The role of anti-Müllerian hormone in prediction of pregnancy in young and older women with unexplained infertility undergoing intrauterine insemination

Anti-Mullerian Hormone Assessment in Assisted Reproductive Technique Outcome and Natural Conception

In recent years, the prevalence of infertility has increased, and appears to affect approximately one in six couples. Some of them must perform assisted reproductive techniques (ART) in order to achieve pregnancy. As a result, growing interest has arisen about predictive factors of pregnancy and live birth with and without ART. Anti-Mullerian hormone (AMH) is a glycoprotein discovered in the 1950s in male embryonic sexual differentiation. Later, in 1984, its role in folliculogenesis was reported: secreted by granulosa cells, this hormone is involved in the regulation of the recruitment of primordial follicles and in follicular growth. AMH assays were developed for women in 1990s, and the serum AMH level has rapidly become a crucial element in managing women's fertility. Based mainly on its ability to be a quantitative but indirect marker of ovarian reserve, the serum AMH assay is widely used in reproductive medicine and ART. This review summarizes current knowledge of the AMH assessment in the field of reproductive medicine. We focus on the role of AMH level to predict spontaneous pregnancy occurrence, ART outcomes, and fertility preservation outcomes.

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.

The Value of Anti-Müllerian Hormone in Predicting Ovulation Induced by Aromatase Inhibitors in Women With Polycystic Ovary Syndrome

OBJECTIVES

This study aimed to evaluate the value of anti-Müllerian hormone (AMH) in predicting ovulation induced by aromatase inhibitors (AI) and pregnancy outcomes in women with polycystic ovary syndrome (PCOS).

METHODS

From January 2018 to December 2020, this prospective cohort study enrolled women with PCOS aged between 18 and 45 years who underwent ovulation induction using AI protocol and intrauterine insemination (IUI) for infertility at a Center for Reproductive Endocrinology and Infertility, University Hospital. Receiver operating characteristic curves were used to estimate the chance of ovulation responses and pregnancy outcomes.

RESULTS

In total, 64% of 65 women with PCOS were recruited following AI treatment, and the clinical pregnancy rate was 19.4% following IUI. Patients who experienced ovulation had a lower mean serum AMH concentration than non-responders (7.11 ng/mL vs. 8.95 ng/mL, respectively), but the difference was not statistically significant. Between the pregnancy and non-pregnancy groups, statistically significant differences in AMH concentrations were observed (8.71 ng/mL vs. 6.73 ng/mL, respectively, P = 0.040). The area under the curve of the receiver operating characteristic for non-ovulation prediction was 0.445, 95% CI (0.284-0.606) with P = 0.467, and for clinical pregnancy was 0.735, 95% CI (0.561-0.910) with P = 0.104.

CONCLUSIONS

In women with PCOS, the AMH level does not predict ovarian responsiveness to AI treatment, but it does predict the success of IUI cycles.

Anti-Müllerian Hormone: A Predictor of Successful Intrauterine Insemination

INTRODUCTION

The anti-Müllerian hormone (AMH) produced by the granulosa cells of ovarian follicles has been shown to correlate with ovarian reserve and is often measured for fertility therapies. In this study, we evaluated the relationship between serum AMH values and the clinical pregnancy (CP) rates of female partners with unexplained infertility undergoing intrauterine insemination utilizing varying ovarian simulation protocols.

METHODS

This is a retrospective cohort study conducted among couples who underwent intrauterine insemination therapy over a period of four years at Charleston Area Medical Center, a tertiary care medical center in West Virginia, USA. Logistic regression was used to determine the best predictor of CP.

RESULTS

A total of 509 intrauterine inseminations resulting in 81 (15.9%) Cps were analyzed. The cycles with a CP had higher mean AMH values (3.7+3.5 vs. 2.2+2.1; p<0.001). The majority of patients were nulliparous (77.0%) with a mean age of 33.6+5.0 years. After including only patients with unexplained infertility (the predominate infertility diagnosis; n=255 (50.1% of the cycles)) and stimulation cycles >10, the final sample size for the analysis was 245/509=48.1%. Following a receiver operating characteristic (ROC) curve analysis, the optimal AMH cut-off point was 2.1 ng/mL with an area under the curve (AUC) equal to 0.61 and 95% confidence intervals (CIs) of 0.55- 0.67 (p=0.002). The CP rate was significantly higher with the AMH >2.1 ng/mL (20.0%) compared to <2.1 ng/mL (10.0%; p=0.041). With Clomid/human gonadotropins/human chorionic gonadotropin (hCG) trigger treatment, the CP rate quadrupled (odds ratio (OR): 4.6; 95% CI: 2.1-9.7; p<0.001).

CONCLUSION

This study indicates that higher AMH levels and a more aggressive ovarian stimulation protocol for intrauterine insemination therapy (IUI) have a better probability of resulting in CP.

Using serum anti-Müllerian hormone levels to predict the chance of live birth after spontaneous or assisted conception: a systematic review and meta-analysis

STUDY QUESTION

Is serum anti-Müllerian hormone (AMH) level predictive of cumulative live birth (CLB) rate after ART or in women trying to conceive naturally?

SUMMARY ANSWER

Serum AMH level is linked to CLB after IVF/ICSI but data are lacking after IUI or in women trying to conceive without ART.

WHAT IS KNOWN ALREADY

Serum AMH level is a marker of ovarian reserve and a good predictor of ovarian response after controlled ovarian stimulation. It is unclear whether AMH measurement can predict CLB in spontaneous or assisted conception.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis was undertaken to assess whether serum AMH level may predict chances of CLB in infertile women undergoing IVF/ICSI or IUI and/or chances of live birth in women having conceived naturally.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A systematic review and meta-analysis was performed using the following keywords: 'AMH', 'anti-mullerian hormone', 'live-birth', 'cumulative live birth'. Searches were conducted from January 2004 to April 2021 on PubMed and Embase. Two independent reviewers carried out study selection, quality, and risk of bias assessment as well as data extraction. Odds ratios were estimated using a random-effect model. Pre-specified sensitivity analyses and subgroup analyses were performed. The primary outcome was CLB.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 32 studies were included in the meta-analysis. Overall, 27 articles were included in the meta-analysis of the relation between AMH and CLB or AMH and LB after IVF/ICSI. A non-linear positive relation was found in both cases. A polynomial fraction was the best model to describe it but no discriminant AMH threshold was shown, especially no serum AMH level threshold below which live birth could not be achieved after IVF/ICSI. After IVF-ICSI, only four studies reported CLB rate according to AMH level. No statistically significant differences in mean serum AMH levels were shown between patients with and without CLB, but with a high heterogeneity. After exclusion of two studies with high risks of bias, there was no more heterogeneity [I2 = 0%] and the mean AMH level was statistically significantly higher in women with CLB. There were not enough articles/data to assess the ability of AMH to predict CLB rate or find an AMH threshold after IUI or in women without history of infertility trying to conceive without ART.

LIMITATIONS, REASONS FOR CAUTION

The systematic review and meta-analysis had some limitations owing to the limits and bias of the studies included. In the present meta-analysis, heterogeneity may have been caused by different baseline characteristics in study participants, different stimulating protocols for ART, different serum AMH level thresholds used and the use of various assays for serum AMH. This could explain, in part, the absence of a discriminating AMH threshold found in this analysis.

WIDER IMPLICATIONS OF THE FINDINGS

Serum AMH level is linked to CLB rate after IVF/ICSI but no discriminating threshold can be established, therefore low serum AMH level should not be used as the sole criterion for rejecting IVF treatment, especially in young patients. Data are lacking concerning its predictive value after IUI or in women trying to conceive without ART. Our findings may be helpful to counsel candidate couples to IVF-ICSI.

STUDY FUNDING/COMPETING INTERESTS

No external funding was obtained for this study. There are no conflicts of interest.

REGISTRATION NUMBER

PROSPERO CRD42021269332.

Evaluating the efficacy of ovulation stimulation with intrauterine insemination in women with diminished ovarian reserve compared to women with normal ovarian reserve

OBJECTIVE

To assess the efficacy of ovulation induction and intrauterine insemination (IUI) in couples with diminished ovarian reserve (DOR).

METHODS

Women aged 20-39 years and men younger than 50 years were included. Four "ovarian reserve groups" were created according to anti-Müllerian hormone (AMH) and the partner's age. Gestational sac finding on ultrasound examination was the primary outcome measure.

RESULTS

The study was carried out on a total of 770 cycles of 362 women in an infertility cohort that consisted of 75 women with DOR treated by 153 cycles and 287 women without DOR treated by 617 cycles. The pregnancy rate was similar in the four ovarian reserve groups in terms of first, second, third plus fourth, and total attempts of IUI cycles. Moreover, the pregnancy rate, miscarriage rate, and multiple pregnancy rate were similar. We found no difference in the cumulative pregnancy rate among the groups after four IUI cycles. Multivariate logistic regression analysis of the entire cohort revealed that infertility duration, post-wash sperm count, and follicle number greater than 11 mm on the day of human chorionic gonadotropin trigger were independent predictors of pregnancy (P < 0.001). Neither age nor AMH predicted pregnancy after ovulation stimulation and IUI.

CONCLUSIONS

Ovulation stimulation and IUI are equally effective in women with DOR and in women with normal ovarian reserve in terms of pregnancy rate, multiple pregnancy rate, and miscarriage rate per IUI cycle or cumulative pregnancy rate after four cycles of IUI.

Serum leptin level in Sudanese women with unexplained infertility and its relationship with some reproductive hormones

BACKGROUND

The excessive concentration of leptin has negative effects on all aspects of female reproduction. Despite this established relationship, the exact role of leptin in women’s fertility is not clear enough and needs more clarification.

AIM

To evaluate the serum leptin levels in Sudanese women and to ascertain the relationship between serum leptin levels and unexplained infertility (UI).

METHODS

A matched (age and body mass index) case-control study was conducted from March 2021 to February 2022. The study samples were 210 women with UI and 190 fertile women of reproductive age who were attending the maternity hospitals and fertility clinics in Khartoum state Sudan. The serum concentration of leptin and other serum biomarkers were determined using enzyme-linked immunosorbent assays.

RESULTS

The results showed that there was a highly statistically significant difference between the two groups (P < 0.001) for all examined eight biomarkers. Whereby, leptin, luteinizing hormone (LH)/follicular stimulating hormone (FSH) ratio, prolactin hormone (PRL) and testosterone (T) were significantly higher in the UI group compared with the control group. In contrast, FSH and estradiol (E2)/T ratio were significantly lower in the UI group than in the control group and the effect size test for the difference between the two groups was very large (effect size > 0.80), for leptin level, LH/FSH ratio, PRL level, and E2/T ratio, and large (effect size 0.50- ≤ 0.80) for FSH and T.

CONCLUSION

This study reveals that leptin could be a potential biomarker for UI in Sudanese women and it may be useful for identifying women with a high risk of infertility.

Predicting success of intrauterine insemination using a clinically based scoring system

Purpose

To develop a predictive score for the success of intrauterine insemination (IUI) based on clinical parameters.

Methods

We performed a retrospective cohort study evaluating the homologous IUI cycles performed at a single university-based reproductive medical center between 2009 and 2017. The primary outcome measure was pregnancy, defined as positive serum human chorionic gonadotropin (hCG) 12–14 days after IUI. Predictive factors for pregnancy after IUI were identified, and a predictive score was developed using a multivariable continuation ratio model.

Results

Overall, 1437 IUI cycles in 758 couples were evaluated. We found a per cycle pregnancy rate of 10.9% and a cumulative pregnancy rate of 19.4%. In a multivariable analysis, the probability of pregnancy was negatively associated with female age ≥ 35 years (OR 0.63, 95% CI 0.41–0.97, p = 0.034), endometriosis, unilateral tubal factor, or anatomical alteration (OR 0.54, 95% CI 0.33–0.89, p = 0.016), anti-Mullerian hormone (AMH) < 1 ng/ml (OR 0.50, 95% CI 0.29–0.87, p = 0.014), and total progressive motile sperm count (TPMSC) < 5 mil (OR 0.47, 95% CI 0.19–0.72, p = 0.004). We developed a predictive clinical score ranging from 0 to 5. Following 3 cycles, couples in our cohort with a score of 5 had a cumulative probability of achieving pregnancy of nearly 45%. In contrast, couples with a score of 0 had a cumulative probability of only 5%.

Conclusion

IUI success rates vary widely depending on couples’ characteristics. A simple to use score could be used to estimate a couple’s chance of achieving pregnancy via IUI, facilitating individualized counseling and decision-making.

Anti-Müllerian hormone as a predictor of pregnancy in women under 35 years with unexplained infertility undergoing ICSI: a retrospective study

BACKGROUND

Anti-Müllerian hormone (AMH) is a well-established marker for the determination of ovarian reserve. However, its role in the prediction of pregnancy is still under debate. In this retrospective study, we aimed to evaluate the relationship of serum AMH levels with pregnancy rates in patients with unexplained infertility undergoing ICSI. Moreover, we compared the predictive value of AMH with that of antral follicle count (AFC).

METHODS

Records of 76 patients under 35 years of age with AMH levels between 1 and 3.5 ng/ml were examined retrospectively. Participants were divided into groups based on their AMH level and age.

RESULTS

AMH levels in women under 30 years were found significantly higher than those in women over 30 years (P=0.033). 57 of 76 patients (75%) were pregnant. Age did not have a significant effect on the pregnancy rates in the selected study group (P=0.252). On the other hand, despite the poor predictive accuracy, serum AMH was shown to have a predictive value with a cut-off point of 1.95 ng/mL. Logistic regression tests demonstrated a higher pregnancy rate (3.396 fold) with an AMH level 1.95 or above. There was no significant relationship between AFC and pregnancy.

CONCLUSIONS

AMH might have a role in the prediction of pregnancy after ICSI in patients under 35 years with unexplained infertility.

Molecular Mechanisms of Laparoscopic Ovarian Drilling and Its Therapeutic Effects in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinopathy, characterized by chronic anovulation, hyperandrogenism, and multiple small subcapsular cystic follicles in the ovary during ultrasonography, and affects 5–10% of women of reproductive age. PCOS is frequently associated with insulin resistance (IR) accompanied by compensatory hyperinsulinemia and, therefore, presents an increased risk of type 2 diabetes mellitus (DM). The pathophysiology of PCOS is unclear, and many hypotheses have been proposed. Among these hypotheses, IR and hyperandrogenism may be the two key factors. The first line of treatment in PCOS includes lifestyle changes and body weight reduction. Achieving a 5–15% body weight reduction may improve IR and PCOS-associated hormonal abnormalities. For women who desire pregnancy, clomiphene citrate (CC) is the front-line treatment for ovulation induction. Twenty five percent of women may fail to ovulate spontaneously after three cycles of CC treatment, which is called CC-resistant PCOS. For CC-resistant PCOS women, there are many strategies to improve ovulation rate, including medical treatment and surgical approaches. Among the various surgical approaches, one particular surgical method, called laparoscopic ovarian drilling (LOD), has been proposed as an alternative treatment. LOD results in an overall spontaneous ovulation rate of 30–90% and final pregnancy rates of 13–88%. These benefits are more significant for women with CC-resistant PCOS. Although the intra- and post-operative complications and sequelae are always important, we believe that a better understanding of the pathophysiological changes and/or molecular mechanisms after LOD may provide a rationale for this procedure. LOD, mediated mainly by thermal effects, produces a series of morphological and biochemical changes. These changes include the formation of artificial holes in the very thick cortical wall, loosening of the dense and hard cortical wall, destruction of ovarian follicles with a subsequently decreased amount of theca and/or granulosa cells, destruction of ovarian stromal tissue with the subsequent development of transient but purulent and acute inflammatory reactions to initiate the immune response, and the continuing leakage or drainage of “toxic” follicular fluid in these immature and growth-ceased pre-antral follicles. All these factors contribute to decreasing local and systemic androgen levels, the following apoptosis process with these pre-antral follicles to atresia; the re-starting of normal follicular recruitment, development, and maturation, and finally, the normalization of the “hypothalamus–pituitary–ovary” axis and subsequent spontaneous ovulation. The detailed local and systematic changes in PCOS women after LOD are comprehensively reviewed in the current article.

Interactions of Cortisol and Prolactin with Other Selected Menstrual Cycle Hormones Affecting the Chances of Conception in Infertile Women

One of the major problems of success in infertility treatment could depend on the understanding how the potential factors may affect the conception. The aim of this study was to evaluate present understanding of such factors or hormonal causes that may induce infertility. We studied the interactions between the two menstrual cycle hormones i.e., cortisol (COR) and prolactin (PRL), along with the ultrasonographic ovulation parameters in a group of N = 205 women with diagnosed infertility. The control group consisted of N = 100 women with confirmed fertility. In both groups, follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-Müllerian hormone (AMH), thyroid stimulating hormone (TSH), PRL, COR were examined on the third day of the cycle, and estradiol (E2), progesterone (P), and COR were examined during ovulation and 7-days afterwards. In the infertile group, higher levels of PRL and COR were observed than that of in the control group. Cortisol levels at all phases of the menstrual cycle and PRL negatively correlated with E2 secretion during and after ovulation, thus contributed to the attenuation of the ovulatory LH surge. Infertile women who conceived presented with higher levels of E2 during and after ovulation, higher P after ovulation, and thicker endometrium than that of the women who failed to conceive. In conclusion, elevated secretion of COR and PRL in infertile women impairs the menstrual cycle by decreasing the pre-ovulatory LH peak and E2 and postovulatory E2 levels that affect the endometrial growth, and consequently reduce the chances to conceive.