Anti-mullerian hormone: clinical relevance in assisted reproductive therapy

Serum levels of anti-Müllerian hormone influence pregnancy outcomes associated with gonadotropin-releasing hormone antagonist treatment: a retrospective cohort study

As a specific predictor of ovarian reserve, serum anti-Müllerian hormone (AMH) has become an area of intense research interest in the field of assisted reproductive technology. We assessed the relationship between AMH levels and pregnancy outcomes in Chinese patients and investigate the influencing factors of cumulative live birth in patients with high AMH levels. A total of 1379 patients starting their IVF/ICSI cycle were divided into normal (Group A, 1.1-4.0 ng/ml, n = 639) and high (Group B, > 4.0 ng/ml, n = 740) groups by serum AMH levels. Live birth rate (LBR), cumulative live birth rate (CLBR) and cumulative clinical pregnancy rate (CCPR) were also investigated. Compared with Group A, Group B had a significantly higher CLBR (65.80% vs. 43.95%) and CCPR (76.77% vs. 57.14%), respectively. Binomial logistic regression analysis showed that age over 40 years, LH/FSH > 2.5, total Gn dose and Gn duration, and greater than 4000 ng/ml serum E2 levels on HCG day were significantly associated with CLBR in Group B. The AUC value of CLBR averaged 0.664 (ranging from 0.621 to 0.706) (p < 0.001). The patients with high AMH levels had higher CPR, higher LBR, and lower MR with no statistically significant differences, although there were significant improvements in CLBR. Advanced age (> 40 years) still impacted CLBR, even in women with good ovarian reserves. Consequently, it is still recommended that patients over 40 years old with high AMH levels actively receive IVF treatment if they seek to become pregnant. PCOS diagnoses did not influence the CLBR. In summary, this study showed that serum AMH levels could positively predict patient ovarian responses and further affect pregnancy outcomes.

Predictive value of anti-Müllerian hormone on pregnancy outcomes in in-vitro fertilization/intracytoplasmic single sperm injection patients at different ages

PURPOSE

To investigate the predictive value of AMH level for pregnancy outcomes in different age groups of IVF/ICSI patients.

METHODS

The study was a cohort study that included 11,484 patients that had their first IVF/ICSI procedure between 2016 and 2019. All patients who met the inclusion and exclusion criteria were divided into 6 groups according to 5-year age intervals, namely, Group 1: 20-24 years (n = 725); Group 2: 25-29 years (n = 4019); Group 3: 30-34 years (n = 3600); Group 4: 35-39 years (n = 1915); Group 5: 40-44 years (n = 1006); and Group 6: ≥ 45 years (n = 219).

RESULTS

Receiver operating characteristic (ROC) curve analysis revealed that AMH level could only predict the outcome of live birth in Group 3 and Group 4 (p < 0.05). The area under the curve (AUC) of Group 3 was 0.536 (95% CI 0.510-0.561, p = 0.006), and that of Group 4 was 0.562 (95% CI 0.527-0.598, p = 0.001). The cutoff values of AMH for predicting live birth in Group 3 and Group 4 were 1.84 ng/ml and 1.86 ng/ml, respectively. Further logistic regression analysis showed that only the cutoff values of AMH and age could predict live birth in Groups 3 and 4.

CONCLUSIONS

AMH level could predict live birth in IVF/ICSI patients at the age of 30-39. However, it could not be used to predict live birth in patients < 30 years or ≥ 40 years.

Are ovarian reserve tests reliable in predicting ovarian response? Results from a prospective, cross-sectional, single-center analysis

OBJETIVE

Several biomarkers of ovarian reserve have been proposed as possible predictors of the response to controlled ovarian stimulation (COS). We aimed to evaluate age, FSH, AMH, antral follicle count (AFC), and ovarian response prediction index (ORPI), as potential predictors of response to COS.

METHODS

Cross-sectional study enrolling of 188 infertile women who underwent the first cycle of IVF/ICSI. AFC was evaluated; serum FSH and AMH levels were measured by ELISA. ORPI was calculated as AMH x AFC/patient´s age.

RESULTS

As expected, hypo-responder group had less retrieved oocytes, MII, and embryos compared to the good responders. The hyper-response patients were younger, with lower FSH, increased AMH, AFC, and ORPI values. Regarding the assessment of the predictive capacity of ovarian reserve tests, none of them individually or combined showed a good predictive capacity for hypo-response. With respect to the hyper-responder group, individually AMH was the best predictor, while in the multivariable model, ORPI demonstrated the best predictive capacity. Furthermore, patients with serum AMH < 2.09 ng/mL (p25) had fewer AFC than patients with higher AMH values.

CONCLUSIONS

Our findings suggest that none of the ovarian reserve tests showed a good predictive capacity for hypo-response, while the ORPI was the strongest predictor of hyper-response in normovulatory infertile women.

Are age and anti-Müllerian hormone good predictors of ovarian reserve and response in women undergoing IVF?

Objective

Ovarian reserve evaluation has been the focus of substantial clinical research for several years. This study aimed to examine the associations between markers of ovarian reserve and ovarian response.

Methods

This prospective study included 132 infertile women aged 24-48 years undergoing routine exploration during unstimulated cycles prior to the start of assisted reproductive technology (ART) treatments at our center from July 2015 to January 2017. Descriptive parameters and patient characteristics were reported as mean (SD) or median (range) values depending on the data distribution pattern. Student’s t-test was performed for continuous variables; the Wilcoxon and Pearson’s test were used for data not following a normal distribution; and Fisher’s test was used for categorical variables. p<0.05 was considered statistically significant.

Results

At the time of the study, the patients had a mean age of 35.7±3.84 years. On day 3 of the cycle, the mean anti-Müllerian hormone (AMH) serum level was 2.84±1.57 ng/mL and the patients had 14.68±4.2 antral follicles (AFC). A significant correlation was observed between AMH and age (r=-0.34 p<.01), follicle stimulating hormone (FSH) serum levels (r=-0.32, p<.01), AFC (r=0.81, p<.00001), total dose of medication during ovarian stimulation (r=-0.28, p<.0003), and ongoing pregnancy rate (p<.05). Age was significantly correlated with FSH (r=0.46, p<.01), AFC (r=-0.34, p<.00001), total dose of medication during ovarian stimulation (r=0.43, p<.0003), and ongoing pregnancy rate (p<.04).

Conclusion

Serum AMH and age are independent predictors of ovarian reserve and ovarian stimulation outcome in infertile women. Age and serum AMH level may be used to advise subfertile couples of their pregnancy prospects.

"Anti-Mullerian Hormone: Marker for Ovarian Response in Controlled Ovarian Stimulation for IVF Patients": A First Pilot Study in the Indian Population

OBJECTIVE

To measure the levels of early follicular phase Anti-Mullerian hormone (AMH) in Indian patients of IVF and to evaluate the AMH as a predictive marker of ovarian response in assisted reproductive technology outcome.

METHODS

Sixty women (age 25-40 years) selected for in vitro fertilization treatment were included in this study. Analysis of day-2 serum samples was done for the AMH, FSH, Inhibin B, and LH by ELISA kit methods. USG was done for the antral follicle count (AFC) and oocytes' retrieval. Hormone parameters were compared and correlated with the oocytes' retrieval count and the AFC. The discriminant analysis was done to compare relevance of different parameters for predicting ovarian response.

RESULTS

The Anti-Mullerian hormone showed a significant correlation with the oocytes' retrieval after ovulation induction for IVF (r = 0.648, p < 0.0001) and no correlation was seen with serum FSH, LH, and Inhibin. Serum AMH levels show 80 % sensitivity and 80 % specificity in predicting poor ovarian response.

CONCLUSIONS

There is a significant correlation between day-2 serum AMH levels and the oocytes' retrieval count in women undergoing ovulation induction for IVF, and the AMH is a good marker as the negative predictive values for the success of ART. There is no correlation found between other hormonal ovarian reserve markers and the oocytes' retrieval count.

Anti-mullerian hormone and antral follicle count as predictors of ovarian response in assisted reproduction

OBJECTIVE

The objective of this study was to test the hypothesis that AMH and antral follicle count (AFC) are good predictors of ovarian response to controlled ovarian stimulation and to compare them.

MATERIALS AND METHODS

This observational cross-sectional study included 56 subjects aged between 25 and 42 years who were enrolled between 1(st) January and 31(st) December 2010 for their first intracytoplasmic sperm injection (ICSI) program. Baseline hormone profiles including serum levels of Estradiol (E2), Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), and Anti-mullerian Hormone (AMH) were determined on day 3 of the previous cycle. The antral follicle count measurements were performed on days 3-5 of the same menstrual cycle. Antral follicles within the bilateral ovaries between 2-6 mm were recorded. The subjects were treated with long protocol for ovarian stimulation. Ovulation was induced with 10,000 IU of human chorionic gonadotropin (hCG) when at least 3 follicles attained the size of more than 17 mm. Transvaginal oocyte retrieval was performed under ultrasound guidance 36 hours after hCG administration. An oocyte count less than 4 and absence of follicular growth with controlled ovarian hyper stimulation was considered as poor ovarian response. Oocyte count of 4 or more was considered as normal ovarian response.

RESULTS

Statistical analysis was performed using SPSS software trail version 16.0. Subjects were divided into 2 groups, depending on the ovarian response. The mean oocyte counts were 12.27 ± 6.06 and 2.22 ± 1.24 in normal and poor responders, respectively, (P = 001). Multiple regression analysis revealed AMH and antral follicle count as predictors of ovarian response (β coefficient ± SE for AMH was 1.618 ± 0.602 (P = 0.01) and for AFC, it was, 0.528 ± 0.175 (P = 0.004). AFC was found to be a better predictor of ovarian response compared to AMH in controlled ovarian hyper stimulation.

CONCLUSION

The observations made in this study revealed that both AMH and AFC are good predictors of ovarian response; AFC being a better predictor compared to AMH.

[Low circulating anti-Müllerian hormone and normal follicle stimulating hormone levels: which prognosis in an IVF program?]

OBJECTIVE

To evaluate the results of controlled ovarian hyperstimulation (COH) for IVF in patients with low anti-Müllerian hormone (AMH) and normal basal follicle stimulating hormone (FSH) and Estradiol levels (≤50 pg/mL).

PATIENTS AND METHODS

A retrospective cohort study including 704 patients for whom AMH and FSH levels (measured between days 3 and 5 of the menstrual cycle) were available, is performed in the IVF center at the Sèvres Hospital (France). Three groups are designed and analyzed: group 1 with AMH less or equal to 2 ng/mL and FSH less or equal to 10 mUI/mL (study group), Group 2 with AMH greater than 2 ng/mL and FSH less or equal to 10 mUI/mL (control group) and Group 3 with AMH less or equal to 2 ng/mL and FSH greater than 10 mUI/mL (group with decreased ovarian reserve).

RESULTS

IVF outcome for patients from the study group is significantly worse than that of the second but not than that of the third group. In the first group, the number of retrieved oocytes, the number of total obtained embryos, the clinical pregnancy rate and the live birth rate are significantly lower than in the second group; moreover, there are more cancelled cycles because of poor response in the first group. There is no difference with the third group.

DISCUSSION AND CONCLUSIONS

This study shows that women with a low baseline AMH have a similar response to COH to the poor responders patients with a decreased ovarian reserve revealed by an elevated FSH level. Thus, when a woman undergoing IVF cycle presents a low AMH, she might be considered as a poor responder patient regardless of the FSH level and, although the clinical pregnancy rate is not so disappointing (18%), the couple should be informed of a higher risk of cycle cancellation.

Serum anti-Müllerian hormone level as a predictor of poor ovarian response in in vitro fertilization patients

Purpose

To evaluate the clinical value of day 3 serum anti-Müllerian hormone (AMH) compared with day 3 serum follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG) day estradiol (E2) levels and antral follicle count (AFC) in the prediction of poor ovarian response in controlled ovarian hyperstimulation (COH).

Methods

AMH, FSH and AFC on day 3 as well as hCG day E2 levels were determined in 164 subjects. Receiver operating curve analyses and area under curves (AUC) of the study parameters were performed. Predictive values of the levels of day 3 AMH, FSH, AFC, and hCG day E2 as clinical parameters of ovarian response to COH were studied.

Results

Thirty-eight women were defined as poor responders. The day 3 AMH and hCG day E2 levels and AFC of normal responders were significantly higher than those of the poor responders. In predicting poor response, the AUC of day 3 AMH level was significantly higher than that of day 3 FSH level but was similar to the hCG day E2 level. Day 3 AMH, FSH and hCG day E2 levels and AFC were found to predict a poor response. Day 3 AMH and hCG day E2 levels were more predictive compared with day 3 FSH level and AFC. The cut-off level of AMH was ≤2 with a sensitivity of 78.9% and a specificity of 73.8%.

Conclusion

Day 3 AMH has the ability to predict a poor response to COH and it is more predictive than day 3 FSH and AFC.

Clinical biochemistry of assisted conception

Assisted reproductive technology has shown rapid advancement since the birth of the first 'test-tube' baby in Oldham, UK, in 1978. Since April 2005, women between the ages of 23 and 39, who meet the described eligibility criteria, are able to get one free in vitro fertilization cycle funded by the National Health Service. Private treatment costs anything from pound4000 to pound8000 for a single cycle of treatment. Almost 15% of the couples in UK are affected by fertility problems and undergo detailed investigations before being offered assisted conception. Assisted reproduction is the collective name for treatments designed to lead to conception by means other than sexual intercourse. These include intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection and gamete donation. This review is intended to summarize the principles of assisted conception and examine the role of the biochemistry laboratory in: (A) the diagnosis and subsequent management of ovulatory disorders; (B) assessing ovarian reserve before initiating fertility treatment and (C) monitoring fertility treatment. It touches on the screening of potential gamete donors and follow-up of children born after assisted conception. This article was prepared at the invitation of the Clinical Sciences Reviews Committee of the Association of Clinical Biochemistry.