Mean AMH Research Articles

Avoiding OHSS: Controlled Ovarian Low-Dose Stimulation in Women with PCOS.

The polycystic ovary syndrome is a common endocrine disorder which influences outcome and potential risks involved with controlled ovarian stimulation for artificial reproductive techniques (ART). Concrete practical recommendations for the dosage of gonadotropins, the preferred protocol and preventive methods to avoid ovarian hyperstimulation syndrome (OHSS) are lacking. We present retrospective data of 235 individually calculated gonadotropin low-dose stimulations for ART in a single center from 2012 to 2014. Clinical data and outcome parameter of patients diagnosed with PCOS according to Rotterdam criteria (n = 39) were compared with patients without PCOS (n = 196). The starting dose of gonadotropins was individually calculated depending on patients' age, BMI, ovarian reserve, ovarian response in previous cycles, and diagnostic criteria of PCOS. Mean age and duration of infertility did not differ between the groups, whereas mean BMI (p = 0.007) and AMH (p < 0.001) were higher in the PCOS-group. A lower mean FSH-starting and maximum dose was administered to women with PCOS (p < 0.001). The biochemical pregnancy rate of 42.4 % and the clinical pregnancy rate of 32.2 % for PCOS-patients did not differ from those of the control group (42.2 % and 34.4 % respectively). Neither mild, nor moderate or severe manifestation of OHSS occurred significantly more often in patients with PCOS. Our study supports the use of a calculated low-dose FSH-stimulation strategy in ART for patients with PCOS. Further randomized clinical trials should confirm this strategy and lead to define individual risk factors for OHSS, which can be used for recommendation of safer ART-techniques like in vitro maturation.

The value of different ovarian reserve tests in the prediction of ovarian response in patients with unexplained infertility

Abstract Background: Ovarian reserve tests in unexplained infertility patients before management either by ovulation induction or IVF program are a worthy procedure as it saves unnecessary procedures, induction complications, canceled cycles, wasted resources and emotional stress to the couple in case of low estimate, and can as well help in adjusting the doses to obtain the most appropriate response. Aim of work: To determine the value of mean ovarian volume, AFC, maternal age, FSH and AMH in infertile patients undergoing ovulation induction or IVF cycles. Primary outcome is to predict the best parameter of ovarian reserve. Design: Prospective cross-sectional study. Patients and methods: One hundred infertile women received treatment in the form of induction of ovulation and timed intercourse/IUI or IVF. They had basal FSH, AMH, AFC and mean ovarian volume assessment. The response was then evaluated according to the number of follicles on the day of hCG or the number of oocytes retrieved in IVF cycles. Results and conclusion: The total AFC and AMH are found to correlate significantly with the ovarian response with p values

Anti Müllerian hormone levels before and after uterine artery embolization: A preliminary report

Objective: To determine the effects of uterine artery embolization on Anti-Müllerian hormone levels for women under 40 years of age. Material and methods: Non-randomized, observational study of women under 40 years of age and who received UAE. Twenty-seven women under the age of 40 who underwent UAE were included in the study. Hormone levels were measured prior to UAE, and at least six months post UAE. Results: Statistical analysis from a paired t-test showed that the AMH levels pre- and post-embolization of these women fell within the normal range. The average AMH level prior to embolization was 2.54 ± 3.99 ng/mL. The mean AMH concentration after embolization was 2.33 ± 2.70 ng/mL. The average change in AMH levels between pre-and post-embolization was -0.21 ± 1.08 ng/mL. There is no statistically significant difference between the pre- and post- UAE AMH levels (95% CI -0.64 to 0.22, p=0.32). Conclusion: UAE does not affect ovarian reserve in women under 40 as evidenced by no significant change in AMH levels before and after embolization. Women who are of reproductive age and have fibroids can consider UAE without concern for adverse effects on their fertility.

IN VITRO FERTILIZATION

Various ovarian reserve tests were developed to estimate the ovarian reserve and predict about the outcome in subfertile females undergoing evaluation for assisted reproduction. FSH and AMH levels are considered to be good ovarian reserve indicators along with antral follicle count. Objectives: To explore relationship of AMH and FSH in patients undergoing IVF with respect to ovarian reserve and outcome of the treatment. Study Design: Prospective cohort. Study Period: 1st January 2015 to 31st December 2015. Place of study: Lahore Institute of Fertility and Endocrinology, Hameed Latif Hospital, Lahore Material and Methods: In 346 IVF/ ICSI patients after anthropometric measurements and transvaginal ultrasound antral follicle count were assessed in each ovary. For the hormone measurements blood samples were taken during the early follicular phase of menstrual cycle. Clinical pregnancy was also visualized through transvaginal ultrasound. Results: From the 346 IVF/ICSI patients 89 (25.79%) clinical pregnancies resulted. The mean age in pregnant group was 32.89 ± 2.99 years and in non- pregnant group was 33.62 ±4.36. Mean FSH and AMH in pregnant group was 6.38 ±2.38, 3.27 ±1.86 and in non- pregnant group was 7.54±3.76, 2.72 ± 1.82 respectively. Age and FSH are significantly associated with each other (p-vale = 0.000) and mostly patients had FSH below 9(mIU/mL). Age and AMH are significantly associated with each other (p-vale = 0.000) and mostly patients had AMH above 1.5 (ng/mL). Conclusions: Better pregnancy rate was associated with FSH below than 9 (mIU/mL) and AMH above 1.5 (ng/mL).

Comparing long term impact on ovarian reserve between laparoscopic ovarian cystectomy and open laprotomy for ovarian endometrioma

ObjectiveTo compare the long term impact on ovarian reserve between laparoscopic ovarian cystectomy with bipolar electrocoagulation and laparotomic cystectomy with suturing for ovarian endometrotic cyst.Patient and method(s)121 patients with benign ovarian endometroitic cysts were randomised to either laparoscopic ovarian cystectomy using bipolar electrocoagulation (61 patients) or laparotomic ovarian cystectomy using sutures (60 patients). Serum follicle-stimulating hormone, Antimullerian hormon, Basal antral follicle Count, mean ovarian diameter, and ovarian stromal blood flow velocity were measured at 6, 12 and 18 months after surgery and compared in both groups.Result(s)A statistically significant increase of serum FSH was found in the laproscopic bipolar group at 6-, 12 and 18-month postoperativly compared to open laparotomy suture group. Also, a statistically significant decrease of the mean AMH value occurred in laproscopic bipolar group at 6-, 12 and 18-month follow- up compared to open laparotomy suture group. Basal antral follicle number, mean ovarian diameter and peak systolic velocity were significantly decreased during the 6-, 12,18 -month follow-up in laproscopic bipolar group compared to open laparotomy suture group.Conclusion(s)After laproscopic ovarian cystecomy for endometrioma all pareameter of ovarian reseve are significantly decreased on long term follow up as compared to open laprotomy.

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN OVARIAN CYSTECTOMY ON OVARIAN RESERVE

Objective: To investigate the impact of electrocoagulation on ovarian reserve after laparoscopic excision of ovarian cysts and the possible mechanisms. Design: A prospective study. Setting: Obstetrics and Gynecology Department of a university hospital. Patient(s): 100 patients with benign ovarian cysts undergoing ovarian cystectomy. Intervention(s): Laparoscopic ovarian cystectomy using bipolar electrocoagulation and laparotomic ovarian cystectomy using sutures after the excision of ovarian cysts. Main Outcome Measure(s): Follicle-stimulating hormone (FSH & AMH) assays and transvaginal ultrasound evaluating basal antral follicle number, mean ovarian diameter, and ovarian stromal blood flow velocity at cycles 1, 3 and 6 after surgery. Result(s): When comparing the bipolar group with the suture group, a statistically significant increase of the mean FSH value was found in bilateral-cyst patients at 1-, 3- and 6-month follow- up evaluations and in unilateral-cyst patients at the 1-month follow-up evaluation. When comparing the bipolar group with the suture group, a statistically significant decrease of the mean AMH value was found in bilateral-cyst patients at 1-, 3- and 6-month follow- up evaluations and in unilateral-cyst patients at the 1-month follow-up evaluation. Statistically significant decreases of basal antral follicle number and mean ovarian diameter were found during the 3-, 6-month follow-up evaluations as well as statistically significant decreases of peak systolic velocity at all of the follow-up evaluations. Conclusion(s): Electrocoagulation after laparoscopic excision of ovarian cysts is associated with a statistically significant reduction in ovarian reserve, which is partly a consequence of the damage to the ovarian vascular system. Key Words: Ovarian cysts, laparoscopic ovarian cystectomy, electrocoagulation, ovarian reserve

PP079. Ovarian reserve and function is preserved following severe preeclampsia

Preeclampsia is a multi-organ disorder that predominantly affects renal, cardiovascular, and endocrine systems with long-term consequences for the women's health. As advanced age and history of subfertility increase the risk of developing preeclampsia, reduced ovarian reserve may be associated with preeclampsia. However, long-term effect of preeclampsia on the ovarian function and reserve is not known. We hypothesized that the ovarian reserve and function are reduced in women with a previous history of severe preeclampsia. To compare the plasma levels of markers of ovarian function (FSH, LH, SHBG, testosterone) and reserve (anti-Müllerian hormone, AMH) in women who previously had preeclampsia with their matched controls. Twenty women who had severe preeclampsia (PE group) requiring delivery before 36 weeks of gestation and 20 controls were matched for age, parity, height and weight were included in the study. Women were not breast-feeding, they were having regular menstrual periods and were not using any hormonal contraception. Fasting blood samples were taken during the follicular phase. Plasma was separated and frozen at -70 degrees until analyzed. Comparison between groups was performed using paired sample t-test for parametric and Wilcoxon T-test for nonparametric data. A two-tailed p-value <0.05 was considered significant. The mean age was 36.4 years, height 164cm and weight 72kg in PE group, compared to 37.0 years, 165cm and 69kg, respectively in control group. The mean AMH was 1.34ng/mL in PE group compared to 1.55ng/mL in controls (p=NS). No significant differences were found in the levels of LH (6.72 versus 6.53 IU/L), FSH (5.27 versus 7.16 IU/L), LH/FSH ratio (1.39 versus 1.11), SHBG (63.65 versus 52.90 versus 52.90nmol/L), and testosterone (0.72 versus 1.01nmol/L) between groups. Ovarian reserve and function is not altered significantly in women with a previous history of preeclampsia.

The Impact in Older Women of Ovarian FMR1 Genotypes and Sub-Genotypes on Ovarian Reserve

We recently associated ovarian FMR1genotypes and sub-genotypes with distinct ovarian aging patterns. How they impact older females is, however, unknown. We, therefore, investigated 217 consecutive first in vitro fertilization (IVF) cycles in women >40 assessing oocyte yields, stratified for better (anti-Müllerian hormone, AMH >1.05 ng/mL) or poorer (AMH≤1.05 ng/mL) functional reserve (FOR)). Mean age was 42.4±2.0 years, mean AMH 0.76±0.92 ng/mL and mean oocyte yield 5.3±5.4. Overall, and in women with better FOR, FMR1 did not affect oocyte yields. With poorer FOR (AMH≤1.05 ng/mL) women with het-norm/high, however, demonstrated higher oocyte yields (5.0±3.8) than those with het-norm/low sub-genotype 3.1±2.5; P = 0.03), confirmed after log conversion. Known associated with low FOR at young age, het-norm/high, thus, appears to preserve FOR into older age, and both het sub-genotypes appear to expand female reproductive lifespan into opposite directions.

The use of anti mullerian hormone in the evaluation of egg donors

OBJECTIVE: Based on our experience with infertile women undergoing gonadotropin stimulation we determined that 1.4ng/mL would be the minimal level for allowing women to donate in order to have confidence that an adequate number of oocytes would be retrieved. This study was performed to evaluate the utility of AMH testing in egg donors.DESIGN: Retrospective cohort study.MATERIALS AND METHODS: 25 donors, ages 19 to 28 had undergone ovarian hyperstimulation followed by egg retrieval. All donors had AMH levels ≥1.4 ng/mL. Stimulation consisted of combined oral contraceptive pills followed by FSH stimulation. GnRH antagonist was added once a lead follicle was 12 mm and recombinant hCG (250 mcg) was given when two lead follicles were >17mm. Number of eggs retrieved, number of mature eggs, and number of IUs of FSH used were recorded. We performed linear regression to determine if AMH predicted the number of oocytes retrieved, the number of mature oocytes, and the amount of FSH used. For donors who had undergone multiple cycles for egg donation, only the first cycle was used in the analysis.RESULTS: The mean AMH value was 3.36ng/mL±1.69(SD). The average amount of FSH used was 2264IU±773. The mean number of total and mature eggs retrieved were 21.1±10.1 and 16.6±8.1, respectively. The total number of eggs ranged from 9-46 and the number of mature eggs ranged from 6-36. AMH did not predict the number of eggs retrieved (B=0.9±1.17,t=0.77,P=0.45), the number of mature eggs (B=0.19±0.97,t=0.2,P=0.84), or the amount of FSH used (B=-150.5±76.38,t=-1.97,P=0.57).CONCLUSIONS: In our egg donors, AMH levels did not predict the amount of gonadotropin needed for stimulation. Furthermore, AMH did not predict the total number of eggs retrieved or the number of mature eggs retrieved. In our experience, an AMH level ≥ 1.4 ng/mL allowed us to confidently tell recipients that a donor would produce an average of 21 eggs, with an average of 16 being mature. We propose that an AMH of 1.4 ng/mL be used to determine suitability of a potential egg donor. OBJECTIVE: Based on our experience with infertile women undergoing gonadotropin stimulation we determined that 1.4ng/mL would be the minimal level for allowing women to donate in order to have confidence that an adequate number of oocytes would be retrieved. This study was performed to evaluate the utility of AMH testing in egg donors. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: 25 donors, ages 19 to 28 had undergone ovarian hyperstimulation followed by egg retrieval. All donors had AMH levels ≥1.4 ng/mL. Stimulation consisted of combined oral contraceptive pills followed by FSH stimulation. GnRH antagonist was added once a lead follicle was 12 mm and recombinant hCG (250 mcg) was given when two lead follicles were >17mm. Number of eggs retrieved, number of mature eggs, and number of IUs of FSH used were recorded. We performed linear regression to determine if AMH predicted the number of oocytes retrieved, the number of mature oocytes, and the amount of FSH used. For donors who had undergone multiple cycles for egg donation, only the first cycle was used in the analysis. RESULTS: The mean AMH value was 3.36ng/mL±1.69(SD). The average amount of FSH used was 2264IU±773. The mean number of total and mature eggs retrieved were 21.1±10.1 and 16.6±8.1, respectively. The total number of eggs ranged from 9-46 and the number of mature eggs ranged from 6-36. AMH did not predict the number of eggs retrieved (B=0.9±1.17,t=0.77,P=0.45), the number of mature eggs (B=0.19±0.97,t=0.2,P=0.84), or the amount of FSH used (B=-150.5±76.38,t=-1.97,P=0.57). CONCLUSIONS: In our egg donors, AMH levels did not predict the amount of gonadotropin needed for stimulation. Furthermore, AMH did not predict the total number of eggs retrieved or the number of mature eggs retrieved. In our experience, an AMH level ≥ 1.4 ng/mL allowed us to confidently tell recipients that a donor would produce an average of 21 eggs, with an average of 16 being mature. We propose that an AMH of 1.4 ng/mL be used to determine suitability of a potential egg donor.

Can an anti-mullerain hormone cutoff level predict ovarian response among women with poor ovarian reserve?

OBJECTIVE: The purpose of our study was to determine if the addition of AMH levels can predict ovarian response in IVF cycles among known poor responders undergoing maximal stimulation protocols. AMH, a marker of ovarian reserve that remains relatively consistent throughout the cycle, has been associated with the number of small antral follicles. Recently, levels of ≤1.26ng/ml have been associated with diminished ovarian reserve. However, an AMH level that predicts ovarian response among known poor responders has not been established. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We randomly selected 90 cycles between 2005 and 2006 in patients undergoing IVF using non-suppressed protocols with maximal stimulation. Patients either underwent a short protocol (n=44) or a GnRH antagonist protocol (n=46). Variables evaluated were: AMH levels, Day 2 FSH, antral follicle count, age and BMI. Outcomes of interest were: total number of oocytes retrieved, number of oocytes mature, number of oocytes fertilized and clinical pregnancies. All subjects were defined as poor responders based on a prior poor response to aggressive gonadotropin stimulation. Data were tabulated and analyzed using SPSS software. RESULTS: Mean maternal age was 39.6 (±0.4) years, mean day 2 FSH level was 7.1 (±0.3) mIU/ml, and mean day 2 antral follicle count was 8 (±0.4). Logistic regression analysis revealed that AMH and antral follicle count were significant predictors of very poor response (< 4 oocytes). FSH level in this group was not found to be a significant predictor of number of oocytes. The mean AMH level of all patients was 0.7 (±0.1). We established a cut-off level of 0.38ng/ml based on the mean AMH level among those defined as having a very poor ovarian response. That is, 81% of those with an AMH above the cut-off level had greater than four oocytes retrieved (p<0.0001). We also calculated a positive predictive value of 0.89, suggesting that this cutoff was 89% accurate in identifying those who, although overall poor responders, could still have greater than four oocytes retrieved. CONCLUSIONS: AMH is an additional predictor of response to gonadotropin stimulation. Using a cutoff level 0.38ng/ml we can counsel patients, prior to stimulation, if they are likely to produce more than 4 oocytes. As chances for pregnancy are related to ovarian response, this information would be useful to patients in determining whether or not to proceed with ART or to use gamete donation.