The relationship between anti-Müllerian hormone (AMH) levels and pregnancy outcomes in patients undergoing assisted reproductive techniques (ART)

Derivation and validation of the first web-based nomogram to predict the spontaneous pregnancy after reproductive surgery using machine learning models

Objective

Infertility remains a significant global burden over the years. Reproductive surgery is an effective strategy for infertile women. Early prediction of spontaneous pregnancy after reproductive surgery is of high interest for the patients seeking the infertility treatment. However, there are no high-quality models and clinical applicable tools to predict the probability of natural conception after reproductive surgery.

Methods

The eligible data involving 1013 patients who operated for infertility between June 2016 and June 2021 in Yantai Yuhuangding Hospital in China, were randomly divided into training and internal testing cohorts. 195 subjects from the Linyi People's Hospital in China were considered for external validation. Both univariate combining with multivariate logistic regression and the least absolute shrinkage and selection operator (LASSO) algorithm were performed to identify independent predictors. Multiple common machine learning algorithms, namely logistic regression, decision tree, random forest, support vector machine, k-nearest neighbor, and extreme gradient boosting, were employed to construct the predictive models. The optimal model was verified by evaluating the model performance in both the internal and external validation datasets.

Results

Six clinical indicators, including female age, infertility type, duration of infertility, intraoperative diagnosis, ovulation monitoring, and anti-Müllerian hormone (AMH) level, were screened out. Based on the logistic regression model's superior clinical predictive value, as indicated by the area under the receiver operating characteristic curve (AUC) in both the internal (0.870) and external (0.880) validation sets, we ultimately selected it as the optimal model. Consequently, we utilized it to generate a web-based nomogram for predicting the probability of spontaneous pregnancy after reproductive surgery. Furthermore, the calibration curve, Hosmer-Lemeshow (H-L) test, the decision curve analysis (DCA) and clinical impact curve analysis (CIC) demonstrated that the model has superior calibration degree, clinical net benefit and generalization ability, which were confirmed by both internal and external validations.

Conclusion

Overall, our developed first nomogram with online operation provides an early and accurate prediction for the probability of natural conception after reproductive surgery, which helps clinicians and infertile couples make sensible decision of choosing the mode of subsequent conception, natural or IVF, to further improve the clinical practices of infertility treatment.

A meta-analysis of bariatric surgery in patients with obesity and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a multifactorial disease, which is closely related to obesity. This study evaluated the efficacy of bariatric surgery on obesity complicated with PCOS through meta-analysis. PubMed, Cochrane, EMbase, and WOS databases were searched from 2012 to November 2022. Studies on the efficacy of bariatric surgery in the treatment of obesity combined with PCOS were included. Outcome indicators included menstrual abnormalities, BMI, free testosterone, hypertrichosis, and ovarian volume. Methodological quality of the included studies was evaluated, and statistical analysis was performed using RevMan 5.3 software. Finally, 9 studies were included, and the results of meta-analysis were as follows: After weight loss surgery, menstrual irregularity decreased (RR = -0.83, 95%CI:-1.00∼-0.65, P < 0.00001), and BMI decreased significantly (MD = -13.64, 95%CI:-16.29∼-10.99, P < 0.00001). Free testosterone levels decreased (MD = -22.70, 95 % CI: -36.07 ∼ -9.34, P < 0.00001), the incidence of hypertrichosis decreased (RR = 0.63, 95%CI: 0.45-0.88, p = 0.007 < 0.01), and the ovarian volume decreased (MD = -3.09, 5%CI: -5.76 ∼ -0.42, P < 0.00001).

Factors Associated with Poor Ovarian Reserve in Young Infertile Women: A Hospital-based Cohort Study

Background

In practice, we encounter many young infertile women with poor ovarian reserve though ovarian reserve starts to decline after 35 years of age. One of the established risk factors for poor ovarian reserve in young women is endometriosis. There are other conditions that are reported to be associated which require further research.

Aims

We aimed to study the prevalence of poor ovarian reserve and to find out the associated factors in women who are <35 years of age.

Settings and Design

This was a prospective observational cohort study conducted in a tertiary care setting.

Materials and Methods

Women aged more than 21 years and <35 years without Polycystic Ovarian Syndrome (PCOS) or ovarian dysgenesis with normal male factor were included after ethical approval. The sample size was 166 and serum anti-Mullerian hormone (AMH) was estimated by immunoenzymatic assay and expressed in ng/ml. AMH ≤0.99 ng/ml was considered poor ovarian reserve. Apart from established risk factors, the proposed risk factors studied were age 31-35 years, presence of medical disorders, gynaecological pathology and history of repeated ovulation induction (OI).

Statistical Analysis Used

Data were analysed by SPSS version 25. Chi-square test and Fisher's exact test were used to compare the variables between normal ovarian reserve and poor ovarian reserve. Risk estimation was done by logistic regression and was expressed in odds ratio (OR).

Results

Poor ovarian reserve was diagnosed in 40% of this cohort, and 62% were between 31 and 35 years. After adjusting for age >30 years, women with endometrioma, hypothyroidism and prior history of ≥3 cycles of OI were found to be having poor ovarian reserve (OR was 5.7, 2.5 and 2.3, respectively).

Conclusion

Poor ovarian reserve was present in 40% of young women, and significantly associated factors were hypothyroidism and history of repeated multiple OI. This could be a confounder for other underlying mechanisms driving early exhaustion of ovarian reserve in certain young women. Hence, along with established risk factors, these women should undergo AMH testing irrespective of age.

Evaluation of correlation between antral follicle diameters with Follicular Output Rate (FORT) in women under controlled ovarian hyperstimulation for assisted reproductive techniques

Background

This study aimed to determine the association of diametrical antral follicles with the ovarian response by Follicular Output Rate (FORT) ratio in 100 females undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). This study selected 100 women undergoing controlled ovarian hyperstimulation (COH). The number of antral follicles (diameter of 3–10 mm) was calculated with two-dimensional vaginal sonography on days 1–3 of the cycle. Then, on a triggering day with human chorionic gonadotropin (HCG), the number of follicles (with a diameter of 16–22 mm) and the ratio of FORT were determined. The correlation among FORT with age, antral follicle count (AFC), AFC ≤ 5, AFC > 5, number of preovulatory follicles (16–20 mm), number of metaphase II (MII) oocytes, body mass index (BMI), infertility period, and anti-Mullerian hormone (AMH) was assessed.

Results

There was a significant correlation between FORT and total AFC, AFC > 5, number of preovulatory follicles (16–20 mm), and number of MII oocytes retrieved. There is no significant relationship between FORT and examined two variables (AMH and AFC ≤ 5). Multiple linear regression analysis showed no significant relationship between FORT and examined two variables (AMH and AFC > 5). There was a significant correlation between MII oocytes retrieved and age, total AFC, AFC ≤ 5, AFC > 5, number of preovulatory follicles (16–20 mm), and AMH. A significant positive relationship existed between MII oocytes retrieved and examined two variables (AFC ≤ 5 and AFC > 5).

Conclusion

There was not much difference in the correlation between the AFC ≤ 5 and AFC > 5, and both positively correlated with the number of MII oocytes retrieved.

Clinical Utilities of Anti-Müllerian Hormone

The anti-Müllerian hormone (AMH) plays an essential role in sex determination in early embryonic development. Through a series of sequential steps that follows inheriting an XY chromosome, Sertoli cell differentiation upregulates the expression of AMH-suppressing Müllerian duct development and maintains the AMH at a high level until puberty. In females, the AMH is produced by granulosa cells of follicles beginning in the second half of fetal life and continues through adulthood, with a steady decline through the reproductive years and severe decline at menopause, until levels eventually become undetectable. The AMH is essential for the regulation of follicular maturation via the recruitment of primordial follicles throughout folliculogenesis. AMH serum concentration in women strongly correlates with ovarian reserve quantity and reflects ovulation potential. Because the AMH is expressed almost exclusively by growing follicles before FSH-dependent selection, it commonly serves as a marker for ovarian function in various clinical situations, including in the diagnosis and pathogenesis of polycystic ovarian syndrome, artificial reproductive technology, and predictions of menopause or premature ovarian failure.

Seasonal dynamic of cholecalciferol (D3) and anti-Muellerian hormone (AMH) with impact on ovarian response and IVF/ICSI

OBJECTIVE

Recent studies revealed intriguing associations between cholecalciferol (D3) and reproductive functions. Seasonal changes of D3 concentrations are well known; however, they are not always considered in the context of reproductive functions. In this study, we analyzed D3 serum concentration in IVF/ICSI patients with respect to seasonal 3-month quartiles and anti-Muellerian hormone (AMH) referring to the impact on Assisted Reproductive Technologies (ART) outcome.

MATERIALS AND RESEARCH METHODS

We studied 469 female patients, presenting between 2012 and 2018 for ART treatment in our fertility center. D3 as well as the AMH serum concentrations were measured at the beginning of the follicle stimulation (days 3-5 of menstrual cycles). Results were evaluated with respect to seasonal quartiles and outcome of the ART cycles.

RESULTS

D3 concentrations showed significant fluctuations within annual quartiles with a pronounced peak in August-October and a minimum in February-April (26.0 vs. 20.5 mg/dl; p < 0.0001). Similar seasonal dynamics were found for AMH (2.98 vs. 1.78 ng/ml; p = 0.010) and these were associated with significantly shorter stimulation periods during August-October (11.29 vs. 12.12 days; p = 0.042), higher number of fertilized oocytes between August and October (6.23 vs. 4.97; p = 0.05) along with a trend towards higher numbers of cumulus-oocyte complexes. However, no such differences were found for the numbers of MII oocytes or pregnancy rates.

CONCLUSION

Our data indicate seasonal 3-month quartile variations of AMH concentrations and characteristics of ART, such as days of ovarian stimulation and number of fertilized oocytes. Highest AMH concentrations were found between August and October and this quartile was associated with highest D3 concentrations.

The Predictive Levels of Serum Anti-Müllerian Hormone and the Combined Index of the Number of Retrieved Oocytes and Good-Quality Embryos in Advanced-Age Infertile Women

The primary objective of the study was to assess the values of serum anti-Müllerian hormone (AMH) levels and the combined index for the prediction of number of oocytes retrieved (NOR) and number of good-quality embryos (GQE) in infertile women undergoing IVF/ICSI treatment. A group of 521 infertile women aged 21-46 years were recruited as subject in this study. Serum AMH, hormones, and antral follicle count (AFC) were measured. The infertile women were categorized into three groups: 21-34 years (reproductive age), 35-39 years (reproductive age), and 40-46 years (advanced-age infertile). The predictive accuracy of variables was analyzed by the receiver operating characteristic (ROC) curve. AFC, AFC/age ratio, AMH/age ratio, and ovarian response prediction index (ORPI) decreased gradually, while AMH decreased significantly with increase in age. Moreover, NOR and GQE were positively correlated with AFC, AMH, AFC/age ratio, AMH/age ratio, and ORPI (P < 0.001). A statistical significance was observed in predicted oocyte retrieval including AMH, AMH/age ratio, and ORPI between 21-34 years and 35-46 years; especially in the 35-46 years group, these variables reached a "high" grade in the diagnostic accuracy because area under curve (AUC) ranged from 0.982 to 0.988 significantly. No statistical significance was observed for FSH, AMH, AFC, and related combined index predicting GQE. The predictive value of AFC and AFC/age ratio was limited regarding oocyte retrieval; however, AMH, AMH/age ratio, and ORPI concurrently had an excellent value for predicting NOR in reproductive-age women, especially in advanced-age infertile women.

Predictive factors of ovarian response to GnRH antagonist stimulation protocol: AMH and age are potential candidates

Background

Prediction of ovarian response prior to the ovarian stimulation cycle is useful in determining the optimal starting dose of recombinant follicle-stimulating hormone (r-FSH). This study was designed to (I) evaluate which of the following parameters (age, AMH, and FSH) can be used as a predictor of ovarian response to GnRH antagonist stimulation protocol, (II) determine the cutoff value of AMH and age for predicting poor and high ovarian response, and (III) investigate the relationship between age, AMH level, and other clinical parameters. It is a retrospective study. A total of 318 women with a mean age of 28.2 ± 5.9 years old were included in this study. Hormone levels (FSH, LH, PRL, E2, and AMH) and the number of collected oocytes were determined. Based on the number of retrieved oocytes, the participants were divided into three groups: poor response (oocytes < 4, n= 51), normal response (oocytes 4–14, n= 192), and high response (oocytes > 14, n= 75).

Results

A significant increase has been found in AMH level and number of retrieved oocytes and mature oocytes from low to normal and high ovarian response group (P < 0.001). Also, the age in the poor ovarian response group was significantly greater than normal and high ovarian response groups (P < 0.001). A significant positive correlation has been found between the number of retrieved oocytes and mature oocytes and level of AMH (P < 0.001). The receiver operating characteristic (ROC) curves showed that both AMH and age had the highest accuracy in the prediction of poor ovarian response with a cutoff value < 1.45 and > 31.5 years, respectively. Additionally, the ROC analysis has shown that the AMH had the highest accuracy, followed by age in the prediction of high ovarian response with a cutoff value > 3.55 and < 27.5 years, respectively.

Conclusions

This study demonstrates that AMH level and women’s age may be used as potential predictors of ovarian response to GnRH antagonist stimulation protocol.