Role Of AMH In Infertility , Advantage of AMH , Fecundity / Infertility & AMH , Infertility and AMH ,Prediction of pregnancy chances in couples presenting with infertility , AMH in IVF
3. 3
AMH is a glycoprotein
Originally known as Mullerian Inhibiting
Substance(MIS)
Appears in females at puberty
Produced by granulosa cells of pre-antral and small
antral follicles of 4-6 mm
AMH is not expressed in atretic follicles and theca cells.
AMH
4. BASIS OF AMH
Anti-Mullerian hormone (AMH)
plasma levels reflect the continuous
non-cyclic growth of small follicles,
thereby mirroring the size of the
resting primordial follicle pool and
thus acting as useful marker of
ovarain reserve.
5. FACT ABOUTAMH
After an initial increase until
early adulthood, AMH
concentrations slowly
decrease with increasing age
until becoming undetectable 5
years before menopause.
6. ADVANATAGE OF
AMH
It helps in forecasting of
reproductive lifespan, ovarian
response to stimulation ovarian
dysfunction and gonadotoxic
cancer treatment of ovarian
surgery.
9. 9
AMH is produced by the small growing (primary and preantral) follicles in the
postnatal ovary and has two sites of action. It inhibits initial
follicle recruitment (1) and inhibits FSH-dependent growth and selection of
preantral and small antral follicles (2).
Model of AMH action in the ovary.
10. 10
The intrafollicular concentrations of AMH in
normal human antral follicles show a gradual
reduction as the diameter of the follicle
increases, and a sharp decline is observed
around 8mm
Physiological function- prevent excessive follicle
recruitment. Acts as a Gatekeeper
11. Not cycle dependant-can be measured
any day
Less cycle to cycle variation than FSH.
Not altered after down regulation with
GNRH agonist.
Pregnancy
AMH – factors that Increase
Polycystic ovaries
AMH - unaffected
12. AMH
This renders AMH easy to measure at any
time as opposed to other currently
available markers of ovarian aging, such
as inhibin B, estradiol (E2) and FSH, which
are all menstrual cycle dependent and
constitute relatively late markers of the
ongoing process of primordial follicle
pool depletion.
13. - Overweight
- Ethnicity
- Vitamin D status
- Polymorphisms of AMH and its receptor
- Smoking and Alcohol intake
- Genetic variants across the genome.
Factors influencing AMH
concentrations are
14. 14
High (often PCOS) Over 3.5 ng/ml
Normal Over 1.4 ng/ml
Low Normal Range 0.7 – 1.3 ng/ml
Low 0.3 - 0.6 ng/ml
Very Low Less than 0.3 ng/ml
AMH BLOOD LEVEL
16. 16
High (often PCOS) Over 3.5 ng/ml
Normal Over 1.4 ng/ml
Low Normal Range 0.7 – 1.3 ng/ml
Low 0.3 - 0.6 ng/ml
Very Low Less than 0.3 ng/ml
AMH BLOOD LEVEL
17. AMH of less than 1.36 ng/ml has a
sensitivity of 75.5% and specificity of
74.8% in prediction of poor response.
AMH > 3.5 ng/ml has a sensitivity of 88%
and
67% specificity in prediction of
hyperstimulation
AMH BLOOD LEVEL
18. AMH of less than 1.36 ng/ml has a
sensitivity of 75.5% and specificity of
74.8% in prediction of poor response.
AMH > 3.5 ng/ml has a sensitivity of 88%
and
67% specificity in prediction of
hyperstimulation
AMH BLOOD LEVEL
20. Infertility and AMH
BENEFITS OF ORT IN SUBFERTILE COUPLE
ORT guides in prognosticating outcome in
individual cases by
Pre-treatment counselling
Choice of infertility treatment
Avoidance of ovarian hyperstimulation
21. Fecundity / Infertility
& AMH
AMH helps to predict fecunity and accurate ovarian
reserve.
Increasing age means a decreasing AMH level
Lower AMH levels at any given time
irrespective of age predicts a poor response
to ART.
High AMH levels – candidates prone for OHSS.
22. Prediction of pregnancy chances
in couples presenting with
infertility
Ovarian reserve testing may
allow for a better
assessment of the fertility
potential of a given
woman.
23. AMH in IVF
AMH is the best currently
available measure of ovarian
reserve hence guides in
individualizing dosing for ovarian
stimulation thereby improving
the efficiency and safety of IVF.
24. The dosage is more for a
lesser value and less for a
higher value to achieve a
desired ovarian response.
AMH in IVF
25. ADVANTAGE OVER OTHER
Ovarian reserve MARKERS
It is the earliest marker to change with age
It shows the least intercycle and intracycle
variability
It can be randomly measured during the cycle
It shows no modifications during GnRHa
It needs no modification in hypothalamic
amenorrhea
It is both more convenient and informative
than basal FSH
26. AMH is useful predictor
of ovarian
hyperstimulation.
AMH in IVF
27. La Marca reported the AMH level of 0.7
ng/ ml had a good sensitivity and
specificity of indentifying 75% of poor
responders.
AMH of > 3.5 ng / ml predicted hyper
response and OHSS
Patient management in
IVF
1. La Marca A. Hum Reprod 2007 ; 22:766-71
28. AMH as predictor of ovarian
response
Value of AMH (ng/ml) Ovarian response
<0.4 Extremely poor response and cycle should be
cancelled
0.4 – 1 Poor response
1 – 2 At risk of poor response and short stimulation
protocols should be used
2 – 3.5 Response adequate
3.5 – 6 Chances of hyper stimulation. Caution to be applied
> 6 High chances of severe OHSS
1. La Marca A. Hum Reprod 2007 ; 22:766-71
29. PROPOSED AMH BASED
PROTOCOLS
HIGH AMH (> 3.5 ng/ml)
a. Inform about the risk of OHSS
b. Avoid depot GnRHa
c. Low FSH dose
d. Antagonist cycle preferred
e. Agonist Trigger
f. Blastocyst transfer or Freeze all embryos and
transfer later.
30. Ovarian dysfunction
Assesing AMH concentrations
in anovulatory women may
give additional information of
follicle dynamics with ovarian
reserve.
31. PCOS
• The magnitude of AMH elevations in PCOS is
associated with the extent of disease, improved
reproductive performance in relation to weight
loss and improved ovulatory function with age.
• Hence, AMH testing may allow the early
detection of subclinical disease in siblings of
women diagnosed with PCOS.
1. Broer SL. Et . Hum Reprod. Update 2014 ; 20 (5) : 688-701 .
2. Thomoson RL et al. Hum Reprod 2009 ; 24:1976-1981.
(A)
32. Other forms of anovulation
• Women presenting with functional
hypothalamic amenorrhea were shown to have
normal AMH levels suggesting a normal size of
the cohort of early growing follicles.
• Initial AMH levels predict chances for recovery of
ovarian function following weight gain in women
with anorexia nervosa.
1. Broer SL. Et . Hum Reprod. Update 2014 ; 20 (5) : 688-701 .
2. Luisi S et al. Gynecol Endocrinol 2012 :28:34-38.
(B)
33. Management of women
with cancer & AMH
• AMH appears to facilitate establishing
which chemotherapeutic agents are
particularly toxic to the ovaries.
• They fall during chemotherapy with
some recovery 3 – 6 months thereafter.
1. Broer SL. Et al Anti – Mullerian hormone: ovarian reserve teting and its potential clincal implication.
Hum Reprod. Update 2014 ; 20 (5) : 688-71.
2. Dillon KE, et al Pretreatment antimullerian hormone levels determine rate of posttherapy ovarian
reserve recovery : acute changes in ovarian reserve during and after chemotherapy. Fertil Steril 2013 :
99: 477 – 483
34. Menopause prediction &
AMH
Prediction of at menopause by assessing
AMH at a relatively young age may
enable screening and prevention
programs with reference to
osteoporosis, breast cancer, congnition
and Alzheimer disease, cardiovascular
disease and stroke .
35. Anti mullerian hormone (AMH) alone
or best in combination with
antral follicular count (AFC)
is the
BETTER INDICATOR
of ovarian reserve
than any other hormonal or
sonographic markers available at present.
CONCLUSION
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