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AMH Screening in Infertility
The document discusses the role of Anti-Müllerian Hormone (AMH) in ovarian and male reproductive health. It highlights AMH's significance in assessing ovarian reserve, predicting ovarian responsiveness, and its relation to various reproductive conditions and treatments. Furthermore, it notes AMH's stability during the menstrual cycle and its potential implications in male reproductive screening.
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AMH Screening in Infertility
- 1. Role of AMHScreening Dr Sujoy Dasgupta MBBS (Gold Medalist, Hons), MS (OBGY- Gold Medalist), DNB, FIAOG Fellow- Reproductive Endocrinology & Infertility (ACOG, USA) Consultant, Bavishi Pratiksha Fertility Institute, Kolkata Visiting Consultant, RSV Hospital, Kolkata Secretary, Website and Bulletin Committee, Bengal Obstetric and Gynaecological Society (BOGS) 2017-18 Managing Committee Member, BOGS, 2017-18
- 2. Anti- Müllerian Hormone(AMH) • Hormone found in the testes (Sertoli Cells) • Müllerian regression and sexual differentiation in males • 1986- Isolated from the Sertoli cells in the testes and the granulosa cells in the ovaries (Picard JY, et al.)
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- 4. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH FSH 70-80 days Last 20 days Initial Recruitment Cycle Recruitment Selection Dominance Paracrine Control (Gn Independent) Endocrine Control (Gn Dependent) Estrogen
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- 7. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen
- 8. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH
- 9. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH
- 10. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH FSH
- 11. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH FSH Estrogen
- 12. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH FSH Initial Recruitment Cycle Recruitment Selection Dominance Paracrine Control (Gn Independent) Endocrine Control (Gn Dependent) Estrogen
- 13. Primordial Follicle Small Preantral Large Preantral Small Antral (2-7 mm) Large Antral (8-12 mm) Preovulatory AtresiaAtresia Atresia 1st Migration • Activin • Inhibin • TGF Superfamily 2nd Migration • GH • IGF • Androgen AMH FSH 70-80 days Last 20 days Initial Recruitment Cycle Recruitment Selection Dominance Paracrine Control (Gn Independent) Endocrine Control (Gn Dependent) Estrogen
- 14. Role of AMHin Ovarian Dynamics • Follicular Preservation • Prevention of unnecessary and excessive recruitment of primordial follicles • Restriction of follicular sensitivity to FSH • Indirectly helping mono-follicular development
- 15. Terminology 1. Ovarian Reserve-Number and quality of oocytes present in the ovary 2. Ovarian Responsiveness- Number of oocytes developed/ retrieved after COH 3. Ovarian Ageing- Decline in quantity and quality of ovarian activity because of individualized rhythm of the “biological clock”
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- 17. When to screenfor Ovarian Reserve • Routine Tests in Sub-fertility (NICE 2013) 1. Semen Analysis 2. Tubal Patency- HSG, HyCoSy, Laparoscopy 3. Mid-luteal serum Progesterone • Should AMH be included in routine investigation for Infertility?
- 18. NICE (2013) For alltypes of Subfertility- • Age Before ART- Any one of • AMH, FSH, AFC
- 19. Markers for Ovarianreserve
- 20. AMH- To screenfor Ovarian Reserve • Superior than other markers • Paracrine control, independent of HPO endocrine feedback • Correlates with AFC, FSH, Inhibin B, E2 • Higher sensitivity and specificity than conventional markers
- 21. • Remains relativelystable throughout the cycle (cf FSH, Inhibin B, E2) • Low inter-cycle variability
- 22. Problem with AMH •Measurement not yet standardized • Assays- Diagnostic System Lab (DSL), Immuno-Tech Beckman- Coulter (IBC) • Dispute on lower and higher level • Poor correlation with oocyte quality
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- 25. AMH to predictOvarian Responsiveness • Correlates with number of oocytes retrieved • Predictive value better than FSH, Inhibin B, E2 • Predictive value equal to AFC • AMH <1.0 ng/ml- High chance of cycle cancellation • AMH >4.0 ng/ml- High risk of OHSS
- 26. • Role inpredicting ongoing pregnancy is limited • Correlates with higher number of D2/3 embryos and better embryo morphology score • High AMH correlates with higher live birth rate Aflatoonian A, et al. 2009 Nelson SM, et al. 2009 Fleming R, et al. 2006
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- 28. AMH Screening forOvarian Ageing • Earlier marker and more sensitive for POF than FSH
- 29. When to screenfor Ageing • Family H/O POF • High Risk of POF • Cancer Treatment • Endometriotic Cystectomy
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- 31. AMH Screening inMale • Secreted from Sertoli Cells • Under control of gonadotrophins, suppressed by testosterone • Serum AMH remains high until onset of puberty • Value remains low in adult male • Important in childhood to screen for hypogonadism • Low AMH at puberty → Precocious puberty • High AMH at puberty → Delayed puberty
- 32. Possible Role inAzoospermia • AMH- OA < NOA • Marker (Noninvasive) of successful sperm retrieval in OA • Normal AMH in Sertoli-cell-only Syndrome
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- 34. Low AMH =Poor Ovarian reserve??? Ovum Donation IVF DHEA Clinical Correlation
- 35. Conclusion • Good predictorof ovarian reserve • Predicts ovarian response to Gn Stimulation • Predicts the probability of cycle cancellation and hyper-response in ART • Levels are higher in PCOS • Could be a potential marker of obstructive azoospermia • Role as isolated marker- ?