FRAP) and lipid peroxidation (LPO) by quantification of malondialdehyde (MDA) levels. Our results demonstrated that women with PCOS had significantly higher plasma levels of AMH, ∆4-androstenedione, total testosterone and a free androgen index (FAI) than observed in non-PCOS controls. In women with PCOS, total testosterone and AMH levels in the FF were also higher, while TAC was lower compared to non-PCOS. Furthermore, circulating AMH levels were positively correlated with ∆4-androstenedione, albeit negatively correlated with TAC. In this study we demonstrated that the susceptibility to OS, as assessed by the total antioxidant capacity in the FF, is higher in women with PCOS and inversely related to AMH levels. This study results lead us to forge the reasonable hypothesis that the greater susceptibility to OS within the follicle microenvironment is potentially at the end of a roadway that starts with elevated ∆4-androstenedione and AMH within the FF, which in turn are mirrored by circulating AMH and androgen levels. Thus, suggesting that circulating AMH levels could act as a surrogate biomarker of follicular fluid oxidative stress in women with PCOS.
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Affiliation(s)
- Emídio Vale-Fernandes
- Centre for Medically Assisted Procreation/Public Gamete Bank, Gynaecology Department, Centro Materno-Infantil do Norte Dr. Albino Aroso (CMIN), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
- Gynaecology Department, Centro Materno-Infantil do Norte Dr. Albino Aroso (CMIN), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
| | - Mafalda V. Moreira
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Bárbara Rodrigues
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
- Molecular Genetics Unit, Centro de Genética Médica Dr. Jacinto Magalhães (CGM), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
| | - Sofia S. Pereira
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Carla Leal
- Centre for Medically Assisted Procreation/Public Gamete Bank, Gynaecology Department, Centro Materno-Infantil do Norte Dr. Albino Aroso (CMIN), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Márcia Barreiro
- Centre for Medically Assisted Procreation/Public Gamete Bank, Gynaecology Department, Centro Materno-Infantil do Norte Dr. Albino Aroso (CMIN), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
- Gynaecology Department, Centro Materno-Infantil do Norte Dr. Albino Aroso (CMIN), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
| | - António Tomé
- Gynaecology Department, Centro Materno-Infantil do Norte Dr. Albino Aroso (CMIN), Unidade Local de Saúde de Santo António (ULSSA), Porto, Portugal
| | - Mariana P. Monteiro
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
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Wang S, Zhang M, Hu X, Duan N, Chen X, Yin Y, Wang Z. Diagnostic values of MRI indexes for polycystic ovary syndrome. Acta Radiol 2023; 64:806-813. [PMID: 35188811 DOI: 10.1177/02841851221080521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is a useful non-invasive modality for observation of ovarian morphologic characteristics. Few studies have focused on the value of MRI-derived indexes in reproductive-aged women with polycystic ovary syndrome (PCOS). PURPOSE To assess the diagnostic value of MRI in women with PCOS. MATERIAL AND METHODS This prospective case-control study included 85 women with PCOS and 50 controls who underwent pelvic MRI during 2017-2019. Ovarian volume (OV), follicle count (FC; counts of follicles sizing 2-3, 4-6, 7-9, 2-9 mm, respectively), follicular peripheral distribution, absence of a dominant follicle and stromal to total area ratio (S:A) were determined with MRI. The diagnostic value (sensitivity, specificity, area under the receiver operating characteristic curve [AUC]) of OV, FC2-9, and follicular peripheral distribution for PCOS were assessed. RESULTS The AUCs were 0.94 for OV, 0.96 for FC2-9, and 0.78 for follicular peripheral distribution. The optimal threshold to detect PCOS was 8.5 mL for OV (sensitivity 78%; specificity 96%) and 26 for FC2-9 (sensitivity 85%; specificity 98%). Sensitivity and specificity were 73% and 82% for follicular peripheral distribution, respectively. Reproducibility was perfect for OV (ICC = 0.96) and absence of a dominant follicle (k = 0.85), substantial for FC2-9 (ICC = 0.79) and S:A (ICC = 0.69), and moderate for follicular peripheral distribution (k = 0.56). CONCLUSION Detected by MRI, OV >8.5 mL or FC2-9 >26 are accurate for diagnosing PCOS.
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Affiliation(s)
- Shaojuan Wang
- Department of Radiology, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Meimei Zhang
- Departments of Ultrasonography, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Xuyu Hu
- Department of Radiology, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Na Duan
- Department of Radiology, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Xiao Chen
- Department of Radiology, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Yanyun Yin
- Departments of Gynecology, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, PR China
| | - Zhongqiu Wang
- Department of Radiology, 375808Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, PR China
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Wang SJ, Zhang MM, Duan N, Hu XY, Ren S, Cao YY, Zhang YP, Wang ZQ. Using transvaginal ultrasonography and MRI to evaluate ovarian volume and follicle count of infertile women: a comparative study. Clin Radiol 2022; 77:621-627. [PMID: 35636975 DOI: 10.1016/j.crad.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/22/2022] [Indexed: 11/26/2022]
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Pereira-Eshraghi CF, Tao R, Chiuzan CC, Zhang Y, Shen W, Lerner JP, Oberfield SE, Sopher AB. Ovarian follicle count by magnetic resonance imaging is greater in adolescents and young adults with polycystic ovary syndrome than in controls. F S Rep 2022; 3:102-109. [PMID: 35789714 PMCID: PMC9250127 DOI: 10.1016/j.xfre.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 01/19/2023] Open
Abstract
Objective To use magnetic resonance imaging (MRI) to quantify the follicle number per ovary (FNPO) using biplanar measurements and determine the ovarian volume (OV) using three-dimensional measurements in adolescents and young adults with polycystic ovary syndrome (PCOS) and controls and compare the differences between these groups; to examine the relationships between FNPO and OV and metabolic markers associated with PCOS; to compare OV obtained by use of MRI and ultrasound between young patients with PCOS and controls. Design Cross-sectional study. Setting Outpatient within a major medical center in New York City. Patients Adolescent girls and young women aged 13-25 years with PCOS (n = 16) and body mass index-, age-, and ethnicity-comparable control subjects (n = 15). Interventions None. Main Outcome Measures The OV and FNPO by use of MRI, OV by use of transabdominal pelvic ultrasound, anthropometric measurements, and biochemical and hormonal evaluation. Results The FNPO was higher in participants with PCOS (23.7 ± 4.6 follicles) than in controls (15.2 ± 4 follicles) when adjusted for menstrual age. The OV by use of ultrasound was higher in participants with PCOS (11.7 ± 5.6 mL) than in controls (8.1 ± 3.4 mL); however, OV by use of MRI did not differ between the groups. The OV by use of MRI and ultrasound correlated in participants with PCOS (r = 0.62) but not in controls. Conclusions Our results are in line with prior studies showing that FNPO may be a more sensitive measure of polycystic ovary morphology than OV. The results of this study support the use of ovarian k, a promising diagnostic tool for PCOS, in young patients.
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Affiliation(s)
- Camila Freitas Pereira-Eshraghi
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Rachel Tao
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Codruta C. Chiuzan
- Department of Biostatistics, Columbia University Irving Medical Center, New York, New York
| | - Yuan Zhang
- Department of Biostatistics, Columbia University Irving Medical Center, New York, New York
| | - Wei Shen
- Department of Pediatrics and Nutrition, New York Obesity Center, Columbia University Irving Medical Center, New York, New York
| | - Jodi P. Lerner
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York
| | - Sharon E. Oberfield
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Aviva B. Sopher
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York,Reprint requests: Aviva B. Sopher, M.D., M.S., Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, 622 West 168 Street, PH 17 West 308, New York, New York 10032.
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Guo Y, Jiang H, Hu S, Liu S, Li F, Jin L. Efficacy of three COS protocols and predictability of AMH and AFC in women with discordant ovarian reserve markers: a retrospective study on 19,239 patients. J Ovarian Res 2021; 14:111. [PMID: 34454544 PMCID: PMC8403432 DOI: 10.1186/s13048-021-00863-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/18/2021] [Indexed: 12/17/2022] Open
Abstract
Background Recent studies have consistently shown that AFC and serum AMH are good predictors of ovarian response and have shown strong correlations. However, it is not unusual for reproductive medicine specialists to encounter discordance between them. This is the first study to investigate the efficacies of the different COS protocols when the AFC and AMH levels are discordant. Based on the association between COS protocols and pregnancy outcomes, we attempt to explain the controversial results and clarify the predictive value of AMH and AFC in this context. Methods 19,239 patients undergoing their first fresh in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles with GnRH antagonist protocols, GnRH-a long protocols or GnRH-a ultra-long protocols between January 1, 2016, and December 31, 2019, were enrolled and then divided into four groups in accordance with the boundaries for the AFC and serum AMH level provided by the Poseidon Classification. Our study was divided into two parts. Firstly, we retrospectively compared the effects of the three COS protocols in patients with discordant AMH and AFC. Multivariate logistic regression models were conducted in a forward manner to exclude the influence of confounding factors. Afterward, to increase comparability between Group 2 (low AMH and normal AFC) and Group 3 (normal AMH and low AFC), propensity score matching (PSM) analysis was performed based on age, BMI, the number of embryos transferred, and COS protocol. IVF intermediate and reproductive outcomes were compared between Group 2 and Group 3. Results For people with low AMH and normal AFC (Group 2), the number of total oocytes, clinical pregnancy rate (CPR), live birth rate (LBR) and cumulative live birth rate (CLBR) were significantly higher in GnRH-a ultra-long protocol compared with GnRH antagonist protocol. In multivariate logistic regression models, significant associations of COS protocol with fresh LBR and CPR were found after adjusting for age, BMI, AFC, AMH and the number of embryos transferred. Whereas, in patients with normal AMH and low AFC (Group 3), the number of total oocytes, CLBR, LBR and CPR were highest in the long GnRH-a protocol although there was no statistically significant difference. After PSM, the results showed that although oocytes yield and available embryos in patients with normal AMH and low AFC were significantly higher, there was no significant difference in reproductive outcomes between Group 2 and Group 3. Conclusions We found that women with normal AFC and low AMH may benefit from the GnRH-a ultra-long protocol. Nevertheless, for women with normal AMH and low AFC, the long GnRH-a protocol seems to be associated with better clinical outcomes. Furthermore, after eliminating the confounding factors including the COS protocol, we found that AMH can only predict the number of oocytes but not the quality of oocytes when there was discordance between AFC and AMH. Supplementary Information The online version contains supplementary material available at 10.1186/s13048-021-00863-4.
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Affiliation(s)
- Yaxin Guo
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Huahua Jiang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shiqiao Hu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shuai Liu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Fei Li
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Lei Jin
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Wall DJ, Reinhold C, Akin EA, Ascher SM, Brook OR, Dassel M, Henrichsen TL, Learman LA, Maturen KE, Patlas MN, Robbins JB, Sadowski EA, Saphier C, Uyeda JW, Glanc P. ACR Appropriateness Criteria® Female Infertility. J Am Coll Radiol 2020; 17:S113-S124. [PMID: 32370955 DOI: 10.1016/j.jacr.2020.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/12/2022]
Abstract
The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mark Dassel
- Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | | | - Lee A Learman
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | | | | | | | | | - Carl Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | | | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Petraitiene I, Valuniene M, Jariene K, Seibokaite A, Albertsson-Wikland K, Verkauskiene R. Sex Hormones, Gonad Size, and Metabolic Profile in Adolescent Girls Born Small for Gestational Age with Catch-up Growth. J Pediatr Adolesc Gynecol 2020; 33:125-132. [PMID: 31707058 DOI: 10.1016/j.jpag.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/13/2019] [Accepted: 11/03/2019] [Indexed: 01/21/2023]
Abstract
STUDY OBJECTIVE To characterize and compare sex hormone concentrations, and uterine and ovarian volumes in adolescent girls born small for gestational age (SGA) who had experienced catch-up growth and girls born at a size appropriate for gestational age (AGA), and to investigate the association between these parameters and glucose metabolism, perinatal factors, and early growth. DESIGN A prospective, longitudinal, observational study from birth until adolescence. SETTING Mean age at final assessment was 12.7 ± 0.1 years. PARTICIPANTS We followed 55 girls (20 SGA, 35 AGA). INTERVENTIONS AND MAIN OUTCOME MEASURES Sex hormone concentrations (gonadotropins, estradiol, testosterone, and sex hormone binding globulin) were analyzed, and the oral glucose tolerance test conducted. Uterine and ovarian sizes were assessed using pelvic ultrasound. RESULTS Uterine and ovarian volumes were smaller in SGA-born compared with AGA-born girls (P = .013 and P = .039, respectively). SGA girls had lower sex hormone binding globulin levels (P = .039) and higher testosterone levels (P = .003), free androgen index (P < .001), and glycemia 2 hours post glucose load (P = .005) compared with AGA-born girls. Birth weight and early infancy height velocity explained 37.4% of variation in ovarian volume (P = .004), and body mass index at birth, increase in peripheral skinfold thickness during second year of life, and early childhood height velocity explained 43.2% of variation in testosterone levels in adolescence (P = .006). CONCLUSION SGA-born girls who experienced catch-up growth remain at risk of biochemical hyperandrogenism in adolescence, and have reduced uterine and ovarian volumes, which might influence future reproductive function. Ovarian size and androgen levels in adolescence might be influenced by early growth and subcutaneous fat deposition.
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Affiliation(s)
- Indre Petraitiene
- Department of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Margarita Valuniene
- Mother and Child Clinic, Republican Siauliai County Hospital, Siauliai, Lithuania
| | - Kristina Jariene
- Department of Obstetrics and Gynaecology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audrone Seibokaite
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kerstin Albertsson-Wikland
- Department of Physiology/Endocrinology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rasa Verkauskiene
- Department of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Analysis of ovarian volume of Korean children and adolescents at magnetic resonance imaging. Pediatr Radiol 2019; 49:1320-1326. [PMID: 31346660 DOI: 10.1007/s00247-019-04469-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 05/02/2019] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Knowledge of ovarian volume is important for diagnostic evaluations; however, normal ovarian volume studies on children and adolescents are lacking. OBJECTIVE This study aimed to analyze age-specific ovarian volume and identify the diverse factors that contribute to ovarian diagnoses. MATERIALS AND METHODS We retrospectively enrolled 180 patients (0-18 years of age) with normal ovaries who underwent magnetic resonance imaging (MRI) between 2010 and 2018. MRI sequences included coronal and axial T2-weighted turbo spin echo (TSE) images and coronal T1-weighted TSE images. Ovarian volume was calculated by the standard ellipsoid formula. Age-specific ovarian volume, height, weight, height-adjusted total ovarian volume and body mass index were obtained. Linear regression analysis was used to predict ovarian volume. RESULTS Six age groups (infant; early and late child, and early, middle and late adolescent) were described. The early adolescent group (10-12 years) had the highest rate of increase. In the middle adolescent period (13-15 years), the curve of ovarian volume appeared flat. CONCLUSION Our findings provide age-specific references for ovarian volume.
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Zhou J, Sun Y, Sun J, Zhao JM, Cui YH, Wu LX, Wu HG, Shi Y, Li L. Effect of electroacupuncture on anti-Mullerian hormone expression in rats with polycystic ovarian syndrome. JOURNAL OF ACUPUNCTURE AND TUINA SCIENCE 2019. [DOI: 10.1007/s11726-019-1094-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Feng Y, Tamadon A, Hsueh AJW. Imaging the ovary. Reprod Biomed Online 2018; 36:584-593. [PMID: 29602728 DOI: 10.1016/j.rbmo.2018.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 12/31/2022]
Abstract
During each reproductive cycle, the ovary exhibits tissue remodelling and cyclic vasculature changes associated with hormonally regulated folliculogenesis, follicle rupture, luteal formation and regression. However, the relationships among different types of follicles and corpora lutea are unclear, and the role of ovarian vasculature in folliculogenesis and luteal dynamics has not been extensively investigated. Understanding of ovarian physiology and pathophysiology relies upon elucidation of ovarian morphology and architecture. This paper summarizes the literature on traditional approaches to the imaging of ovarian structures and discusses recent advances in ovarian imaging. Traditional in-vivo ultrasound, together with histological and electron microscopic approaches provide detailed views of the ovary at organ, tissue and molecular levels. However, in-vivo imaging is limited to antral and larger follicles whereas histological imaging is mainly two-dimensional in nature. Also discussed are emerging approaches in the use of near-infrared fluorophores to image follicles in live animals to detect preantral follicles as well as visualizing ovarian structures using CLARITY in fixed whole ovaries to elucidate three-dimensional interrelationships among follicles, corpora lutea and ovarian vasculature. Advances in ovarian imaging techniques provide new understanding of ovarian physiology and allow for the development of better tools to diagnose ovarian pathophysiology.
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Affiliation(s)
- Yi Feng
- Department of Integrative Medicine and Neurobiology, School of Basic Medical Sciences, Institutes of Brain Science, Brain Science Collaborative Innovation Centre, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture and Moxibustion, Fudan Institutes of Integrative Medicine, Fudan University, Shanghai 200032, China.
| | - Amin Tamadon
- Department of Integrative Medicine and Neurobiology, School of Basic Medical Sciences, Institutes of Brain Science, Brain Science Collaborative Innovation Centre, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture and Moxibustion, Fudan Institutes of Integrative Medicine, Fudan University, Shanghai 200032, China
| | - Aaron J W Hsueh
- Program of Reproductive and Stem Cell Biology, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford University, Stanford, CA 94305, USA.
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Peigné M, Catteau-Jonard S, Robin G, Dumont A, Pigny P, Dewailly D. The numbers of 2– 5 and 6–9 mm ovarian follicles are inversely correlated in both normal women and in polycystic ovary syndrome patients: what is the missing link? Hum Reprod 2018; 33:706-714. [DOI: 10.1093/humrep/dey017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/15/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Peigné
- CHU Lille, Service de Gynécologie-Endocrinienne et Médecine de la Reproduction, Hôpital Jeanne de Flandre, rue Eugène Avinée 59000, Lille, France
- AP-HP, Unité de Médecine de la Reproduction, Service de Gynécologie-Obstétrique, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018 Paris, France
| | - S Catteau-Jonard
- CHU Lille, Service de Gynécologie-Endocrinienne et Médecine de la Reproduction, Hôpital Jeanne de Flandre, rue Eugène Avinée 59000, Lille, France
| | - G Robin
- CHU Lille, Service de Gynécologie-Endocrinienne et Médecine de la Reproduction, Hôpital Jeanne de Flandre, rue Eugène Avinée 59000, Lille, France
| | - A Dumont
- CHU Lille, Service de Gynécologie-Endocrinienne et Médecine de la Reproduction, Hôpital Jeanne de Flandre, rue Eugène Avinée 59000, Lille, France
| | - P Pigny
- CHU Lille, Service de Biochimie et Hormonologie, Centre de Biologie Pathologie, Bd du Professeur J. Leclercq 59000, Lille, France
| | - D Dewailly
- CHU Lille, Service de Gynécologie-Endocrinienne et Médecine de la Reproduction, Hôpital Jeanne de Flandre, rue Eugène Avinée 59000, Lille, France
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12
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Quinn MM, Kao CN, Ahmad AK, Haisenleder DJ, Santoro N, Eisenberg E, Legro RS, Cedars MI, Huddleston HG. Age-stratified thresholds of anti-Müllerian hormone improve prediction of polycystic ovary syndrome over a population-based threshold. Clin Endocrinol (Oxf) 2017; 87:733-740. [PMID: 28681949 DOI: 10.1111/cen.13415] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/22/2017] [Accepted: 07/02/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Due to its consistent elevation in polycystic ovary syndrome (PCOS) and correlation with polycystic ovarian morphology (PCOM), anti-Mullerian hormone (AMH) has been proposed as a marker of the syndrome. However, prior studies reporting thresholds of AMH for a PCOS diagnosis have been limited by small sample size, inappropriate controls, and heterogeneous AMH assays. We sought to evaluate the suitability of a standardized AMH assay as a biomarker of PCOS. DESIGN Cross-sectional study at academic medical centres across the United States. PATIENTS Women with PCOS were diagnosed by Rotterdam criteria and included 282 subjects from the multisite PPCOS II trial and 109 patients from a tertiary academic centre's multidisciplinary PCOS clinic. Controls included 245 participants in the ovarian ageing (OVA) study, a community-based cohort of ovulatory women not seeking treatment for fertility. MEASUREMENTS Determination of AMH by a central laboratory. Receiver-operating characteristic (ROC) analyses were used to investigate the accuracy of AMH thresholds for prediction of PCOS diagnosis with stratification by age. RESULTS The optimal threshold of AMH to distinguish PCOS from controls was 55.36 pmol/L (sensitivity: 0.82, specificity: 0.78, J: 0.60). When examining the population by age groups, the optimal AMH threshold decreased with increasing age. CONCLUSIONS AMH is an effective biomarker of PCOS. Age-stratified thresholds more accurately predicted PCOS than an overall population-based threshold.
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Affiliation(s)
- Molly M Quinn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Chia-Ning Kao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Asima K Ahmad
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Daniel J Haisenleder
- Ligand Core Laboratory, University of Virginia Center for Research in Reproduction, Charlottesville, VA, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, CO, USA
| | - Esther Eisenberg
- Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA, USA
| | - Marcelle I Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Heather G Huddleston
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, CA, USA
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Fondin M, Rachas A, Huynh V, Franchi-Abella S, Teglas JP, Duranteau L, Adamsbaum C. Polycystic Ovary Syndrome in Adolescents: Which MR Imaging–based Diagnostic Criteria? Radiology 2017; 285:961-970. [DOI: 10.1148/radiol.2017161513] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Maxime Fondin
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
| | - Antoine Rachas
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
| | - Van Huynh
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
| | - Stéphanie Franchi-Abella
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
| | - Jean-Paul Teglas
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
| | - Lise Duranteau
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
| | - Catherine Adamsbaum
- From the Departments of Pediatric Imaging (M.F., V.H., S.F.A., C.A.), Epidemiology and Public Health (A.R., J.P.T.), and Adolescent and Young Adult Gynecology Unit (L.D.), Centre for Research in Epidemiology and Population Health, INSERM U1018, 63 rue Gabriel Péri, 94276 Le Kremlin Bicêtre, France (A.R., J.P.T); and Faculty of Medicine, Paris Sud University, Le Kremlin Bicêtre, France (A.R., C.A.)
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14
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Nylander M, Frøssing S, Bjerre AH, Chabanova E, Clausen HV, Faber J, Skouby SO. Ovarian morphology in polycystic ovary syndrome: estimates from 2D and 3D ultrasound and magnetic resonance imaging and their correlation to anti-Müllerian hormone. Acta Radiol 2017; 58:997-1004. [PMID: 28273731 DOI: 10.1177/0284185116676656] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Due to improved ultrasound scanners, new three-dimensional (3D) modalities, and novel Anti-Müllerian hormone (AMH)-assays, the ultrasound criteria for polycystic ovarian morphology are under debate and the appropriate thresholds are often requested. Purpose To quantify the differences in estimates of ovarian volume and antral follicle count (AFC) from two-dimensional (2D) and 3D transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI). Material and Methods A cross-sectional study on 66 overweight women with polycystic ovary syndrome (PCOS) according to Rotterdam criteria. Ovarian volume and AFC were estimated from MRI, 2D TVUS, and 3D TVUS, and serum AMH levels were assessed. Bland-Altman statistics were used for comparison. Results Participants had a median age of 29 years (age range, 19-44 years) with a mean BMI of 32.7 kg/m2 (SD 4.5). Ovarian volume from 2D TVUS was 1.48 mL (95% confidence interval [CI], 0.94-2.03; P < 0.001) and 1.25 mL (95% CI, 0.62-1.87; P < 0.001) smaller than from 3D TVUS and MRI, respectively. AFC from 2D TVUS was 18% (95% CI, 13-23; P < 0.005) and 16% (95% CI, 6-25; P < 0.005) smaller than estimates from 3D TVUS and MRI, respectively. Correlations between AMH and AFC from 2D TVUS, 3D TVUS, and MRI were 0.67, 0.78, and 0.70, respectively ( P < 0.001 for all). Conclusion In an overweight PCOS population, 2D TVUS underestimated ovarian volume and AFC as compared with 3D TVUS and MRI. Serum AMH correlated best with AFC from 3D TVUS, followed by MRI and 2D TVUS. The advantage of 3D TVUS might be of minor clinical importance when diagnosing PCOS, but useful when the actual AFC are of interest, e.g. in fertility counseling and research.
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Affiliation(s)
- Malin Nylander
- Department of Obstetrics and Gynecology, Herlev Gentofte Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe Frøssing
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine, Endocrine Unit, Herlev Gentofte Hospital, Herlev, Denmark
| | - Anne H Bjerre
- Department of Obstetrics and Gynecology, Herlev Gentofte Hospital, Herlev, Denmark
| | | | - Helle V Clausen
- Department of Obstetrics and Gynecology, Herlev Gentofte Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Faber
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine, Endocrine Unit, Herlev Gentofte Hospital, Herlev, Denmark
| | - Sven O Skouby
- Department of Obstetrics and Gynecology, Herlev Gentofte Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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15
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Sathyapalan T, Al-Qaissi A, Kilpatrick ES, Dargham SR, Adaway J, Keevil B, Atkin SL. Salivary testosterone measurement in women with and without polycystic ovary syndrome. Sci Rep 2017; 7:3589. [PMID: 28620242 PMCID: PMC5472559 DOI: 10.1038/s41598-017-03945-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/05/2017] [Indexed: 12/26/2022] Open
Abstract
Clinical and/or biochemical hyperandrogenism is one of the diagnostic criteria for PCOS. An evaluation of the role of salivary testosterone (salT) and androstenedione (salA) for the diagnosis of PCOS was undertaken in a cross sectional study involving 65 women without PCOS and 110 women with PCOS fulfilling all 3 diagnostic Rotterdam criteria. Serum and salivary androgen measurements were determined by LC-MS/MS. salT and salA were significantly elevated in PCOS compared to controls (P < 001). No androgen marker was more predictive than another using ROC curves, but multiple logistic regression suggested salT was more predictive than free androgen index (FAI) (p < 0.01). The combination of salT or FAI identified 100% of PCOS women. PCOS women with both biochemical and clinical hyperandrogenism as opposed to clinical hyperandrogenism alone showed a metabolic phenotype (p < 0.05) and insulin resistance (p < 0.001). PCOS patients with an isolated elevated FAI showed increased insulin resistance compared to those with an isolated salT (P < 0.05). salT appeared to be at least as predictive as FAI for the diagnosis of the classical PCOS phenotype, and the combination of salT or FAI identified 100% of PCOS patients. This suggests that salT measurement by LC-MS/MS holds the promise of complementing existing laboratory tests as a means of assessing hyperandrogenemia.
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Affiliation(s)
- Thozhukat Sathyapalan
- Department of Academic Diabetes, Endocrinology and Metabolism, University of Hull, Hull, UK.
| | - Ahmed Al-Qaissi
- Department of Academic Diabetes, Endocrinology and Metabolism, University of Hull, Hull, UK
| | - Eric S Kilpatrick
- Department of Pathology, Sidra Medical and Research Center, Doha, Qatar
| | - Soha R Dargham
- Infectious Disease Epidemiology Group, Weill Cornell Medicine, PO Box, 24144, Doha, Qatar
| | - Joanne Adaway
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, UK
| | - Stephen L Atkin
- Research Faculty, Weill Cornell Medicine, PO Box, 24144, Doha, Qatar
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16
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Specific ranges of anti-Mullerian hormone and antral follicle count correlate to provide a prognostic indicator for IVF outcome. Reprod Biol 2017; 17:51-59. [DOI: 10.1016/j.repbio.2016.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/13/2016] [Accepted: 12/24/2016] [Indexed: 11/23/2022]
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17
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Apparent diffusion coefficient measurement of ovarian stroma: A potential tool for the diagnosis of polycystic ovary syndrome. Diagn Interv Imaging 2017; 98:57-61. [DOI: 10.1016/j.diii.2016.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/18/2016] [Accepted: 09/22/2016] [Indexed: 11/17/2022]
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18
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Wu Y, Robinson N, Hardiman PJ, Taw MB, Zhou J, Wang FF, Qu F. Acupuncture for treating polycystic ovary syndrome: guidance for future randomized controlled trials. J Zhejiang Univ Sci B 2016; 17:169-80. [PMID: 26984837 DOI: 10.1631/jzus.b1500301] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To provide guidance for future randomized controlled trials (RCTs) based on a review concerning acupuncture for treating polycystic ovary syndrome (PCOS). METHODS A comprehensive literature search was conducted in October 2015 using MEDLINE, EMBASE, SCISEARCH, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Menstrual Disorders and Subfertility Group trials register, Allied and Complementary Medicine (AMED), China National Knowledge Infrastructure (CNKI), and the Wanfang databases. RCTs comparing either acupuncture with no/sham/pharmacological intervention or a combination of acupuncture and conventional therapy with conventional therapy in the treatment of PCOS were included in this review. A quality evaluation was performed for each of the included studies. RESULTS Thirty-one RCTs were included in the review and were divided into four categories according to the type of intervention used in the comparator or control group. Menstrual frequency, hormones, anthropometrics, insulin sensitivity, blood lipids, and fertility were used as the main measurements to assess the effects of acupuncture on the patients with PCOS. Thirty trials, except for one, showed an improvement in at least one of the indicators of PCOS after acupuncture treatment. However, normalizing the methodological and reporting format remains an issue. CONCLUSIONS Based upon this review of current clinical trials concerning acupuncture for treating PCOS, we provide guidelines for better clinical trial design in the future.
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Affiliation(s)
- Yan Wu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Nicola Robinson
- School of Health and Social Care, London South Bank University, London, SE1 0AA, UK
| | - Paul J Hardiman
- Institute for Women's Health, University College London Medical School, London, NW3 2PF, UK
| | - Malcolm B Taw
- UCLA Center for East-West Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Westlake Village, CA 91361, USA
| | - Jue Zhou
- College of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou 310018, China
| | - Fang-fang Wang
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Fan Qu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.,Institute for Women's Health, University College London Medical School, London, NW3 2PF, UK
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19
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Rashidi BH, Gorginzadeh M, Aalipour S, Sills ES. Age related endocrine patterns observed in polycystic ovary syndrome patients vs. ovulatory controls: descriptive data from a university based infertility center. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:486-491. [PMID: 27737330 PMCID: PMC10118636 DOI: 10.1590/2359-3997000000215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/25/2016] [Indexed: 11/22/2022]
Abstract
Objective To compare serum anti-Müllerian hormone (AMH) and other endocrine parameters between patients diagnosed with polycystic ovary syndrome (PCOS) and age-matched ovulatory women. Materials and methods AMH, DHEAS, FSH, LH, PRL, TSH and total testosterone (TT) were prospectively measured in oligo-ovulatory PCOS patients (n = 595) and in ovulatory non-PCOS women (n = 157) referred to a tertiary infertility center. Mean BMI was similar across the two study populations and there were no smokers in the sample. Patients in both groups were further classified into three categories by age: < 25 yrs, 25-34 yrs, and ≥ 35 yrs. Selected clinical and demographic characteristics were tabulated for each group. Results Serum AMH was significantly higher among PCOS patients compared to non-PCOS controls in the non-stratified sample (7.54 ± 5.8 vs. 2.49 ± 2.0 ng/mL, respectively; p < 0.0001), while serum FSH, DHEAS, TSH and prolactin were similar for both groups (p > 0.05). As expected, mean (total) testosterone levels were notably different between PCOS vs. non-PCOS controls (0.84 ± 0.76 vs. 0.43 ± 0.38 ng/mL, respectively; p < 0.001), and mean AMH level was significantly lower in the oldest age category (> 35 yrs) compared to both younger control groups (p < 0.0001). Both DHEAS and total testosterone decreased with age among PCOS patients, although mean serum DHEAS for women age > 35 yrs was significantly lower than DHEAS measured in younger women with PCOS (p < 0.02). For PCOS patients, AMH remained relatively stable irrespective of age. Conclusion Although AMH can serve as a satisfactory marker of ovarian reserve, for PCOS patients the expected decline in AMH associated with reproductive aging appears attenuated despite ovarian senescence. In contrast, mean DHEAS levels were markedly lower among older PCOS women (> 35 yrs) compared to younger PCOS patients.
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Affiliation(s)
| | | | | | - Eric Scott Sills
- Center for Advanced Genetics, USA; University of Westminster, UK
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20
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Aiyappan SK, Karpagam B, Vadanika V, Chidambaram PK, Vinayagam S, Saravanan KC. Age-Related Normogram for Ovarian Antral Follicle Count in Women with Polycystic Ovary Syndrome and Comparison with Age Matched Controls Using Magnetic Resonance Imaging. J Clin Diagn Res 2016; 10:TC11-3. [PMID: 26894142 DOI: 10.7860/jcdr/2016/17334.7136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/08/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Antral Follicle count (AFC) is a reliable marker for ovarian reserve. Previous studies have used transvaginal ultrasound for estimation of AFC, however we used magnetic resonance imaging (MRI) for estimation of AFC and for creating an age-related normogram in patients with polycystic ovary syndrome (PCOS) and compared it with normal patients. AIM The aim of this study is to create an age related normogram for AFC in women with PCOS and to compare that with women without polycystic ovarian syndrome using MRI. MATERIALS AND METHODS A total of 1500 women were examined, out of which 400 fitted the criteria for PCOS. They all underwent MRI study and similar age matched women without PCOS also underwent MRI examination. Normogram for AFC were obtained using LMS software and a percentile chart was obtained. RESULTS Normogram for AFC in PCOS women showed decline in number of AFC as the age progresses and the decline was linear. The normogram for AFC was compared with equal number of patients without PCOS and they also showed decline in AFC as the age progresses, however the decline was exponential and faster. CONCLUSION Age related normogram for AFC is widely used and considered as best clinical predictor for ovarian response in assisted reproductive technology. Knowledge of ovarian reserve is important in PCOS and non-PCOS females as PCOS patients are at risk for ovarian hyperstimulation syndrome during gonadotrophin theraphy. MRI is an equally effective and in some times better alternative to transvaginal ultrasound as it has got its own advantages.
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Affiliation(s)
- Senthil Kumar Aiyappan
- Associate Professor, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre , SRM Nagar, Potheri, Kattankulathur, Kancheepuram, Tamilnadu, India
| | - Bulabai Karpagam
- Associate Professor, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre , SRM Nagar, Potheri, Kattankulathur, Kancheepuram, Tamilnadu, India
| | - V Vadanika
- Junior Resident, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre , SRM Nagar, Potheri, Kattankulathur, Kancheepuram, Tamilnadu, India
| | - Prem Kumar Chidambaram
- Assistant Professor, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre , SRM Nagar, Potheri, Kattankulathur, Kancheepuram, Tamilnadu, India
| | - S Vinayagam
- Professor, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre , SRM Nagar, Potheri, Kattankulathur, Kancheepuram, Tamilnadu, India
| | - K C Saravanan
- Professor, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre , SRM Nagar, Potheri, Kattankulathur, Kancheepuram, Tamilnadu, India
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Dumesic DA, Oberfield SE, Stener-Victorin E, Marshall JC, Laven JS, Legro RS. Scientific Statement on the Diagnostic Criteria, Epidemiology, Pathophysiology, and Molecular Genetics of Polycystic Ovary Syndrome. Endocr Rev 2015; 36:487-525. [PMID: 26426951 PMCID: PMC4591526 DOI: 10.1210/er.2015-1018] [Citation(s) in RCA: 565] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a heterogeneous and complex disorder that has both adverse reproductive and metabolic implications for affected women. However, there is generally poor understanding of its etiology. Varying expert-based diagnostic criteria utilize some combination of oligo-ovulation, hyperandrogenism, and the presence of polycystic ovaries. Criteria that require hyperandrogenism tend to identify a more severe reproductive and metabolic phenotype. The phenotype can vary by race and ethnicity, is difficult to define in the perimenarchal and perimenopausal period, and is exacerbated by obesity. The pathophysiology involves abnormal gonadotropin secretion from a reduced hypothalamic feedback response to circulating sex steroids, altered ovarian morphology and functional changes, and disordered insulin action in a variety of target tissues. PCOS clusters in families and both female and male relatives can show stigmata of the syndrome, including metabolic abnormalities. Genome-wide association studies have identified a number of candidate regions, although their role in contributing to PCOS is still largely unknown.
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Affiliation(s)
- Daniel A Dumesic
- Department of Obstetrics and Gynecology (D.A.D.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Pediatric Endocrinology (S.E.O.), Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032; Department of Physiology (E.S.-V.), Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Research in Reproduction and Division of Endocrinology (J.C.M.), Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903; Division of Reproductive Medicine (J.S.L.), Department of Obstetrics and Gynecology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033
| | - Sharon E Oberfield
- Department of Obstetrics and Gynecology (D.A.D.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Pediatric Endocrinology (S.E.O.), Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032; Department of Physiology (E.S.-V.), Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Research in Reproduction and Division of Endocrinology (J.C.M.), Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903; Division of Reproductive Medicine (J.S.L.), Department of Obstetrics and Gynecology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033
| | - Elisabet Stener-Victorin
- Department of Obstetrics and Gynecology (D.A.D.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Pediatric Endocrinology (S.E.O.), Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032; Department of Physiology (E.S.-V.), Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Research in Reproduction and Division of Endocrinology (J.C.M.), Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903; Division of Reproductive Medicine (J.S.L.), Department of Obstetrics and Gynecology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033
| | - John C Marshall
- Department of Obstetrics and Gynecology (D.A.D.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Pediatric Endocrinology (S.E.O.), Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032; Department of Physiology (E.S.-V.), Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Research in Reproduction and Division of Endocrinology (J.C.M.), Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903; Division of Reproductive Medicine (J.S.L.), Department of Obstetrics and Gynecology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033
| | - Joop S Laven
- Department of Obstetrics and Gynecology (D.A.D.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Pediatric Endocrinology (S.E.O.), Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032; Department of Physiology (E.S.-V.), Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Research in Reproduction and Division of Endocrinology (J.C.M.), Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903; Division of Reproductive Medicine (J.S.L.), Department of Obstetrics and Gynecology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033
| | - Richard S Legro
- Department of Obstetrics and Gynecology (D.A.D.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Pediatric Endocrinology (S.E.O.), Children's Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032; Department of Physiology (E.S.-V.), Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Research in Reproduction and Division of Endocrinology (J.C.M.), Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903; Division of Reproductive Medicine (J.S.L.), Department of Obstetrics and Gynecology, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033
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22
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Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril 2015; 103:e44-50. [PMID: 25936238 DOI: 10.1016/j.fertnstert.2015.03.019] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/16/2015] [Indexed: 11/26/2022]
Abstract
Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all relevant factors with initial emphasis on the least invasive methods for detection of the most common causes of infertility. The purpose of this committee opinion is to provide a critical review of the current methods and procedures for the evaluation of the infertile female, and it replaces the document of the same name, last published in 2012 (Fertil Steril 2012;98:302–7).
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Hagen CP, Mouritsen A, Mieritz MG, Tinggaard J, Wohlfart-Veje C, Fallentin E, Brocks V, Sundberg K, Jensen LN, Anderson RA, Juul A, Main KM. Circulating AMH reflects ovarian morphology by magnetic resonance imaging and 3D ultrasound in 121 healthy girls. J Clin Endocrinol Metab 2015; 100:880-90. [PMID: 25485726 DOI: 10.1210/jc.2014-3336] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CONTEXT In adult women, Anti-Müllerian hormone (AMH) is produced by small growing follicles, and circulating levels of AMH reflect the number of antral follicles as well as primordial follicles. Whether AMH reflects follicle numbers in healthy girls remains to be elucidated. OBJECTIVE This study aimed to evaluate whether serum levels of AMH reflects ovarian morphology in healthy girls. DESIGN AND SETTING This was a population-based cohort study involving the general community. PARTICIPANTS Included in the study were 121 healthy girls 9.8-14.7 years of age. MAIN OUTCOME MEASURES Clinical examination, including pubertal breast stage (Tanner's classification B1-5), ovarian volume, as well as the number and size of antral follicles were assessed by two independent modalities: magnetic resonance imaging (MRI), Ellipsoid volume, follicles ≥2 mm; and Transabdominal ultrasound, Ellipsoid and 3D volume, follicles ≥1 mm. Circulating levels of AMH, inhibin B, estradiol, FSH, and LH were assessed by immunoassays; T and androstenedione were assessed by liquid chromatography-tandem mass spectrometry. RESULTS AMH reflected the number of small (MRI 2-3 mm) and medium (4-6 mm) follicles (Pearson's Rho [r] = 0.531 and r = 0.512, P < .001) but not large follicles (≥7 mm) (r = 0.109, P = .323). In multiple regression analysis, small and medium follicles (MRI ≤ 6 mm) remained the main contributors to circulating AMH (β, 0.501; P < .001) whereas the correlation between AMH and estradiol was negative (β, -0.318; P = .005). In early puberty (B1-B3), the number of AMH-producing follicles (2-6 mm) correlated positively with pubertal stages (r = 0.453, P = .001), whereas AMH levels were unaffected (-0.183, P = .118). CONCLUSIONS Similarly to adult women, small and medium antral follicles (≤6 mm) were the main contributors to circulating levels of AMH in girls.
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Affiliation(s)
- Casper P Hagen
- Department of Growth and Reproduction (C.P.H., A.M., M.G.M., J.T., C.W.-V., A.J., K.M.M.), Department of Radiology, (E.F.), Department of Fetal Medicine and Ultrasound (V.B., K.S., L.N.J.), Rigshospitalet Faculty of Health and Medical Sciences, University of Copenhagen, DK-2100 Copenhagen, Denmark; and Medical Research Council Centre for Reproductive Health (R.A.A.), University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
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Ultrasound features of polycystic ovaries relate to degree of reproductive and metabolic disturbance in polycystic ovary syndrome. Fertil Steril 2015; 103:787-94. [DOI: 10.1016/j.fertnstert.2014.12.094] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 11/12/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022]
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25
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Leonhardt H, Hellström M, Gull B, Lind AK, Nilsson L, Janson PO, Stener-Victorin E. Serum anti-Müllerian hormone and ovarian morphology assessed by magnetic resonance imaging in response to acupuncture and exercise in women with polycystic ovary syndrome: secondary analyses of a randomized controlled trial. Acta Obstet Gynecol Scand 2015; 94:279-87. [DOI: 10.1111/aogs.12571] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 12/18/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Henrik Leonhardt
- Department of Radiology; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg Sweden
| | - Mikael Hellström
- Department of Radiology; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg Sweden
| | - Berit Gull
- Department of Obstetrics and Gynecology; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg Sweden
| | - Anna-Karin Lind
- Department of Obstetrics and Gynecology; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg Sweden
| | - Lars Nilsson
- Department of Obstetrics and Gynecology; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg Sweden
| | - Per Olof Janson
- Department of Obstetrics and Gynecology; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg Sweden
| | - Elisabet Stener-Victorin
- Department of Physiology; Institute of Neuroscience and Physiology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm Sweden
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26
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Iliodromiti S, Anderson RA, Nelson SM. Technical and performance characteristics of anti-Müllerian hormone and antral follicle count as biomarkers of ovarian response. Hum Reprod Update 2014; 21:698-710. [PMID: 25489055 DOI: 10.1093/humupd/dmu062] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 11/07/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Stratified (individualized) medicine has been recognized as a key priority for policy makers and healthcare providers. The main principle of individualized care depends on utilizing patients' characteristics and biomarkers to predict prognosis, tailor intended treatment and predict treatment outcomes. In reproductive medicine a wide variety of biomarkers have been proposed as predictors of ovarian response; of these, anti-Müllerian hormone (AMH) and antral follicle count (AFC) are purported as exhibiting the most favourable analytical and performance characteristics. Previously AFC and AMH have been considered essentially interchangeable; however, recent trial data have questioned this postulation. The aim of this review is to present an analysis of the strengths and weaknesses of these biomarkers as predictors of ovarian response, using both physiological and technical perspectives. METHODS We have conducted a systematic search of the most recent (to May 2014) relevant literature and summarized the existing evidence. Articles written in a language other than English without an available English translation were excluded. RESULTS Both AMH values and AFC can be influenced by comparable technical, physiological and exogenous factors. AMH displays some variation within and between cycles, consistent with its physiological role in follicle development, and there are growing data on the impact of pharmacological treatments and pathological conditions but cycle-independent measurement is appropriate for clinical purposes. A range of issues with manual AMH assays may be resolving with the development of fully automated assays. Despite described standardization of its measurement technique, AFC is subject to marked inter- and intra-operator variability and the effects of external influences are likely to be comparable. Outwith some highly specialist centres, the intracyclic variation in AFC requires its measurement between Day 2 and 4 of the cycle. Observational studies suggest comparable performance characteristics for AMH and AFC in predicting poor and high ovarian response, but recent RCTs suggest markedly better performance for AMH. CONCLUSIONS The performance characteristics of both AMH and AFC for the prediction of ovarian response to exogenous gonadotrophins have been inflated by single site observational cohorts, resulting in the viewpoint that AMH and AFC exhibit equivalent performance characteristics. Large scale multicentre RCTs, with centralized assay performance, have demonstrated that AMH is substantially the more accurate and robust biomarker, probably reflecting difficulties with standardization of AFC determination. While AFC retains some advantages, particularly immediacy and accessibility, international standardization of AMH combined with a stable automated assay is likely to enhance its performance as the biomarker of choice in predicting the ovarian response in assisted conception.
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Affiliation(s)
| | - Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow G31 2ER, UK
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Cassar S, Teede HJ, Moran LJ, Joham AE, Harrison CL, Strauss BJ, Stepto NK. Polycystic ovary syndrome and anti-Müllerian hormone: role of insulin resistance, androgens, obesity and gonadotrophins. Clin Endocrinol (Oxf) 2014; 81:899-906. [PMID: 25040369 DOI: 10.1111/cen.12557] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/16/2014] [Accepted: 07/10/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is a complex endocrine disorder associated with insulin resistance, hyperandrogenism, obesity, altered gonadotrophin release and anovulatory infertility. Anti-Müllerian hormone (AMH) has been proposed as a marker of ovarian function and fertility. Across a cohort of lean and overweight women with and without PCOS, we investigated the association of AMH with insulin resistance and body composition using gold standard measures. A secondary aim was to examine whether AMH was useful to determine PCOS status. DESIGN Cross-sectional study. PATIENTS A total of 22 lean and 21 overweight women with PCOS and 19 lean and 16 overweight non-PCOS healthy controls were recruited. PCOS was diagnosed based on the Rotterdam criteria. MEASUREMENTS Euglycaemic-hyperinsulinaemic clamp for assessing insulin resistance, dual energy X-ray absorptiometry and computed tomography for assessing adiposity, and blood sampling for the assessment of androgens, gonadotrophins and AMH. RESULTS Anti-Müllerian hormone levels were increased in women with PCOS (P <0·001) regardless of adiposity, with this increase associated with testosterone (P <0·001) rather than insulin resistance (P = 0·79), adiposity (P = 0·98) or gonadotrophins. In assessing the ability of AMH to predict PCOS, a value of 30 pmol/l or higher indicated 79% of women with PCOS were correctly identified as having the condition. CONCLUSION Anti-Müllerian hormone appears primarily related to androgen status suggesting a direct and predominant role of androgens in the pathophysiology of reproductive dysfunction in PCOS. As AMH reflects PCOS status, it may also be useful in PCOS diagnosis.
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Affiliation(s)
- Samantha Cassar
- College of Sport and Exercise Science, Victoria University, Melbourne, Vic., Australia; Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Vic., Australia; Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
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