Changes in antimüllerian hormone levels in early pregnancy are associated with preterm birth

Association between maternal polycystic ovarian syndrome undergoing assisted reproductive technology and pregnancy complications and neonatal outcomes: a systematic review and meta-analysis

BACKGROUND

Polycystic ovarian syndrome (PCOS) is recognized as the most prevalent endocrine disorder among women of reproductive age. While the utilization of assisted reproductive technology (ART) has resulted in favorable outcomes for infertility treatment in PCOS patients, the inherent pathophysiological features of the condition give rise to complications and consequences during pregnancy and delivery for both the mother and offspring. This study was to assess the correlation between maternal PCOS and various pregnancy complications and neonatal outcomes undergone ART.

METHODS

A systematic search was conducted on PubMed, EmBase, and the Cochrane Library to identify observational studies that investigated the association between PCOS and the risk of various pregnancy complications and neonatal outcomes, including gestational diabetes mellitus (GDM), hypertension in pregnancy (PIH), preeclampsia (PE), preterm birth, abortion, congenital malformations (CA), small for gestational age (SGA), large for gestational age (LGA), low birth weight (LBW), macrosomia, neonatal intensive care unit (NICU) admission and birth weight. Eligible studies were selected based on predetermined inclusion and exclusion criteria. The meta-analysis was conducted using Review Manager and Stata software, with odds ratios (ORs) or mean difference (MD), confidence intervals (CIs), and heterogeneity (I2) being calculated. The search was conducted up to March 2023.

RESULTS

A total of 33 studies with a combined sample size of 92,810 participants were identified. The findings indicate that PCOS is significantly associated with an increased risk of GDM (OR 1.51, 95% CI:1.17-1.94), PIH (OR 1.72, 95% CI:1.25-2.39), PE (OR 2.12, 95% CI:1.49-3.02), preterm birth (OR 1.29, 95% CI:1.21-1.39), and LBW (OR 1.29, 95% CI:1.14-1.47). In subgroup analyses, the risks of GDM (OR 1.80, 95% CI:1.23-2.62) and abortion (OR 1.41, 95% CI:1.08-1.84) were elevated in fresh embryo transferred (ET) subgroup, whereas elevated risk of PE (OR 1.82, 95% CI:1.17-2.83) and preterm birth (OR 1.31, 95% CI:1.21-1.42) was identified in frozen ET subgroup. Whatever with or without hyperandrogenism, patients with PCOS had a higher risk in preterm birth (OR 1.69, 95% CI: 1.31-2.18; OR 1.24, 95% CI:1.02-1.50) and abortion (OR 1.38, 95% CI:1.12-1.71; OR 1.23, 95% CI:1.06-1.43).

CONCLUSION

Our findings suggest that individuals with PCOS undergone ART are at a notably elevated risk for experiencing pregnancy complications and unfavorable neonatal outcomes. Nevertheless, to establish a definitive association between PCOS and pregnancy-related outcomes, it is necessary to conduct extensive prospective, blinded cohort studies and effectively control for confounding variables.

Reference ranges of anti-Müllerian hormone and interaction with placental biomarkers in early pregnancy: the Generation R Study, a population-based prospective cohort study

Objective

The primary objective of this study is to establish maternal reference values of anti-Müllerian hormone (AMH) in a fertile multi-ethnic urban pregnant population and to evaluate the effect of gestational age. The secondary objective of this study is to explore the association between AMH and placental biomarkers.

Design

This study was embedded in the Generation R Study, an ongoing population-based prospective cohort study from early pregnancy onwards.

Setting

City of Rotterdam, the Netherlands, out of hospital setting.

Patients

In 5806 women, serum AMH levels were determined in early pregnancy (median 13.5 weeks; 95% range 10.5-17.2).

Intervention(s)

None.

Main outcome measures

Maternal AMH levels in early pregnancy and its association with placental biomarkers, including human chorionic gonadotrophin (hCG), soluble fms-like tyrosine kinase-1 (sFLT), and placental growth factor (PLGF).

Results

A nomogram of AMH in early pregnancy was developed. Serum AMH levels showed a decline with advancing gestational age. Higher AMH levels were associated with a higher level of the placental biomarkers hCG and sFLT in early pregnancy. This last association was predominantly mediated by hCG. AMH levels were negatively associated with PLGF levels.

Conclusion

In this large study, we show that AMH levels in early pregnancy decrease with advancing gestational age. The association between AMH and the placental biomarkers hCG, sFLT, and PLGF suggests a better placental development with lower vascular resistance in mothers with higher AMH levels. Hence, AMH might be useful in predicting adverse pregnancy outcomes due to impaired placental development.

Serum anti-müllerian hormone (AMH) concentration during pregnancy: a longitudinal study

A prospective longitudinal cohort study aimed to longitudinally examine the kinetics of Anti-müllerian hormone (AMH) during the first two trimesters of pregnancy. Pregnant women with stored 1st trimester serum samples were recruited at 24-28 weeks gestation during their gestational diabetes testing, where they provided an additional serum sample. The samples were analysed for AMH, oestradiol and progesterone concentrations. A decrease in serum AMH was observed in 40 out of 45 (88.9%) (95% CI 75.9% to 96.3%) of the participants in this study. The median serum AMH concentration was 10.9 pmol/L in the 1st trimester and 6.5 pmol/L during the 2nd trimester, with a significantly different distribution of the values between the 1st and the 2nd trimester AMH samples (p<0.001). The median percentage of AMH difference of -39.8%. This study demonstrated a significant decrease in serum AMH levels from the 1st to the 2nd trimester of pregnancy. The absolute decrease in AMH levels seems to be positively associated with 1st trimester AMH levels, whereas the percentage of AMH difference is not. Further studies are required to elucidate the potential physiological mechanisms of this finding.

Is There a Relationship between Serum Anti-Mullerian Hormone Levels and Abortion Rates in Patients Who Received In vitro Fertilisation-Embryo Transfer Cycles?

Background

The studies which investigated the relationship between anti-Mullerian hormone (AMH) level and abortion rate have conflicting results.

Aims

This retrospective study aimed to evaluate the relationship between AMH levels and abortion in women who achieved pregnancy with in vitro fertilisation (IVF) treatment.

Settings and Design

This retrospective study was conducted in the Department of Gynecology and Obstetrics, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, between January 2014 and January 2020.

Materials and Methods

Patients below 40 years of age who conceived after IVF-embryo transfer treatment during a 6-year period and had a serum AMH level measurement were included. The patients were divided into three groups according to the serum AMH levels as low AMH (L-AMH, ≤1.6 ng/mL), intermediate AMH (I-AMH, 1.61-5.6 ng/mL) and high AMH (H-AMH, >5.6 ng/mL). The groups were compared in terms of obstetric, treatment cycle characteristics and abortion rates.

Statistical Analysis Used

The Mann-Whitney U-test was used in comparison of non-parametric data of two groups; the Kruskal-Wallis test was used to compare the data of more than two groups. When a statistically significant difference was found in the Kruskal-Wallis test result, the groups were compared in pairs using the Mann-Whitney U-test, and the groups that made a statistical difference were determined. The Pearson's Chi-square and Fisher's exact tests were used to compare the independent categorical variables.

Results

L-AMH (n = 164), I-AMH (n = 153) and H-AMH (n = 59) groups were similar in terms of obstetric histories and number of cycles applied, with an abortion rate of 23.8%, 19.6% and 16.9%, respectively (P = 0.466). The same analyses were repeated in two subgroups under 34 years of age and above, and no difference was found in terms of miscarriage rates. The number of oocytes retrieved and the number of mature oocytes were higher in H-AMH group compared to intermediate and low groups.

Conclusion

No relationship was found between serum AMH level and abortion rate in women who achieved clinical pregnancy with IVF treatment.

The impact of low-dose aspirin on markers of inflammation and placental function: an ancillary study of the ASPIRIN trial

OBJECTIVE

To determine the impact of low-dose aspirin (81 mg) on markers of maternal inflammation and placental function.

SETTING

Rural Southern India.

POPULATION

Nulliparous women with a singleton pregnancy dated by ultrasound who were enrolled in the ASPIRIN (Aspirin Supplementation for Pregnancy Indicated risk Reduction In Nulliparas) Trial.

METHODS

We performed a case-control study to elucidate the impact of low dose aspirin (LDA) on markers of placental function and maternal inflammation among women who delivered prematurely compared to term controls in women enrolled in the ASPIRIN trial. Women were prospectively enrolled in an ancillary observational trial wherein maternal serum was collected and measured between 10 to 13 weeks and 17 to 21 weeks of gestation after initiation of aspirin or an identical placebo.

RESULTS

From 2016-18 with a total of 666 n women enrolled in this ancillary trial of whom 269 were selected for analyte analysis. Women who received LDA had lower levels of Alpha Feto-Protein (AFP) at 10 to 13 weeks than women who received placebo (Placebo) (LDA 18.3 ng/mL vs 21.4 ng/mL -P 0.001). AFP was similar between the two groups at 17 to 21 weeks. No other differences were seen in C-Reactive protein or Anti-Mullerian Hormone.

CONCLUSION

Low-dose aspirin administration lowers AFP early in pregnancy.

Is there a maternal blood biomarker that can predict spontaneous preterm birth prior to labour onset? A systematic review

Introduction

The ability to predict spontaneous preterm birth (sPTB) prior to labour onset is a challenge, and it is currently unclear which biomarker(s), may be potentially predictive of sPTB, and whether their predictive power has any utility. A systematic review was conducted to identify maternal blood biomarkers of sPTB.

Methods

This study was conducted according to PRISMA protocol for systematic reviews. Four databases (MEDLINE, EMBASE, CINAHL, Scopus) were searched up to September 2021 using search terms: “preterm labor”, “biomarker” and “blood OR serum OR plasma”. Studies assessing blood biomarkers prior to labour onset against the outcome sPTB were eligible for inclusion. Risk of bias was assessed based on the Newcastle Ottawa scale. Increased odds of sPTB associated with maternal blood biomarkers, as reported by odds ratios (OR), or predictive scores were synthesized. This review was not prospectively registered.

Results

Seventy-seven primary research articles met the inclusion criteria, reporting 278 unique markers significantly associated with and/or predictive of sPTB in at least one study. The most frequently investigated biomarkers were those measured during maternal serum screen tests for aneuploidy, or inflammatory cytokines, though no single biomarker was clearly predictive of sPTB based on the synthesized evidence. Immune and signaling pathways were enriched within the set of biomarkers and both at the level of protein and gene expression.

Conclusion

There is currently no known predictive biomarker for sPTB. Inflammatory and immune biomarkers show promise, but positive reporting bias limits the utility of results. The biomarkers identified may be more predictive in multi-marker models instead of as single predictors. Omics-style studies provide promising avenues for the identification of novel (and multiple) biomarkers. This will require larger studies with adequate power, with consideration of gestational age and the heterogeneity of sPTB to identify a set of biomarkers predictive of sPTB.

Expression of Anti-Müllerian Hormone and Its Type 2 Receptor in the Ovary of Pregnant and Cyclic Domestic Cats

To evaluate the expression of AMH and its receptor AMHRII, ovaries of 33 p cats were investigated by western blot and immunohistochemistry. After ovariohysterectomy, the cats were grouped according to pregnancy stages and ovarian/placental endocrine activity: group I (n = 3, 24−29 days), II (n = 8, 32−40 days), III (n = 4, 41−46 days), IV (n = 6, 53−61 days) and according to cycle stages: V (n = 6, interestrus) and VI (n = 6, estrus). Serum progesterone- and AMH-concentration was measured. Follicle numbers did not differ between groups. The number of corpora lutea was higher in pregnant cats than in the non-pregnant cats. Serum AMH concentration was at maximum between day 30 and 50 of gestation, and was higher than in non-pregnant cats, then decreased towards term (p < 0.05). In the ovaries, AMH immunopositivity was observed in granulosa cells of secondary and antral follicles, and in interstitial cells of corpora lutea; highest percentage of immunopositive areas was detected in group III (p < 0.05). A positive correlation between the number of corpora lutea and the positive AMH signals in ovarian tissue was determined (r2 = 0.832, p < 0.05); however, only during mid-gestation (group II). Expression of AMHRII was in close co-localization with AMH and strong in the interstitial cells surrounding follicles undergoing atresia. AMHRII expression did not differ between pregnant groups but was higher compared to estrus cats (p ˂ 0.05). We conclude that AMH and AMHRII expression in the feline ovary is comparable to other species. The high serum AMH concentration and ovarian AMHRII expression between day 30 and 50 of gestation are probably related to ovarian activity and follicular atresia.

Anti-Mullerian hormone levels in spontaneous pregnancies with hyperemesis gravidarum

We investigated the serum anti-Mullerian hormone (AMH), oestrogen and progesterone levels in spontaneously conceiving pregnant women, diagnosed for hyperemesis gravidarum (HG), in the first trimester. Pregnant women admitted at Hospital between 5 and 12 gestational weeks and treated for HG were compared, in this prospective case-control study, to a control group. The serum AMH, oestradiol, and progesterone values of both groups were evaluated and compared, and potential correlations were calculated. The serum AMH values were significantly higher in the HG group than the control group (3.15 ± 1.51 ng/mL vs. 2.27 ± 1.20 ng/mL; p = 0.012). No significant difference in the two groups was about serum oestradiol and progesterone values (p = 0.264, p = 0.235). In the HG group, there was no significant correlation between AMH and oestradiol (p = 0.570). However, a significant positive correlation was determined between AMH and progesterone (p = 0.050). The area under the ROC curve (AUC) was 0.669 and the cut-off value was 2.65 ng/ml with sensitivity of 58.3% and specificity of 66.7% for AMH in pregnant women with HG. A correlation between AMH high values and unexplained HG was detected in spontaneous pregnancies in the first trimester. High AMH levels may play a role in HG etiopathogenesis, especially in pregnant women with low progesterone levels.Impact statementWhat is already known on this subject? Aetiological causes of Hyperemesis gravidarum (HG) include hormonal, immunological, genetic, and psychological issues. However, no conclusive etiopathogenesis to explain the pathophysiological mechanism of HG has been stated.What do the results of this study add? Authors focussed on investigation a possible correlation between pregnant hormones and the HG pathogenesis, prevalent in the first trimester, when hormones are produced by either the placenta or corpus luteum. High anti-Mullerian hormone (AMH) levels may play a role in HG etiopathogenesis, especially in pregnant women with low progesterone levels.What are the implications of these findings for clinical practice and/or further research? A serum AMH level of ≥2.65 mg/mL could be predictive for the development of HG in the first trimester of a spontaneous pregnancy. Basing on these findings, more selective pharmacological treatments could be administrated to these patients.

OUP accepted manuscript

STUDY QUESTION

Is the presence of polycystic ovary syndrome (PCOS) associated with more adverse infant outcomes in mothers with different types of diabetes?

SUMMARY ANSWER

The presence of PCOS implies higher risks of total (medically indicated and spontaneously combined) and spontaneous preterm birth in mothers with non-insulin-treated type 2 diabetes and gestational diabetes mellitus (GDM), and lower risk of offspring being large for gestational age (LGA) in mothers with insulin-treated diabetes.

WHAT IS KNOWN ALREADY

PCOS is suggested to be an independent risk factor for adverse infant outcomes, and it is highly prevalent in mothers with diabetes. However, the impact of PCOS on the associations of different types of maternal diabetes with preterm birth and offspring birth sizes has not been reported.

STUDY DESIGN, SIZE, DURATION

This is a population-based cohort study including all live births between 1996 and 2014 in Finland. Children with concurrent maternal diagnoses that could cause signs and symptoms similar to PCOS were excluded. A total of 1 097 753 children were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

National registries were linked to identify births with maternal PCOS (n = 24 682), stratified by diabetes types. Logistic regression was used to examine the association of maternal PCOS and comorbid insulin-treated diabetes, non-insulin-treated type 2 diabetes or GDM with offspring LGA and small for gestational age (SGA). Generalized estimating equation was used to assess the risk of preterm birth in relation to maternal PCOS and diabetes. Potential interaction between PCOS and diabetes was evaluated on both additive and multiplicative scales.

MAIN RESULTS AND THE ROLE OF CHANCE

Using mothers with no PCOS and no diabetes as the reference and adjusting for maternal and birth factors, there were higher risks of total (odds ratio (OR) 2.84, 95% CI 2.21 − 3.66 vs. OR 1.91, 95% CI 1.77 − 2.07, P = 0.01) and spontaneous (OR 4.02, 95% CI 2.94 − 5.50 vs. OR 2.35, 95% CI 2.13 − 2.59, P = 0.001) preterm birth for those with PCOS in mothers with non-insulin-treated type 2 diabetes and higher risks of total (OR 1.42, 95% CI 1.27–1.58 vs. OR 0.89, 95% CI 0.86–0.91, P = 0.0001) and spontaneous (OR 1.80, 95% CI 1.59–2.05 vs. OR 1.01, 95% CI 0.98–1.05, P = 0.0001) preterm birth for those with PCOS in mothers with GDM. Among mothers with type 2 diabetes, further adjusting for maternal BMI eliminated the difference in preterm birth risks between those with and those without PCOS, and adjustment for infertility treatment and pre-eclampsia also reduced the preterm risks associated with PCOS significantly. For mothers with GDM, however, the risks of total and spontaneous preterm birth remained higher for those with PCOS following these aforementioned adjustments or stratified analysis. The risk of offspring being LGA was lower for those with PCOS than those without PCOS among mothers with insulin-treated diabetes (OR 18.90, 95% CI 14.21–25.14 vs. OR 32.04, 95% CI 29.79–34.46, P = 0.0001), showing departure from additivity (relative excess risk due to interaction −11.74, 95% CI −16.17 to −7.31, P < 0.001) and multiplicativity (P < 0.001). PCOS did not alter the risk estimate of preterm birth in mothers with insulin-treated diabetes or offspring LGA and SGA in mothers with type 2 diabetes or GDM.

LIMITATIONS, REASONS FOR CAUTION

The register-based diagnoses used in this study captured only women with PCOS seeking medical care and having live births. Including female infertility associated with anovulation as PCOS exposure was a risk for misclassification. Sample sizes for pregestational diabetes were small. Insulin purchase during pregnancy in those without a diabetes diagnosis was not accounted for in the analysis. For patients treated with insulin or other medications, we were unable to assess how they complied with such prescriptions. Also, maternal BMI was recorded only once in early pregnancy, thus the potential influence of gestational weight gain on birth outcomes could not be examined. Data on the causes for preterm birth were not available from the registers.

WIDER IMPLICATIONS OF THE FINDINGS

The presence of PCOS implied higher risks of total and spontaneous preterm birth in mothers with type 2 diabetes or GDM, and lower risk of offspring being LGA in mothers with insulin-treated diabetes. The higher risks of preterm birth added by PCOS could be explained by prepregnancy BMI or in part by infertility treatment and pre-eclampsia in maternal non-insulin-treated type 2 diabetes, but not in maternal GDM. The differential effects of PCOS on the associations of different types of maternal diabetes with infant outcomes have implications for preventative strategies and clinical counseling for affected pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Shandong Provincial Natural Science Foundation, China (ZR2020MH064 to X.C.), Shandong Province Medical and Health Technology Development Plan (2018WS338 to X.C.), the joint research funding of Shandong University and Karolinska Institute (SDU-KI-2019-08 to X.C. and C.L.), the Finnish National Institute for Health and Welfare: Drug and pregnancy project (M.G.), the Swedish Research Council (2014-10171 to C.L.), the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institute Stockholm County Council (SLL20170292 and SLL20190589 to C.L.), the Swedish Brain Foundation (FO2019-0201 and FO2020-0305 to C.L.). X.C. received grants from the China Scholarship Council at the beginning of the study. The authors have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.

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

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

The Influence of Cesarean Delivery on Ovarian Reserve: a Prospective Cohort Study

To assess the association between cesarean delivery and ovarian reserve, as compared to vaginal delivery. A prospective case control study conducted at a single tertiary medical center between June 2018 and June 2019. Study population included women with singleton pregnancy that underwent first cesarean delivery that were compared to women undergoing normal vaginal delivery. Women with low ovarian reserve, endometriosis, previous pelvic surgery, chronic maternal disease, and active labor were excluded. Ovarian reserve was estimated by Anti-Mullerian hormone (AMH) levels that was determined twice for each participant: up to a week before and 3 months after delivery. Primary outcome was defined as the delta in AMH levels. Data were analyzed by non-parametric tests. During the study period, 135 women were enrolled, of them 63 (47%) underwent cesarean delivery and 72 (53%) had vaginal delivery. Women in the cesarean delivery group were older (34 (31-38) vs. 32 (29-35); p = 0.001); nevertheless, AMH levels measured before delivery were comparable between the two groups (0.92 (0.51-1.79) vs. 0.95 (0.51-1.79) pg/mL; p = 0.42). AMH levels measured after delivery were more than doubled in the study and control groups (2.15 (1.24-3.05) vs. 2.62 (1.05-5.09); p = 0.50), and delta AMH levels were also found comparable (1.25 (0.61-2.22) vs. 1.59 (0.63-3.41), respectively; p = 0.43). Linear regression analysis including age, mode of delivery, gestational age at delivery, and delta hemoglobin levels revealed that only maternal age was significantly associated with delta in AMH levels (B =  - 0.09, p = 0.04). Cesarean delivery does not decrease ovarian reserve as estimated by AMH.

Clinical Applications of Serum Anti-Müllerian Hormone Measurements in Both Males and Females: An Update

Infertility is one of the most common non-communicable diseases, affecting both men and women equally. Ovarian reserve, the number of primordial follicles in the ovaries is believed to be the most important determinants for female fertility. Anti-Müllerian hormone (AMH) secreted from granulosa cells of growing follicles is recognized as the most important biomarker for ovarian reserve. Ovarian reserve models have been developed using AMH and other hormonal indicators, thus childbearing plans and reproductive choices could be arranged by women. In assisted reproductive technology cycles, measurement of AMH helps to predict ovarian response and guide recombinant follicle-stimulating hormone dosing in women. Serum AMH level is increasingly being recognized as a potential surrogate marker for polycystic ovarian morphology, one of the criteria for diagnosis of polycystic ovarian syndrome. AMH is also secreted by Sertoli cells of testes in men, and AMH measurements in the prediction of surgical sperm recovery rate in men have also been investigated. AMH levels are significantly higher in boys than in girls before puberty. Therefore, serum levels of AMH in combination with testosterone is used for the differential diagnosis of disorders of sex development, anorchia, non-obstructive azoospermia, and persistent Müllerian duct syndrome. Recently, serum AMH measurements have also been used in fertility preservation programs in oncofertility, screening for granulosa cell tumors, and prediction of menopause applications. In this review, we will focus on clinical application of AMH in fertility assessments for healthy men and women, as well as for cancer patients.

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Anti-Müllerian hormone (AMH) plays a key role in models assessing ovarian reserve

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AMH is used for the differential diagnosis of disorders of sex development

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AMH provides a molecular marker for related fertility and infertility disorders

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An international standard will aid in the development of various AMH assays

Serum anti-Müllerian hormone levels in women are unstable in the postpartum period but return to normal within 5 months: a longitudinal study

PURPOSE

Anti-Müllerian hormone (AMH) levels fall during pregnancy but the amount of time required for AMH levels to return to normal has not been accurately determined. We have previously shown that AMH levels have yet to return to normal in some women at 3-months postpartum. In this study, AMH levels were examined at 1- and 5-months postpartum to examine whether AMH levels had returned to normal within this interval.

METHODS

Longitudinal study involving 38 pregnant women, with serum samples taken in the first trimester, third trimester, 1-month postpartum, 5-months postpartum and 4-6 years postpartum. Participants were recruited from a tertiary maternity clinic (single centre). All women in the study were intending to breastfeed exclusively for at least 5 months, with all 38 participants achieving this at 1-month postpartum and 36/38 after 5 months.

RESULTS

Serum AMH concentrations had not returned to expected non-pregnant levels by 1-month postpartum. At 5-months postpartum, mean AMH concentrations were similar to expected non-pregnant levels but the rank order of AMH concentrations was still dissimilar to the non-pregnant state.

CONCLUSIONS

The regulation of AMH secretion appears to be distinctly different in non-pregnant, pregnant and postpartum populations. This may affect the conclusions that can be drawn from AMH measurements in women during pregnancy and the postpartum period.

The anti-Mullerian hormone as a predictor of early pregnancy loss in subfertile women

The aim of this study was to evaluate the predictive value of the anti-Mullerian hormone (AMH) level for early pregnancy loss and to compare the significance of AMH level to age as prognostic factors of pregnancy loss in subfertile women. The outcome of 848 subfertile patients confirmed with intrauterine pregnancies by ultrasound within 1 year of measuring serum AMH level were retrospectively analyzed. Among 848 patients, 206 women were diagnosed with early pregnancy loss. The mean age of the 848 patients was 35.66 ± 3.61 years (range: 26-46 years), and the mean AMH level was 2.95 ± 1.89 (range: 0.14-8.82 ng/mL). There were no significant differences in gravidity, parity, body mass index (BMI), and previous abortion history depending on early pregnancy loss. However, multivariable logistic regression analysis confirmed that the probability of early pregnancy loss is significantly affected by age (odd ratio, 1.079: 1.025-1.135, P = 0.004) and AMH (odd ratio, 0.885: 0.797-0.982, p = 0.022). According to this study, AMH level and age are both powerful predictors of early pregnancy loss. While chronological age is already well known as a factor related to early pregnancy loss, AMH was also considered when individualizing risk prediction for early pregnancy loss.

Highly elevated level of antimüllerian hormone associated with preterm delivery in polycystic ovary syndrome patients who underwent ovulation induction

OBJECTIVE

To determine the relationship between high antimüllerian hormone (AMH) levels and increased preterm delivery risk in populations of women with polycystic ovary syndrome (PCOS) or unexplained infertility undergoing ovulation induction.

DESIGN

Secondary analysis of data from two multicenter randomized clinical trials: Pregnancy in Polycystic Ovary Syndrome II (PPCOS II); and Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS).

SETTING

Not applicable.

PATIENTS

Live births at ≥24 weeks' gestation from both the PPCOS II (n = 172) and AMIGOS (n = 222) cohorts were evaluated, and those at risk for iatrogenic preterm delivery including placental conditions, fetal growth restriction, multiple gestations, hypertensive diseases of pregnancy, and pre-gestational diabetes were excluded. The final analysis included 118 women with PCOS from the PPCOS II cohort and 146 women with unexplained infertility from the AMIGOS cohort.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Spontaneous preterm delivery.

RESULTS

In the PCOS population, median AMH overall was 5.5 ng/dL (interquartile range 2.9-9.3 ng/dL). In all, 62% of participants who delivered preterm had AMH levels above the 75th percentile. When comparing clinical covariates between the preterm and term deliveries, women with PCOS who delivered preterm had notably higher AMH than their term counterparts (11.1 vs. 5.4 ng/mL). In the univariate logistic regression analysis, each unit increase in AMH raised the odds of preterm delivery by 14% (odds ratio 1.14, 95% confidence interval 1.02-1.26). The effect was magnified only after adjusting for age, race, body mass index, smoking status, testosterone, homeostatic model assessment for insulin resistance, and treatment randomization group (adjusted odds ratio 1.25, 95% confidence interval 1.06-1.49). Unlike in the PCOS population, the unexplained infertility cohort had no significant difference in AMH levels between those with or without preterm delivery (2.3 vs. 2.6 ng/mL).

CONCLUSIONS

Our findings suggest that women with PCOS and high AMH who conceived after ovulation induction represent a high-risk group for preterm delivery. These data indicate that closer monitoring in the third trimester of pregnancies in PCOS patients with early first trimester AMH levels above 9.3 ng/mL may be warranted.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01044862.

Anti-Müllerian hormone in dogs and cats reproduction

The anti-Müllerian hormone (AMH) is a glycoprotein secreted by Sertoli cells in males and granulosa cells in females. It has first been determined in blood serum of dogs and cats by Place et al. in 2011 with the use of a human-based ELISA test. Meanwhile, different immunoassays have been validated for AMH determination in animals and a variety of studies have demonstrated the clinical significance of AMH. This review summarizes the current knowledge about AMH in dogs and cats and describes future opportunities for its diagnostic use.

Can delivery mode influence future ovarian reserve? Anti-Mullerian hormone levels and antral follicle count following cesarean section: a prospective cohort study

Background

The incidence of Cesarean has increased in recent years. The purpose of this study is to evaluate the effect of cesarean section on ovarian reserve.

This is a prospective cohort study from January 2016 to November 2017. Inclusion criteria included singleton primigravid pregnant women whose gestational age was above 37 weeks. Exclusion criteria included history of infertility, pelvic surgery, underlying chronic diseases, any adverse pregnancy outcome and postpartum complication in current pregnancy and hormonal medication within six months of delivery. Anti-Mullerian hormone was measured at the admission time for delivery. The type of delivery was determined based on obstetrics indications. Six months after delivery, antral follicle count was performed and anti-Mullerian hormone was measured again.

Result(s)

First blood sample was taken from 730 women. After excluding 550 women, the second blood sample was taken from 180 participants. The mean of first anti-Mullerian hormone in women with cesarean and vaginal delivery were 1.01 ng/mL (95% CI 0.82 to 1.18) and 1.18 ng/mL (95% CI 0.96 to 1.40) respectively (P = 0.211). The mean of second anti-Mullerian hormone in women with cesarean and vaginal delivery were 4.77 ng/mL (95% CI:3.91 to 5.63) and 4.92 ng/mL (95% CI: 4.01 to 5.82) respectively (P = 0.818). No statistically significant difference existed in total AFC between cesarean and vaginal delivery groups (MD: 0.41, 95% CI: − 1.05 to 1.89, P = 0.576).

Conclusion

Antral follicle count and anti-Mullerian hormone, six month after delivery, are not affected by delivery mode even after adjusting for women’s age, baseline Anti-Mullerian hormone, body mass index, gestational age at delivery, breastfeeding, postpartum menstruation, neonatal sex and weight. Based on our best knowledge, this is the first report that investigates the effects of delivery mode on ovarian reserve. Decreased fertility following cesarean has been shown in some previous studies but most of them had assessed this association based on the incidence of subsequent pregnancy. Since subsequent pregnancy can be influenced by several confounding factors, we investigated the effect of cesarean on fertility using its impact on anti-Mullerian hormone levels and antral follicle count. We hope that this study will be a beginning of more detailed studies in this field. We believe that this link is yet to be studied.

Effect of folic acid supplementation on preterm delivery and small for gestational age births: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of folic acid (FA) supplementation on the risks of preterm delivery (PTD) and small for gestational age births (SGA).

DATA SOURCES

Cohort studies were identified from MEDLINE, EMBASE, the Cochrane Library, CINAHL, and CBM from inception to January 2015.

PARTICIPANTS AND INCLUDED STUDIES

Healthy women who want to get pregnancy or being pregnant.

MAIN OUTCOME MEASURES

PTD and SGA.

RESULTS

The association of FA and PTD was significant when supplement initiated after pregnancy (RR=0.68, 95%CI, 0.52-0.90), whereas no effect was founded if the initiation time was before conception (RR=0.89, 95%CI, 0.80-1.01). The results for the association between FA supplementation and SGA showed significant protective effect: initiated before conception (RR=0.70, 95%CI, 0.57-0.85) and initiated after conception (RR=0.84, 95%CI, 0.81-0.89).

CONCLUSION

Folic acid supplementation is associated with a significant reduction on the risk of PTD when initiated after conception. It can also protect fetus from SGA.