Anti-Mullerian hormone levels do not predict response to pulsatile GnRH in women with hypothalamic amenorrhea

New insights into the role of LH in early ovarian follicular growth: a possible tool to optimize follicular recruitment

Evidence shows that LH participates in enhancing transition from the early stage to the antral stage of folliculogenesis. It has been demonstrated that functional LH receptors are expressed, albeit at a very low level and even in smaller follicles, during the phase that was traditionally considered to be gonadotrophin independent, suggesting a role for LH in accelerating the rate of progression of non-growing and primary follicles to the preantral/antral stage. Hypogonadotropic hypogonadism, together with other clinical conditions of pituitary suppression, has been associated with reduced functional ovarian reserve. The reduction in LH serum concentration is associated with a low concentration of anti-Müllerian hormone. This is the case in hypothalamic amenorrhoea, pregnancy, long-term GnRH-analogue therapy and hormonal contraception. The effect seems to be reversible, such that after pregnancy and after discontinuation of drugs, the functional ovarian reserve returns to the baseline level. Evidence suggests that women with similar primordial follicle reserves could present with different numbers of antral follicles, and that gonadotrophins may play a fundamental role in permitting a normal rate of progression of follicles through non-cyclic folliculogenesis. The precise role of gonadotrophins in early folliculogenesis, as well as their use to modify the functional ovarian reserve, must be investigated.

Extended LH administration as a strategy to increase the pool of recruitable antral follicles in hypothalamic amenorrhea: evidence from a case series

New evidence is indicating a growing role of LH in promoting ovarian follicular growth and maturation, even at the early stages. LH seems to enhance the transition of follicles to the antral stage hence leading to an increase in the so-called functional ovarian reserve (recruitable antral follicles). Hypogonadotropic hypogonadism is characterized by low, and sometimes undetectable, serum LH and FSH levels, which may indeed explain the low anti-Müllerian hormone (AMH) levels and antral follicle count (AFC) found in patients affected by this condition. We report here the cases of two young women affected by hypothalamic amenorrhea (HA) that presented for fertility treatment with very low functional ovarian reserve. The two patients were treated with exogenous LH for 1 and 2 months (extended LH administration: ELHA) at the dose of 187.5 IU LH every day and 150 IU LH every other day, respectively. In both the cases there was an increase in serum AMH levels and in the AFC. In one patient, the AMH and AFC increased from a baseline 1.3 ng/ml and 8 to 2.3 ng/ml and 14 at end of treatment, respectively. In the second case, serum AMH and AFC increased from 0.4 ng/ml and 6 to 1.6 ng/ml and 13, respectively. One patient underwent ovarian stimulation before and after ELHA, showing an increase in the number of mature oocytes recruited (3 versus 8 metaphase II (MII) oocytes before and after, respectively). The second patient underwent an IVF cycle after ELHA resulting in the retrieval of six MII oocytes and an ongoing pregnancy following transfer of a single blastocyst. Women with HA are characterized by chronic, low levels of gonadotrophins, which may impact not only on the cyclic recruitment of follicles but also the progression of small growing follicles through the first stages of folliculogenesis. Some women with HA may in fact show very low serum AMH and AFC. Our case series shows that the administration of LH at a dose of at least 150–187.5 IU every day or every other day may contribute to a clinically evident increase in the functional ovarian reserve (AFC), and probably accounts for a positive effect of LH on the progression of follicles throughout the early stages of folliculogenesis.

The Reproductive Outcome of Women with Hypogonadotropic Hypogonadism in IVF

OBJECTIVE

The purpose of this study was to evaluate the reproductive outcome of patients with hypogonadotropic hypogonadism (HH) receiving in vitro fertilization and embryo transfer (IVF-ET).

METHODS

The reproductive outcome of 81 HH patients and 112 controls who underwent oocyte retrieval was evaluated retrospectively in the Center for Reproductive Medicine of Peking University Third Hospital from 2010 to 2019.

RESULTS

The basic levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), androstenedione (A) and prolactin (PRL) were significantly lower in the HH group than the control group. Although the HH patients required a significantly longer stimulation and higher gonadotropin (Gn) doses than the control patients, the total number of oocytes retrieved, fertilized embryos, two pronuclear (2PN) embryos, transferable embryos, fertilization and 2PN rates were comparable between the two groups. Although the live birth rate (LBR) of the first fresh cycle was higher in the control group than the HH group, there was no statistical significance. Then we further divided HH patients into two subgroups according to the etiology. Forty-one cases were termed as congenital HH (CHH), while the other 40 cases were termed as acquired HH (AHH), the latter includes functional hypothalamic amenorrhea (FHA) and pituitary HH (PHH). Our results showed that there were no significant differences in basic clinical characteristics and IVF parameters between the two groups. In the HH group, a total of 119 oocyte retrieval cycles were carried out and they responded adequately to ovulation induction. Urinary human menopausal gonadotropin (HMG) was used alone in 90 cycles while combination of HMG and recombinant human follicle stimulating hormone (rFSH) in the other 29 cycles. There were no significant differences in IVF-related parameters between the two groups. The conservative cumulative live birth rates (CLBRs) after the first, the second and ≥third cycles were 43.21%, 58.02% and 60.49%, respectively, while the corresponding optimal CLBRs were 43.21%, 68.45% and 74.19%. The preterm birth (PTB) rates of singletons and twin pregnancy in HH patients were 8.33% (3/36) and 30.77% (4/13), respectively.

CONCLUSION

IVF-ET is an effective treatment for HH patients with infertility and patients can get satisfactory pregnancy outcomes.

Efficacy and safety of pulsatile gonadotropin-releasing hormone therapy among patients with idiopathic and functional hypothalamic amenorrhea: a systematic review of the literature and a meta-analysis

OBJECTIVE

To systematically review and appraise the existing evidence in relation to the efficacy and safety of pulsatile gonadotropin-releasing hormone (pGnRH) for the treatment of women with hypothalamic amenorrhea (HA).

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

A total of 35 studies (three randomized and 32 observational) encompassing 1,002 women with HA.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcomes: ovulation rate (OvR), pregnancy per ovulatory cycle rate (POR), and live birth per ovulatory cycle rate (LBOR).

SECONDARY OUTCOMES

multiple gestation (MG), ovarian hyperstimulation syndrome (OHSS), and superficial thrombophlebitis (ST) rates. The summary measures were expressed as proportions and 95% confidence intervals (CI).

RESULT(S)

Pulsatile GnRH treatment appears to achieve high OvRs. A trend toward high PORs and LBORs among women with HA is demonstrated. SC pGnRH achieves comparable OvR compared with IV pGnRH. The incidence of OHSS is low and of mild severity. Treatment with pGnRH is associated with low but slightly higher MG rates compared with the general population. IV administered pGnRH is rarely associated with ST.

CONCLUSION(S)

The high OvRs leading to a high rate of singleton pregnancies and the low likelihood of OHSS render the pGnRH treatment modality both effective and safe for the treatment of women with HA of either primary or secondary origin.

The correlation between AMH assays differs depending on actual AMH levels

STUDY QUESTION

What is the correlation of serum anti-Müllerian hormone (AMH) levels between two frequently used laboratory assays?

SUMMARY ANSWER

A considerable difference was found in serum AMH levels measured with the two different assays, particularly for low AMH values.

WHAT IS KNOWN ALREADY

AMH is regarded as being a robust, highly sensitive and specific biomarker for ovarian response and has become widely used as the basis for fertility treatment decisions. However, several available assays with different reference values, in addition to inter-laboratory variations and issues of sample stability, make interpretation of the AMH values and their clinical implications complicated.

STUDY DESIGN SIZE DURATION

An observational study was performed including 269 serum samples from infertile women, originating from a RCT conducted in 2013-2016 (www.clinicaltrials.gov NCT02013973).

PARTICIPANTS/MATERIALS SETTING METHOD

Serum AMH levels analysed with the Modified Beckman Coulter Gen II ELISA assay (Premix method) were compared to AMH levels analysed with the Beckman Coulter Gen II ELISA original assay (Gen II original). All samples were handled identically and analysed with the two assays in a parallel setting.

MAIN RESULTS AND THE ROLE OF CHANCE

The slope of the regression line showed a mean of 18% higher values with the Premix method compared to the Gen II original assay, and more than 40% higher values for AMH levels in the lower range.

LIMITATIONS REASONS FOR CAUTION

The Gen II original assay is no longer in clinical use as it has been replaced by the Premix method, which, in turn, recently has been further developed into an automated method.

WIDER IMPLICATIONS OF THE FINDINGS

The finding of differences in AMH levels between assays is clinically important and may imply an incorrect classification in the assessment of ovarian reserve. The robustness of serum AMH as a marker for ovarian reserve and as a tool for fertility counselling has to be investigated further. There is an urgent need for international standards on interpretation of AMH values for different assays.

STUDY FUNDING/COMPETING INTERESTS

Financial support was received through Sahlgrenska University Hospital (ALFGBG-70940) and the Hjalmar Svensson Research Foundation. None of the authors declares any conflict of interest.