Anti-Müllerian hormone as a qualitative marker - or just quantity?

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and validation of a nomogram for predicting ongoing pregnancy in single vitrified-warmed blastocyst embryo transfer cycles

Introduction

The global adoption of the "freeze-all strategy" has led to a continuous increase in utilization of single vitrified-warmed blastocyst embryo transfer (SVBT) owing to its clinical effectiveness. Accurate prediction of clinical pregnancy is crucial from a patient-centered perspective. However, this remains challenging, with inherent limitations due to the absence of precise and user-friendly prediction tools. Thus, this study primarily aimed to develop and assess a nomogram based on quantitative clinical data to optimize the efficacy of personalized prognosis assessment.

Materials and methods

We conducted a retrospective cohort analysis of ongoing pregnancy data from 658 patients with infertility who underwent SVBT at our center between October 17, 2017, and December 18, 2021. Patients were randomly assigned to the training (n=461) or validation (n=197) cohort for nomogram development and testing, respectively. A nomogram was constructed using the results of the multivariable logistic regression (MLR), which included clinical covariates that were assessed for their association with ongoing pregnancy.

Results

The MLR identified eight significant variables that independently predicted ongoing pregnancy outcomes in the study population. These predictors encompassed maternal physiology, including maternal age at oocyte retrieval and serum anti-Müllerian hormone levels; uterine factors, such as adenomyosis; and various embryo assessment parameters, including the number of fertilized embryos, blastocyst morphology, blastulation day, blastocyst re-expansion speed, and presence of embryo string. The area under the receiver operating characteristic curve in our prediction model was 0.675 (95% confidence interval [CI], 0.622-0.729) and 0.656 (95% CI, 0.573-0.739) in the training and validation cohorts, respectively, indicating good discrimination performance in both cohorts.

Conclusions

Our individualized nomogram is a practical and user-friendly tool that can provide accurate and useful SVBT information for patients and clinicians. By offering this model to patients, clinical stakeholders can alleviate uncertainty and confusion about fertility treatment options and enhance patients' confidence in making informed decisions.

Antimüllerian hormone (AMH) and age as predictors of preimplantation genetic testing for aneuploidies (PGT-A) cycle outcomes and blastocyst quality on day 5 in women undergoing in vitro fertilization (IVF)

PURPOSE

The objective of this study was to investigate whether women with diminished ovarian reserve who planned for PGT-A exhibit a lower number of blastocysts for biopsy, ploidy outcomes, and blastocyst quality on day 5, regardless of age.

METHODS

A retrospective analysis was performed between March 2017 and July 2020 at ART Fertility Clinics Abu Dhabi, including couples that were triggered for final oocyte maturation in an ovarian stimulated cycle planned for PGT-A. Patients were stratified into four AMH groups: < 0.65 ng/ml, 0.65-1.29 ng/ml, 1.3-6.25 ng/ml, and > 6.25 ng/ml; four age categories: ≤ 30, 31-35, 36-40, and > 40 years.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1410 couples with a mean maternal age of 35.2 ± 6.4 years and AMH of 2.7 ± 2.6 ng/ml were included. In a multivariate logistic regression analysis, controlling for age, the chance of having at least one blastocyst biopsied/stimulated cycle (1156/1410), the chance of having at least one euploid blastocyst/stimulated cycle (880/1410), and the chance of having one euploid blastocyst once biopsy was performed (880/1156) were affected in all patients with AMH < 0.65 ng/ml [AdjOR 0.18[0.11-0.31] p = 0.008)], [AdjOR 0.18 [0.11-0.29] p < 0.001], and [AdjOR 0.34 [0.19-0.61] p = 0.015] as well as in patients with AMH 0.65-1.29 ng/ml (AdjOR 0.52 [0.32-0.84] p < 0.001), (AdjOR 0.49 [0.33-0.72] p < 0.001), and (AdjOR 0.57 [0.36-0.90] p < 0.001), respectively. In a multivariate linear regression analysis, AMH values did not affect blastocyst quality (- 0.72 [- 1.03 to - 0.41] p < 0.001).

CONCLUSION

Irrespective of age, patients with diminished ovarian reserve (AMH < 1.3 ng/ml) have a lower chance of having at least one blastocyst biopsied and lower chance of having at least one euploid blastocyst per ovarian stimulated cycle. Blastocyst quality was not affected by AMH values.

AMH independently predicts aneuploidy but not live birth per transfer in IVF PGT-A cycles

BACKGROUND

While anti-Müllerian hormone (AMH) predicts quantitative IVF outcomes such as oocyte yield, it is not certain whether AMH predicts markers of oocyte quality such as aneuploidy.

METHODS

Retrospective case-control analysis of the SART-CORS database, 2014-2016, to determine whether anti-Müllerian hormone (AMH) predicts aneuploidy and live birth in IVF cycles utilizing preimplantation genetic testing for aneuploidy (PGT-A).

RESULTS

Of 51,273 cycles utilizing PGT-A for all embryos, 10,878 cycles were included in the final analysis; of these, 2,100 cycles resulted in canceled transfer due to lack of normal embryos and 8,778 cycles resulted in primary FET. AMH levels of cycles with ≥ 1 euploid embryo were greater than those of cycles with no normal embryos, stratifying by number of embryos biopsied (1-2, 3-4, 5-6, and ≥ 7), P < 0.017 for each stratum. Adjusting for age and number of embryos biopsied, AMH was a significant independent predictor of ≥ 1 euploid embryo for all age groups: < 35 yrs (aOR 1.074; 95%CI 1.005-1.163), 35-37 years (aOR 1.085; 95%CI 1.018-1.165) and ≥ 38 years (aOR 1.055; 95%CI 1.020-1.093). In comparative model analysis, AMH was superior to age as a predictor of  ≥ 1 euploid embryo for age groups < 35 years and 35-37 years, but not  ≥ 38 years. Across all cycles, age (aOR 0.945, 95% CI 0.935-0.956) and number of embryos (aOR 1.144, 95%CI 1.127-1.162) were associated with live birth per transfer, but AMH was not (aOR 0.995, 95%CI 0.983-1.008). In the subset of cycles resulting in ≥ 1 euploid embryo for transfer, neither age nor AMH were associated with live birth.

CONCLUSIONS

Adjusting for age and number of embryos biopsied, AMH independently predicted likelihood of obtaining ≥ 1 euploid embryo for transfer in IVF PGT-A cycles. However, neither age nor AMH were predictive of live birth once a euploid embryo was identified by PGT-A for transfer. This analysis suggests a predictive role of AMH for oocyte quality (aneuploidy risk), but not live birth per transfer once a euploid embryo is identified following PGT-A.

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.

Cyanidin-3-O-glucoside ameliorates cadmium induced uterine epithelium proliferation in mice

Cadmium (Cd) is an environmental pollutant and endocrine disrupter, abundantly present in water, food, and soil. Accumulation of Cd in the body can negatively affect female reproduction; especially the uterus is exceptionally sensitive to the toxic actions of Cd. The anthocyanin cyanidin-3-O-glucoside (C3G) is a naturally occurring phenolic compound in fruits and plants that can antagonize the toxic effects of Cd. This capacity makes C3G a possible candidate to prevent Cd-induced female infertility. The present study aimed to investigate: 1) whether C3G intake could prevent Cd-induced female reproductive toxicity, and 2) the underlying mechanisms responsible for this protective effect. The results of our study indicated that Cd exposure did not affect ovarian function, but induced hypertrophy of the uterine endometrium. Oral intake of C3G markedly reduced the effects of Cd exposure on the thickness of the uterine epithelium cells. Transcriptomic analysis of the endometrium revealed that C3G intake had anti-estrogenic effects, attenuating Cd-induced endometrial epithelial cell proliferation by inhibiting estrogen-responsive genes, enhancing epithelial progesterone receptor expression, and regulating Klf4 expression. The current findings implicate that C3G has the potential to be used as a dietary supplement based on its capacity to intervene in Cd-induced female reproductive toxicity.

Decreased Ovarian Reserves With an Increasing Number of Previous Early Miscarriages: A Retrospective Analysis

The fact of ovarian reserve (OR) decreased in women with recurrent miscarriage has been well known. However, Whether OR would decrease with increasing numbers of previous miscarriages (PMs) is still unclear. To address this, OR parameters of following four groups' patients were evaluated: 99 women with one previous miscarriage (PM1), 46 women with two previous miscarriages (PM2) and 35 women with three or more previous miscarriages (PM3). The control group included 213 women without a history of miscarriage (PM0). The correlation of OR parameters and the proportion of diminished ovarian reserve (DOR) patients between the four groups were analyzed using Kendall's Tau-B coefficients. The results showed the median anti-Müllerian hormone (AMH) levels were 4.04, 3.40, 3.14 and 2.55 respectively in the PM0, PM1, PM2 and PM3 groups, respectively (H=15.99, P = 0.001); the median antral follicle counts (AFCs) were 10, 8, 8 and 6, respectively (H=24.53, P < 0.001); and the proportions of DOR patients were 10.8%, 15.2%, 23.9% and 31.4% (χ2 = 13.01, P = 0.005). In addition, AMH level and AFC correlated negatively with the number of PMs (correlation coefficients -0.154, P < 0.001; -0.205, P < 0.001 respectively), the proportion of DOR patients correlated positively with the number of PMs (correlation coefficients 0.156, P = 0.001). After stratification by age, AMH and AFC levels were still significantly lower in the PM3 group than the PM0 group (P < 0.05). The proportion of DOR patients between the PM0 and PM3 groups was statistically significant (P < 0.001). This study showed that AMH levels and AFCs decreased as well as the proportion of DOR patients increased significantly as the number of PMs increased. In conclusion, our study indicates decreased AMH levels and AFCs might be one of the factors contributing to early miscarriage.