Is the measurement of anti-Müllerian hormone essential?

Biomarkers identification in follicular fluid of women with OHSS by using UPLC-MS method

To figure out the differentially changed metabolites and disturbed pathways in follicular fluid (FF) of patients with OHSS in comparison to the control group undergoing in vitro fertilization (IVF), we conducted this metabolomic analysis between two groups, the OHSS group included 30 patients treated with oocyte retrieval and developed OHSS in the next 7-14 days, while another 30 patients without OHSS tendency were selected as the control group. The FF samples were obtained during the process of oocyte retrieval. FF samples were analyzed using ultra-high liquid chromatography-tandem mass spectrometry (UPLC-MS). The results identified a total of 59 differentially changed metabolites, including 33 decreased metabolites (P < 0.01) and 26 increased metabolites (P < 0.01) in FF of OHSS compared with the control group. 12 metabolites could be the most valuable biomarkers for OHSS based on ROC results. Our correlation analyses showed that deoxyinosine levels were found positively correlated with serum estradiol (E2) levels in OHSS patients, while L-isoleucine, pyruvic acid, maleamate, and arachidonic acid were found to be positively correlated with the number of retrieved oocytes. Furthermore, 4-hydroxyphenylacetaldehyde, deoxycorticosterone, creatinine, and creatine were found to be negatively associated with serum E2 levels, while 4-hydroxyphenylacetaldehyde, L-carnitine, isovaleric acid and L-2-hydroxyglutaric acid were negatively related with the number of oocytes retrieved in OHSS patients. Taken together, our study provides better identification of OHSS FF metabolic dynamics, suggesting the metabolic compounds can be used as valuable predictors or treatment targets of OHSS.

Anti-Mullerian Hormone Levels Increase After Bariatric Surgery in Obese Female Patients With and Without Polycystic Ovary Syndrome

This study was aimed to investigate the effect of weight loss by bariatric surgery on the level of anti-Mullerian hormone (AMH) in morbidly obese female patients with or without polycystic ovary syndrome (PCOS). This prospective study includes 70 females, obese, and fertile patients of reproductive age. All patients were evaluated to determine the changes in weight, body mass index (BMI), serum AMH, and other biochemical parameters at the end of six months. The mean levels of the preop and postop AMH were 1.66±0.87 ng/ml and 5.99±1.39 ng/ml in the PCOS group; 1.35±0.76 ng/ml and 6.23±1.47 ng/ml in the non-PCOS group, respectively. The postop AMH levels were significantly higher than the preop levels for both groups (p<0.001). There were significant differences in the level of glucose, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride, total cholesterol, hemoglobin A1c, HOMA-IR, insulin between preop and postop 6th month. A negative correlation was found between postop AMH and body weight in all patients (r=-0.337, p=0.031). Postop AMH levels were negatively correlated with postop BMI levels in the non-PCOS patient group (r=-0.408, p=0.043). No significant difference was observed between the PCOS and non-PCOS groups in terms of all the parameters examined. In conclusion, our study suggests that the significantly increased AMH levels by losing weight with bariatric surgery in patients with morbid obesity with and without PCOS may indicate the improvement of fertilization potential. It could be considered when evaluating fertility in patients with morbid obesity.

Do trends of adiposity and metabolic parameters vary in women with different ovarian reserve status? A population-based cohort study

OBJECTIVE

To investigate whether trends of adiposity and glucose metabolism parameters in women with low ovarian reserve status based on their anti-Mullerian hormone (AMH) levels differ from those with high ovarian reserve.

METHODS

In this population-based prospective study, eligible women, aged 20 to 50 years, were selected from among participants of the Tehran Lipid and Glucose Study (TLGS). Generalized estimating equation (GEE) models were applied to compare changes in various adiposity and metabolic parameters across time between women in the first and fourth quartiles of age-specific AMH, after adjustment for confounders. Pooled logistic regression was used to compare progression of prediabetes mellitus (pre-DM) and diabetes mellitus (DM) between the women of these two age-specific AMH quartiles.

RESULTS

In this study of a total of 1,015 participants and with a median follow-up of 16 years, we observed that over time, both groups of women in the first and fourth quartiles of age-specific AMH experienced significant positive trends in their adiposity indices including central obesity, waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), a body shape index (ABSI), and a negative trend in visceral adiposity index (VAI), whereas there was no significant difference in these parameters between the two groups. This study revealed that odds ratios of diabetes and prediabetes in women in the first quartile of age-specific AMH were not significantly different, compared with those in the fourth quartile.

CONCLUSION

Women with lower ovarian reserve do not experience different over time trends of adiposity and glucose metabolism parameters during their reproductive life span.

Anti-Müllerian Hormone Predictive Levels to Determine The Likelihood of Ovarian Hyper-Response in Infertile Women with Polycystic Ovarian Morphology

BACKGROUND

The objective of this study was to investigate serum levels of anti-Müllerian hormone (AMH) in normal-ovulatory infertile women with polycystic ovarian morphology (PCOM) and their association with ovarian hyper-response.

MATERIALS AND METHODS

This prospective cohort study was carried out on 100 infertile women with PCOM who were treated with an antagonist/agonist triggered stimulation protocol at Shahid Akbar-Abadi Hospital IVF Centre, Tehran, Iran. Serum AMH levels were measured before starting the assisted reproductive technology (ART) cycle and the ovarian hyper-response was evaluated by retrieved oocyte numbers, ooestradiol levels on the triggering day, and the incidence of ovarian hyper-stimulation syndrome (OHSS) clinical signs and symptoms. Logistic regression and the area under the curve (AUC) were used to estimate the effects of AMH and the accuracy of the test.

RESULTS

Receiver operating characteristic (ROC) curve analysis showed that AMH could significantly predict ovarian hyper-response in PCOM patients (AUC=0.73). The estimated threshold value was 4.95 ng/ml, with a specificity of 74.58% (95% confidence interval [CI]: 50.85, 93.22) and sensitivity of 73.17% (95% CI: 48.78, 92.68). Logistic regression results showed a significant interaction between AMH and body mass index (BMI, P=0.008), which indicated that BMI had a moderation effect.

CONCLUSION

Individualized stimulation protocols for patients with isolated PCOM and AMH greater than 4.95 ng/ml may significantly reduce the chances of developing OHSS. However, the AMH cut-off values to predict ovarian hyperresponse differ for different BMI categories among PCOM patients; thus, it becomes a more precise predictive marker with increasing BMI.

Ethnic and Sociocultural Differences in Ovarian Reserve: Age-Specific Anti-Müllerian Hormone Values and Antral Follicle Count for Women of the Arabian Peninsula

BACKGROUND

Anti-Müllerian hormone (AMH) and antral follicle count (AFC) age-specific reference values form the basis of infertility treatments, yet they were based upon studies performed primarily on Caucasian populations. However, they may vary across different age-matched ethnic populations. This study aimed to describe age-specific serum AMH and AFC for women native to the Arabian Peninsula.

METHODS

A retrospective large-scale study was performed including 2,495 women, aged 19 to 50 years, native to the Arabian Peninsula. AMH and AFC were measured as part of their fertility assessment at tertiary-care fertility centres. Age-specific values and nomograms were calculated.

RESULTS

2,495 women were evaluated. Mean, standard deviation and median values were calculated for AMH and AFC by 1-year and 5-years intervals. Median age was 34.81 years, median AMH was 1.76ng/ml and median AFC was 11. From the total group, 40.60% presented with AMH levels below 1.3ng/mL. For women <45 years old, the decrease in AFC was between -0.6/-0.8 per year. Up to 36 years old, the decrease of AMH was 0.1ng/ml. However, from 36 to 40 years old, an accelerated decline of 0.23ng/ml yearly was noted. In keeping with local customs, 71.23% of women wore the hijab and 25.76% the niqab. AMH and AFC were significantly lower for niqab group compared with hijab group (p=0.02 and p=0.04, respectively).

CONCLUSION

This is to-date the largest data set on age-specific AMH and AFC values in women from the Arabian Peninsula aiming to increase clinical awareness of the ovarian reserve in this population.

Inhibin A-A Promising Predictive Parameter for Determination of Final Oocyte Maturation in Ovarian Stimulation for IVF/ICSI

The number of mature oocytes is a key factor in the success of Assisted Reproductive Techniques (ART). Exogenous gonadotropins are administered during ovarian stimulation in order to maximize the number of oocytes available for fertilization. During stimulation, monitoring is mandatory to evaluate individual response, to avoid treatment complications and assist in the determination of the optimal day for final oocyte maturation and oocyte retrieval. Routine monitoring during stimulation includes transvaginal ultrasound examinations and measurement of serum estradiol (E2). Due to multifollicular growth of follicles of varying size, serum E2 levels are commonly supraphysiological and often variable, rendering E2-measurement during ovarian stimulation unreliable as a determinant of oocyte maturity. In contrast to serum E2, serum Inhibin A levels increase once a minimum follicle size of 12-15 mm is achieved. Due to this fact, serum Inhibin A levels could present in combination with ultrasound monitoring a more reliable parameter to determine the optimal follicle size for final oocyte maturation, as only follicles with a size of 12 mm and beyond will contribute to the serum Inhibin A level. This prospective observational, cross-sectional study demonstrates, that on the day of final oocyte maturation serum Inhibin A is strongly correlated to the number of follicles ≥15 mm (0.72) and to the number of retrieved and mature oocytes (ρ 0.82/0.77, respectively), whereas serum E2 is moderately correlated to the parameters mentioned above (ρ 0.64/0.69/0.69, respectively). With an area under the curve (AUC) of 0.91 for Inhibin A, compared to an AUC of 0.84 for E2, Inhibin A can be regarded as a better predictor for the optimal timing of trigger medication with a threshold number of ≥10 mature oocytes. It can be concluded from this data that serum Inhibin A in combination with transvaginal ultrasound monitoring may be a more powerful tool in the decision making process on trigger timing as compared to E2.

Decline in Female Fertility After 40 Years

Important factor related to the conception possibility is women age. The decline in fertility with aging is proven and evident in literature. Infertility is increasing and many couples seek help in advanced techniques such as IVF (in vitro fertilization) in order to overcome the problem caused by aging, but the quality of the oocytes is a significant limiting factor. With the aging the quantity and quality of oocytes decreases, such as the quality of the embryo after fertilization. The accelerated rhythm of life, liberty and women inclusion in all kinds of professions brought many benefits to women, but also increasingly postponing births. Each person is unique individual, and can be more or less fertile compared to the average at same age. Unfortunately, some women has a rapid decline in fertility - accelerate aging, very early, already in the early twenties and when testing them with different methods and exams, the result is very low number of oocytes, low value of anti-Müllerian hormone and also very poor quality of these oocytes, or low ovarian reserve. The problem is that when you have accelerate aging, even IVF techniques can not be of great help in achieving pregnancy. The pregnancy rate (17,65%) and the childbirth rate (5,88%) with the patients older than 40 is very low, although comparable to the data from the scientific literature and speaks in favour of the fact that the success of assisted reproductive techniques is very modest with women older than 44.

Bariatric Surgery Reduces Serum Anti-mullerian Hormone Levels in Obese Women With and Without Polycystic Ovarian Syndrome

PURPOSE

Obesity in fertile women has negative effect on fertility. Anti-mullerian hormone (AMH) represents a good index of fertility, and it is considered a marker of ovarian reserve and of polycystic ovarian syndrome (PCOS) gravity. Previous studies evaluated the relationship between obesity and AMH with contradictory results. The aim of the study was to investigate the relationship between obesity and AMH and the changes of AMH in obese women in reproductive age submitted to bariatric surgery.

MATERIALS AND METHODS

Fifty-five obese patients between 18 and 39 years with (29 patients) and without PCOS (26 patients) were compared with a control group of normal weight women with (24 patients) and without PCOS (19 patients). Fourteen obese women with PCOS and 18 without PCOS underwent to bariatric surgery. Serum AMH, testosterone, androstenedione, and DHEAS were performed in all patients before and 1 year after surgical intervention.

RESULTS

AMH was significantly higher in the PCOS groups (p < 0.001), both in obese (5.84 ± 3.94 ng/ml) and non-obese women (7.35 ± 4.39 ng/ml). AMH was positively related to testosterone (p < 0.0001), androstenedione (p = 0.0005), and DHEAS (p = 0.003). After bariatric surgery, AMH levels were reduced in the both PCOS (p = 0.02) and non-PCOS group (p = 0.04).

CONCLUSIONS

AMH levels are elevated in PCOS patients regardless of the body weight. Bariatric surgery is effective in the normalization of AMH levels (a possible indirect marker of better fertility) only in obese patients with PCOS.

An Update on Ovarian Aging and Ovarian Reserve Tests

Ovaries are the female organs that age more quickly than other tissues such as the uterus, the pituitary gland or pancreas. Different from males, an interesting question is why and how the females lose fertility so rapidly. During the aging process, both the number and quality of the oocytes in the ovaries decrease and reach to a point beyond that no more viable offspring may be produced and the associated cyclic endocrinological activities cease, entering the menopause in females at an average age of 50 years. Females who delayed childbearing with or without their willing until their 30 years or 40 years constitute the largest portion of the total infertility population. Ovarian reserve tests (ORTs) provide an indirect estimate of a female’s diminishing ovarian reserve or remaining follicular pool. This article briefly reviews recent progresses in relation to ovarian aging and ORTs.

Can Doppler study of the ovarian artery predict the fertility outcome of intrauterine insemination?

BACKGROUND

To test the velocimetric pattern of the ovarian artery as a routine ovarian reserve test.

METHODS

We enrolled 317 consecutive patients from January 2011 to June 2012. At the second day of the menstrual cycle, a transvaginal ultrasound was performed to evaluate the antral follicle count and ovarian volume, and Doppler of both ovarian arteries was also performed. Controlled ovarian stimulation was performed and the patients were divided in two groups according to the result of the intrauterine insemination: group A (nonpregnant women) and group B (pregnant women).

RESULTS

Ovarian velocimetric pattern was similar between the two groups. Follicle stimulating hormone value had a significant correlation with the ultrasound markers; however, the multiple regression linear analysis showed that the only independent variables were the antral follicle count (t = -2.74, p = 0.008) and the systolic/diastolic ratio (t = 3.95, p = 0.0005). The best parameters in predicting the pregnancy were the mean ovarian volume, total and partial antral follicle count between 7 and 10 mm, and the mean resistance index (area under the curve: 0.744, 0.671, 0.667, 0.573, respectively).

CONCLUSIONS

The Doppler study of the ovarian arteries did not add significant information about the ovarian reserve status. Only the mean resistance index had a significant diagnostic accuracy, but its specificity (53%) is too low to consider it a screening test.

Does loop electrosurgical excision procedure of the uterine cervix affect anti-Müllerian hormone levels?

BACKGROUND

A delayed time to pregnancy was recently reported for women who had a loop electrosurgical excision procedure (LEEP) to remove cervical intraepithelial neoplasia (CIN) grade 2 or 3. The objective of the current study was to determine if treatment of CIN with LEEP is associated with decreased levels of anti-Müllerian hormone (AMH), a marker of ovarian reserve.

METHODS

AMH levels were measured in 18 women treated with LEEP and 18 age-matched controls, who had colposcopy only and did not require LEEP. Cases and controls had their blood drawn at study entry time zero and again 6 months later.

RESULTS

The mean AMH level decreased significantly from baseline to follow-up; however, no significant differences were observed when stratifying by LEEP status, suggesting that both groups experienced a similar decrease in AMH levels during the follow-up period. Although women treated with LEEP had lower overall AMH levels than controls at both baseline and follow-up, these differences were not statistically significant.

CONCLUSION

Overall, the delayed time to pregnancy observed in women treated with LEEP is likely not due to a LEEP-associated decrease in ovarian reserve as measured by AMH; thus, other mechanism are responsible for the delayed time to pregnancy associated with LEEP.