Evaluating AFC and Hormonal Profiles in Infertility: Insights into PCOS Diagnosis in Samawa City, Iraq

BackgroundThis study aimed to evaluate the cut-off value of anti-Müllerian hormone (AMH) combined with body mass index (BMI) in the diagnosis of polycystic ovary syndrome (PCOS) and polycystic ovary morphology (PCOM).MethodsThis retrospective study included 15,970 patients: 3775 women with PCOS, 2879 women with PCOM, and 9316 patients as controls. Multivariate logistic regression analysis was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for AMH. We randomly divided the patients into two data sets. In dataset 1, a receiver operating characteristic (ROC) curve was generated to analyze the accuracy of basic AMH levels in diagnosing PCOS and PCOM. The optimal cut-off value was calculated in dataset 1 and validated in dataset 2, expressed as sensitivity and specificity.ResultsIn the PCOS group, obese patients had the lowest AMH levels, while underweight patients had the highest AMH level (P < 0.001). After adjusting for age, the ratio of luteinizing hormone (LH) and follicle stimulating hormone (FSH), serum testosterone level, and BMI, AMH was an independent predictor of PCOS and PCOM. In the group with BMI < 18.5 kg/m2, the optimistic AMH cut-off value was 5.145 ng/mL with a sensitivity of 84.3% and specificity of 89.1%, whereas in the BMI ≥ 28 kg/m2 group, the optimistic AMH cut-off value was 3.165 ng/mL with a sensitivity of 88.7% and specificity of 74.6%. For the BMI range categories of 18.5–24, 24.0–28 kg/m2, the optimistic AMH cut-off values were 4.345 ng/mL and 4.115 ng/mL, respectively. The tendency that the group with lower weight corresponded to higher AMH cut-off values was also applicable to PCOM. In the same BMI category, patients with PCOM had a lower AMH diagnosis threshold than those with PCOS (< 18.5 kg/m2, 5.145 vs. 4.3 ng/mL; 18.5–24 kg/m2, 4.345 vs. 3.635 ng/mL; 24.0–28 kg/m2, 4.115 vs. 3.73 ng/mL; ≥ 28 kg /m2, 3.165 vs. 3.155 ng/mL). These cut-off values had a good diagnostic efficacy in the validation dataset. Based on different phenotypes and severity of ovulation disorders, the distribution of AMH in PCOS were also significantly different (P < 0.001).ConclusionsAMH is a potential diagnostic indicator of PCOS and is adversely associated with BMI. The AMH cut-off value for diagnosing PCOS was significantly higher than that for PCOM.

Biomarkers of ovarian response: current and future applications

The role of anti-müllerian hormone in the classification of anovulation

Study question How does MoM AMH perform as a surrogate of polycystic ovary morphology (PCOM) in diagnosing polycystic ovary syndrome (PCOS) among anovulatory women? Summary answer Age-specific MoM-AMH is a good surrogate biomarker to define PCOM in anovulatory women; a cut-off at 2.6 has sensitivity and specificity of 80% and 79%. What is known already The latest international guideline endorses the use of serum AMH level for defining PCOM as one of the three diagnostic criteria for PCOS, although not as a standalone test to replace the current diagnostic criteria. As such, diagnostic cut-offs have been suggested but the value varies with the assay method. Moreover, serum AMH levels changes with age, and it is imprecise to use one cut-off value for women of all ages. The use of age-specific MoM AMH would be a more reasonable approach, utilising the age-specific reference ranges of serum AMH on the same assay platform in the same population. Study design, size, duration This is a retrospective study on women undergoing assisted reproduction between May 2022 and November 2024 at Queen Mary Hospital and Kwong Wah Hospital, Hong Kong. Among the cohort, 83 women diagnosed with PCOS according to the international guideline criteria (2023), 242 anovulatory women with antral follicle count below 20 in both ovaries (i.e. non-PCO), and 465 women documented to be ovulatory and non-PCO, had AMH data available and were included in this study. Participants/materials, setting, methods Serum AMH level was measured during the early follicular phase using the Access platform (Beckman-Coulter). Age-specific MoM AMH was compared between women with PCOS and those with non-PCO anovulation as well as ovulatory women with PCOM. The performance of MoM AMH in distinguishing women with PCOS from those with non-PCO anovulation and normal ovulation (non-PCO) respectively was analysed by receiver-operating characteristic (ROC) curves. Main results and the role of chance Age-specific MoM AMH was significantly higher in women with PCOS (3.6, 2.7 – 5.2) (median, 25th – 75th percentile) and non-PCO anovulation (1.5, 0.8 – 2.4) compared to non-PCO ovulatory women (1.0, 0.6 – 1.6) (p &amp;lt; 0.05 for both), with those in the PCOS group being significantly higher than those with non-PCO anovulation (P &amp;lt; 0.05). The area under the ROC curve for age-specific MoM AMH in distinguishing women with PCOS from non-PCO ovulatory women is 0.958 (95% CI 0.937 to 0.973; p &amp;lt; 0.001). The area under the ROC curve for distinguishing women with PCOS from those with non-PCO anovulation is 0.867 (95% CI 0.825 to 0.902; p &amp;lt; 0.001); at a cut-off of 2.6 (maximal Youden index), the sensitivity and specificity are 80% and 79% respectively. Limitations, reasons for caution Non-PCO anovulation could comprise a heterogeneous spectrum of causes; those in this cohort were mainly having WHO II anovulation and those with premature ovarian insufficiency were excluded. Factors like body mass index and smoking history may impact on AMH levels, but only &amp;lt;5% in our cohort were obese or smoking. Wider implications of the findings While this study validated the use of age-specific MoM AMH as an appropriate approach of utilising serum AMH levels for defining PCOM in the diagnosis of PCOS in a mainly Chinese population, further validation in women of other ethnicities and in those who are obese or smoking would be useful. Trial registration number No

Comparison of body mass index, anti-müllerian hormone and insulin resistance parameters among different phenotypes of polycystic ovary syndrome

Anti-Müllerian hormone (AMH) defines, independent of age, low versus good live-birth chances in women with severely diminished ovarian reserve

Low anti-mullerian hormone decreased clinical pregnancy and increased risk of poor ovarian response in women over 35 years of age.

Antimüllerian hormone as a predictor of controlled ovarian hyperstimulation outcome: comparison of two commercial immunoassay kits

Study question What are the optimal cut-off values for anti-Müllerian hormone (AMH) in diagnosing polycystic ovary syndrome (PCOS) among Japanese women according to the Rotterdam criteria? Summary answer AMH cut-off values suitable for the Rotterdam criteria were separately established for the 20-29, 30-34 and 35-39 age groups, and for Access/Lumipulse and Elecsys assays. What is known already AMH is secreted by the granulosa cells of small antral and pre-antral follicles, and its level is significantly elevated in patients with PCOS, gradually declining with age. The Rotterdam criteria was recently updated to incorporate elevated serum AMH level as a surrogate marker of polycystic ovarian morphology based on the International Evidence-Based Guideline for the assessment and management of PCOS (IEBG) 2023. However, the optimal AMH cut-off values remain unclear. The cut-off value for AFC in the Rotterdam criteria was revised to the presence of 20 or more follicles and/or increased ovarian volume based on IEBG 2018. Study design, size, duration The national survey in Japan was conducted at 643 public and private university hospitals and assisted reproductive technology facilities registered with the Japan Society of Obstetrics and Gynecology. Case data were collected using the REDCap (Research Electronic Data Capture) data collection management system. On September 15, 2022, a notice of the fact-finding survey was sent by regular mail, and the survey commenced on September 16, 2022, with a response deadline of December 23, 2022. Participants/materials, setting, methods Data were collected for 986 PCOS cases meeting the Rotterdam criteria and 965 control cases. Serum AMH levels, measured using the Access and Elecsys assays, were converted to Lumipulse values using regression equations to correct for assay-related differences in measured values. Cut-off values for AMH and AFC were established to have high specificity (≥95%) based on the concept and the structure of the Rotterdam criteria, stratified by age groups, and for different assay systems. Main results and the role of chance Serum AMH level was significantly higher in the PCOS group compared to the Control group. Serum AMH level showed a significant negative correlation with age and significant positive correlation with AFC, luteinizing hormone, and total testosterone (T), but it did not show a significant correlation with BMI in the PCOS group. In multiple regression analysis, serum AMH level was independently affected by AFC (standardized partial regression coefficient = 0.434; p&amp;lt;0.01) and T (0.176; p&amp;lt;0.05). AMH cut-off values having high specificity (≥95%) for the Access and the Lumipulse assays were 9.9 ng/mL for the 20-29 age group, 7.3 ng/mL for the 30-34 age group, and 6.0 ng/mL for the 35-39 age group. In contrast, the cut-off values for the Elecsys assay were 9.0 ng/mL for the 20-29 age group, 6.7 ng/mL for the 30-34 age group, and 5.5 ng/mL for the 35-39 age group. Additionally, AFC cut-off value having high specificity (≥95%) was revealed to be approximately 20 in all age groups. The coefficient of variation (CV) of the mean AMH level in each institute was 0.274, whereas CV of the mean AFC in each institute was 0.374, indicating that AFC exhibited greater variability than AMH (p&amp;lt;0.01). Limitations, reasons for caution As this study was based on a nationwide survey in Japan, it is necessary to consider the impact of racial and ethnic differences. Additionally, AFC was not assessed using identical equipment or by a single investigator. Furthermore, cut-off values for AMH and AFC in adolescents were not determined. Wider implications of the findings This study is the first in the world to establish AMH cut-off values suitable for the Rotterdam criteria, considering age groups, assay systems, and the structure of the diagnostic criteria. This study would serve as a role model to establish AMH cut-off value in each country. Trial registration number No

To evaluate revised criteria for polycystic ovarian morphology (PCOM) in the diagnosis of polycystic ovary syndrome (PCOS) in anovulatory infertility. Prospective cohort study. WHO Group II anovulatory infertile women (n=75). Clinical, sonographic and endocrine parameters, including anti-Müllerian hormone (AMH). The Rotterdam criteria for PCOM (antral follicle count (AFC) ≥12 and/or ovarian volume >10ml) were fulfilled in 93% of the women. The PCOM prevalence was 68% when increasing the threshold to AFC >20 and 76% according to an AMH-based threshold of >35pmol/l. The most recently proposed AFC≥25 threshold reduced the PCOM prevalence to 52% (n=39), leaving 48% (n=36) without features of PCOM. Comparing the 36 women with non-PCOM with the 39 women in the PCOM group according to AFC≥25, 22% vs 59% (P=0·001) had serum LH>10IU/l, 11% vs 41% (P=0·003) had an LH/FSH ratio >2 and 19% vs 41% (P=0·04) had hirsutism and/or elevated total testosterone, free testosterone, and/or androstenedione. The non-PCOM group included significantly more women with secondary infertility. The median AMH in the non-PCOM group was 47pmol/l, which was twofold lower than in the PCOM group but above the upper limit of normo-ovulatory women. According to a revised threshold of 25 follicles, almost half the anovulatory infertile women do not have PCOM. The characteristics of these women may be compatible with hypothalamic anovulation, but according to AMH levels, the ovaries remain multifollicular. A better distinction between hypothalamic amenorrhoea and PCOS could improve treatment strategies for anovulatory infertility.

Study question How does the anti-Müllerian hormone (AMH) cutoff of 3.2 ng/mL perform in diagnosing polycystic ovarian morphology (PCOM) in young adult women 18-24 years of age? Summary answer At the cutoff of 3.2 ng/mL using Elecsys AMH Plus immunoassay, AMH shows a high sensitivity and specificity in identifying PCOM in young adult women. What is known already Polycystic ovary syndrome (PCOS) is diagnosed using the Rotterdam criteria with at least two out of three criteria being met: oligo-anovulation (OA), hyperandrogenism (HA) and PCOM. The diagnosis of PCOM is using either antral follicle count (AFC) or AMH. The Roche Elecsys AMH Plus immunoassay was validated at a cutoff of 3.2 ng/mL for detecting PCOM as part of the PCOS diagnosis in 25-45 year old women. Study design, size, duration This was a retrospective case-control study conducted between October 2024 and December 2024. The study used banked samples from 136 women with PCOS and 85 controls in the age range 18-24 years. The PCOS cases were defined by Rotterdam criteria fulfilling at least 2 out of 3 diagnostic criteria (OA, HA and PCOM), and the control women were healthy subjects with an AFC of &amp;lt; 20 antral follicles/ovary. Participants/materials, setting, methods Serum levels of AMH were measured using the Roche Elecsys® AMH Plus immunoassay, AFC was determined using transvaginal ultrasound. The performance of the AMH cutoff of 3.2 ng/mL to distinguish between PCOM cases using PCOS phenotype A (OA+HA+PCOM) and strict controls (primary population) was assessed. As sensitivity analysis the performance of the cutoff was assessed in a cohort consisting of the PCOS phenotypes with PCOM (OA+HA+PCOM, OA+PCOM, HA+PCOM) and strict controls. Main results and the role of chance In the primary population, women with PCOS (cases) and healthy women (controls) were similar in age (median age 21.0 vs 22.0 years) and body mass index (median BMI 23.8 vs 22.0 kg/m2). At the previously established cut off of 3.2 ng/mL the Elecsys AMH Plus immunoassay showed 85.0 % sensitivity (95% confidence interval [CI]: 76.5–91.4%) and 68.2% specificity (95% CI: 57.2–77.9%) for detecting PCOM in the primary population that consisted of women aged 18-24 years with the full blown PCOS (OA+HA+PCOM) and healthy controls. The overall percentage agreement (OPA) in this population was 77.3% (95% CI: 70.6-83.1%) and the area under the receiver operating characteristic curve (AUC-ROC) for the prediction of case-control status by serum AMH was 85.8% (95% CI: 80.5–91.0%). When all phenotypes with PCOM (OA+HA+PCOM; OA+PCOM; HA+PCOM) were included the sensitivity was 83.5% (95% CI: 76.0-89.3%) and the specificity 68.2% (95% CI 57.2-77.9%). OPA was 77.5% (95% CI 71.4-82.9%) and AUC-ROC was found to be 84.6% (95% CI 79.5-89.6%) including all phenotypes with PCOM. The Spearman correlation coefficient between AMH and AFC found in the full study population, was 0.70. Limitations, reasons for caution The study design was a case-control study in a cohort with control women being healthy without any symptoms of PCOS. Therefore, the AMH cutoff of 3.2 ng/mL needs to be further validated in independent cohort study in young adult women with suspected PCOS. Wider implications of the findings The Roche Elecsys AMH Plus immunoassay is a useful and robust method for identifying PCOM as part of the PCOS diagnosis in conjunction with other clinical characteristics defined by the Rotterdam criteria in young women in the age range from 18 to 24 years. Trial registration number No

Can anti-Müllerian hormone (AMH) level replace the morphologic description in the diagnosis of polycystic ovary syndrome (PCOS) and what is the relationship between AMH and different diagnostic criteria of PCOS? AMH may be a good substitute for polycystic ovarian morphology (PCOM) in diagnosing PCOS. AMH has been suggested as an alternative to antral follicle count (AFC) in diagnosing PCOS. Cut-off values for AMH studied so far show an acceptable specificity but a rather poor sensitivity, leaving up to one-third of PCOS women undiagnosed. We used data from a cross-sectional, case-control study on women with prior preterm birth and their controls, i.e. women with prior full-term birth. Among 262 women, 56 met the Rotterdam criteria (PCOS-R) and 44 the Androgen Excess-PCOS Society (PCOS-AES) criteria of PCOS. Fasting blood samples were collected, a transvaginal ultrasound investigation and a clinical examination were performed. PCOS-R and PCOS-AES were re-diagnosed by replacing PCOM with AMH. Main outcome measures were the prevalence of PCOS, PCOM, hirsutism, oligoamenorrhoea and serum levels of AMH and androgens. When replacing PCOM with AMH, the specificity and sensitivity for identifying PCOS were 97.1 and 94.6% according to the PCOS-R criteria and 97.2 and 95.5% according to the PCOS-AES criteria, respectively, at an AMH cut-off value of 20 pmol/l. The results need to be confirmed when international standards and methods for AMH measurements are established. AMH may be a good substitute for PCOM in diagnosing PCOS. This study was financed by the Cooperative of Central Norway Regional Health Authority and Norwegian University of Science and Technology. The authors have no interests to disclose. This study is registered at www.clinicaltrials.gov as NCT01355536.

Polycystic ovarian syndrome (PCOS) is a heterogeneous condition, is present in 12–21% of women of reproductive age. The Rotterdam Criteria for PCOS require the presence of two of the following criteria: oligo/anovulation, hyperandrogenism antral follicle count (AFC) on ultrasound. The purpose of this paper is to bring new information from recent studies regarding the diagnosis of this disease using anti-Mullerian hormone (AMH) vs. AFC. AMH levels accurately reflect the ovarian follicular reserve and could be considered as an extremely sensitive marker of ovarian aging. Special reference is made to the possible implications of AMH in the pathogenesis of PCOS. The measurement of AMH was made by some clinicians the gold standard for diagnosis of PCOS. Because the serum concentrations of AMH is increased in most patients with PCOS and it is an association between the performance of serum AMH and AFC, has led to compare the performance of AMH levels and AFC in diagnosis of PCOS. With evolving progress in ultrasound device, recent studies have suggested increasing the threshold of AFC to 19 or even 26. The real-time interpretation of two-dimensional ultrasonography may underestimate the absolute number of follicles compared with three-dimensional ultrasound.

Anti-Müllerian hormone (AMH) is produced by granulosa cells of pre-antral and small antral ovarian follicles. In polycystic ovary syndrome (PCOS), higher levels of serum AMH are usually encountered due to the ample presence of small antral follicles and a high AMH production per follicular unit which have led to the proposal of AMH as a serum diagnostic marker for PCOS or as a surrogate for polycystic ovarian morphology (PCOM). However, heterozygous coding mutations of the AMH gene with decreased in vitro bioactivity have been described in some women with PCOS. Such mutation carriers have a trend toward reduced serum AMH levels compared to noncarriers, although both types of women with PCOS have similar circulating gonadotropin and testosterone (T) levels. This report describes a normal-weight woman with PCOS by NIH criteria with severely reduced AMH levels (index woman with PCOS). Our objective was to examine the molecular basis for her reduced serum AMH levels and to compare her endocrine characteristics to similar-weight women with PCOS and detectable AMH levels. Twenty normoandrogenic ovulatory (control) and 13 age- and BMI-matched women with PCOS (19-35 years; 19-25 kg/m2) underwent transvaginal sonography and serum hormone measures including gonadotropins, sex hormone-binding globulin, total and free T, androstenedione, dehydroepiandrosterone sulfate, estrone, estradiol and AMH. The latter was measured by ELISA (Pico-AMH: Ansh Labs, Webster, TX, USA). Women with PCOS and detectable AMH had higher serum AMH (10.82 (6.74-13.40) ng/ml, median (interquartile range)), total and free T (total T: 55.5 (49.5-62.5) ng/dl; free T: 5.65 (4.75-6.6) pg/ml) levels and greater total antral follicle count (AFC) (46 (39-59) follicles) than controls (AMH: 4.03 (2.47-6.11) ng/ml; total T: 30 (24.5-34.5) ng/dl; free T: 2.2 (1.8-2.45) pg/ml; AFC 16 (14.5-21.5) follicles, P < 0.05, all values), along with a trend toward LH hypersecretion (P = 0.06). The index woman with PCOS had severely reduced serum AMH levels (∼0.1 ng/ml), although she also had a typical NIH-defined PCOS phenotype resembling that of the other women with PCOS and elevated AMH levels. All women with PCOS, including the index woman with PCOS, exhibited LH hypersecretion, hyperandrogenism, reduced serum estrogen/androgen ratios and PCOM. A homozygous Ala515Val variant (rs10417628) in the mature region of AMH was identified in the index woman with PCOS. Recombinant hAMH-515Val displayed normal processing and bioactivity, yet had severely reduced immunoactivity when measured by the commercial pico-AMH ELISA assay by Ansh Labs. In conclusion, homozygous AMH variant rs10417628 may severely impair serum AMH immunoactivity without affecting its bioactivity or PCOS phenotypic expression. Variants in AMH can interfere with serum AMH immunoactivity without affecting the phenotype in PCOS. This observation can be accompanied by discordance between AMH immunoactivity and bioactivity.

The diagnosis of polycystic ovary syndrome (PCOS) remains a challenge to clinicians due to heterogeneous clinical presentation and diagnostic criteria. This study investigated the utilization of Anti-Müllerian hormone (AMH) alone or replacing polycystic ovarian morphology (PCOM) in the PCOS diagnostic criteria. A total of 401 women were categorised as PCOS (n:154), nonPCOS with polycystic ovarian morphology (PCOM) (n:105), and nonPCOS with normal ovarian morphology (NOM) (n:142). First, the diagnostic performance of AMH for PCOS diagnosis in Rotterdam, Androgen Excess Society, and National Institutes of Health (NIH) criteria was analyzed. Second, AMH was used instead of PCOM in Rotterdam criteria and we searched diagnostic performance for PCOS phenotypes. AMH levels were positively correlated with LH, testosterone, hirsutism score, menstrual cycle length, and antral follicle count (p < 0.05). AMH alone had specificity and sensitivity for PCOS diagnosis were 84.9% and 72.4% in Rotterdam (AUC: 0.866); 84.4% and 72% in Androgen Excess Society (AUC: 0.857); 83.3% and 66.4% in National Institute of Health criteria (AUC: 0.825). AMH alone had satisfactory diagnostic potential for phenotype A, but not other phenotypes. The replacement of PCOM with AMH in Rotterdam criteria had a high diagnostic potential for PCOS (AUC: 0.934, sensitivity:97.4%, specificity: 90.67%). Phenotype A and phenotype D were diagnosed with 100% sensitivity and 94.5% specificity. Phenotype C was recognised with 96.15% sensitivity and 94.5% specificity. AMH may be used with high diagnostic accuracy instead of PCOM in the Rotterdam PCOS criteria.