Antimüllerian hormone levels are strongly associated with live-birth rates after assisted reproduction

Anti-Müllerian hormone a surrogate of follicular fluid oxidative stress in polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women at childbearing age. Anti-Müllerian hormone (AMH) is a widely accepted sensitive marker of ovarian reserve, which has been suggested that could also act as biomarker of ovarian morphology for PCOS diagnosis. Oxidative stress (OS) is known to be associated and have a negative impact factor in several reproductive conditions, including PCOS. However, the relationship between circulating AMH and OS within the follicular fluid (FF), and its potential impact on in vitro fertilization (IVF) outcomes of women with PCOS, remains largely unexplored. A total of 84 women, with PCOS (n = 30) or ovulatory controls (n = 54), were enrolled in this study. Women underwent individualized controlled ovarian stimulation for oocyte retrieval. Blood and FF obtained from mature follicles were collected at the time of oocyte retrieval, for measuring total testosterone, ∆4-androstenedione, progesterone, sex hormone binding globulin (SHBG) and AMH. OS in the FF was assessed by measuring total antioxidant capacity (TAC) through the ferric reducing antioxidant power (FRAP) and lipid peroxidation (LPO) by quantification of malondialdehyde (MDA) levels. Our results demonstrated that women with PCOS had significantly higher plasma levels of AMH, ∆4-androstenedione, total testosterone and a free androgen index (FAI) than observed in non-PCOS controls. In women with PCOS, total testosterone and AMH levels in the FF were also higher, while TAC was lower compared to non-PCOS. Furthermore, circulating AMH levels were positively correlated with ∆4-androstenedione, albeit negatively correlated with TAC. In this study we demonstrated that the susceptibility to OS, as assessed by the total antioxidant capacity in the FF, is higher in women with PCOS and inversely related to AMH levels. This study results lead us to forge the reasonable hypothesis that the greater susceptibility to OS within the follicle microenvironment is potentially at the end of a roadway that starts with elevated ∆4-androstenedione and AMH within the FF, which in turn are mirrored by circulating AMH and androgen levels. Thus, suggesting that circulating AMH levels could act as a surrogate biomarker of follicular fluid oxidative stress in women with PCOS.

Predictive model of IVF outcomes for polycystic ovarian morphology and polycystic ovary syndrome in GnRH antagonist protocol using AMH-MoM and ovarian sensitivity index

AIM

To evaluate the relationship between AMH and ovarian response to controlled ovarian hyperstimulation in women with PCOM and PCOS.

METHODS

A retrospective study was conducted on 559 patients who underwent the IVF-ET cycle between January 2018 and December 2022 at Gangnam Cha Hospital. Patients were divided into 3 groups matched for age and BMI: the PCOS group (n = 54), based on the new 2023 PCOS guideline; the PCOM group (n = 53); and the control group (n = 452) with normal ovaries. Serum AMH levels were converted to multiples of the median (MoM) for each corresponding age. The ovarian sensitivity index (OSI) was calculated as the number of retrieved oocytes divided by the total dose of recombinant FSH administered (per 1000 IU).

RESULTS

There were significant differences in AMH-MoM value among women with PCOS [2.7 ± 1.3 (95% CI 2.3-3.0)], those with PCOM [2.0 ± 1.0 (95% CI 1.7-2.3)], and controls [0.8 ± 0.7 (95% CI 0.8-0.9)] (p < 0.001). The abortion rates in the normoovulatory, PCOM, and PCOS groups were 18.2%, 21.1%, and 25.0%, respectively. OSI and live birth rate were positively correlated with the AMH-MoM value in normoovulatory women (r = 0.389, p < 0.05, r = 0.122, p < 0.05), while no such correlation was observed in women with PCOM and PCOS.

CONCLUSIONS

Ovarian response and live birth rate are possibly correlated with the AMH-MoM value in normoovulatory women, but not in women with PCOM and PCOS.

Ovarian response to controlled stimulation and its predictors in a limited-resource setting

BACKGROUND

Infertility remains a serious health concern for Ethiopian women. Most of its treatment approaches entail controlled ovarian stimulation, the responses of which vary. However, there are no data on ovarian response to stimulation or its predictors in our situation. Thus, the current study aimed to assess the ovarian response to controlled stimulation and identify predictors.

METHODS

A retrospective follow-up study was undertaken from April 1, 2021, to March 31, 2022, among patients who had first-cycle controlled ovarian stimulation at St.Paul's Hospital Fertility Center in Addis Ababa, Ethiopia. Clinical data were extracted using a checklist. SPSS-26 for data analysis and Epidata-4.2 for data entry were employed. The binary logistic regression model was fitted. A p-value < 0.05 indicated a significant association. The ROC curve was used to determine cutoff values and identify accurate predictors.

RESULTS

A total of 412 study participants were included in the final analysis. The patients had a mean age of 32.3 ± 5.1 years (range: 20 - 4). The good ovarian response rate was 67% (95% CI: 62.2-71.5). An anti-Mullerian hormone (AMH) concentration < 1.2ng/ml (AOR = 0.19, 95% CI (0.06-0.57)), an antral follicle count (AFC) < 5 (AOR = 0.16, 95% CI (0.05-0.56)), and an induction length < 10 days (AOR = 0.23, 95% CI (0.06-0.93)) were significantly associated with ovarian response. The prediction accuracies for the AFC and AMH concentrations were 0.844 and 0.719, respectively. The optimal cutoff point for prediction was 5.5 AFC, which had a sensitivity of 77.2% and a specificity of 72.8%. However, its positive and negative predictive values were 85.2% and 61.1%, respectively. For AMH, the optimal cutoff value was 0.71ng/mL, with a corresponding sensitivity and specificity of 65.2% and 66%. At this value, the positive and negative predictive values were 63.8% and 67.3%, respectively.

CONCLUSION

Only two-thirds of our patients achieved a good ovarian response. Induction duration, AMH concentration, and AFC were found to be predictors, with the AFC being the strongest predictor. Therefore, the AFC should be performed on all of our patients, and the AMH is selectively employed. Future research must verify the best cutoff points and investigate additional factors affecting ovarian response.

Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

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-Mullerian Hormone and Fertility Treatment Decisions in Polycystic Ovary Syndrome: A Literature Review

Anti-Mullerian hormone is a robust marker of ovarian reserve and ovarian response in in vitro fertilisation (IVF). However, its role extends beyond improving the safety of IVF by aiding in choosing appropriate protocols and dosing. This review looks at the value of pre-treatment anti-Mullerian hormone (AMH) value in choosing the appropriate modality of treatment and its predictive ability for the outcomes of such treatment. It briefly addresses the factors that may modulate AMH levels and make clinical decision-making challenging.

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.

High anti-Mullerian hormone level is adversely associated with cumulative live birth rates of two embryo transfers after the first initiated cycle in patients with polycystic ovary syndrome

Objective

Anti-Mullerian hormone (AMH) has been recently identified as a potential predictor of live birth rates (LBRs) following assisted reproductive technology (ART) treatment. This study aimed to investigate the association between AMH levels and the outcomes of in vitro fertilization (IVF) in patients with polycystic ovary syndrome (PCOS).

Methods

Patients with PCOS initiating their first ovarian stimulation under the gonadotropin-releasing hormone antagonist protocol at the Guangdong Women and Children Hospital, China, were enrolled from November 2014 to September 2018. A total of 157 patients who underwent fresh embryo transfer (ET) cycles were included in group A, whereas 187 patients who underwent frozen-thawed ET cycles were included in group B. After the failure of the first ET cycle, 94 patients underwent the second ET cycle with frozen-thawed embryos. Of these 94 patients, 52 had failed the first fresh ET cycle (group C) and 42 had failed the first frozen-thawed ET cycle (group D). Successful embryo transfer was defined as live birth. This retrospective cohort study addressed the association between AMH levels and pregnancy outcomes using logistic regression approaches. After adjusting for age, body mass index, antral follicle counts, baseline follicle-stimulating hormone levels and baseline progesterone levels, LBRs were compared among the four groups and the cumulative live birth rate after two embryo transfers (TCLBR) was calculated.

Results

The LBRs showed no differences among the four groups. Higher serum AMH levels were found to be associated with a lower TCLBR [adjusted OR 0.937 (0.888-0.987), P = 0.015]. In patients who underwent the second ET cycle, LBRs were inversely proportional to AMH levels [crude OR 0.904 (0.828-0.986), P = 0.022 versus adjusted OR 0.845 (0.754-0.946), P = 0.004, respectively]. In addition, the LBR was approximately 61%-78% lower in the group with AMH levels of >12 ng/mL [crude OR 0.391 (0.168-0.912), P = 0.030 versus adjusted OR 0.217 (0.074-0.635), P = 0.005, respectively].

Conclusions

Among PCOS patients high AMH level (>12 ng/ml) is found to be associated with low TCLBR and low LBR of the second embryo transfer cycles. The results provide limited clinical inferences and warrant further investigation.

Nomogram for Predicting Live Birth after the First Fresh Embryo Transfer in Patients with PCOS Undergoing IVF/ICSI Treatment with the GnRH-Ant Protocol

Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility. A better understanding of factors associated with pregnancy outcomes and successful prediction of live birth after IVF/ICSI are important to guide clinical practice. This was a retrospective cohort study investigating live birth after the first fresh embryo transfer using the GnRH-ant protocol in patients with PCOS between 2017 and 2021 at the Reproductive Center of Peking University Third Hospital. A total of 1018 patients with PCOS were qualified for inclusion in this study. BMI, AMH level, initial FSH dosage, serum LH and progesterone levels on the hCG trigger day, and endometrial thickness were all independent predictors of live birth. However, age and infertility duration were not significant predictors. We developed a prediction model based on these variables. The predictive ability of the model was demonstrated well, with areas under the curve of 0.711 (95% CI, 0.672-0.751) and 0.713 (95% CI, 0.650-0.776) in the training cohort and validation cohort, respectively. Additionally, the calibration plot showed good agreement between the prediction and the observation (p = 0.270). The novel nomogram could be helpful for clinicians and patients in clinical decision-making and outcome evaluation.

A Longitudinal Study of the Relationship of Adiponectin with Reproduction in Infertile Women Undergoing IVF/ICSI Treatment, and an Experimental Study in Human Granulosa Cells

This study investigated the roles of adiponectin in IVF treatment during Phase I (the basal stage before gonadotropin administration), Phase II (approximately 8 days after gonadotropin administration), and Phase III (on the ovum pick-up day), as well as the effects of adiponectin on CYP19A1 and the FSH receptor (FSHR) mRNA expression in a human granulosa-like tumor cell line (KGN). In human subjects (a longitudinal study, n = 30), blood samples were collected in all phases, while follicular fluid (FF) was only collected in Phase III. The participants were classified into successful and unsuccessful groups based on the determination of fetal heartbeats. KGN cells were treated with adiponectin/FSH/IGF-1 (an experimental study, n = 3). There was no difference in the adiponectin levels between successful and unsuccessful pregnancies in the FF (Phase III) and in serum (all phases), as well as among the three phases in both groups. Serum FSH (Phase I) was positively associated with serum adiponectin in the unsuccessful group, but it had a negative association in the successful group (all phases). Serum adiponectin and serum FSH (Phase I) were positively correlated in the unsuccessful group, whereas they were negatively correlated (all phases) in the successful group. The serum adiponectin levels (Phase III) were significantly higher than in the FF in unsuccessful pregnancies, but there was no difference in successful pregnancies. FF adiponectin concentrations were negatively correlated with serum LH in successful subjects. In KGN cells, adiponectin had no influence on CYP19A1 and FSHR mRNA expression. High adiponectin levels in serum compared to FF (Phase III) in unsuccessful subjects might negatively impact IVF treatment.

Retrospective study of ovarian reaction and fertility in women with discordant antimullerian hormone and follicle-stimulating hormone/luteinizing hormone ratios during in vitro fertilization

OBJECTIVE

The objective of this study was to examine the predictive ability of follicle-stimulating hormone (FSH)/luteinizing hormone (LH) ratio and antimullerian hormone (AMH) levels in the same cohort when both are inconsistent and to identify which has an excellent ability to predict live birth and ovarian response to in vitro fertilization (IVF).

METHODS

A retrospective cohort study was performed within 6096 IVF cycles executed between January 2016 and August 2019 at the Center for Assisted Reproduction, The Third Affiliated Hospital of Zhengzhou University, and Jiaozuo Maternity and Child Health Care Hospital. Initially, IVF cycles were classified according to basal FSH/LH ratio and AMH values, and the primary outcome was a comparison of live birth rate per cohort. Secondary outcomes included characteristics of the study individuals such as body mass index (BMI), age, antral follicle count, ovarian sensitivity index, cycle cancellation rate, and cycle outcome data.

RESULT(S)

Women with FSH/LHhigh ratio and AMHnormal levels had a meaningly higher live birth rate compared with those with FSH/LHnormal ratio and AMHlow levels (46.59% vs. 21.21%, p < 0.001). In addition, women with FSH/LHnormal ratio and AMHlow levels were found to have a higher cancellation rate in their IVF cycles (80.98%). In women with FSH/LHnormal ratio, further multivariate analysis revealed that AMH level, age, number of retrieved oocytes, and FSH dosage were relevant risk factors for live birth. The relative risk of live birth was 0.11 (95% [CI] 0.06-0.20, p < 0.001) in patients with AMHlow compared with patients with AMHnormal . It also suggested that the probability of AMHlow level may be higher as the women's age (≥35 years, odd ratio [OR] 1.94, 95% [CI] 1.44-2.61; p < 0.001) and increasing BMI (≥28 kg/m2 , OR 2.38, 95% [CI] 1.33-4.27; p = 0.004). Receiver operating characteristic curve analysis indicated that AMH had higher sensitivity and specificity to predict live birth compared with FSH/LH (AUC 0.627 vs. 0.539).

CONCLUSION(S)

AMH levels can be an excellent predictor of the discrepancy between FSH/LH ratio and AMH levels regarding living birth rates in women undergoing IVF.

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

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

Impact of increasing antimüllerian hormone level on in vitro fertilization fresh transfer and live birth rate

Objective

The objective of our study was to assess the association between AMH and live birth among women with elevated AMH undergoing first fresh IVF. Serum antimüllerian hormone (AMH) correlates with oocyte yield during in vitro fertilization (IVF). However, there are limited data regarding IVF outcomes in women with elevated AMH levels.

Design

Retrospective cohort study using the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System database from 2012-2014.

Setting

Fertility clinics reporting to Society for Assisted Reproductive Technology.

Patients

First, fresh, autologous IVF cycles with elevated AMH levels (≥5.0 ng/mL). Subanalyses were performed to examine patients with or without polycystic ovary syndrome (PCOS).

Interventions

None.

Main Outcome Measures

Odds of live birth.

Results

Our cohort included 10,615 patients with elevated an AMH level, including 2,707 patients with PCOS only. The adjusted odds of live birth per initiated cycle were significantly lower per each unit increase in the AMH level (odds ratio, 0.97; 95% confidence interval, 0.96-0.98). Increasing AMH level was associated with increased cancellation of fresh transfer (odds ratio, 1.12; 95% confidence interval, 1.10-1.15) up to an AMH level of 12 ng/mL. The decrease in the live birth rate appears to be caused by the increasing incidence of cancellation of fresh transfer because the live birth rate per completed transfer was maintained. Similar trends were observed in the PCOS and non-PCOS subanalyses.

Conclusions

Among patients with AMH levels of ≥5 ng/mL undergoing fresh, autologous IVF, each unit increase in AMH level is associated with a 3% decrease in odds of live birth because of the increased incidence of fresh embryo transfer cancellation.

Anti-müllerian hormone as a predictor for live birth among women undergoing IVF/ICSI in different age groups: an update of systematic review and meta-analysis

PURPOSE

To update the evidence of anti-müllerian hormone (AMH) as predictive factors for live birth outcome in women undergoing assisted conception and discover the modulating effect of age.

METHODS

PubMed, Embase, Medline, and Web of Science were searched for studies published until June 2021. We included studies that measured serum AMH levels and reported the subsequent live birth outcomes. Random effects models and hierarchical summary receiver operating characteristics (HSROC) models were used. The QUADAS-2 checklist was employed to assess the quality of the included studies.

RESULTS

We included 27 studies (27,029 women) investigating the relationship between AMH and live birth outcome after assisted conception. The diagnostic odds ratios (DOR) from random effects models were ruled out due to high heterogeneity. Our findings suggested that AMH was associated with live birth. The DOR was 2.21 (95% CI 1.89-2.59), and 2.49 (95% CI 1.26-4.91) for studies on women with unspecified ovarian reserve and women with low ovarian reserve, respectively. The DOR of those with advanced ages was 2.50 (95% CI 1.87-2.60). For younger women, the DOR was 1.41 (95% CI 0.99-2.02). HSROCs showed that AMH had no predictive ability towards live birth in women with diminished ovarian reserve or younger age. Exclusion of Chinese cohorts lowered the heterogeneity.

CONCLUSIONS

This study revealed that AMH had better prediction for live birth in advanced-age women. AMH may have implicative predictive value for assisted conception counseling of couples of advanced ages.

Myostatin: a multifunctional role in human female reproduction and fertility - a short review

Myostatin (MSTN) is member of the transforming growth factor β (TGF-β) superfamily and was originally identified in the musculoskeletal system as a negative regulator of skeletal muscle growth. The functional roles of MSTN outside of the musculoskeletal system have aroused researchers' interest in recent years, with an increasing number of studies being conducted in this area. Notably, the expression of MSTN and its potential activities in various reproductive organs, including the ovary, placenta, and uterus, have recently been examined. Numerous studies published in the last few years demonstrate that MSTN plays a critical role in human reproduction and fertility, including the regulation of follicular development, ovarian steroidogenesis, granule-cell proliferation, and oocyte maturation regulation. Furthermore, findings from clinical samples suggest that MSTN may play a key role in the pathogenesis of several reproductive disorders such as uterine myoma, preeclampsia (PE), ovary hyperstimulation syndrome (OHSS), and polycystic ovarian syndrome (PCOS). There is no comprehensive review regarding to MSTN related to the female reproductive system in the literature. This review serves as a summary of the genes in reproductive medicine and their potential influence. We summarized MSTN expression in different compartments of the female reproductive system. Subsequently, we discuss the role of MSTN in both physiological and several pathological conditions related to the female fertility and reproduction-related diseases.

Follicular fluid and blood levels of persistent organic pollutants and reproductive outcomes among women undergoing assisted reproductive technologies

Persistent organic pollutants (POPs) are industrial chemicals resistant to degradation and have been shown to have adverse effects on reproductive health in wildlife and humans. Although regulations have reduced their levels, they are still ubiquitously present and pose a global concern. Here, we studied a cohort of 185 women aged 21-43 years with a median of 2 years of infertility who were seeking assisted reproductive technology (ART) treatment at the Carl von Linné Clinic in Uppsala, Sweden. We analyzed the levels of 9 organochlorine pesticides (OCPs), 10 polychlorinated biphenyls (PCBs), 3 polybrominated diphenyl ethers (PBDEs), and 8 perfluoroalkyl substances (PFASs) in the blood and follicular fluid (FF) samples collected during ovum pick-up. Impact of age on chemical transfer from blood to FF was analyzed. Associations of chemicals, both individually and as a mixture, to 10 ART endpoints were investigated using linear, logistic, and weighted quantile sum regression, adjusted for age, body mass index, parity, fatty fish intake and cause of infertility. Out of the 30 chemicals, 20 were detected in more than half of the blood samples and 15 in FF. Chemical transfer from blood to FF increased with age. Chemical groups in blood crossed the blood-follicle barrier at different rates: OCPs > PCBs > PFASs. Hexachlorobenzene, an OCP, was associated with lower anti-Müllerian hormone, clinical pregnancy, and live birth. PCBs and PFASs were associated with higher antral follicle count and ovarian response as measured by ovarian sensitivity index, but also with lower embryo quality. As a mixture, similar findings were seen for the sum of PCBs and PFASs. Our results suggest that age plays a role in the chemical transfer from blood to FF and that exposure to POPs significantly associates with ART outcomes. We strongly encourage further studies to elucidate the underlying mechanisms of reproductive effects of POPs in humans.

Anti-Müllerian hormone is a predictor of medium-term cumulative live birth following in vitro fertilization/intracytoplasmic sperm injection: A retrospective study

OBJECTIVES

This study aims to examine the capacity of anti-Müllerian hormone (AMH) to predict cumulative live birth rate (CLBR) following IVF/ICSI within 36 months since start of treatment.

STUDY DESIGN

This is a cohort study of women seeking IVF/ICSI fertility treatment in a private Australian IVF clinic in a single calendar year. Live births were monitored over three years following start date of IVF/ICSI. The impact of serum AMH level on the CLBR was assessed using Cox's proportional hazard models, and its incremental values in the prediction of CLBR were evaluated.

RESULTS

The CLBRs were significantly higher in women with AMH levels in the highest (>44.5 pmol/L; 87.0%, 95% CI 79.2% - 95.1%) and in the middle two quartiles (between 11.5 and 44.5 pmol/L; 81.0%, 95% CI 74.2% - 87.6%), compared with AMH levels below the 25th percentile (≤11.5 pmol/L; 63.2%, 95% CI 53.2% - 74.5%). Approximately half of the women with AMH in the lowest quartile conceived a live birth within 12 months of starting IVF compared with two-thirds of the women in the upper three quartiles. After adjusting for confounders, AMH remained a significant, albeit slight predictor of CLBR with a fall of 3 pmol/L equating to an 1% decrease in CLBR. The AMH's added values into the prediction of live birth were slight, indicated by a net reclassification improvement of 13.8%. The value is lower than that of maternal age (35.1%).

CONCLUSIONS

Serum AMH level was a significant slight predictor of CLBR following IVF/ICSI. AMH should not be used to exclude women from IVF/ICSI however, women with low AMH should be counselled on the likelihood of taking longer to achieve a live birth than individuals with normal AMH levels.

Association of antimüllerian hormone with polycystic ovarian syndrome phenotypes and pregnancy outcomes of in vitro fertilization cycles with fresh embryo transfer

Objective

The current study was undertaken to investigate the relationship between antimüllerian hormone (AMH) and polycystic ovarian syndrome (PCOS) phenotypes and to determine whether AMH is associated with pregnancy outcomes in infertile women undergoing their first in vitro fertilization (IVF) treatment.

Methods

We performed a retrospective cohort study of 2973 infertile women, including 418 women with PCOS undergoing their first IVF treatment at a private fertility center from January 2014 to March 2018. Women were stratified into three groups using cutoffs defined by the 25^th and 75^th percentiles of the serum AMH level: 746 women had AMH ≤ 2.25 ng/mL; 1486 women had AMH between 2.25 to 5.71 ng/mL; and 741 women had AMH > 5.71 ng/mL. Endocrine characteristics, PCOS phenotypes, stimulation outcomes, pregnancy outcomes were compared among these groups. When there were any statistical differences (P < 0.05) among the three groups, Bonferroni test was performed as post-hoc tests to determine where the statistical differences existed. To assess the relationships between AMH and pregnancy outcomes in total patients and PCOS patients, logistic regression analysis, adjusted for potential confounding covariates, were performed.

Results

Women with high AMH had greater prevalence of hyperandrogenism (HA), polycystic ovarian morphology (PCOM) and amenorrhea than women with low or average AMH. The clinical pregnancy rate were significantly higher in the high-AMH group compared with low- and average-AMH groups (69.9% vs. 58.8% and 64.7% respectively; P < 0.001). The live birth rate was significantly lower in women with AMH ≤ 2.25 ng/mL compared with average- and high-AMH groups (47.6% vs. 55.2 and 59.5% respectively; P < 0.001). However, after controlling for maternal age, oocyte yield, as well as other confounders, AMH was no longer associated with a higher live birth rate (aOR 1.037, 95% CI 0.853–1.261, P = 0.717; aOR 1.099, 95% CI 0.858–1.408, P = 0.455, respectively) and clinical pregnancy rate (aOR 1.064, 95% CI 0.834–1.359, P = 0.617; aOR 1.181, 95% CI 0.875–1.595, P = 0.276, respectively). Moreover, pregnancy outcomes did not differ in PCOS women according to AMH quartiles.

Conclusion

Increased AMH levels associated with PCOS severity and greater ovarian stimulation. However, AMH was not associated with clinical pregnancy rate and live birth rate after controlling for other confounders in women undergoing IVF. Thus, AMH should not be used to alter clinical decisions and exclude patients based on a low or even undetectable AMH value.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04518-0.

Assessment of anti-Müllerian hormone in mares' transitional period and in relation to fertility in elderly mares

Anti-Müllerian Hormone (AMH) has been linked to reproductive tract abnormalities in mares and stallions. This study aimed at evaluating AMH as a biomarker for two reproductive conditions in mares. In the first part of this study, plasma AMH was evaluated as an early indicator of the onset of cyclicity in mares in the transitional period from the anovulatory phase during winter anoestrus to the cyclic phase during the breeding season. Ten mares between 8 and 17 years old were included in the experiment which lasted from mid-February until the end of April. Ovarian activity was monitored with ultrasonography three times per week, the detection of a corpus haemorrhagicum/luteum was documented and antral follicle counts (AFC) were recorded. Blood samples were collected weekly by jugular venipuncture during the whole study period to compare AMH concentrations before and after the first ovulation of the year. The second objective was to evaluate if plasma AMH concentrations in middle-aged mares are linked to fertility and could serve as a prognostic marker in that age group. A total of 41 privately-owned clinically sound mares aged between 12 and 21 years of various breeds were inseminated with fresh or frozen semen. Mares were scanned between day 14 and 20 and the "early pregnancy rate" included only positive pregnancy examinations after the first observed cycle in the season of each mare. Potential associations between the early pregnancy rate in the first cycle and the explanatory factors AMH concentrations, age, status of the mare, stud, development of post-breeding endometritis, number of inseminations and semen type were analysed using logistic regression models. In the first part of the study, correlation between AMH and AFC for the whole study period (P = 0.0002, ρ = 0.55) as well as prior to (P = 0.008, ρ = 0.58) and after the first ovulation (P = 0.0007, ρ = 0.69) were observed. However, AMH concentrations before and after the first ovulation of the year were not statistically different. The second part of the study revealed no association between early pregnancy rate and AMH concentrations or any of the other mentioned factors. In conclusion, this study showed no evidence of a difference between AMH concentrations before and after the first ovulation of the year thus not supporting the use of AMH as a biomarker to predict the onset of cyclicity in mares. We could furthermore not show a relationship between plasma AMH concentrations and early pregnancy rates in this cohort of animals.

Comparison of the predictive capability of antral follicle count vs. the anti-Müllerian hormone for ovarian response in infertile women

OBJECTIVES

The aim of this study was to compare the predictive capability of antral follicle count (AFC) and the anti-Müllerian hormone (AMH) on ovarian response in infertile women and to identify potential factors influencing retrieved oocytes.

METHODS

A total of 2585 infertile women who underwent in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles had been enrolled in this study. Spearman correlation was used to investigate the correlation between retrieved oocytes and AFC. Multiple linear regression analysis was used to study the parameters affecting the number of retrieved oocytes.

RESULTS

Spearman correlation and multiple linear regression analysis revealed that the oocyte retrieval number was positively correlated with AFC (r = 0.651, p < 0.001) and AMH (r = 0.566, p < 0.001) and negatively correlated with age (r = -0.425, p < 0.001) and regimen selection (r = -0.233 p < 0.001). There was no significant correlation between retrieved oocytes and BMI (p = 0.913). ROC analysis revealed that AFC was a better predictor of adverse effects than AMH, BMI, and age (AUC: 0.916 VS 0.791, 0.575, 0.752). Meanwhile, AFC and AMH were comparable in predicting high response (AUC = 0.731 and AUC = 0.733, respectively).

CONCLUSIONS

This study showed that retrieved oocytes were positively correlated with serum AMH and AFC and negatively correlated with age and BMI. AFC had an ideal predictive performance in ovarian response prediction. The mechanism of the effect of AFC on ovarian response during controlled ovarian hyperstimulation (COH) needs to be further investigated.

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.

Can high antimüllerian hormone mitigate some of the age-related decline in live birth rates? The association between antimüllerian hormone and live birth among women over 40 undergoing in vitro fertilization

Objective

To examine the association between serum antimüllerian hormone (AMH) and live birth among women aged ≥41 years undergoing in vitro fertilization (IVF).

Design

Retrospective cohort study using the 2012-2014 Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.

Setting

Fertility clinics reporting to the Society for Assisted Reproductive Technology.

Patients

The analysis included 7,819 patients aged ≥41 years who underwent a first fresh, autologous IVF cycle during the study period. Cycles with preimplantation genetic testing were excluded.

Interventions

None.

Main outcome measures

Live birth rate.

Results

The empirical distribution of AMH was examined, and extreme values were observed. Therefore, the natural logarithm transformation of AMH (log-AMH) was used in all analyses. Before adjustment for covariates, a one-unit increase in log-AMH was associated with doubling of the odds of live birth up to a log-AMH of -0.34 (equivalently, AMH, 0.71 ng/mL; odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.46). Above an AMH level of 0.71 ng/mL, the odds of live birth increased by only 40% with each unit increase in log-AMH (OR, 1.40; 95% CI, 1.22-1.61). After adjusting for covariates, the odds of live birth increased by 91% with each unit increase in log-AMH up to -0.34 (AMH, 0.71 ng/mL; OR, 1.91; 95% CI, 1.56-2.34). Above an AMH level of 0.71 ng/mL, the odds of live birth increased by only 32% with each unit increase in log-AMH (OR, 1.32; 95% CI, 1.15-1.53).

Conclusions

Among women aged ≥41 years undergoing fresh, autologous IVF, the odds of live birth significantly increase with increasing serum AMH level. As the AMH level increases above 0.71 ng/mL, the association maintains statistical significance, but the effect size is diminished.

AMH Highly Correlates With Cumulative Live Birth Rate in Women with Diminished Ovarian Reserve Independent of Age

CONTEXT

Antimüllerian hormone (AMH) level is strongly associated with ovarian response in assisted reproductive technology (ART) cycles but is a poor predictor of live birth. It is unknown whether AMH is associated with cumulative live birth rates (CLBRs) in women with diminished ovarian reserve (DOR).

OBJECTIVE

To examine the association between serum AMH and CLBR among women with DOR undergoing ART.

METHODS

Retrospective analysis of Society for Assisted Reproductive Technology Clinic Outcome Reporting System database 2014-16. A total of 34 540 index retrieval cycles of women with AMH <1 ng/mL. The main outcome measure was cumulative live birth.

RESULTS

A total of 34 540 (25.9%) cycles with AMH <1 ng/mL out of 133 442 autologous index retrieval cycles were analyzed. Cycles with preimplantation genetic testing or egg/embryo banking were excluded. Data were stratified according to AMH and, age and regression analysis of AMH and CLBR was performed for each age stratum. Multiple logistic regression demonstrated that AMH is an independent predictor of CLBR (odds ratio [OR] 1.39, 95% CI 1.18-1.64). Serum AMH was strongly associated with number of oocytes retrieved, embryos cryopreserved, mean number of cumulative embryos transferred, and percentage of cycles that had an embryo transfer. Linear regression analysis demonstrated that AMH highly correlated with CLBR in each age stratum.

CONCLUSION

Serum AMH is highly correlated with CLBR in women with DOR independent of age. The addition of AMH to current age-based prognostication counseling particularly in women with DOR would provide more informative and personalized CLBR prediction prior to ART.

Is diminished ovarian reserve a risk factor for miscarriage? Results of a systematic review and meta-analysis

BACKGROUND

Anti-Müllerian hormone (AMH) serum concentration and antral follicle count (AFC), as measured by transvaginal ultrasonography, accurately reflect the antral follicle pool. However, AMH and AFC association with fertility surrogates (i.e. age at menopause, probability of conceiving naturally and ART success rate) is questioned. Miscarriage is often considered an alternative measure of reproductive capacity. Nonetheless, the impact of diminished ovarian reserve (DOR) on miscarriage incidence remains an understudied and unresolved issue.

OBJECTIVE AND RATIONALE

The aim of this systematic review and meta-analysis was to elucidate associations between DOR and miscarriage risk, both in women who conceived naturally and in those who achieved pregnancy through ART.

SEARCH METHODS

Relevant studies were identified by a systematic search in PubMed, MEDLINE, Embase and Scopus, from database inception to 1 March 2021. Studies were included only if all the following conditions were met: DOR was defined using serum AMH concentration or AFC; miscarriage rate was reported separately for different groups of women categorized according to the AMH and/or AFC level; authors reported either the rate of intrauterine pregnancy loss before 22 weeks of gestation or enough data were available to calculate it.

OUTCOMES

From a total of 347 publications initially identified, 16 studies were included. Pooled results from 13 retrospective studies focusing on ART pregnancies showed a significantly higher rate of miscarriage in women with a low AMH, as compared to women with a medium or high serum AMH concentration (12 042 women, random effects model, odds ratio (OR) 1.35; 95% CI, 1.10-1.66; P = 0.004; I2=50%). The only prospective study on ART pregnancies failed to show any association (61 women, risk ratio (RR) 2.95; 95% CI, 0.66-3.18; P = 0.16). Data from two prospective studies, which included naturally conceived pregnancies, showed a significantly increased miscarriage risk for women with low serum AMH. However, these data could not undergo meta-analysis owing to differing study designs. Using three retrospective studies, we observed an association between low AFC and miscarriage incidence (three retrospective studies on ART pregnancies, random effects model, OR 1.81; 95% CI, 1.02-3.21; P = 0.04; I2=64%).

WIDER IMPLICATIONS

Our meta-analysis findings suggest that within the DOR patient subgroup, serum AMH and AFC biomarker levels may correlate with both the quantitative and qualitative aspects of ovarian reserve. However, owing to study limitations, the aetiology of this effect remains unclear and we are unable to define a causal relationship between DOR and increased miscarriage or to provide clinical recommendations based on this information. However, if confirmed by future well-designed studies, these findings would be profoundly informative for guiding women in family planning decisions.

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

PURPOSE OF REVIEW

In this review, we will summarize research looking into anti-Müllerian hormone (AMH) as a measure of oocyte quality.

RECENT FINDINGS

AMH is a key factor involved in embryogenesis but also in the development of early follicles. Owing to its relatively small inter and intracycle variability, it has become a widely used method of ovarian reserve testing. In the realm of assisted reproductive technology, it has demonstrated a reliable ability to gauge the number of oocytes obtained during an in-vitro fertilization cycle. For these purposes, AMH is a readily measured quantitative tool. However, its qualitative role is as yet undefined.

SUMMARY

Although levels of this hormone have been associated with fertilization, blastulation, implantation, and clinical pregnancy rates, there is no clear link with live-birth rates. Furthermore, AMH levels do not appear to correspond with risk of fetal trisomy. AMH does show significant predictive value for the risk of premature ovarian insufficiency and time to onset of menopause.

Do Strategies Favoring Frozen-thawed Embryo Transfer Have an Impact on Differences in IVF Success Rate, Multiple Pregnancy Rate, and Cost per Live Birth Between Fertility Clinics?

The aim of this retrospective cohort study is to establish whether strategies favoring frozen-thawed embryo transfer (FET) have an impact on differences in cumulative live birth rate (CLBR), weighted mean cost per live birth, and multiple pregnancy rate (MPR) between fertility clinics. Data were extracted from the Assisted Reproductive Technology (ART) Italian National Registry and refer to classical IVF or intracytoplasmic sperm injection (ICSI) cycles performed in 2018 in public funded Lombardy region fertility clinics. Propensity to FET cycles was expressed with the so-called freezing tendency index (FTI): [(No. of FETs + No. of transfers of embryos obtained from frozen-thawed oocytes) / (No. of fresh ETs + No. of canceled IVF cycles + Numerator)] × 100. Fertility clinics were divided according to their FTI: group A (FTI: 0-20%); group B (FTI: 20-40%); and group C (FTI: 40-60%). Groups A, B, and C included 6, 8, and 8 fertility clinics, respectively. The CLBR (95% CI) per started COH cycle was 13.1% (11.8-14.5%) in group A, 19.6% (18.6-20.7%) in group B, and 27.8% (26.8-28.9%) in group C (p < 0.0001). The weighted mean live birth cost was 32,770 ± 10,662 € in group A, 25,863 ± 11,510 € in group B, and 20,426 ± 3788 € in group C (p < 0.0001). The MPR (95% CI) was 15.4% (12.1-19.4%) in group A, 10.2% (8.7-12.1%) in group B (p = 0.0065), and 6.3% (5.2-7.6%) in group C (p = 0.0001). In conclusion, our results suggest that strategies favoring FET cycles are associated with an increased CLBR, a decreased weighted mean cost per live birth, and a decreased MPR.

Age-specific definition of low anti-Mullerian hormone and associated pregnancy outcome in women undergoing IVF treatment

BACKGROUND

The age-specific definition of low anti-müllerian hormone (AMH) is lacking. This study aims to define an age-specific reference for low AMH and to evaluate the associated outcome in women undergoing IVF treatment.

METHODS

A retrospective study was performed in women receiving IVF treatment at the Shenzhen maternity and child healthcare hospital between September 2016 and September 2018. We excluded cases without AMH concentration. Polynomial least-squares regression was used to estimate the age-specific reference ranges for AMH after log-transformed. The age-specific 10th centile was defined as the threshold of low AMH concentration.

RESULTS

A total of 909 patients were analyzed in this study. The age-specific reference ranges for AMH were established using linear regression model and resulted in an age-specific equation for mean: mean of LnAMH = (- 0.085 × age) + 3.722 (ng/ml, in unit). Women with AMH level higher than 10th centile had favorable outcomes in ovarian stimulation compared to those with low AMH level. In patients younger than 35 years, the rates of clinical pregnancy per transfer and ongoing pregnancy per transfer in the subgroup with AMH level higher than 10th centile were significantly higher than that in the subgroup of low AMH level, 57% versus 31.3% p = 0.003 and 51.9% versus 21.9% p = 0.001, respectively.

CONCLUSION

Women with AMH lower than age-specific 10th centile had significantly unfavorable outcomes after IVF treatment. The age-specific 10th centile of AMH concentration may be useful to predict the outcome of IVF treatment.

Infertility in women with bowel endometriosis: first-line assisted reproductive technology results in satisfactory cumulative live-birth rates

OBJECTIVE

To evaluate the assisted reproductive technology (ART) cumulative live-birth rate (LBR) in a cohort of bowel endometriosis patients with no prior history of surgery for endometriosis.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENT(S)

One hundred and one consecutive infertile bowel-endometriosis patients with no prior history of surgery for endometriosis in whom the diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging.

INTERVENTION(S)

First-line ART.

MAIN OUTCOME MEASURE(S)

Cumulative LBR, with statistical analysis via Kaplan Meier method with a "conservative" method, whereby it was assumed that no live births took place for patients who did not return.

RESULT(S)

Between January 2016 and December 2018, 101 bowel endometriosis patients underwent 176 ART cycles. The mean number of deep-infiltrating endometriosis lesions per patient was 3 ± 0.9, with a mean number of bowel lesions of 1.3 ± 0.6. Seventy-three percent of the patients had associated endometriomas, and 88.1% had associated adenomyosis. Overall, the cumulative LBR after four ART cycles was 64.4%, using the conservative Kaplan-Meier method.

CONCLUSION(S)

The ART cumulative LBR was very satisfactory (64.4%) in bowel endometriosis patients with no prior history of surgery for endometriosis. In light of these data, clinicians should carefully weigh the pros and cons before systematically referring infertile bowel endometriosis patients to fertility-preserving surgery because as first-line ART appears to offer satisfactory results.

Anti-Müllerian hormone is correlated with cumulative live birth in minimal ovarian stimulation with clomiphene citrate: a retrospective cohort study

BACKGROUND

Several studies have investigated the correlation between the serum anti-Müllerian hormone (AMH) level and in vitro fertilization (IVF) outcomes in controlled ovarian stimulation cycles; however, studies regarding the correlation of the serum AMH level with IVF outcomes in minimal ovarian stimulation cycles remain limited. In this study, we aimed to analyze the correlation of the serum AMH level with ovarian responsiveness, embryonic outcomes, and cumulative live birth rates in clomiphene citrate (CC)-based minimal ovarian stimulation cycles.

METHODS

Clinical records of 689 women whose entire ovarian stimulation regimen consisted solely of minimal stimulation cycle IVF using CC alone from November 2017 to October 2019 were retrospectively reviewed. The association between IVF outcomes and the serum AMH level before the initiation of the first fertility treatment was analyzed. Furthermore, the correlation of the serum AMH level with cumulative live birth rates after IVF treatment was assessed. The Cochran-Armitage test, Pearson's chi-squared test, Spearman rank correlation test, Student's t-test, one-way analysis of variance, logistic regression analysis, Kaplan-Meier method and Cox proportional hazards model were used to analyze the data.

RESULTS

The serum AMH level positively correlated with the number of retrieved oocytes, blastocyst formation rate, blastocyst cryopreservation rate, and live birth rate per oocyte retrieval in CC-based minimal ovarian stimulation cycles without any exogenous gonadotropin administration. Furthermore, the cumulative live birth rate and treatment period required for conceiving were strongly associated with the serum AMH level at the initiation of fertility treatment.

CONCLUSIONS

A low serum AMH level correlated with low ovarian responsiveness, impaired pre-implantation embryonic development, and decreased cumulative live birth rate in CC-based minimal ovarian stimulation cycles. Therefore, the cycle success rate would be predicted by measuring the serum AMH level in minimal ovarian stimulation with CC alone.

Genetic Parameters and Genome-Wide Association Studies for Anti-Müllerian Hormone Levels and Antral Follicle Populations Measured After Estrus Synchronization in Nellore Cattle

Reproductive efficiency plays a major role in the long-term sustainability of livestock industries and can be improved through genetic and genomic selection. This study aimed to estimate genetic parameters (heritability and genetic correlation) and identify genomic regions and candidate genes associated with anti-Müllerian hormone levels (AMH) and antral follicle populations measured after estrous synchronization (AFP) in Nellore cattle. The datasets included phenotypic records for 1099 and 289 Nellore females for AFP and AMH, respectively, high-density single nucleotide polymorphism (SNP) genotypes for 944 animals, and 4129 individuals in the pedigree. The heritability estimates for AMH and AFP were 0.28 ± 0.07 and 0.30 ± 0.09, and the traits were highly and positively genetically correlated (rG = 0.81 ± 0.02). These findings indicated that these traits can be improved through selective breeding, and substantial indirect genetic gains are expected by selecting for only one of the two traits. A total of 31 genomic regions were shown to be associated with AMH or AFP, and two genomic regions located on BTA1 (64.9-65.0 Mb and 109.1-109.2 Mb) overlapped between the traits. Various candidate genes were identified to be potentially linked to important biological processes such as ovulation, tissue remodeling, and the immune system. Our findings support the use of AMH and AFP as indicator traits to genetically improve fertility rates in Nellore cattle and identify better oocyte donors.

The Protective Effect of Pre-Moxibustion on Reproductive Hormones Profile of Rats with Tripterygium Glycosides-Induced Ovarian Damage

BACKGROUND

Acupuncture and moxibustion have been proven to be conducive to improving the ovarian reserve. However, the mechanism of pre-moxibustion on Tripterygium glycosides (TG)-induced ovarian damage has not been previously reported.

METHOD

Female rats were randomly divided into 5 groups: control, model (75 mg/kg TG, 14 days), preventive moxibustion 1 (PM1, receiving moxibustion for 4 weeks before TG administration), preventive moxibustion 2 (PM2, receiving moxibustion for 2 weeks before TG administration and another 2 weeks during TG administration), and preventive moxibustion 3 (PM3, receiving 4 weeks of moxibustion during TG administration). The estrous cycle of the animal was recorded after TG administration. Rats were sacrificed 14 days after TG administration. The reproductive hormones profiles in serum, ovary, and hypothalamic tissues were analyzed.

RESULT

Pre-moxibustion could revert abnormal estrous cycles, relieve follicle damage, and improve abnormal secretion of reproductive hormones resulting from ovarian damage. However, both PM2 and PM3 were more effective than PM1. In addition, PM2 disclosed more advantages in regulating reproductive hormones abnormalities, while PM3 performed better in follicular development.

CONCLUSION

In combination, the findings of this study suggest that pre-moxibustion is effective in protecting the ovary from damage in TG-induced ovarian damage rats. But different time points correspond to different modulation targets and mechanisms.

High serum Antimullerian hormone levels are associated with lower live birth rates in women with polycystic ovarian syndrome undergoing assisted reproductive technology

INTRODUCTION

Antimullerian hormone (AMH) strongly correlates with ovarian reserve and response to controlled ovarian stimulation. Emerging data suggests that serum AMH level may also predict ART outcomes. However, AMH is characteristically elevated in PCOS women and it is unknown whether it may predict live birth outcomes in this population.

METHODS

This was a retrospective cohort study of 184 PCOS women (Rotterdam criteria) who underwent their first fresh IVF/ICSI cycle. Women were divided into 3 groups according to the <25th (low), 25 to 75th (average), or > 75th (high) percentile of serum AMH concentration. Cycle stimulation parameters and reproductive outcomes were compared between groups.

RESULTS

Women in the low serum AMH group were older than those in the average or high AMH (p < 0.05), and required greater gonadotropin dose for stimulation compared to the high AMH group (p < 0.05). Women with high AMH had greater testosterone level compared to women in the low or average AMH groups. No differences were noted between groups in terms of maximal E2, oocytes retrieved and fertilization rate. However, low serum AMH women had significantly greater live birth rates (p < 0.05) and showed a trend towards greater clinical pregnancy rates compared to women in the average and high AMH groups (p = 0.09). The significant association of AMH with live birth rate remained after adjusting for age, BMI, day of transfer and number of embryos transferred.

CONCLUSIONS

In PCOS women, elevated AMH concentrations are associated with hyperandrogenism and lower live birth rates.

Ethnicity/Race and Age-Specific Variations of Serum AMH in Women-A Review

PURPOSE OF REVIEW

In this review, we summarize ethnic/race- and age-related variation in AMH and discuss the underpinnings behind these differences.

RECENT FINDINGS

Anti-mullerian hormone (AMH) has become a widely used method of ovarian reserve testing over the last 15 years. Numerous studies have shown substantial ethnic/race and age-related differences. When compared to age-matched Caucasian women, AMH levels tend to be lower in black and Hispanic women. Chinese women tend to have significantly greater AMH levels prior to age 25 than Caucasian women. When considering subpopulations within ethnicities, at least one study noted lower AMH levels among Maya women compared to other Hispanic women. Age exhibits a positive trend with AMH up until at least 25 years of age with a consistent decline after 34 years of age extending to menopause.

SUMMARY

AMH levels are highly variable among ethnicities and race with higher age-matched levels typically seen in Caucasian women. Age does not exhibit a consistent linear relationship with AMH, but a consistent decline is seen starting in the third decade of life and proceeding to menopause.

Relationships between the antral follicle count, steroidogenesis, and secretion of follicle-stimulating hormone and anti-Müllerian hormone during follicular growth in cattle

BACKGROUND

The antral follicle count (AFC) in mammalian ovaries positively correlates with female fertility. To clarify the causes of differences in fertility between low and high AFC cows, we investigated follicular growth dynamics and hormone concentrations in plasma, follicular fluid, and in vitro growth (IVG) media at different stages of follicular growth.

METHODS

Seven cows were divided into high AFC (n = 4, > 30 follicles) and low AFC (n = 3, < 30 follicles) groups based on the peak AFC detected by ultrasonography. These cows were subjected to estrous synchronization, daily ovarian ultrasonography, and blood collection. Their follicular fluid was collected from dominant follicles at different stages (selection, luteal, and ovulatory phases). In another experiment, we cultured oocyte-cumulus-granulosa cell complexes collected from early antral follicles (< 1 mm) for 12 days. Estradiol-17β (E₂), testosterone (T), progesterone (P₄), and anti-Müllerian hormone (AMH) concentrations in follicular fluids and plasma were measured. Plasma follicle-stimulating hormone (FSH) concentrations were examined. E₂, P₄, and AMH concentrations were also measured in IVG media.

RESULTS

The numbers of small (< 4 mm) and intermediate (4-8 mm) follicles were larger in the high AFC group than in the low AFC group (P < 0.05). The number of intermediate follicles was stable in the low AFC group, indicating consistent development. However, the number of these follicles fluctuated in the high AFC group. Plasma FSH concentrations were higher, whereas E₂ and T concentrations were lower in the low AFC group (P < 0.05). E₂ concentrations and the E₂/P₄ ratio in ovulatory follicles and IVG media on day 8 were higher in the high AFC group (P < 0.05). AMH concentrations in plasma and IVG media (P < 0.01) were higher in the high AFC group.

CONCLUSIONS

The weaker response to FSH of granulosa cells caused low E₂ production in the low AFC group, resulting in high FSH concentrations and the consistent development of intermediate follicles. Conversely, higher E₂ concentrations suppressed FSH secretion in the high AFC group. Granulosa cells in the high AFC group had the ability to produce more AMH than those in the low AFC group throughout IVG culture.

Anti-müllerian Hormone for the Prediction of Ovarian Response in Progestin-Primed Ovarian Stimulation Protocol for IVF

Background: The ability of anti-Müllerian hormone (AMH) to predict ovarian response has been studied extensively in gonadotropin-releasing hormone agonist and antagonist treatments, but no information is available regarding its value in progestin-primed ovarian stimulation (PPOS) protocol. Methods: This retrospective data analysis included 523 patients without polycystic ovary syndrome who underwent their first in vitro fertilization/intracytoplasmic sperm injection cycle with PPOS protocol at our center between Jan. 2015 and Jul. 2018. Serum AMH measurements were acquired within 12 months prior to ovarian stimulation using the automated Access AMH assay. Results: AMH exhibited a significantly positive correlation with the number of retrieved oocytes (r = 0.744, P < 0.001). For the prediction of poor (<4 oocytes) and high (>15 oocytes) response, AMH had an area under the receiver operating characteristic curve (AUC) of 0.861 and 0.773, corresponding with an optimal cutoff point of 1.26 and 4.34 ng/mL, respectively. When stratified according to the dose of medroxyprogesterone acetate (MPA) (4 mg vs. 10 mg per day), AMH retained its similarly high predictive value for poor (AUC = 0.829 and 0.886, respectively) and high response (AUC = 0.770 and 0.814, respectively) in both groups. Amongst the 314 women who received their first frozen embryo transfer (FET) following PPOS protocol, no significant differences were observed on the rates of biochemical pregnancy, clinical pregnancy, implantation, early miscarriage, multiple pregnancy and ectopic pregnancy (all P > 0.05) across AMH quartiles (≤1.43, 1.44-2.55, 2.56-4.35, >4.35 ng/mL). In a multivariable logistic regression model, age was suggested to be the only independent risk factor for clinical pregnancy (P = 0.011). Conclusions: Our data demonstrated that AMH is an adequate predictor of both high and poor ovarian response in PPOS protocol regardless of MPA dose, but it does not associate with pregnancy outcomes in the first FET cycles in a freeze-all strategy.

Age-specific anti-Mullerian hormone (AMH) levels poorly affects cumulative live birth rate after intra-uterine insemination

Objective

To evaluate the impact of age-specific anti-Mullerian (AMH) levels on the cumulative live birth rate after 4 intra uterine inseminations (IUI).

Study Design

The retrospective study study involved 509 couples who underwent their first IUI between January 2011 and July 2017 in the Toulouse University Hospital. All IUI were performed after an ovarian stimulation combining recombinant FSH and GnRH antagonist. The main measure outcome was the cumulative live birth rate (LBR) defined as the number of deliveries with at least one live birth resulting from a maximum of 4 IUI attempts.

Results

When compared to normal or high levels, low age-specific AMH (<25th of the AMH in each age group) was associated to a non-significant lower live birth rate (31%, 38% and 42% respectively for low, normal and high age-specific groups; P = 0.170) and non-significant higher miscarriage rate (26%; 19% and 14% respectively for low, normal and high age-specific groups; P = 0.209). However, it must be pointed out that in low age-specific AMH the initial FSH doses used for stimulation were higher than in the other groups.

Conclusion

This study shows that the age-specific levels of AMH have only a slight effect on IUI outcome when adapting the stimulation protocols to their level.

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.

Latent genital tuberculosis adversely affects the ovarian reserve in infertile women

STUDY QUESTION

What is the effect of latent genital tuberculosis (GTB) on ovarian reserve in infertile women?

SUMMARY ANSWER

Women with latent GTB have lower ovarian reserves and yield lower numbers of oocytes in IVF.

WHAT IS KNOWN ALREADY

Limited evidence suggests that women with GTB may have a low ovarian reserve. Infertile women have a high incidence of latent GTB and treatment improves fertility outcomes.

STUDY DESIGN, SIZE, DURATION

This prospective study from February 2013 to January 2016 compared 431 infertile women diagnosed with latent GTB (Group I) to 453 infertile women without latent GTB (Group II).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at Shreyas Hospital, Kolhapur, India, a tertiary referral centre for infertility. Women of both groups were 21-38 years of age. Group I consisted of infertile women with proven tubal patency but with latent GTB diagnosed by DNA PCR testing of an endometrial biopsy. Day 2-4 anti-Mullerian hormone (AMH) and antral follicle count (AFC) were assessed in both groups. All women with latent GTB took antituberculosis therapy (ATT). Gonadotropin dosages and oocyte and embryo details were noted in both groups for those who underwent IVF.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with latent GTB were younger (29.8 ± 4.4 years vs. 30.8 ± 4.5 years; P = 0.003) and, following adjustment for age, had significantly lower AMH [Median (IQR): 2 (0.9, 4.1) ng/ml vs 2.8 (1.3, 5) ng/ml; P = 0.01] and AFC [Median (IQR): 7 (5, 11) vs 8 (5, 14); P < 0.001]. Post ATT, women with latent GTB yielded fewer oocytes (9.3 ± 7.6 vs. 10.9 ± 8.1; P = 0.01), but had more grade I embryos transferred (1.1 ± 0.5 vs. 0.89 ± 1.0; P = 0.001) and a better implantation rate (26.8% vs. 17.5%; P = 0.004) in IVF compared to women in Group II. Group I had a higher pregnancy rate compared to Group II (51.6% vs. 40.5%; P = 0.001), through various treatment modalities. Considering the adequacy of the sample size and use of robust ovarian reserve markers, the role of chance is minimal.

LIMITATIONS REASONS FOR CAUTION

The study is limited to an infertile population visiting a tertiary referral centre. The mechanisms by which latent GTB infection would lead to ovarian damage are unclear.

WIDER IMPLICATIONS OF THE FINDINGS

It is believed that latent GTB is without any clinical significance. However, a low ovarian reserve in young women with latent GTB necessitates considering it as a cause of infertility, in women with prolonged infertility. These women may experience an accelerated decline in ovarian reserve with reduced success in achieving biological parenthood. Clinicians must be aware of this condition and its consequences while managing infertility.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Sushrut Assisted Conception Clinic, Shreyas Hospital, Kolhapur, India. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Comparison of ovarian responsiveness tests with outcome of assisted reproductive technology - a retrospective analysis

INTRODUCTION

This study aims to compare the association between the most commonly used ovarian responsiveness markers - age, anti-Müllerian hormone levels (AMH), antral follicle count (AFC), ovarian sensitivity index (OSI), and ovarian response prediction index (ORPI) - and ovarian responsiveness to gonadotropin stimulation in assisted reproductive technology (ART) cycles.

MATERIAL AND METHODS

Patients who underwent intracytoplasmic sperm injection treatment using either a gonadotropin releasing hormone (GnRH) antagonist or agonist protocol were enrolled in the study. Data of the patients were abstracted from the hospital's database. Tests were compared for total number of retrieved oocytes, metaphase II (MII) oocytes, embryos, good quality embryos on day 1 and day 3, and ongoing pregnancies per cycle.

RESULTS

The OSI was the ovarian response test that had the strongest relationship with the ART outcomes. The level of association between the ovarian response tests and poor ovarian response data was (in descending order): OSI, ORPI, AFC, AMH, and age (AUC_OSI = 0.976, AUC_ORPI = 0.905, AUC_AFC = 0.899, AUC_AMH = 0.864, AUC_age = 0.617). The overall association between OSI and poor ovarian response was significantly higher than the other parameters (p₁ = 0.0023, p₂ = 0.0014, p₃ = 0.0001, p₄ ≤ 0.0001). In patients with high ovarian response data, OSI had the highest association, followed by AFC and ORPI age (AUC_OSI = 0.984, AUC_AFC = 0.907, AUC_ORPI = 0.887). There was no statistically significant difference among the tests for the data of patients with ongoing pregnancies.

CONCLUSIONS

In this study, which is the first study comparing the five most frequently used ovarian responsiveness markers and the second study signifying the role of OSI in an antagonist protocol, OSI was found to be more convenient to calculate, and it could be superior to other ovarian responsiveness markers for poor and high ovarian responses on cycles with agonist or antagonist protocols.

Cumulative live birth rates after IVF in patients with polycystic ovaries: phenotype matters

RESEARCH QUESTION

Do cumulative live birth rates (CLBR) vary among women with different polycystic ovary syndrome (PCOS) phenotypes who undergo IVF/intracytoplasmic sperm injection (ICSI) treatment?

DESIGN

In this retrospective cohort study, data from 567 patients undergoing an assisted reproductive technology (ART) cycle between January 2010 and December 2015 were collected. Demographical traits, cycle characteristics and clinical and laboratory data were analysed.

RESULTS

After conventional ovarian stimulation using a gonadotrophin-releasing hormone antagonist protocol, the median number of oocytes retrieved ranged between 11 and 13.5 and did not differ significantly among the studied groups. Live birth rate (LBR) after fresh embryo transfer and CLBR after transfer of all fresh and vitrified embryos were significantly lower in women with hyperandrogenic PCOS phenotypes A (LBR 16.7%, CLBR 25.8%) and C (LBR 18.5%, CLBR 27.8%) compared with women with normoandrogenic PCOS phenotype D (LBR 33.7%, CLBR 48%) (P-value for LBR 0.01 and 0.03, respectively; P-value for CLBR 0.002 and 0.01, respectively) and controls with a polycystic ovarian morphology (LBR 37.1%, CLBR 53.3%) (P-value for LBR 0.002 and 0.01, respectively; P-value for CLBR <0.001 and 0.001, respectively). Multivariate regression analysis indicated that after adjustment for relevant confounders, PCOS phenotype was an independent predictor for CLBR.

CONCLUSIONS

Hyperandrogenic PCOS phenotypes confer significantly lower CLBR compared with their normoandrogenic counterparts. These findings may imply the need for adapted counselling and tailored approaches when treating PCOS patients with hyperandrogenism who require ART.

Anti-müllerian hormone levels are associated with live birth rates in ART, but the predictive ability of anti-müllerian hormone is modest

OBJECTIVES

The aim was to evaluate the association between serum Anti-Müllerian Hormone (AMH) level and cumulative live birth rates (LBR) in patients undergoing their first in vitro fertilization (IVF) treatment cycle, and to compare serum AMH levels with Antral Follicle Count (AFC) and Ovarian Sensitivity Index (OSI) as predictors of live birth.

STUDY DESIGN

A prospective cohort study of 454 patients under the age of 40 and with a regular menstrual cycle of 21-35 days, undergoing their first IVF treatment cycles between September 2010 and June 2015. Participants were divided into three groups based on their AMH level, (AMH ≤10, AMH 10-<30 and AMH ≥30 pmol/l). Any difference in AMH-distribution between patients with or without live birth was analyzed using a Mann-Whitney-test, and live birth rates were compared between groups by a chi-squared test for linear trend. The ability of AMH, OSI and AFC as predictors of live birth was assessed by a receiver operating characteristics-analysis and the area under the curve (AUC) was calculated.

RESULTS

Patients with live birth had a higher AMH, median (range) 26 [0-137] pmol/l, compared with patients without live birth, AMH 22 [0-154] pmol/l, p = 0.035. Mean live birth rate (SD) was 0.36 (0.48) in the total cohort, 0.26 (0.44) in AMH-group <10, 0.34 (0.48) in AMH-group 10-<30, and 0.41(0.49) in AMH-group ≥30. Thus live birth rates increased with 8% per AMH-group (95% CI: 0.02 -0.14, p = 0.015). The AUC for AFC was 0.56, for AMH 0.57 and for OSI 0.63, respectively.

CONCLUSION

AMH concentration in serum is associated with live birth rates after IVF. Our results suggest that both AMH, AFC and OSI have an equal but modest predictive ability in relation to live birth rate.

Ovarian function, fertility and reproductive lifespan in cancer patients

INTRODUCTION

The increasing survival of girls and young women after cancer has led to a rapid growth in research into assessment of ovarian function after treatment.

AREAS COVERED

This aim of this review is to discuss normal ovarian function over time, the impact of cancer treatment on ovarian function, the assessment of ovarian reserve after treatment, and pretreatment predictors of ovarian recovery.

EXPERT COMMENTARY

Ovarian function damage after chemotherapy and radiotherapy will impact on fertility and reproductive lifespan, but with great variability. Age at menopause has implications for the duration of estrogen deficiency, with its own adverse health consequences. This has led to identification of the key treatment and patient factors at the time of treatment, notably age and ovarian reserve that impact on post-treatment ovarian function. However, most studies have used outcome measures such as ongoing menses, or biomarkers such as anti-mullerian hormone (AMH), with few reporting on fertility or age at menopause.

Nanosized titanium dioxide-induced premature ovarian failure is associated with abnormalities in serum parameters in female mice

Background

Exposure to titanium dioxide nanoparticles (TiO₂ NPs) that are widely used in food, medicine, sunscreen products and cosmetics is reported to cause ovarian damage and lower fertility in animals. However, the potential effects of TiO₂ NPs application on premature ovarian failure (POF) have rarely been evaluated to date.

Methods

In this study, female mice were continuously exposed to TiO₂ NPs at doses of 2.5, 5 or 10 mg/kg via gavage instillation for 30 days, and investigated the serum hormones and autoimmunity markers associated with POF.

Results

Exposure to TiO₂ NPs resulted in POF, reductions in the levels of estradiol, progesterone and inhibin B and increases in luteinizing hormone, follicle-stimulating hormone, follicle-stimulating hormone/luteinizing hormone ratio, anti-Müllerian hormone, thyroid-stimulating hormone, free triiodothyronine, free tetraiodothyronine, anti-nuclear antibody and anti-thyroid peroxidase antibody levels in serum.

Conclusion

Exposure to TiO₂ NPs induced POF triggered by alterations in hormones and autoimmunity markers. Our findings highlight the necessity for significant caution in handling and usage of TiO₂ NPs by female consumers.