Can we use serum Anti-Mullerian hormone to differentiate the diagnosis between polycystic ovary syndrome patients and healthy women with polycystic ovarian morphology and regular menstrual cycles

Anti-müllerian hormone as a diagnostic biomarker for polycystic ovary syndrome and polycystic ovarian morphology: a systematic review and meta-analysis

IMPORTANCE

As part of the 2023 international evidence-based polycystic ovary syndrome (PCOS) guideline, this meta-analysis investigated the inclusion of Anti-Müllerian hormone (AMH) levels in the diagnostic criteria for PCOS.

OBJECTIVE

To answer the following three questions: 1) Are AMH levels effective in diagnosing PCOS in adult women? 2) Are AMH levels effective in diagnosing PCOS in adolescents? Are AMH levels effective in diagnosing polycystic ovarian morphology (PCOM)?

DATA SOURCES

Searches were conducted in six databases until July 31, 2023.

STUDY SELECTION AND SYNTHESIS

Eligible studies were those conducted in humans, published in English, and reporting sensitivity, specificity, and/or area under the curve values. Extracted data included study population, age, body mass index, AMH assay, cut-off value of AMH levels, sensitivity, specificity, and area under the curve values. The risk of bias was assessed using the quality assessment of diagnostic accuracy studies tool. A random effects model was used to test diagnostic accuracy.

MAIN OUTCOMES

Pooled sensitivity and specificity to use AMH levels for PCOS diagnosis in adults as well as adolescents and for detecting PCOM in adults.

RESULTS

Eighty-two studies were included. The adult AMH-PCOS meta-analyses (n = 68) showed a pooled sensitivity and specificity of 0.79 (95% confidence interval [CI], 0.76-0.82; I2 = 86%) and 0.87 (95% CI, 0.84-0.89; I2 = 91%). The adolescent AMH-PCOS meta-analysis (n = 11) showed a pooled sensitivity and specificity of 0.66 (95% CI, 0.58-0.73; I2 = 74%) and 0.78 (95% CI, 0.71-0.83; I2 = 45%). The adult AMH-PCOM meta-analysis (n = 7) showed a pooled sensitivity and specificity of 0.79 (95% CI, 0.72-0.85; I2 = 94%) and 0.87 (95% CI, 0.78-0.93; I2 = 94%). CONCLUSION AND RELEVANCE: This study investigated the most profound change in the 2023 international evidence-based PCOS guideline, which now recommends AMH levels for defining PCOM in adults in accordance with the diagnostic algorithm. Antimüllerian hormone levels alone are insufficient for PCOS diagnosis and are nonspecific for PCOM in adolescents. Multiple factors influence AMH levels and cause heterogeneity as well as limitations in this study. Consequently, no international cut-off value could be recommended, emphasizing the need for research on more individualized cut-off values.

Updated meta-analysis on the diagnostic accuracy of serum anti-Mullerian hormone in poly cystic ovary syndrome involving 13 509 subjects

AIM

To determine the diagnostic accuracy of anti-Mullerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS).

METHODS

Two independent reviewers searched the electronic databases and search engines using PubMed, Cochrane library, and Google Scholar systematically to retrieve relevant articles published from inception to September 2021. The diagnostic efficacy of AMH was computed using the random-effects model in terms of pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence interval (CI). A meta-regression and subgroup analysis were performed to check for any source which could explain possible heterogeneity. Risk of bias assessment was conducted using the QUADAS-2 tool recommended by Cochrane Library.

RESULTS

This meta-analysis included a total of 41 studies involving 13 509 subjects. We observed promising pooled sensitivity 0.78 (95% CI 0.74 to 0.81), specificity 0.87 (95% CI 0.84 to 0.90), and diagnostic odds ratio (DOR) 24 (95% CI 15 to 37), for AMH in detecting PCOS and discriminatory power (summary receiver operating characteristic [SROC] curves, 0.89 [95% CI 0.86-0.92]). The most prominent bias was noted in the patient selection and index test assessment.

CONCLUSIONS

With the findings of this current meta-analysis, we conclude serum AMH to be a promising biomarker for the diagnosis of PCOS, however, substantial heterogeneity among studies needs individual patient data analysis in order to identify an optimal cut-off value and homogenous findings.

REGISTRATION NUMBER AND GUIDELINES

This meta-analysis was performed according to constructed protocol registered in the PROSPERO database with registration number CRD42021246910.

Mutational Analysis of the Putative Anti-Müllerian Hormone (AMH) Binding Interface on its Type II Receptor, AMHR2

Anti-Müllerian hormone (AMH) or Müllerian inhibiting substance is a unique member of the TGF-β family responsible for development and differentiation of the reproductive system. AMH signals through its own dedicated type II receptor, anti-Müllerian hormone receptor type II (AMHR2), providing an exclusive ligand-receptor pair within the broader TGF-β family. In this study, we used previous structural information to derive a model of AMH bound to AMHR2 to guide mutagenesis studies to identify receptor residues important for AMH signaling. Nonconserved mutations were introduced in AMHR2 and characterized in an AMH-responsive cell-based luciferase assay and native PAGE. Collectively, our results identified several residues important for AMH signaling within the putative ligand binding interface of AMHR2. Our results show that AMH engages AMHR2 at a similar interface to how activin and BMP class ligands bind the type II receptor, ACVR2B; however, there are significant molecular differences at the ligand interface of these 2 receptors, where ACVR2B is mostly hydrophobic and AMHR2 is predominately charged. Overall, this study shows that although the location of ligand binding on the receptor is similar to ACVR2A, ACVR2B, and BMPR2; AMHR2 uses unique ligand-receptor interactions to impart specificity for AMH.