Discordances between follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) in female infertility

Prevalence of diminished ovarian reserve in Chinese women with follicular cysts and menstrual disorders

OBJECTIVES

To assess the prevalence of diminished ovarian reserve (DOR) in Chinese women with follicular cysts and menstrual disorders and relationship to hormonal markers.

METHODS

117 women with follicular cysts and menstrual disorders, aged 24 ∼ 53 (39.19 ± 6.61) years; measurements of height, weight, follicle-stimulating hormone (FSH), luteinizing hormone (LH), E2, progesterone (Po), prolactin (PRL), total testosterone, AMH, follicular cyst diameter, endometrial thickness. Three age groups were compared: 1) 21 ∼ 30 years, 2) 30 ∼ 40 years, 3) > 40 years.

RESULTS

Total prevalence of DOR 86.3%, in the groups 50%, 81.6%, and 98.4%, in group-3 significantly higher than in group-1 and 2. 34.2% of the 117 patients complained of cessation of regular menstruations or amenorrhea, 65.8% of abnormal uterine bleeding. Follicular cysts disappeard in cycle-1 for 98 (83.8%) and in cycle-2 for 117 (100%) patients. AMH decreased with age, significantly different between the three groups. Total testosterone in group-1 and 2 was significantly higher than in group-3. In total AMH had a negative correlation with age and E2 (p < 0.01) and positive correlation with total testosterone (p < 0.05).

CONCLUSIONS

Assessing ovarian reserve with follicular cysts and menstrual disorders is important because often pointing to DOR. The overall prevalence of DOR was high; even young women (<40 years) with follicular cysts and menstrual disorders had a low level of AMH. So AMH can be used as a marker to define DOR with higher sensitivity than other markers like FSH and E2. Primarily, these results only apply to Chinese women and should be confirmed in further studies.

Intake of soy products and soy isoflavones in relation to ovarian reserve

OBJECTIVE

To investigate the association between intake of soy food and isoflavone with ovarian reserve. Previous studies suggest on the relationship between soy intake and human fertility are inconsistent. Some clinical studies suggest that soy and phytoestrogens may not be deleterious to reproduction and may even be beneficial in couples undergoing infertility treatment. However, no studies have evaluated the relationship between soy or isoflavone intake with markers of ovarian reserve other than follicle-stimulating hormone (FSH).

DESIGN

Cross-sectional study.

SETTING

An academic fertility center.

PATIENT(S)

Patients presenting to an academic fertility center between 2007 and 2019 were invited to participate in the Environment and Reproductive Health Study.

INTERVENTION(S)

Six hundred and sixty seven participants reported their soy food intake and had an antral follicle count (AFC) assessment. Intake of 15 soy-based foods during the previous 3 months was obtained at baseline and intake of isoflavone was estimated. Participants were divided into 5 groups based on soy food and isoflavone intake considering those who did not consume soy as the reference group.

MAIN OUTCOME MEASURE(S)

Ovarian reserve was assessed using AFC as the primary outcome measure, with antimüllerian hormone (AMH) and FSH as secondary outcome measures. The AFC was measured on the third day of the menstrual cycle. Moreover, FSH and AMH levels were measured in blood samples obtained on the third day and the follicular phase of the menstrual cycle. To evaluate the association between soy intake and ovarian reserve, we used Poisson regression models for AFC and quantile regression models for AMH and day 3 FSH levels by adjusting for confounders.

RESULT(S)

Participants had a median age of 35.0 years. The median intake of soy was 0.09 servings/day and isoflavones was 1.78 mg/day. Moreover, AFC, AMH, and FSH were unrelated to soy intake in crude analyses. We found no association between soy food intake with AFC or day 3 FSH level in multivariable models. However, participants in the highest category of soy food intake had significantly low AMH levels (-1.16, 95% confidence interval: -1.92, -0.41). Soy intake had no association with AFC, AMH, or FSH in sensitivity analyses that included using different cutoff points of soy intake, excluding participants in the highest 2.5 percentile of intake, and additional statistical adjustment for dietary patterns.

CONCLUSION(S)

The results of this study are not consistent with a strong positive or inverse association of soy or isoflavone intakes within the observed range of intake, which substantially overlaps with that in the general population of the United States as well as the ovarian reserve among individuals presenting to fertility centers.

2,3,5,4′-Tetrahydroxystilbene-2-O-β-D-Glucoside improves female ovarian aging

Reduced fertility associated with normal aging may reflect the over-maturity of oocytes. It is increasingly important to reduce aging-induced infertility since recent trends show people marrying at later ages. 2,3,5,4′-Tetrahydroxystilbene-2-O-β-D-glucoside (THSG), a polyphenol extracted from Polygonum multiflorum, has been reported to have anti-inflammatory and anti-aging properties. To evaluate whether THSG can reduce aging-related ovarian damage in a female mouse model of aging, THSG was administered by gavage at a dose of 10 mg/kg twice weekly, starting at 4 weeks of age in a group of young mice. In addition, the effect of THSG in a group of aged mice was also studied in mice starting at 24 weeks of age. The number of oocytes in the THSG-fed group was higher than in the untreated control group. Although the percentage of secondary polar bodies (PB2) decreased during aging in the THSG-fed group, it decreased much more slowly than in the age-matched control group. THSG administration increased the quality of ovaries in young mice becoming aged. Western blotting analyses also indicated that CYP19, PR-B, and ER-β expressions were significantly increased in 36-week-old mice. THSG also increased oocyte numbers in aged mice compared to mice without THSG fed. Studies of qPCR and immunohistochemistry (IHC) analyses of ovaries in the aged mice groups were conducted. THSG increased gene expression of anti-Müllerian hormone (AMH), a biomarker of oocyte number, and protein accumulation in 40-week-old mice. THSG increased the expression of pgc1α and atp6, mitochondrial biogenesis-related genes, and their protein expression. THSG also attenuated the fading rate of CYP11a and CYP19 associated with sex hormone synthesis. And THSG maintains a high level of ER-β expression, thereby enhancing the sensitivity of estrogen. Our findings indicated that THSG increased or extended gene expression involved in ovarian maintenance and rejuvenation in young and aged mice. On the other hand, THSG treatments significantly maintained oocyte quantity and quality in both groups of young and aged mice compared to each age-matched control group. In conclusion, THSG can delay aging-related menopause, and the antioxidant properties of THSG may make it suitable for preventing aging-induced infertility.

The putative roles of FSH and AMH in the regulation of oocyte developmental competence: from fertility prognosis to mechanisms underlying age-related subfertility

BACKGROUND

Fertility loss during female ageing is associated with increasing basal FSH and decreasing anti-Müllerian hormone (AMH) concentrations, together with compromised oocyte quality, presumably due to increased oxidative stress (OS) and DNA damage, as well as reduced metabolic and meiotic competences. Basal FSH and AMH circulatory concentrations have been broadly utilized as IVF success predictors, regardless of fluctuations in prognostic accuracy; basal FSH and AMH perform better in pre-advanced maternal age (AMA: >35 years) and AMA patients, respectively. The relationships between FSH and AMH intrafollicular levels and IVF outcomes suggest, nevertheless, that both hormones regulate oocyte competence, supporting the hypothesis that changes in FSH/AMH levels cause, at least in part, oocyte quality degradation during ageing. To understand the reasons behind the fluctuations in FSH and AMH prognostic accuracies and to clarify their participation in mechanisms determining oocyte competence and age-related subfertility, a deeper knowledge of the regulation of FSH and AMH intrafollicular signalling during the female reproductive lifespan, and of their effects on the cumulus-oocyte complex, is required.

OBJECTIVE AND RATIONALE

An extensive body of information on the regulation of FSH and AMH intrafollicular availability and signalling, as well as on the control of folliculogenesis and oocyte metabolism, has been accumulated. However, these datasets have been explored within the relatively narrow boundaries of their specific subjects. Given the aforementioned gaps in knowledge and their clinical relevance, herein we integrate clinical and basic data, within a wide biological perspective, aiming to shed light on (i) the reasons for the variability in the accuracy of serum FSH and AMH as fertility markers, and on (ii) the potential roles of these hormones in mechanisms regulating oocyte quality, particularly those associated with ageing.

SEARCH METHODS

The PubMed database encompassing the period between 1960 and 2021 was searched. Principal search terms were FSH, FSH receptor, AMH, oocyte, maternal age, cumulus, transzonal projections (TZPs), actin, OS, redox, reactive oxygen species, mitochondria, DNA damage, DNA repair, aneuploidy, spindle, meiosis, gene expression, transcription, translation, oocyte secreted factors (OSFs), cAMP, cyclic guanosine monophosphate, natriuretic peptide C, growth differentiation factor 9, bone morphogenetic protein 15 and fibroblast growth factor.

OUTCOMES

Our analysis suggests that variations in the accuracy of fertility prognosis reflect a modest association between circulatory AMH levels and oocyte quality as well as increasing basal FSH inter-cycle variability with age. In addition, the basic and clinical data articulated herein support the hypothesis that increased intrafollicular FSH levels, as maternal age advances, may override the physiological protective influences of AMH and OSFs against excessive FSH signalling in cumulus cells. This would result in the disruption of oocyte homeostasis via reduced TZP-mediated transfer of cumulus-derived molecules essential for meiotic competence, gene expression, redox activity and DNA repair.

WIDER IMPLICATIONS

In-depth data analysis, encompassing a wide biological perspective has revealed potential causative mechanisms of age-related subfertility triggered by alterations in FSH/AMH signalling during the female reproductive life. Insights from new mechanistic models arising from this analysis should contribute to advancing our comprehension of oocyte biology in humans and serve as a valuable reference for novel AMA subfertility treatments aimed at improving oocyte quality through the modulation of AMH/FSH action.

Discordance between day-3 follicle stimulating hormone & anti-Müllerian hormone is predictive of clinical pregnancy during fertility treatment

OBJECTIVE

To evaluate the role of discordant Day-3 follicle stimulating hormone (FSH) & anti-Müllerian hormone (AMH) levels in predicting pregnancy outcome after controlled ovarian stimulation (COS) followed by intrauterine insemination or timed intercourse.

METHODS

Retrospective study of 745 couples with regular menstrual cycles, at least one patent fallopian tube, and normal semen analysis that underwent infertility treatment between June 2013 and March 2017. Women with documented serum AMH and FSH levels (<10 (mIU/ml were considered normal), and undergo COS were studied. Clinical pregnancy rate is the cumulative pregnancy obtained after maximum of three cycles of COS with or without IUI.

RESULTS

As expected, patients with normal concordant AMH/FSH achieved a significantly (p < .01) higher pregnancy than all other groups. 22.4% of those with discordant normal AMH/abnormal FSH became pregnant while only 10.8% of those with discordant abnormal AMH/normal FSH levels did. 11.7% of patients with abnormal concordant values achieved pregnancy. Patients with discordant abnormal AMH/normal FSH were not statistically different (p = .084) from abnormal concordance AMH/FSH but significantly (p < .01) lower than normal concordant AMH/FSH. However, patients with discordant normal AMH/abnormal FSH were statistically different from both concordant normal and concordant abnormal AMH/FSH values (p < .04).

CONCLUSIONS

This study showed that both discordant abnormal Day-3 FSH and/or abnormal AMH serum levels, as well as concordant abnormal FSH and AMH values, were predictive of lower clinical pregnancy rates after COS. However, abnormal FSH with a normal AMH does not have as poor a prognosis as the presence of an abnormal AMH.

Maternal age affects the relationship of basal FSH and anti-Müllerian hormone concentrations with post-ICSI/IVF live birth

RESEARCH QUESTION

Does the association of basal FSH and anti-Müllerian hormone (AMH) concentrations with post-IVF/intracytoplasmic sperm injection (ICSI) live birth change with maternal age?

DESIGN

A total of 2003 IVF/ICSI patients were stratified according to basal FSH/AMH in concordant favourable (CF; AMH >1 ng/ml and FSH ≤10 IU/l), concordant unfavourable (CU; AMH ≤1 ng/ml and FSH >10 IU/l), discordant with favourable AMH (DFA) and discordant with favourable FSH (DFF) groups, as well as according to age in pre-advanced maternal age (pre-AMA; <35), AMA-1 (≥35, ≤37), AMA-2 (>37, ≤40) and AMA-3 (>40). IVF/ICSI outcomes were compared among CF, CU, DFA and DFF groups, and the association of basal FSH and AMH concentrations with live birth was tested by univariate and multivariate analysis in total, pre-AMA and AMA groups, separately.

RESULTS

Different outcome patterns were observed in discordant AMH/FSH groups from different age categories; favourable basal FSH concentrations were associated with higher delivery rates in pre-AMA patients, but with lower delivery rates in AMA groups. Within pre-AMA patients, DFF patients presented higher delivery rates but lower oocyte yield compared with DFA patients. In the univariate analysis, favourable AMH (P < 0.02) and oocyte yield (P < 0.002) were positively associated with live birth in all AMA groups. The multivariate analysis revealed that favourable basal FSH, but not AMH or oocyte yield, is associated with live birth in pre-AMA patients independently of other variables (P = 0.012).

CONCLUSIONS

The relationship of basal FSH and AMH with IVF/ICSI success changes with maternal age; basal FSH better reflects clinical outcomes probably determined by oocyte quality in pre-AMA patients, while AMH better suits AMA patients.

Role of Antioxidant Natural Products in Management of Infertility: A Review of Their Medicinal Potential

Infertility, a couple's inability to conceive after one year of unprotected regular intercourse, is an important issue in the world. The use of natural products in the treatment of infertility has been considered as a possible alternative to conventional therapies. The present study aimed to investigate the effects and the mechanisms of various natural products on infertility. We collected articles regarding infertility and natural products using the research databases PubMed and Google Scholar. Several natural products possess antioxidant properties and androgenic activities on productive factors and hormones. Antioxidants are the first defense barrier against free radicals produced by oxidative stress (OS). They remove reactive oxygen stress (ROS), reducing insulin resistance, total cholesterol, fat accumulation, and cancer growth. Moreover, various natural products increase endometrial receptivity and fertility ability showing androgenic activities on productive factors and hormones. For example, Angelica keiskei powder and Astragalus mongholicus extract showed anti-infertility efficacies in males and females, respectively. On the other hand, adverse effects and acute toxicity of natural products were also reported. Tripterygium glycoside decreased fertility ability both in males and females. Results indicate that management of infertility with natural products could be beneficial with further clinical trials to evaluate the safety and effect.

Cutting the ovarian surface improves the responsiveness to exogenous hormonal treatment in aged mice

Purpose

Ovarian vascular abnormality and ovarian fibrosis are observed in the low responder patients and aging mice. Vascularization and fibrosis are regulated by injury‐repair system, such as wound. Thus, in this study, the authors tried to investigate the effect of the surgical treatment to ovarian surface with cutting on the functions of ovary in aging mouse model, gcNrg1KO.

Method

The ovarian surface of gcNrg1KO was surgically cut, and then the ovary was returned inside of bursa ovarica. To assess the effect of cutting on fertility, mating test, smear analysis, and exogenous hormonal treatment were done. Additionally, the histological analysis was used for observing the remodeling of ovarian stroma after the surgical approach.

Result

Ovarian fibrosis disappeared at 7 days after surgery. With the abrogation of fibrosis, the blood vessels were fluently observed around the follicles, and the follicular development was re‐started. The responses against exogenous hormone were recovered at 21 days after the surgery, and estrous cycle and delivery were also recovered by the surgery and the fertility was maintained for 3 months.

Conclusion

This cutting method of ovarian surface becomes a good option against low responder patients.

Predictive serum markers for unexplained infertility in child-bearing aged women

PROBLEM

Unexplained infertility (UI) represents about 25%-40% of all infertility and is a formidable obstacle for successful pregnancy for child-bearing aged women. However, up to now, there is no reliable method to predict this condition with high accuracy, thereby hindering early management of this condition.

METHOD OF STUDY

Our prospective study consists of 84 child-bearing aged women that were clinically diagnosed UI. Forty-four matched healthy fertility (HF) women were served as controls. We examined the profiles of 25 hormones and cytokines that were likely related to pathogeneses and molecular pathways involved in UI with the technique of protein array. The samples were randomly stratified 7:3 into a training set and a testing set. We used the SMOTEboost model with 10 serum proteins in a clinical verification study to identify UI cases.

RESULTS

The predictor had an area under the receiver operating characteristic curve (AUC) of 0.788 with 24 serum protein features. The predictive performance in terms of AUC of the model with the top 10 important serum proteins in the clinical verification study to classify UI cases was 0.809. Three most significantly differentially expressed proteins (DEPs) were prolactin, monocyte chemotactic protein-1 (MCP-1), and leptin.

CONCLUSION

Examination of serum-based protein profile changes could help to identify child-bearing aged women at risk of UI. This would enable early detection and facilitate development of clinical strategies to treat UI and guide their planned parenthood. It may also give clues to pathogeneses of the condition of test subjects.

Discordance between antral follicle counts and anti-Müllerian hormone levels in women undergoing in vitro fertilization

BACKGROUND

In general, anti-Müllerian hormone (AMH) is positively associated with antral follicle count (AFC). However, there is often discordance between the AMH level and AFC in clinical practice. In cases of discordance, which indicator should be chosen to predict ovarian response and subsequently develop an ovulation induction protocol? The objective of this study was to investigate which indicator was more accurate in predicting ovarian response and pregnancy outcomes when the AMH level and AFC were discordant.

METHODS

A total of 1121 infertile women undergoing IVF/ICSI were recruited in this study. During the study period, patients were subjected to individualized controlled ovarian hyperstimulation (COH) protocols according to specific characteristics. The AMH levels and AFCs were measured on days 2-3 of the menstrual cycle. Serum samples were obtained to determine AMH levels. Transvaginal ultrasound was performed to determine the AFC. All patients were divided into four groups: Group A had AFCs and AMH levels in the normal range; Group B had normal AFCs and low AMH levels; Group C had low AFCs and normal AMH levels; and Group D had low AFCs and AMH levels.

RESULTS

Two hundred three women (18.11%) showed discordant AFCs and AMH levels. In the two groups with discordant AFCs and AMH levels, namely, Group B and Group C, the oocyte yield, good-quality embryo rate and clinical pregnancy rate were significantly higher in Group B than in Group C. The incidence of poor ovarian response (POR) was significantly lower in Group B than in Group C. According to the stratified analysis of age, for the three categories above the age of 30, oocyte yield was higher in Group B than in Group C. In all age categories, the clinical pregnancy rate was higher in Group B than in Group C.

CONCLUSIONS

Our study demonstrated that approximately one in five patients in clinical practice showed discordance between AFCs and AMH levels. In view of the AFC being better than AMH for predicting POR, the AFC should be the preferred indicator for predicting ovarian response to subsequently develop an optimal individualized COH protocol.

Low antimüllerian hormone (AMH) is associated with decreased live birth after in vitro fertilization when follicle-stimulating hormone and AMH are discordant

OBJECTIVE

To evaluate which factor, AMH or FSH, was superior in predicting live birth after assisted reproductive technologies (ART) when the tests are discordant, using data from the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System database.

DESIGN

Retrospective cohort.

SETTING

Clinic-based data.

PATIENT(S)

The study population included 44,696 fresh embryo transfer cycles using autologous oocytes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth (≥22 wk gestation and ≥300 g birth weight).

RESULT(S)

Live birth rate per started cycle was lower in patients with low AMH and normal FSH than in patients with normal AMH and elevated FSH (26% vs. 39%). A multivariate analysis was performed on patients with normal FSH and low AMH, and the following factors were independently associated with live birth: AMH, age >40 years, body mass index >30 kg/m², race African-American or Asian, IVF clinic region West, uterine factor infertility diagnosis, agonist suppression, and FSH dosage. IVF cycle cancellation rate was higher in patients with low AMH and normal FSH (30%).

CONCLUSION(S)

AMH is a superior predictor of live birth in patients undergoing IVF when FSH and AMH values are discordant. Lower AMH is independently associated with lower live birth and higher IVF cycle cancellation rates than elevated FSH in patients with discordant values.

Discordant anti-müllerian hormone (AMH) and follicle stimulating hormone (FSH) among women undergoing in vitro fertilization (IVF): which one is the better predictor for live birth?

Background

This study sought to clarify the roles of Anti-müllerian hormone (AMH) and follicle stimulating hormone (FSH) in predicting live birth, especially in patients with discordant AMH and FSH. A large IVF data set provided by eIVF®, consisting of 13,964 cycles with AMH, FSH, age, BMI, and birth outcomes were evaluated. Patients were categorized into four groups: Good prognosis group (AMH ≥1 ng/ml; FSH < 10 mIU/ml), Poor prognosis group (AMH < 1 ng/ml; FSH ≥10 mIU/ml), Reassuring AMH group (AMH ≥1 ng/ml; FSH ≥10 mIU/ml), and Reassuring FSH group (AMH < 1 ng/ml; FSH < 10 mIU/ml). The interaction between AMH, FSH, and their impact on live birth rate among these four groups was evaluated using Generalized Additive Mixed Modeling (GAMM).

Results

Analysis revealed a nonlinear relationship of AMH and FSH with live birth rate among all ages. Among the four groups, the good prognosis group had the highest live birth rate while the poor prognosis group had the lowest live birth rate (29.3% vs 13.1%, p < 0.005). In the discordant groups, the live birth rate of the reassuring AMH group was significantly higher than the reassuring FSH group (22.8% vs 15.6%, p < 0.005).

Conclusions

Although both FSH and AMH are widely use to assess the ovarian reserve in women undergoing evaluation for infertility, AMH appears to be superior to FSH among all age groups. This is particularly important for patients with discordant AMH and FSH where reassuring AMH is a better clinical predictor of cycle success.

Electronic supplementary material

The online version of this article (10.1186/s13048-018-0430-z) contains supplementary material, which is available to authorized users.

Reproductive ovarian testing and the alphabet soup of diagnoses: DOR, POI, POF, POR, and FOR

There are large variations in the number of oocytes within each woman, and biologically, the total quantity is at its maximum before the woman is born. Scientific knowledge is limited about factors controlling the oocyte pool and how to measure it. Within fertility clinics, there is no uniform agreement on the diagnostic criteria for each common measure of ovarian reserve in women, and thus, studies often conflict. While declining oocyte quantity/quality is a normal physiologic occurrence as women age, some women experience diminished ovarian reserve (DOR) much earlier than usual and become prematurely infertile. Key clinical features of DOR are the presence of regular menstrual periods and abnormal-but-not-postmenopausal ovarian reserve test results. A common clinical challenge is counseling patients with conflicting ovarian reserve test results. The clinical diagnosis of DOR and the interpretation of ovarian reserve testing are complicated by changing lab testing options and processing for anti-mullerian hormone since 2010. Further, complicating the diagnostic and research scenario is the existence of other distinct yet related clinical terms, specifically premature ovarian failure, primary ovarian insufficiency, poor ovarian response, and functional ovarian reserve. The similarities and differences between the definitions of DOR with each of these four terms are reviewed. We recommend greater medical community involvement in terminology decisions, and the addition of DOR-specific medical subject-heading search terms.

What are the likely IVF/ICSI outcomes if there is a discrepancy between serum AMH and FSH levels? A multicenter retrospective study

OBJECTIVE

The principal outcome was to assess the ovarian response to controlled hyperstimulation during in vitro fertilization (IVF) with or without micro-injection (ICSI) in patients whom ovarian reserve testing revealed a discrepancy between the serum levels of FSH and AMH. The secondary outcome was to determine whether AMH and FSH profiles could predict the IVF/ICSI response.

STUDY DESIGN

This was a multicenter, retrospective study analysing all controlled ovarian hyperstimulation cycles with attempted fresh embryo transfer(s) carried out during IVF/ICSI treatment and in which the AMH level had been assayed between January 01, 2008 and December 31, 2011. This enabled us to form 2 control groups (NOR, normal ovarian reserve: normal AMH and FSH and DOR, diminished ovarian reserve: diminished AMH, increased FSH) and 2 study groups (DAMH: diminished AMH, normal FSH and NAMH: normal AMH, increased FSH). The principal assessment criterion was quantitative ovarian response to stimulation defined by the mean number of oocytes punctured, the secondary assessment criterion the qualitative response to stimulation defined by the pregnancy rate per cycle.

RESULTS

We were able to analyse 1803 stimulation cycles. The mean number of oocytes punctured was significantly reduced in the DAMH and DOR groups compared to the NAMH and NOR groups (5.2±3.9 and 4.1±3.3 vs. 11.5±7 and 9.5±5.6, respectively [P<0.01]). The pregnancy rate per initiated cycle was significantly reduced in the DAMH and DOR groups compared to the NAMH and NOR groups (20% and 24% vs. 32 and 35%, respectively [P<0.01]). Live birth rates did not differ between the groups however. Multivariate analysis with logistic regression revealed that AMH, FSH and age independently had an effect on the number of oocytes punctured, although the effect exerted by AMH seemed to be preponderant (OR: 2.75: 95%CI [2.39-3.19]). AMH appeared to be the sole factor independently predictive of pregnancy per cycle.

CONCLUSION

The serum AMH level appears to provide an additional item of discriminatory information, which should not be overlooked. Ovarian reserve work-up should include routine AMH assay.

The role of gene polymorphisms and AMH level in prediction of poor ovarian response in Egyptian women undergoing IVF procedure

OBJECTIVE

The aim of this study is to assess the role of AMH in prediction of poor ovarian response as well as the relation between ESR ₂ (+ 1730G>A) (rs4986938) and FSHR p.Thr³⁰⁷Ala (c.919A>G, rs6165) SNPs and the poor ovarian response in Egyptian women undergoing IVF procedure. Discovering the genetic variants associated with ovarian response is an important step towards individualized pharmacogenetic protocols of ovarian stimulation.

METHODS

We performed a prospective study on 216 young women with unexplained infertility. Ovarian stimulation was performed according to the GnRH antagonist protocol with a fixed daily morning dose of human menopausal gonadotrophin (HMG). The estrogen receptor (ESR2) (+ 1730G>A) (rs4986938) and FSH receptor p.Thr307Ala (c.919A>G, rs6165) single nucleotide polymorphisms (SNPs) were detected by real-time polymerase chain reaction. Serum FSH, Estradiol (E2) and anti-Müllerian hormone (AMH) levels were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

This study revealed that the low AMH level was highly significantly related to the poor ovarian response (p < 0.001). Furthermore, the frequency of the ESR2 (AA) genotype and the FSHR (Ala³⁰⁷Ala) genotypes were highly significantly associated with the poor ovarian response (p < 0.001).

CONCLUSION

The AMH level in combination with the ESR2 and the FSHR gene polymorphisms predict the poor ovarian response to COH in Egyptian women.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02640976.

Ovarian reserve testing: a user's guide

Ovarian reserve is a complex clinical phenomenon influenced by age, genetics, and environmental variables. Although it is challenging to predict the rate of an individual's ovarian reserve decline, clinicians are often asked for advice about fertility potential and/or recommendations regarding the pursuit of fertility treatment options. The purpose of this review is to summarize the state-of-the-art of ovarian reserve testing, providing a guide for the obstetrician/gynecologist generalist and reproductive endocrinologist. The ideal ovarian reserve test should be convenient, be reproducible, display little if any intracycle and intercycle variability, and demonstrate high specificity to minimize the risk of wrongly diagnosing women as having diminished ovarian reserve and accurately identify those at greatest risk of developing ovarian hyperstimulation prior to fertility treatment. Evaluation of ovarian reserve can help to identify patients who will have poor response or hyperresponse to ovarian stimulation for assisted reproductive technology. Ovarian reserve testing should allow individualization of treatment protocols to achieve optimal response while minimizing safety risks. Ovarian reserve testing may inform patients regarding their reproductive lifespan and menopausal timing as well as aid in the counselling and selection of treatment for female cancer patients of reproductive age who receive gonadotoxic therapy. In addition, it may aid in establishing the diagnosis of polycystic ovary syndrome and provide insight into its severity. While there is currently no perfect ovarian reserve test, both antral follicular count and antimüllerian hormone have good predictive value and are superior to day-3 follicle-stimulating hormone. The convenience of untimed sampling, age-specific values, availability of an automated platform, and potential standardization of antimüllerian hormone assay make this test the preferred biomarker for the evaluation of ovarian reserve in women.

Weight loss in obese girls with polycystic ovarian syndrome is associated with a decrease in Anti-Muellerian Hormone concentrations

OBJECTIVE

The Anti-Muellerian Hormone (AMH) has been reported as surrogate marker of antral follicles, which are the origins of hyperandrogenism in polycystic ovarian syndrome (PCOS). Therefore, AMH may be useful for the diagnosis of PCOS. The objective was to study the longitudinal changes in AMH concentrations in girls with and without PCOS.

DESIGN

This is a longitudinal study of obese girls participating in a 1-year lifestyle intervention.

PATIENTS

Forty obese girls aged 13-16 years (50% with PCOS) were included in the study. Girls with and without PCOS were matched to age, BMI and change in weight status.

MEASUREMENTS

AMH, gonadotropins, androstenedione, testosterone, oestradiol and sex hormone-binding globulin (SHBG) were determined.

RESULTS

Obese girls with PCOS demonstrated significantly (P<.001) higher AMH concentrations (5.8±3.1 ng/mL) compared to obese girls without PCOS (2.4±1.4 ng/mL). None of the girls without PCOS had AMH concentrations ≥6 ng/mL and none of the PCOS girls showed AMH concentrations ≤3 ng/mL. Weight loss in girls with PCOS was associated with a significant drop in AMH concentrations (-1.4±1.8 ng/mL, P=.045). AMH was significantly related to testosterone (cross-sectional: b-coefficient 3.7±1.7, P=.001, longitudinal: b-coefficient 0.54±0.47, P=.026) and luteinizing hormone (LH) (cross-sectional: b-coefficient 0.05±0.04, P=.039, longitudinal: b-coefficient 0.005±0.004, P=.039), but not to any other analysed parameter in multiple linear regression analyses adjusted to multiple confounders.

CONCLUSIONS

AMH was increased in adolescent girls with PCOS and normalized with weight loss. AMH was cross-sectionally and longitudinally related to hyperandrogenism.

Circulating Anti-Müllerian Hormone Levels in Daughters of Women with and without Polycystic Ovary Syndrome

BACKGROUND/AIMS

The aim of this study was to assess whether circulating anti-Müllerian hormone (AMH) levels in daughters of women with polycystic ovary syndrome (PCOSd) correspond with clinical and biochemical features of hyperandrogenism, polycystic ovary morphology and menstrual cycle disturbances.

METHODS

Menstrual cycle disturbances, hirsutism, acne and ultrasonographic ovarian morphology were assessed in 75 girls aged 13-18 years (35 PCOSd and 40 daughters of healthy women). Serum gonadotropins, androgens, sex hormone-binding globulin and plasma AMH were measured in a fasting state, and the free androgen index was calculated.

RESULTS

A significant correlation between the AMH level and mean ovary volume was found (r = 0.36; p < 0.01). AMH levels were not related to hirsutism, acne and polycystic ovary morphology. Significantly higher AMH levels were found only in PCOSd with irregular menstruation or secondary amenorrhea. The results of logistic regression analysis showed that in that group for each 1-ng/ml increase in the AMH level, the odds ratio of the PCOS occurrence in the future was increased 1.27 times (95% CI: 1.09-1.47; p < 0.01).

CONCLUSIONS

A higher AMH level in PCOSd is associated with menstrual cycle disturbances and larger ovarian volume but not with clinical and biochemical features of hyperandrogenism. Thus, the risk for PCOS development among genetically predisposed girls may be related to increased AMH levels.

Chinese medicine as complementary therapy for female infertility

Chinese medicine (CM) has been used in clinical treatment for thousands of years in China, Japan, Korea, and other countries. CM is at present attracting many attentions around the world for reproductive health care and disease prevention, including treatment of female infertility. This review focuses on the CM treatment for female infertility patients, and supplies a summary on the efficacy, safety, and mechanism of some Chinese herbal medicines, herbal medicine-derived active compounds, and acupuncture. A large number of researches have reported that CM could alleviate or even cure female infertility by regulating hormone, improving reproductive outcome of in vivo fertilization, affecting embryonic implantation, curing polycystic ovarian syndrome, endometriosis, pelvic inflammatory disease, relieving mental stress, and regulating immune system. Meanwhile, a few studies claimed that there was little adverse reaction of CM in randomized controlled trials. However, up to present there is a lack of adequate evidences with molecular mechanistic researches and randomized controlled trials to prove the CM as an effective and safe treatment for infertility. Thus, utility of CM as a complementary medicine will be a feasible method to improve the outcome of female infertility treatment.

Mechanistic Study on Triptorelin Action in Protecting From 5-FU-Induced Ovarian Damage in Rats

Triptorelin, a kind of GnRH agonist, is widely used in the treatment of hormone-responsive cancers in the clinic. This study aimed to discover the underlying mechanism of triptorelin in protection from 5-fluorouracil (5-FU)-induced ovarian damage in Sprague–Dawley rats. In the present study, after using 5-FU to induce ovarian damage in rats, body weight and wet ovaries were weighed, the levels of estradiol (E2), follicle-stimulating hormone (FSH), and anti-Müllerian hormone (AMH) in blood were detected, and the expression of Bcl-2, Bax, and NF-κB was determined. It suggested that, compared to the control, body weight gain, the ratio of ovarian wet weight to body weight, primary follicle numbers, and the levels of AMH were significantly decreased, while the concentration of E2 and FSH was heavily increased following 5-FU administration. In contrast, after coadministration of triptorelin with 5-FU, the ratio of ovarian wet weight to body weight and the levels of AMH were significantly increased, whereas the level of E2 and FSH was decreased significantly when compared with the 5-FU group. Furthermore, at indicated times, 5-FU led to the reduced Bcl-2 and NF-κB expression and increased Bax expression while triptorelin plus 5-FU increased Bcl-2 and NF-κB expression and decreased Bax expression. It was indicated that triptorelin could protect rats from 5-FU-induced ovarian damage by modulation of hormones, Bcl-2, Bax, and NF-κB. These results might highlight the mechanism of triptorelin as a protective agent in clinical chemotherapy for ovarian damage.

Assessment of the Access AMH assay as an automated, high-performance replacement for the AMH Generation II manual ELISA

BACKGROUND

The manual Generation II (Gen II) ELISA method used to measure Anti-Müllerian Hormone (AMH) from Beckman Coulter has recently been superseded by a fully automated AMH immunoassay. The aim of this study was to evaluate the performance of the Access AMH assay and directly compare it to the modified Gen II ELISA method. A secondary aim was to verify that the fertile age-related AMH range previously established using the Gen II ELISA could be used to interpret results from the new automated Access assay.

METHODS

The precision, stability, linearity, measurement range and detection limits were determined using recombinant AMH and patient serum samples. Different diluents and their effects on AMH concentration were compared. A correlation study was performed on patient samples to compare the Access AMH assay to the ELISA method on the Access2 and DxI800 analysers. The fertile AMH range was verified by comparing the 10th, 50th and 90th percentile values from both methods obtained from 489 natural conception pregnant women.

RESULTS

The Access AMH assay showed good performance across the measuring range for both intra-assay (CV 1.41-3.30 %) and inter-assay (CV 3.04-5.76 %) precision and acceptable sample stability. Dilution of the high concentration samples with the recommended diluent resulted in a small but significant downward shift in values. The assay was linear over the range of values recommended by the manufacturer, allowing for accurate reporting within the reported range. The two assay types were highly correlated (R(2) = 0.9822 and 0.9832 for Access2 and DxI800, respectively), and the differences observed between the Access2 and DxI800 analysers were within clinically acceptable ranges, indicating that the methods are interchangeable. Furthermore, we demonstrated that results from the published reference range for the Gen II ELISA correlate with those from the automated Access AMH assay.

CONCLUSION

Here, we verified the published performance of the Access AMH assay and showed excellent correlation with the Gen II ELISA method. Moreover, we validated this correlation by confirming that the results from a fertile AMH reference range established using the preceding Gen II ELISA are interchangeable with the new automated Access AMH assay.

Ovarian response and cumulative live birth rate of women undergoing in-vitro fertilisation who had discordant anti-Mullerian hormone and antral follicle count measurements: a retrospective study

OBJECTIVE

To evaluate ovarian response and cumulative live birth rate of women undergoing in-vitro fertilization (IVF) treatment who had discordant baseline serum anti-Mullerian hormone (AMH) level and antral follicle count (AFC).

METHODS

This is a retrospective cohort study on 1,046 women undergoing the first IVF cycle in Queen Mary Hospital, Hong Kong. Subjects receiving standard IVF treatment with the GnRH agonist long protocol were classified according to their quartiles of baseline AMH and AFC measurements after GnRH agonist down-regulation and before commencing ovarian stimulation. The number of retrieved oocytes, ovarian sensitivity index (OSI) and cumulative live-birth rate for each classification category were compared.

RESULTS

Among our studied subjects, 32.2% were discordant in their AMH and AFC quartiles. Among them, those having higher AMH within the same AFC quartile had higher number of retrieved oocytes and cumulative live-birth rate. Subjects discordant in AMH and AFC had intermediate OSI which differed significantly compared to those concordant in AMH and AFC on either end. OSI of those discordant in AMH and AFC did not differ significantly whether either AMH or AFC quartile was higher than the other.

CONCLUSIONS

When AMH and AFC are discordant, the ovarian responsiveness is intermediate between that when both are concordant on either end. Women having higher AMH within the same AFC quartile had higher number of retrieved oocytes and cumulative live-birth rate.

Discrepancies between Antimullerian Hormone and Follicle Stimulating Hormone in Assisted Reproduction

Data from 107 women undergoing their first IVF/ICSI were analyzed. Relationships between antimullerian hormone (AMH) and follicle stimulating hormone (FSH) were analyzed after dividing patients into four groups according to AMH/FSH levels. Concordance was noted in 57% of women (both AMH/FSH either normal or abnormal) while 43%of women had discordant values (AMH/FSH one hormone normal and the other abnormal). Group 1 (AMH and FSH in normal range) and group 2 (normal AMH and high FSH) were younger compared to group 3 (low AMH and normal FSH) and group 4 (both AMH/FSH abnormal). Group 1 showing the best oocyte yield was compared to the remaining three groups. Groups 3 and 4 required higher dose of gonadotrophins for controlled ovarian hyperstimulation showing their low ovarian reserve. There was no difference in cycle cancellation, clinical pregnancy, and live birth/ongoing pregnancy rate in all groups. These tests are useful to predict ovarian response but whether AMH is a substantially better predictor is not yet established.

Chronological age vs biological age: an age-related normogram for antral follicle count, FSH and anti-Mullerian hormone

Objective

To evaluate the correlation between chronological and biological age by comparing the normograms of AFC, AMH, and FSH.

Design

Retrospective study

Setting

Data were taken from patients who visited the Infertility Clinic at Dr. Cipto Mangunkusumo General Hospital Jakarta, Indonesia, between January 2008 and December 2010.

Patient(s)

Infertile women who visited the Infertility Clinic.

Intervention(s)

None.

Main Outcome Measure(s)

Normogram of AFC (n = 366), AMH (n = 1616) and FSH (n = 415).

Result(s)

The correlations among AFC, AMH, FSH, and age are statistically significant. Normograms of AFC and AMH with 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles showed a decrease in age where FSH increased. A cut-off value of AFC, AMH, and FSH for poor responders was plotted at the 50th percentile of each normogram. Serum AMH and AFC started to decline in women between 34 and 35 years old. We found a relatively lower slope increase of FSH in older patients compared to that of AFC and AMH. FSH was observed to be a later predictor of biological age than AMH and AFC.

Conclusion(s)

AMH predicted biological age earlier than FSH or AFC. Normograms can provide a reference guide for physicians to counsel infertile women. However, future validation with longitudinal data is still needed.

Clinical relevance of combined FSH and AMH observations in infertile women

CONTEXT

FSH and anti-Müllerian hormone (AMH) are, individually, widely used to assess functional ovarian reserve (FOR) but demonstrate discrepancies in efficacy. How predictive they are combined is unknown.

OBJECTIVE

The purpose of this study was to assess predictive values of different FSH and AMH combinations on in vitro fertilization (IVF).

DESIGN AND SETTING

FSH and AMH levels in patients were categorized as low, normal, and high, based on age-specific 95% confidence intervals. This allowed for establishment of nine combinations of low, normal, or high FSH/AMH patient categories. With use of various statistical methods, patients in individual categories were then compared in outcomes.

PATIENTS

We investigated 544 consecutive infertility patients in their first IVF cycles.

INTERVENTIONS

IVF cycles were managed.

MAIN OUTCOME MEASURES

Oocyte yields and implantation and pregnancy rates, adjusted for age and fragile X mental retardation 1 (FMR1) genotypes/subgenotypes, were measured.

RESULTS

The most notable repeated finding was a strong statistical association of the FSH/AMH high/high category (characterized by abnormally high FSH and AMH levels) with favorable IVF outcomes compared with outcomes for other FSH/AMH variations (4.34 times odds of high oocyte yields and 1.93 times odds of clinical pregnancy). Addition of age to the model only minimally further improved the odds of pregnancy to 2.03 times. The positive association with high oocyte yields, however, turned negative (0.75 times lower yields) with addition of FMR1 to the model for women with FSH/AMH high/high and the het-norm/low FMR1 subgenotype compared with women with the norm FMR1 genotype and other FSH/AMH categories.

CONCLUSIONS

In the absence of het-norm/low FMR1, abnormally high FSH and AMH, a seemingly contradictory combination, reflects highly beneficial outcomes in IVF compared with the other FSH/AMH categories, suggesting greater importance of FSH in early follicle maturation than currently recognized. The study also confirms adverse outcome effects of het-norm/low FMR1 and, therefore, the gene's importance for reproductive success.

Does hormonal contraception prior to in vitro fertilization (IVF) negatively affect oocyte yields? A pilot study

BACKGROUND

As oral contraceptives (OCs) suppress anti-Müllerian hormone (AMH), and hormonal contraceptives (HCs), likely, suppress functional ovarian reserve, this study was initiated to determine whether HC affect oocyte yields.

METHODS

We investigated in a retrospective cohort study 43 oocyte donors in 71 in vitro fertilization (IVF) cycles, evaluating anti-Müllerian hormone (AMH) and oocyte yields as reflections of functional ovarian reserve (OR). In 25 IVF cycles egg donors were on HC within one month prior to IVF, and in 46 cycles they were not. Donors, based on their HCs, were further subdivided into 12 with less, and 13 with more androgenic progestins.

RESULTS

While the three groups did not differ in age, age at menarche, BMI and AMH, oocyte yields among donors who utilized estrane- and gonane-derived (higher androgenic) HCs were lower 11.3 (95% CI 8.3 - 14.3) than either donors using no HCs 16.6 (95% CI 14.7 -18.4) (P < 0.05) or those using anti-androgenic HCs 19.0 (95% CI 12.2-25.8) (P< 0.01). Significance was maintained after adjustments for the donor age and total FSH dose used in ovulation induction.

CONCLUSIONS

Even in young oocyte donors, high androgenic OC exposure appears to suppress functional ovarian reserve and oocyte yields. Since OCs are often routinely used in preparation for IVF, such practice may require reevaluation. Especially in women with diminished ovarian reserve OCs, and especially high androgenic progestin HCs, should, likely, be avoided.

The impact of androgen metabolism and FMR1 genotypes on pregnancy potential in women with dehydroepiandrosterone (DHEA) supplementation

BACKGROUND

For decades androgens have been considered detrimental to follicle maturation. Animal studies now suggest that they are essential for normal folliculogenesis. Especially in women with premature ovarian aging (POA), recent IVF data in humans are supportive. The literature also suggests an association between recently reported ovarian genotypes of the FMR1 gene and ovarian aging patterns. We, therefore, attempted to determine a potential difference in androgen concentrations and androgen interactions in women with POA who do or do not become pregnant while undergoing androgen supplementation, and whether androgen concentrations and pregnancy chances are affected by FMR1 genotypes.

METHODS

We longitudinally assessed androgen metabolism in 91 women with POA, following pre-supplementation with micronized dehydroepiandrosterone (DHEA) prior to IVF. IVF outcomes were assessed based on androgen levels and ovarian FMR1 genotypes.

RESULTS

The mean age of the women was 39.8 ± 4.4 years; the clinical pregnancy rate was 25.3%. Total androgen concentrations were not associated with pregnancy; however, in women with abnormal FMR1 genotypes, but not those with the normal genotype, free testosterone significantly affected clinical pregnancy potential (β = 1.101, SE ± 0.508, P = 0.03). At the start of the IVF cycle, interactions of DHEA with total and free testosterone also significantly affected subsequent pregnancy rates (β = -0.058, SE ± 0.023, P = 0.01 and β = -0.496, SE ± 0.197, P = 0.012).

CONCLUSIONS

Androgen interactions significantly influence IVF pregnancy rates in women with POA, with the impact of total androgens on cycle outcomes varying according to FMR1 genotypes. These observations suggest that the effectiveness of androgen supplementation in women with POA varies based on FMR1 genotypes, and defines androgen deficiency as a subset of diminished ovarian reserve.

High frequency of discordance between antimüllerian hormone and follicle-stimulating hormone levels in serum from estradiol-confirmed days 2 to 4 of the menstrual cycle from 5,354 women in U.S. fertility centers

OBJECTIVE

To determine the frequency of clinical discordance between antimüllerian hormone (AMH, ng/mL) and follicle-stimulating hormone (FSH, IU/L) by use of cut points defined by response to controlled ovarian stimulation in the same serum samples drawn on estradiol-confirmed, menstrual cycle days 2 to 4.

DESIGN

Retrospective analysis.

SETTING

Fertility centers in 30 U.S. states and a single reference laboratory with uniform testing protocols.

PATIENT(S)

5,354 women, 20 to 45 years of age.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Frequency of discordance between serum AMH and FSH values.

RESULT(S)

Of the 5,354 women tested, 1 in 5 had discordant AMH and FSH values defined as AMH <0.8 (concerning) with FSH <10 (reassuring) or AMH ≥ 0.8 (reassuring) with FSH ≥ 10 (concerning). Of the women with reassuring FSH values (n = 4,469), the concerning AMH values were found in 1 in 5 women in a highly age-dependent fashion, ranging from 1 in 11 women under 35 years of age to 1 in 3 women above 40 years of age. On the other hand, of the women with reassuring AMH values (n = 3,742), 1 in 18 had concerning FSH values, a frequency that did not vary in a statistically significant fashion by age.

CONCLUSION(S)

Clinical discordance in serum AMH and FSH values was frequent and age dependent using common clinical cut points, a large patient population, one reference laboratory, and uniform testing methodology. This conclusion is generalizable to women undergoing fertility evaluation, although AMH testing has not been standardized among laboratories, and the cut points presented are specific to the laboratory in this study.

Follicle stimulating hormone and anti-Müllerian hormone per oocyte in predicting in vitro fertilization pregnancy in high responders: a cohort study

Background

Follicle stimulating hormone (FSH) and Anti-Müllerian hormone (AMH) are utilized to differentiate between good and poor response to controlled ovarian hyperstimulation. Their respective roles in defining functional ovarian reserve remain, however, to be elucidated. To better understand those we investigated AMH and FSH per oocyte retrieved (AMHo and FSHo).

Methodology/Principal Findings

Three-hundred and ninety-six women, undergoing first in vitro fertilization cycles, were retrospectively evaluated. Women with oocyte yields >75^th percentile for their age group were identified as high responders. In a series of logistic regression analyses, AMHo and FSHo levels were then evaluated as predictive factors for pregnancy potential in high responders. Patients presented with a mean age of 38.0±5.0 years, mean baseline FSH of 11.8±8.7 mIU/mL and mean AMH of 1.6±2.1 ng/mL. Those 88 women, who qualified as high responders, showed mean FSH of 9.7±6.5 mIU/mL, AMH of 3.1±3.1 ng/mL and oocyte yields of 15.8±7.1. Baseline FSH and AMH did not predict pregnancy in high responders. However, a statistically significant association between FSHo and pregnancy was observed in high responders, both after univariate regression (p = 0.02) and when adjusted for age, percentage of usable embryos, and number of embryos transferred (p = 0.03). Rate of useable embryos also significantly affected pregnancy outcome independently of FSHo (p = 0.01). AMHo was also associated with clinical pregnancy chances in high responders (p = 0.03) and remained significant when adjusted for usable embryos and number of embryos transferred (p = 0.04).

Conclusions

AMHo and FSHo are predictive of pregnancy potential in high responders, but likely reflect different responsibilities in recruitment and maturation of growing follicle cohorts.

[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 as a predictive marker of polycystic ovarian syndrome

Background

The anti-Müllerian hormone (AMH) is a dimeric protein secreted by the female ovaries and has two fundamental roles in follicle genesis. It delays the entrance of the primordial follicle into the pool of follicles in growth and diminishes the sensitivity of the ovarian follicle towards follicle-stimulating hormone (FSH). The purpose of this work was to study the AMH (nv 2.0–6.8 ng/mL) as a marker during assisted reproductive technology (ART), in order to identify cases of infertility due to polycystic ovarian syndrome (PCOS). This syndrome affects 10% of women with infertility problems, and a new biological marker could be useful to general practitioners of internal medicine to help generate the suspicion of PCOS so that they can refer the patient to the gynecologist for confirmation.

Methods

This study enrolled 236 patients aged 26–46 years undergoing assisted reproductive technology at the Institute for Maternal and Child Health, Trieste, Italy. On the third day of the ovarian cycle, the patients were given doses of AMH, FSH, and luteinizing hormone (LH, in cases of AMH < 2.0–6.8 ng/mL). A control pelvic ultrasound was also carried out.

Results

We identified 57 patients who were starting in vitro fertilization or embryo transfer with AMH values within the normal range (3.64 ± 1.51 ng/mL), 77 with values below normal (1.38 ± 0.32 ng/mL), and 96 cases with undetectable values of AMH. Six patients had very high AMH levels (10.0 ± 2.28 ng/mL) and, of these, five were found to have PCOS on pelvic ultrasound examination (P < 0.05). We also found inverse correlations between AMH levels and age (r = −0.52) and between AMH and FSH levels (r = −0.32).

Conclusion

In clinical practice it is common to encounter patients who turn to medicine in search of a cure for female infertility. In our experience, AMH two or three times the normal amount (10 ± 2.28 ng/mL), is a good indication of PCOS and infertility.

Defining ovarian reserve to better understand ovarian aging

Though a widely utilized term and clinical concept, ovarian reserve (OR) has been only inadequately defined. Based on Medline and PubMed searches we here define OR in its various components, review genetic control of OR, with special emphasis on the FMR1 gene, and discuss whether diminished OR (DOR) is treatable. What is generally referred to as OR reflects only a small portion of total OR (TOR), a pool of growing (recruited) follicles (GFs) at different stages of maturation. Functional OR (FOR) depends on size of the follicle pool at menarche and the follicle recruitment rate. Both vary between individuals and, at least partially, are under genetic control. The FMR1 gene plays a role in defining FOR at all ages. Infertility treatments have in the past almost exclusively only centered on the last two weeks of folliculogenesis, the gonadotropin-sensitive phase. Expansions of treatments into earlier stages of maturation will offer opportunity to significantly improve ovarian stimulation protocols, especially in women with DOR. Dehydroepiandrosterone (DHEA) may represent a first such intervention. Data generated in DHEA-supplemented women, indeed, suggest a new ovarian aging concept, based on aging of ovarian environments and not, as currently is believed, aging oocytes.