Prediction of age at menopause from assessment of ovarian reserve may be improved by using body mass index and smoking status

Antimüllerian Hormone as a Tool to Predict the Age at Menopause

This study aimed to assess an eligible cut-off value of anti-Müllerian hormone (AMH) to detect ovarian senescence in a group of premenopausal Greek women to evaluate the possible link between AMH-values and the severity of climacteric symptoms during a follow-up of 24 months. This study included 180 women (group A, 96 women of late reproductive stage/early perimenopause; group B, 84 women in late perimenopause). We measured AMH blood levels and assessed climacteric symptoms using the Greene scale. Log-AMH is inversely associated with postmenopausal status. The AMH cut-off of 0.012 ng/mL predicts the postmenopausal status with a sensitivity of 24.2% and specificity of 30.5%. The postmenopausal stage associated with age (OR = 1.320, 95%CI: 1.084-1.320) and AMH (values ≥ vs. <0.012 ng/mL, OR = 0.225, 95%CI: 0.098-0.529, p-value < 0.001). Moreover, the severity of vasomotor symptoms (VMS) was only associated inversely with AMH (b-coefficient = -0.272, p-value = 0.027). In conclusion, AMH levels measured in the late premenopausal period are inversely associated with the time to ovarian senescence. In contrast, AMH levels measured in the perimenopausal period are inversely associated only with the severity of VMS. Therefore, a cut-off of 0.012 ng/mL predicts menopause with low sensitivity and specificity, making it challenging to use in a clinical setting.

Investigating the Clinical Utility of the Anti-Mullerian Hormone Testing for the Prediction of Age at Menopause and Assessment of Functional Ovarian Reserve: A Practical Approach and Recent Updates

Low ovarian reserve is a serious condition, leading to sterility in up to 10% of women in their mid-thirties. According to current knowledge, serum anti-Müllerian hormone (AMH) levels for age are the best available marker for the screening the quantity of a woman's functional ovarian reserve, better than age alone or other reproductive markers. This review summarizes recent findings, clinical utility and limitations in the application of serum AMH testing as an accurate marker for the screening of functional ovarian reserves and predicting age at menopause. AMH assessment hold promise in helping women make informed decisions about their future fertility and desired family size. However, screening of the functional ovarian reserve could be offered to all women at 26 years of age or older who seek to assess future fertility or in case of personal request, ovarian reserve screening may be considered beyond 30 years; however, it has never been advocated beyond 35 years, since it is not advisable to delay childbearing beyond this age. In this respect, an age-specific serum AMH levels lower than the 10th percentile may be used as a threshold for the identification of a low functional ovarian reserve in an individual woman. Its level should be interpreted with caution in the adolescent and young women aged below 25 years (since AMH levels peak at this age); recent users of hormonal contraceptives (since AMH levels transiently decrease until two months after discontinuation); and women with PCOS (which dramatically increases AMH levels). However, the ability of AMH levels to predict the time to menopause is promising but requires further investigation and routine AMH testing for the purposes of predicting the time to menopause is not recommended.

Machine Learning-Based Approach Highlights the Use of a Genomic Variant Profile for Precision Medicine in Ovarian Failure

Ovarian failure (OF) is a common cause of infertility usually diagnosed as idiopathic, with genetic causes accounting for 10-25% of cases. Whole-exome sequencing (WES) may enable identifying contributing genes and variant profiles to stratify the population into subtypes of OF. This study sought to identify a blood-based gene variant profile using accumulation of rare variants to promote precision medicine in fertility preservation programs. A case-control (n = 118, n = 32, respectively) WES study was performed in which only non-synonymous rare variants <5% minor allele frequency (MAF; in the IGSR) and coverage ≥ 100× were considered. A profile of 66 variants of uncertain significance was used for training an unsupervised machine learning model to separate cases from controls (97.2% sensitivity, 99.2% specificity) and stratify the population into two subtypes of OF (A and B) (93.31% sensitivity, 96.67% specificity). Model testing within the IGSR female population predicted 0.5% of women as subtype A and 2.4% as subtype B. This is the first study linking OF to the accumulation of rare variants and generates a new potential taxonomy supporting application of this approach for precision medicine in fertility preservation.

"There's a problem, now what's the solution?": suggestions for technologies to support the menopausal transition from individuals experiencing menopause and healthcare practitioners

OBJECTIVE

To elicit novel ideas for informatics solutions to support individuals through the menopausal transition. (Note: We use "individuals experiencing menopause" and "experiences" rather than "symptoms" when possible to counter typical framing of menopause as a cisgender women's medical problem.).

METHODS

A participatory design study was conducted 2015-2017 in the Western US. Two sessions were held with individuals experiencing menopause recruited from the general public; and 3 sessions with healthcare practitioners (HCPs) including nurses, physicians, and complementary and integrative health (CIH) practitioners were held. Participants designed technologies addressing informational needs and burdensome experiences. HCPs reflected on designs from participants experiencing menopause. Directed content analysis was used to analyze transcripts.

RESULTS

Eight individuals experiencing menopause (n = 4 each session) and 18 HCPs (n = 10 CIH, n = 3 nurses, n = 5 physicians) participated. All participants provided ideas for solution purpose, hardware, software, features and functions, and data types. Individuals experiencing menopause designed technologies to help understand and prevent burdensome menopause experiences. HCPs designed technologies for tracking and facilitating communication. Compared to nurses and physicians, CIH practitioners suggested designs reframing menopause as a positive experience and accounted for the complex lives of individuals experiencing menopause, including stigma; these ideas corresponded to comments made by participants experiencing menopause. Participants from both populations were concerned about data confidentiality and technology accessibility.

CONCLUSIONS

Participant generated design ideas included novel ideas and incorporated existing technologies. This study can inform the development of new technologies or repurposing of existing technologies to support individuals through the menopausal transition.

Is ovarian reserve associated with body mass index and obesity in reproductive aged women? A meta-analysis

OBJECTIVE

The associations of body mass index (BMI) and obesity with ovarian reserve are controversial. This systematic review and meta-analysis was conducted to investigate the associations in reproductive-aged women.

METHODS

PubMed and Scopus were searched up to December, 2016. Original studies on the association of BMI with ovarian reserve markers, anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), inhibin β, and antral follicle count (AFC), either according to BMI categories or a continuous variable, were selected. Analyses were stratified into three groups based on polycystic ovary syndrome (PCOS) and fertility status of women.

RESULTS

Of 4,055 records identified, 45 studies were eligible for inclusion. Comparing the obese with nonobese, the pooled mean differences (MDs) and 95% confidence intervals (CIs) were -1.08 (95% CIs -1.52, -0.63) ng/mL for AMH, -0.22 (95% CIs -0.39, -0.06) mIU/mL for FSH, -0.09 (95% CIs -0.60, 0.42) for AFC, and -21.06 (95% CIs -41.18, -0.85) pg/mL for inhibin β in overall populations. The MDs were significant for AMH in fertile non-PCOS and PCOS women, and for FSH only in PCOS women. Fisher's Z showed significant correlations of BMI with AMH in the overall populations (-0.15 [95% CIs -0.20, -0.11]) and in all subgroups, and with FSH in the fertile non-PCOS women (-0.16 [95% CIs -0.28, -0.04]).

CONCLUSION

Ovarian reserve markers of AMH and FSH are significantly lower in obese than in nonobese women, and BMI is negatively correlated with AMH in all study populations, and with FSH in fertile non-PCOS subgroups. PCOS and fertility status do not appear to affect the associations.

Age at natural menopause in Koreans: secular trends and influences thereon

OBJECTIVES

Age at natural menopause (ANM) has become an important health issue in older women. We explored secular trends in ANM in Korea during the past decade, and defined factors predicting ANM.

METHODS

A total of 12,761 naturally menopausal women were selected from the 2001 to 2014 data of the Korea National Health and Nutrition Examination Survey, stages II to VI. The participants were divided into four groups based on 5-year ANM categories: <45, 45 to 49, 50 to 54, and ≥55 years. To identify factors associated with ANM, the regression analysis was used.

RESULTS

Both the mean (SE) and median (SE) ANM were 49.30 (0.07) years. The cumulative proportion of women experiencing menopause before the age of 40, 45, 50, and 55 years was 3.6%, 11.8%, 46.0%, and 90.3%, respectively. The mean (SE) ANM in women born in 1929 or earlier, and between 1930 to 1934, 1935 to 1939, 1940 to 1944, and 1945 to 1949, was 47.9 (0.3), 48.1 (0.2), 48.8 (0.2), 50.1 (0.2), and 50.5 (0.1) years, respectively (P < 0.001). Residence in a rural area (odds ratio [OR] 1.82), low weight status (OR 1.61), a history of or current smoking, a low educational level, being without a partner, and participating in at least moderate physical activity (OR 1.47, 1.33, 1.32, and 1.26, respectively) were more likely to result in an early ANM. Women with prior childbirth were less likely to experience early menopause (OR 0.34). In contrast, late menopause was associated with obesity and being overweight (OR 1.63 and 1.27).

CONCLUSIONS

We found that the mean ANM exhibited upward secular trends. Socioeconomic status and lifestyle factors were the principal independent factors affecting ANM.

Overtime trend of thyroid hormones and thyroid autoimmunity and ovarian reserve: a longitudinal population study with a 12-year follow up

BACKGROUND

Ovarian reserve, vital for reproductive function, can be adversely affected by thyroid diseases. Despite alternations of thyroid hormones with ageing, data on interactions between the overtime trend of thyroid functions and ovarian reserve status has rarely been reported. We aimed to examine the overtime trend of thyroid hormones, thyroid peroxidase antibody (TPO Ab) and their associations with ovarian reserve status, identified by levels of age specific anti-mullerian hormone (AMH) in reproductive aged women, who participated in 12-year cohort of Tehran Thyroid Study (TTS).

METHODS

Reproductive age women(n = 775) without any thyroid disease or ovarian dysfunction were selected from the Tehran Thyroid Study cohort. Participants were divided into four age specific AMH quartiles (Q1-Q4), Q1, the lowest and Q4, the highest. AMH was measured at the initiation of study and thyroid stimulating hormone (TSH), free T4 (FT4), and TPO Ab were measured at baseline and at three follow up visits.

RESULTS

At baseline, there was no statistically significant difference in thyroid hormones between women of the four quartiles, although TPO Ab levels were higher in women of Q1. During the follow ups, FT4 was decreased in all quartiles (p < 0.05), whereas TPO Ab increased in Q1 (p = 0.02). Odds ratio of overall TPO Ab positivity in women of Q1 was 2.08 fold higher than those in Q4. (OR: 2.08, 95%CI: 1.16, 3.72; p = 0.01).

CONCLUSION

Women with the lowest ovarian reserves had higher levels of TPO Ab, with a positive trend of this antibody overtime in comparison to other quartiles, indicating that this group may be at a higher risk of hypothyroidism over time.

Advances in the Molecular Pathophysiology, Genetics, and Treatment of Primary Ovarian Insufficiency

Primary ovarian insufficiency (POI) affects ∼1% of women before 40 years of age. The recent leap in genetic knowledge obtained by next generation sequencing (NGS) together with animal models has further elucidated its molecular pathogenesis, identifying novel genes/pathways. Mutations of >60 genes emphasize high genetic heterogeneity. Genome-wide association studies have revealed a shared genetic background between POI and reproductive aging. NGS will provide a genetic diagnosis leading to genetic/therapeutic counseling: first, defects in meiosis or DNA repair genes may predispose to tumors; and second, specific gene defects may predict the risk of rapid loss of a persistent ovarian reserve, an important determinant in fertility preservation. Indeed, a recent innovative treatment of POI by in vitro activation of dormant follicles proved to be successful.

Individualized predictions of time to menopause using multiple measurements of antimüllerian hormone

OBJECTIVE

The ability of antimüllerian hormone (AMH) to predict age at menopause has been reported in several studies, and a decrease in AMH level has been found to increase the probability of menopause. The rate of decline varies among women, and there is also a variability of decline between women's cycles. As a result, individualized evaluation is required to accurately predict time of menopause. To this end, we have used the AMH trajectories of individual women to predict each one's age at menopause.

METHODS

From a cohort study, 266 women (ages 20-50 y) who had regular and predictable menstrual cycles at the initiation of the study were randomly selected from among 1,265 women for multiple AMH measurements. Participants were visited at approximately 3-year intervals and followed for an average of 6.5 years. Individual likelihood of menopause was predicted by fitting the shared random-effects joint model to the baseline covariates and the specific AMH trajectory of each woman.

RESULTS

In total, 23.7% of the women reached menopause during the follow-up period. The estimated mean (SD) AMH concentration at the time of menopause was 0.05 ng/mL (0.06 ng/mL), compared with 1.36 ng/mL (1.85 ng/mL) for those with a regular menstrual cycle at their last assessment. The decline rate in the AMH level varied among age groups, and age was a significant prognostic factor for AMH level (P < 0.001). Adjusting for age and body mass index, each woman had her own specific AMH trajectory. Lower AMH and older age had significant effects on the onset of menopause. Individualized prediction of time to menopause was obtained from the fitted model.

CONCLUSIONS

Longitudinal measurements of AMH will enable physicians to individualize the prediction of menopause, thereby facilitating counseling on the timing of childbearing or medical management of health issues associated with menopause.

Female age, serum antimüllerian hormone level, and number of oocytes affect the rate and number of euploid blastocysts in in vitro fertilization/intracytoplasmic sperm injection cycles

OBJECTIVE

To study the relative role of female age and ovarian reserve, measured through serum antimüllerian hormone (AMH) in determining the rate and number of euploid blastocysts in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Retrospective analysis of cycles performed in 2014-2015.

SETTING

Tertiary referral IVF center.

PATIENT(S)

A total of 578 infertile couples undergoing IVF/ICSI and preimplantation genetic screening (PGS) analysis.

INTERVENTIONS(S)

All embryos were cultured and biopsied at the blastocyst stage. The method involved whole-genome amplification followed by array comparative genome hybridization. Serum AMH was measured by means of the modified Beckman Coulter AMH Gen II assay.

MAIN OUTCOME MEASURES

The rate and number of euploid blastocysts and their correlation with ovarian reserve and response to stimulation.

RESULT(S)

The mean (±SD) age of patients was 37.6 ± 4.1 years, and the mean number of blastocysts per patient was 3.1 ± 2. The total number of blastocysts available to the analysis was 1,814, and 36% of them were euploid after PGS. Age and serum AMH were significantly and independently related to the rate of euploid blastocysts available for patients. As an effect of the cohort size, the number of mature oocytes positively affected the total number of euploid blastocysts per patient.

CONCLUSION(S)

A strong positive age-independent relationship between AMH level and the rate of euploid blastocysts was found. This confirms that the measurement of ovarian reserve by means of AMH has high relevance when counseling infertile patients.

Antimüllerian Hormone Levels Are Not Altered by Glucose Challenge or a Meal

BACKGROUND

Measurement of antimüllerian hormone (AMH) is used to assess ovarian reserve. Circulating levels of AMH correlate with antral follicle count, with relatively high levels indicating an ample reserve of primary and preantral follicles in the ovary. AMH levels are stable with dilution and freezer storage, and are not altered by hemolysis or menstrual cycle day in young women of reproductive age. We sought to examine whether glucose challenge or food intake modifies AMH levels compared with fasting.

METHODS

Residual plasma samples were available from 54 pregnant women under fasting conditions and then 1, 2, and 3 h after ingestion of a 100-g glucose challenge. These samples were collected as part of routine clinical care to identify gestational diabetes (GDM) at 24-28 weeks of gestation. Twelve of these women met criteria for GDM based on an increased glucose level at a minimum of 2 time points. A second set consisted of serum samples collected from 8 nonpregnant women at fasting and 1 h after a meal. Levels of AMH were measured using an ultrasensitive assay (Ansh Labs, Webster, TX). A 2-way ANOVA (sample timing and GDM status) or matched t-test was performed. AMH measurements were subject to a logarithmic transformation before analysis.

RESULTS

Median AMH levels in pregnant women at 1, 2, or 3 h after glucose challenge did not differ compared with AMH levels at fasting or by diagnosis of GDM. Similarly, there was no difference in median AMH levels in nonpregnant women of reproductive age at fasting and after a meal.

CONCLUSION

AMH levels are not altered by glucose or food intake.

Unintended pregnancy risk and contraceptive use among women 45-50 years old: Massachusetts, 2006, 2008, and 2010

BACKGROUND

Little is known about unintended pregnancy risk and current contraceptive use among women ≥45 years old in the United States.

OBJECTIVES

The purpose of this study was to describe the prevalence of women ages 45-50 years old at risk for unintended pregnancy and their current contraceptive use, and to compare these findings to those of women in younger age groups.

STUDY DESIGN

We analyzed 2006, 2008, and 2010 Massachusetts Behavioral Risk Factor Surveillance System data, the only state in the United States to collect contraceptive data routinely from women >44 years old. Women 18-50 years old (n = 4930) were considered to be at risk for unintended pregnancy unless they reported current pregnancy, hysterectomy, not being sexually active in the past year, having a same-sex partner, or wanting to become pregnant. Among women who were considered to be at risk (n = 3605), we estimated the prevalence of current contraceptive use by age group. Among women who were considered to be at risk and who were 45-50 years old (n = 940), we examined characteristics that were associated with current method use. Analyses were conducted on weighted data using SAS-callable SUDAAN (RTI International, Research Triangle Park, NC).

RESULTS

Among women who were 45-50 years old, 77.6% were at risk for unintended pregnancy, which was similar to other age groups. As age increased, hormonal contraceptive use (shots, pills, patch, or ring) decreased, and permanent contraception (tubal ligation or vasectomy) increased as did non-use of contraception. Of women who were 45-50 years old and at risk for unintended pregnancy, 66.9% reported using some contraceptive method; permanent contraception was the leading method reported by 44.0% and contraceptive non-use was reported by 16.8%.

CONCLUSION

A substantial proportion of women who were 45-50 years old were considered to be at risk for unintended pregnancy. Permanent contraception was most commonly used by women in this age group. Compared with other age groups, more women who were 45-50 years old were not using any contraception. Population-based surveillance efforts are needed to follow trends among this age group and better meet their family planning needs. Although expanding surveillance systems to include women through 50 years old requires additional resources, fertility trends that show increasingly delayed childbearing, uncertain end of fecundity, and potential adverse consequences of unplanned pregnancy in older age may justify these expenditures.

Ethnicity or environment: effects of migration on ovarian reserve among Bangladeshi women in the United Kingdom

OBJECTIVE

To assess whether the quality of early childhood environments among different groups of Bangladeshi women, including migrants to the United Kingdom (UK), contributes to variation in ovarian reserve and the rate of reproductive aging in later life.

DESIGN

Cross-sectional study.

SETTING

Not applicable.

PATIENT(S)

A total of 179 healthy women volunteers aged 35-59 years were divided into four groups: [1] 36 Bangladeshis living in Sylhet, Bangladesh; [2] 53 Bangladeshis who migrated to the UK as adults; [3] 40 Bangladeshis who migrated to the UK as children aged 0-16 years; and [4] a reference group of 50 women of European origin living in London.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of serum antimüllerian hormone, inhibin B, FSH, and E2, and anthropometrics derived from biomarkers; reproductive, demographic, and health variables from structured questionnaires.

RESULT(S)

Bangladeshi migrants who moved to the UK as children and European women had a highly significantly larger, age-related ovarian reserve compared with migrant Bangladeshis who had moved to the UK as adults or Bangladeshi women still living in Bangladesh. There were no other significant covariates in the model aside from age and menopausal status.

CONCLUSION(S)

The study points to the importance of childhood development in considering variation in ovarian reserve across different ethnic groups. Clinical studies and research in assisted reproductive technology have emphasized the role of genes or race in determining inter-population variation in ovarian reserve. Early life developmental factors should be given due consideration when evaluating inter-group differences in response to assisted reproductive technology.

Interaction between a single exposure and age in cohort-based hazard rate models impacted the statistical distribution of age at onset

OBJECTIVE

Statistical interaction between a single, instantaneous exposure and attained age (age during follow-up; attained age = age at exposure + time since exposure) is used in risk analyses to assess potential effect modification by unmeasured factors correlated with age. However, the impact of such interaction on the statistical distribution of age-at-onset of outcome (disease or death) is infrequently assessed. We therefore explored the impact of such interaction on the shape of the onset-age distribution.

STUDY DESIGN AND SETTING

We use for illustration age-at-onset of radiation-related early menopause in a cohort of female Japanese Atomic Bomb Survivors. The statistical distribution of age-at-onset was derived from a parametric hazard rate model fit to the data, assuming an underlying Gaussian onset-age distribution among nonexposed women.

RESULTS

Commonly used forms of exposure-by-age (attained age) interaction led to unnatural estimates of the age-specific rate function and unreasonable estimates of the onset-age distribution among exposed women, including positive risk of menopause before menarche.

CONCLUSION

We recommend that researchers examine the distribution of age-at-onset and exposure-age interaction when conducting risk analyses. To distinguish this from potential etiologic interaction between exposure and unmeasured factors represented by age as a surrogate, richer models or additional data may be required.

The utility of measuring anti-Müllerian hormone in predicting menopause

Menopause is a relevant phase in a woman's reproductive life. Accurate estimation of the time of menopause could improve the preventive management of women's health. Reproductive hormones reflect the activity of follicle pools and provide information about ovarian aging. Anti-Mu llerian hormone (AMH) is secreted from small antral follicles and its level is correlated to the ovarian reserve. AMH declines with age, and data suggest that it can provide information on menopausal age and reproductive lifespan. Serum AMH levels become low approximately 5 years before the final menstrual period and are undetectable in postmenopausal women. The majority of studies indicate that AMH is relatively stable throughout the menstrual cycle; however, there are interindividual variabilites of serum AMH concentration under different conditions. AMH is an independent predictor of time to menopause. AMH coupled with age for menopause prediction provides stronger information than using age alone. Ongoing research is focused on constructing a multivariate model including AMH values, genes related to follicular recruitment and maternal age of menopause that would predict more precisily time to menopause.

Predicting Ovarian Activity in Women Affected by Early Breast Cancer: A Meta-Analysis-Based Nomogram

BACKGROUND

The assessment of ovarian reserve in premenopausal women requiring anticancer gonadotoxic therapy can help clinicians address some challenging issues, including the probability of future pregnancies after the end of treatment. Anti-Müllerian hormone (AMH) and age can reliably estimate ovarian reserve. A limited number of studies have evaluated AMH and age as predictors of residual ovarian reserve following cytotoxic chemotherapy in breast cancer patients.

MATERIALS AND METHODS

To conduct a meta-analysis of published data on this topic, we searched the medical literature using the key MeSH terms "amenorrhea/chemically induced," "ovarian reserve," "anti-Mullerian hormone/blood," and "breast neoplasms/drug therapy." Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements guided the search strategy. U.K. National Health Service guidelines were used in abstracting data and assessing data quality and validity. Area under the receiver operating characteristic curve (ROC/AUC) analysis was used to evaluate the predictive utility of baseline AMH and age model.

RESULTS

The meta-analysis of data pooled from the selected studies showed that both age and serum AMH are reliable predictors of post-treatment ovarian activity in breast cancer patients. Importantly, ROC/AUC analysis indicated AMH was a more reliable predictor of post-treatment ovarian activity in patients aged younger than 40 years (0.753; 95% confidence interval [CI]: 0.602-0.904) compared with those older than 40 years (0.678; 95% CI: 0.491-0.866). We generated a nomogram describing the correlations among age, pretreatment AMH serum levels, and ovarian activity at 1 year from the end of chemotherapy.

CONCLUSION

After the ongoing validation process, the proposed nomogram may help clinicians discern premenopausal women requiring cytotoxic chemotherapy who should be considered high priority for fertility preservation counseling and procedures.

Menopause prediction and potential implications

Reproductive ageing in women is characterized by a decline in both the quantity and quality of oocytes. Menopause is reached upon exhaustion of the resting primordial follicle pool, occurring on average at 51 years of age (range 40-60 years). The mean global age at natural menopause (ANM) appears robust, suggesting a distinct genetic control. Accordingly, a strong correlation in ANM is observed between mothers and daughters. Few specific genetic determinants of ANM have been identified. Substantial efforts have been made to predict ANM by using anti-Müllerian hormone (AMH) levels. AMH serum concentrations at reproductive age predict ANM, but precision is currently limited. Early ANM is associated with early preceding fertility loss, whereas late menopause is associated with reduced morbidity and mortality later in life. Menopause affects various women's health aspects, including bone density, breast, the cardiovascular system, mood/cognitive function and sexual well-being. If the current trend of increasing human life expectancy persists, women will soon spend half their life postmenopause. Unfortunately, increased longevity does not coincide with an equal increase in years spend in good health. Future research should focus on determinants of long term health effects of ANM, and efforts to improve women's postmenopausal health and quality of life.

Maximizing the clinical utility of antimüllerian hormone testing in women's health

Purpose of review

To provide an update on the latest clinical applications of serum antimüllerian hormone (AMH) testing with practical approaches to mitigate the impact of significant variability in AMH results.

Recent findings

Recent studies continue to demonstrate that AMH is the best single serum test for ovarian response management with, at most, a weak-to-moderate age-independent association with live-birth rate and time to conception. Data confirm serum AMH levels improve menopause prediction, monitoring of ovarian damage, and identification of women at risk for several ovary-related disorders such as polycystic ovary syndrome and premature or primary ovarian insufficiency. However, it is now recognized that serum AMH results can have dramatic variability due to common, biologic fluctuations within some individuals, use of hormonal contraceptives or other medications, certain surgical procedures, specimen treatment, assay changes, and laboratory calibration differences. Practical guidelines are provided to minimize the impact of variability in AMH results and maximize the accuracy of clinical decision-making.

Summary

AMH is an ovarian biomarker of central importance which improves the clinical management of women's health. However, with the simultaneous rapid expansion of AMH clinical applications and recognition of variability in AMH results, consensus regarding the clinical cutpoints is increasingly difficult. Therefore, a careful approach to AMH measurement and interpretation in clinical care is essential.

Current Concepts in Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is a life-changing diagnosis, with profound physical and psychological consequences. Unfortunately, there are many deficiencies in our understanding of the condition as the underlying etiology and optimum management strategies are poorly understood. Improved awareness of POI and its long-term implications has led to increased research interest in recent years. Current research has allowed a greater understanding of the changing epidemiology in POI, genetic factors in its etiology and randomized controlled trials of hormone therapy are underway to provide evidence for treatment. This article reviews the latest literature on POI to summarize current understanding and future directions.

Recent progress in the utility of anti-Müllerian hormone in female infertility

PURPOSE OF REVIEW

To discuss the recent developments in the utility of anti-Müllerian hormone (AMH) in the context of female infertility.

RECENT FINDINGS

AMH measurements have entered the clinical practice in counseling of women before in-vitro fertilization (IVF) treatment. AMH measurements can predict both poor and hyperresponse, and can enable clinicians to individualize the treatment strategies. In natural conception, AMH is a good predictor of age at menopause, but it is unclear whether AMH correlates with the fecund ability in the normal population. AMH has also proven its utility in the assessment of ovarian damage due to gonadotoxic treatment or ovarian surgery. Lastly, AMH might assist in the initial diagnosis of oligomenorrhea or amenorrhea, as high levels of AMH are suggestive of polycystic ovarian syndrome and seem to correlate with the severity of the syndrome.

SUMMARY

AMH is a glycoprotein secreted by the granulosa cells of small growing follicles and indirectly reflects the primordial follicle pool. The ovaries contain a limited number of primordial follicles and their depletion marks the menopause. Thus, the remaining primordial follicle pool is referred to as the ovarian reserve. The clearest data for the clinical utility of AMH is in the context of IVF. The support for other indications is weaker, but rapidly increasing.

Elevated serum thyroid-stimulating hormone is associated with decreased anti-Müllerian hormone in infertile women of reproductive age

PURPOSE

Thyroid dysfunction and autoimmune thyroiditis are associated with fertility in women of reproductive age. Anti-Müllerian hormone (AMH), a known biomarker of ovarian function, may be affected by impaired thyroid function; however, the relationship between AMH and thyroid hormone has not been elucidated.

METHODS

In this case-control study, to identify the impact of thyroid hormone on ovarian reserve, we recruited 67 consecutive Japanese infertile patients and 27 normal fertile women aged 30-39 years without impact factors on thyroid and ovarian functions between 2012 and 2013. We assessed patient age, BMI and AMH, prolactin, TSH and FT4 levels of all study participations as independent variables. To evaluate the relationship between AMH and thyroid hormone, we matched patients by age and body mass index as confounding factors using 1:1 matching for statistical analysis of healthy fertile women and infertile patients and obtained 23 pairs. Then, independent variables were subjected to multiple regression analysis.

RESULTS

Multiple regression analysis showed that both thyroid-stimulating hormone (TSH) levels and patient age were negatively correlated with AMH levels in infertile patients (patient age and TSH: standardized partial regression coefficient (β), -0.534 and -0.361; p = 0.003 and 0.036, respectively), but not in normal fertile women.

CONCLUSIONS

AMH levels were inversely correlated with TSH levels in infertile women of reproductive age.

Reproductive function assessment after surgery plus chemotherapy for germ cell ovarian tumors (MOGCT): novel clues deriving from the field of fertility preservation

Germ cell ovarian tumors (malignant ovarian germ cell tumors - MOGCT) affect young women and are treated by surgery plus chemotherapy. It is well known that cytotoxic treatment may accelerate depletion of the primordial follicle pool leading to impaired fertility and premature menopause. Aim of this study is to identify patient candidates for fertility preservation strategies. We report our experience in preservation of fertility for four patients affected by MOGCT, referred to San Raffaele Hospital Oncofertility Unit. All patients received fertility sparing surgery plus platinum-based chemotherapy. Two patients were affected by mixed germ cell tumors and two by disgerminomas. After 24 months from the end of treatment, serum AMH levels have been measured. We report lower serum anti-Mullerian hormone (AMH) levels in our patients than in healthy general population as serum AMH levels were under the 25th age-specific percentiles. Fertility preservation, in terms of oocytes cryopreservation, was offered to those two patients with serum AMH levels predictive of significantly poor ovarian reserve (1st and 2nd patients). Using the gonadotropin releasing hormone (GnRH) antagonist protocol for ovarian stimulation, we obtained two and six oocytes, respectively. Therefore, serum AMH, as a marker of ovarian function, can improve the identification of patients that need to be referred to fertility preservation strategies.

BRCA1 germline mutations may be associated with reduced ovarian reserve

OBJECTIVE

To determine whether BRCA carriers have a decreased ovarian reserve compared with women without BRCA mutations, because BRCA mutations may lead to accelerated oocyte apoptosis due to accumulation of damaged DNA.

DESIGN

Cross-sectional study.

SETTING

Academic tertiary care center.

PATIENT(S)

A total of 143 women, aged 18-45 years, who underwent clinical genetic testing for BRCA deleterious mutations because of a family history of cancer, were included. The cohort was classified into three groups: BRCA1 carriers, BRCA2 carriers, and women without BRCA mutations (controls). None had a personal history of breast or ovarian cancer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The main outcome was serum antimüllerian hormone (AMH) level. Linear and logistic regression models adjusting for age and body mass index (BMI) were performed to determine the association between BRCA mutations and AMH.

RESULT(S)

BRCA1 mutation carriers had a significant decrease in AMH levels compared with controls after adjusting for age and BMI (0.53 ng/mL [95% confidence interval (CI) 0.33-0.77 ng/mL] vs. 1.05 ng/mL [95% CI 0.76-1.40 ng/mL]). Logistic regression confirmed that BRCA1 carriers had a fourfold greater odds of having AMH <1 ng/mL compared with controls (odds ratio 4.22, 95% CI 1.48-12.0). There was no difference in AMH levels between BRCA2 carriers and controls.

CONCLUSION(S)

BRCA1 carriers have lower age- and BMI-adjusted serum AMH levels compared with women without BRCA mutations. Our results contribute to the current body of literature regarding BRCA carriers and their reproductive outcomes. Larger prospective studies with clinical outcomes such as infertility and age at menopause in this population are needed to further substantiate our findings.

How Much Does AMH Really Vary in Normal Women?

Anti-Mullerian Hormone (AMH) is an ovarian hormone expressed in growing follicles that have undergone recruitment from the primordial follicle pool but have not yet been selected for dominance. It is considered an accurate marker of ovarian reserve, able to reflect the size of the ovarian follicular pool of a woman of reproductive age. In comparison to other hormonal biomarkers such as serum FSH, low intra- and intermenstrual cycle variability have been proposed for AMH. This review summarizes the knowledge regarding within-subject variability, with particular attention on AMH intracycle variability. Moreover the impact of ethnicity, body mass index, and smoking behaviour on AMH interindividual variability will be reviewed. Finally changes in AMH serum levels in two conditions of ovarian quiescence, namely contraceptives use and pregnancy, will be discussed. The present review aims at guiding researchers and clinicians in interpreting AMH values and fluctuations in various research and clinical scenarios.