The document discusses the role of anti-Müllerian hormone (AMH) in fertility, emphasizing its importance as a biomarker for ovarian reserve and its clinical applications in assisted reproductive technology, fertility preservation, and various gynecological conditions like polycystic ovarian syndrome (PCOS). It details how AMH levels can aid in individualizing treatment plans for women, particularly those at risk of diminished ovarian function or undergoing cancer treatments, while also discussing its limitations as a sole predictor of pregnancy outcomes. Furthermore, the document outlines the implications of AMH testing in pediatric reproductive endocrinology and its potential use as a diagnostic marker in both males and females.

1. • Chairperson Elect ICOG –Indian College of OB/GY
• National Corresponding Editor-Journal of OB/GY of India JOGI
• National Corresponding Secretary Association of Medical Women, India
• Founder Patron & President –ISOPARB Vidarbha Chapter 2019-21
• Chairperson-IMS Education Committee 2021-23
• President-Association of Medical Women, Nagpur AMWN 2021-24
• Nagpur Ratan Award @ hands of Union Minister Shri Nitinji Gadkari
• Received Bharat excellence Award for women’s health
• Received Mehroo Dara Hansotia Best Committee Award for her work as
Chairperson HIV/AIDS Committee, FOGSI 2007-2009
• Received appreciation letter from Maharashtra Government for her work in the
field of SAVE THE GIRL CHILD
• Senior Vice President FOGSI 2012
• President Menopause Society, Nagpur 2016-18
• President Nagpur OB/GY Society 2005-06
• Delivered 11 orations and 450 guest lectures
• Publications-Thirty National & Eleven International
• Sensitized 2 lakh boys and girls on adolescent health issues
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra

2. AMH & its Clinical Implications
Dr Laxmi Shrikhande
Consultant Shrikhande fertility Clinic
Nagpur

3. AMH
Anti-Müllerian Hormone (AMH) is critical for physiologic involution of the
Mullerian ducts during sexual differentiation in the male foetus.
In women,AMH is a product of the small antral follicles in the ovaries and
serves to function as an autocrine and paracrine regulator of follicular
maturation.
As the size of the residual follicular pool depends on the quantity of small
antral follicles and declines over time, the serum AMH level in women
follows a characteristic trajectory: a gradual decline throughout the
reproductive years and a precipitous drop at menopause, becoming
undetectable soon after.
Thus, AMH is clinically useful as a screening tool for diminished ovarian
reserve.

4. Clinical Applications of AMH
Assisted Reproductive Technology
Fertility preservation
Ovarian neoplasms
Polycystic Ovarian Syndrome (PCOS)
Pediatric Reproductive Endocrinology
Prediction of early menopause

5. AMH in Assisted Reproductive Technology (ART)
AMH in the evaluation of ovarian reserve

6. AMH
 AMH is a substance produced by granulosa cells in
ovarian follicles, mainly by the preantral and small antral
stages (less than 4mm diameter) of follicle development.
 Production decreases and then stops as the follicles grow
larger.
 There is almost no AMH made in human follicles over
8mm in size.
 Because of this, the levels are quite constant and the
AMH test can be done on any day of a woman's cycle.

7. Role of AMH
 Plays a role in the initial recruitment and selection of
the dominant follicle.
 Reflects the growing pool of follicles in the ovary and
indirectly the entire pool of remaining eggs – the
“ovarian reserve”
7

8. Why we need ORT
 In general the average age at first child is 30 yrs
 Accurate OR testing will motivate some women to start family early or
go for oocyte freezing
 Alternatively it can reassure some women about delaying childbirth
 Helps in individualisation of treatment plan

9. Poor ovarian responses:
 Cycle cancellation
 Poor pregnancy rates
Excessive ovarian responses:
 Risk of ovarian hyperstimulation syndrome
 High E2 detrimental to the outcome
Ng et al., 2000
Concerns with infertility treatment

10. But we want
a baby !
Clinically relevant information should be obtained before treatment
starts…
 Helps counsel the patient in advance so that patients can
make an appropriate and informed choice.
 Individualize expectation of oocyte yield
 Cost of drug regimens
 Discomfort to the patient expected
 Risk of complications
 Chances of disappointment
HOW ORT helps in individualizing treatment plan ?

11. Consider following groups of women for ORT:
 women over 30 years of age
 women with a history of exposure to a confirmed gonadotoxin, i.e., tobacco
smoke, chemotherapy, radiation therapy.
 women with a strong family history of early menopause or premature ovarian
failure.
 women who have had extensive ovarian surgery, i.e., cystectomy and unilateral
oophorectomy.
 You feel it is indicated in a given situation
Whom to offer Ovarian Reserve Tests ?

12. Women who are overweight have 65% lower
AMH levels than thin women,
 indicating that obesity may be associated with
decreased ovarian reserve and/or with ovarian
dysfunction.
Obesity and AMH
AMH & Obesity

13. A. Factors that decrease AMH
 Increasing age
 Obesity
 Administration of gonadotropins
 Administration of chemotherapy or radiation
 Surgical removal of one or both ovaries
B. Factors that increase AMH
 Polycystic Ovarian Syndrome
What are the factors that influence AMH levels?

14. C. Factors that do not influence AMH
 Day of menstrual cycle
 GnRH agonists
 Birth Control Pills
 Pregnancy
Factors that do not influence AMH

15. AMH assay
2 assays-apply diff antibodies
 1.DSL-Diagnostic Systems Laboratory
 2. IOT-immunotech
 AMH levels are 40 % higher in IOT assay as compared to DSL assay
 No international standard yet developed

16. AMH assay
 With the merger of both the companies in 2010 under Beckman
Coulter led to the introduction of a single new 2 step sandwich type
enzymatic , microplate assay (the AMH gen II assay)
 AMH gen II assay is calibrated to the old IOT standards and are thus
comparable to IOT assay
 It has 2 fold greater sensitivity than the IOT assay

17. Pico AMH assay
 Has different calibration than Gen II assay
 Enhanced sensitivity over Gen II-enables measurement of very low
AMH concentrations
 Suitable for clinical use
 Need further studies in diff centres regarding its stability

18. AMH – test
 Optimal storage and handling conditions
 Urgent need to prepare international reference preparation to make
test results comparable
 Until then we need to be careful in translating AMH cut off values
from studies to our clinical practice

19. AMH – test
 Ideally tested in frozen serum samples
 Elisa
 Beckman Coulter Assay Gen II
 Semi quantitative test
 Fresh sample results do not correlate well with published results

20. PARAMETERS OF AMH GEN II KIT
Kit
Methods
Materials
Volume
of sample
Sensitivity
Time of
incubation
Calibration range
AMH Gen II
ELISA
Serum
plasma
20 µl 0.08 ng/ml
2 x 1h
+ 30 + 10 min
0.16 – 22.5 ng/ml
Manufactured by: Beckman Coulter Inc.
Specificity:
There are no cross-reaction with
Inhibin A, Activin A, FSH, LH

21. AMH and its Interpretation
Ovarian Fertility
Potential
Pmol/L ng/ml
Optimal Fertility 28.6 to 48.5 4.0 to 6.8
Satisfactory Fertility 15.7 to 28.6 2.2 to 4.0
Low Fertility 2.2 to 15.7 0.3 to 2.2
Very low/ undetected 0.0 to 2.2 < 0.3

22. Poor
responder
Normal
responder
Hyper
responder
AMH helps define patient subgroups
<1ng 2-3.5ng >3.5ng
Highly correlates with ovarian response-
97%sensitivity in predicting poor response
98%accuracy in predicting normal response
Current Opin Obstet Gynae 2010 Jan
Hum Reprod Update 2010 Mar-Apr 16(2)
Fertil Steril 2010 Feb 93(3)

23. Limitations of AMH as ORT
However, it is also important to recognize the limitations of AMH as its
utilization for predicting pregnancy in patients undergoing ART is fraught
with diagnostic uncertainties, being neither sensitive nor specific.
The possible explanation is that serum AMH is a quantitative marker of
small antral follicles and cannot be substituted as a marker of oocyte
quality.
Hence, women can be infertile even with high AMH levels whereas there
are pregnancies described in women with near undetectable AMH.
Intra-follicular AMH level may provide more accurate information
regarding successful pregnancy with IVF but needs further research to be
validated as a clinical tool.
Y. Tokura, O. Yoshino, S. Ogura-Nose et al., “The significance of serum anti-M¨ullerian hormone (AMH) levels in patients over age 40 in first IVF
treatment,” Journal of Assisted Reproduction and Genetics, vol. 30, no. 6, pp. 821–825, 2013.
A. Karkanaki, C. Vosnakis, and D. Panidis, “The clinical significance of anti-m¨ullerian hormone evaluation in gynecological
endocrinology,” Hormones, vol. 10, no. 2, pp. 95–103, 2011.

24. Ovarian Reserve Tests (ORT)
ORT
BIOLOGICAL BIOCHEMICAL BIOPHYSICAL
Chronological
Age
Static Dynamic USG
FSH, FSH:LH
INHIBIN B,E2
AMH
CCCT
GAST
EFORT
HISTOLOGICAL
OVARIAN
BIOPSY
AFC
OV VOL
OV BLD FLOW

25. Age
Single most important factor
At no cost
Both quality and quantity

26. Decline in Ovarian reserve
Age related decline in female fertility well
recognised
 Starts at 30,
 rapid decline after 37,
 virtually zero at 43.
• Due to decrease in
• Oocyte quantity
• Oocyte quality

27. • Loss of oocytes Is a continuous process
• Aging oocytes have been widely suggested to be the major cause for the infertility
Age
At fetal life:
6–7 million oocytes
At birth:
1–2 million
oocytes
At menarche:
300,000 ovarian
follicles At menopause:
1000 ovarian
follicles
Meczekalski B, et al. J Endocrinol Invest. 2016;39(11):1259 – 1265.

28. AFC
 Result immediately available
 Moderate inter-observer
variability
 Moderate inter-cycle variability
 Good correlation with oocyte
number
Hormonal Markers (AMH)
 Results not immediately
available
 No inter-observer variability
 Less inter-cycle variability
 Good correlation with oocyte
number
AFC VS HORMONAL MARKERS

29.  AMH levels decrease over time even in
“fertile” women who have regular
menstrual cycles.
 AMH levels correlate well with the
ovarian antral follicle count and were
the only levels that decreased
longitudinally over time compared
with FSH, estradiol, and inhibin-B
levels.
 With ovarian aging, the first change is
a decrease in AMH levels, followed by
a decline in inhibin-B and finally by an
increase in FSH levels.
RELATION OF AMH WITH OTHER BIOCHEMICAL PREDICTORS OF OR

30. AMH – Advantages over other OR
• Not cycle dependent - can be measured any day
• Less cycle-to-cycle variation than FSH.
• Not altered after hormonal therapy.
• Not altered even after down regulation with GNRH agonist.

31. Summary of AMH as ORT
 ORTs till date have modest predictive value for pregnancy outcome as
this is dependent on many more factors apart from OR
 ORTs are indicative of ovarian reserve status in both the quantitative
and qualitative sense
 ORTs at best should be considered as screening tests and not as
diagnostic tests
 Treatment should not be denied based on these tests to assumed
ovarian aged woman
 Age + AFC + AMH == Fair idea of OR

32. AMH for Fertility Preservation (FP) prior to cancer
therapy
Cancer treatment with chemotherapy and/or radiation is a known
cause of premature ovarian insufficiency (POI) in reproductive age
women and effectively renders them infertile.
As rapid strides in cancer therapy allow more survival than ever
before, a discussion regarding fertility preservation assumes great
importance in these women.

33. AMH for Fertility Preservation (FP) prior to cancer
therapy
Several studies report a correlation between serum AMH levels prior
to therapy with the ovarian reserve after completion of treatment.
Thus, measurement of AMH can give practical insights into the
potential reproductive lifespan after completion of treatment.
Peigne M, Decanter C. Serum AMH level as a marker of acute and long-term effects of chemotherapy on the ovarian follicular content: a
systematic review. Reprod Biol Endocrinol. 2014;12:26.
Dillon KE, Sammel MD, Prewitt M, et al. Pretreatment anti-Müllerian 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. AMH for Fertility Preservation (FP) prior to cancer
therapy
 Furthermore, pre-treatment AMH measurement can also assist in
predicting cancer therapy related amenorrhea significantly, especially
in breast cancer patients.
 These results can help physicians generate individualized risks of POI,
have comprehensive discussions with their patients regarding residual
ovarian function post-therapy and allow patients to make a well-
informed decision as to undergo fertility preservation treatments or
not.
Dunlop CE, Anderson RA. Uses of anti-Müllerian hormone (AMH) measurement before and
after cancer treatment in women. Maturitas. 2015;80:245–250

35. AMH for Fertility Preservation (FP) prior to cancer
therapy
 An important caveat is that although AMH levels assist in determining
ovarian reserve post-therapy, an individual susceptibility to
gonadotoxicity should also be accounted for.
 Decanter et al showed different patterns of ovarian recovery (based
on ultrasensitive AMH assays) in 32 patients treated for breast cancer
with the same treatment protocol.
 Patients must also be informed that neither pre-treatment nor post-
treatment AMH levels predict subsequent successful pregnancy and
pregnancies can occur even with a markedly low serum AMH level.
Decanter C, Cloquet M, Dassonneville A, D’Orazio E, Mailliez A, Pigny P. Different patterns of ovarian recovery after cancer
treatment suggest various individual ovarian susceptibilities to chemotherapy. Reprod Biomed Online. 2018;36:711–718

36. AMH in Ovarian Neoplasms
AMH has been identified as a tumor marker in adult granulosa cell
tumors since a long time and levels are elevated in up to 93% cases.
More recent reviews have focussed on the anti-proliferative effects of
AMH on epithelial ovarian neoplasms.
Thus, recombinant AMH holds great promise as an investigational
targeted therapy in epithelial ovarian cancers.
Roness, H., Spector, I., Leichtmann-Bardoogo, Y. et al. Pharmacological administration of recombinant human AMH rescues ovarian reserve and preserves
fertility in a mouse model of chemotherapy, without interfering with anti-tumoural effects. J Assist Reprod Genet 36, 1793–1803 (2019)

37. AMH in Polycystic Ovaries Syndrome (PCOS)
PCOS is a widely prevalent disorder, affecting more than 100 million
women worldwide.
Most clinicians diagnose PCOS on the basis of the Rotterdam criteria.
However these features, especially ultrasound appearance of the ovaries,
can be menstrual cycle-dependent and/or be affected by oral contraceptive
use.
Hence serum AMH, which remains stable with cycles and is independent of
oral contraceptive use has been explored as a diagnostic marker for PCOS,
either alone or in combination with other markers to improve detection.
M. P. Lauritsen, J. G. Bentzen, A. Pinborg et al., “The prevalence of polycystic ovary syndrome in a normal population according to the Rotterdam criteria
versus revised criteria including anti- M¨ullerian hormone,” Human Reproduction, vol. 29, no. 4, pp.791–801, 2014.

38. AMH in Polycystic Ovaries Syndrome (PCOS)
AMH levels are elevated in PCOS, reflecting the increased load of
small antral follicles
As AMH is produced by granulosa cells of the same small antral
follicles, it may be utilized as an indirect marker of the degree of intra-
ovarian hyperandrogenism in these women.
In light of these discoveries, it is plausible that once diagnostic
thresholds have been established, AMH may well be considered
indispensable for the diagnosis and assessment of severity of PCOS .
L. Bungum, F. Franssohn, M. Bungum, P. Humaidan, and A. Giwercman, “The circadian variation in Anti-M¨ullerian hormone in patients with
polycystic ovary syndrome differs significantly from normally ovulating women,” PLoS ONE, vol. 8, no. 9, Article ID e68223, 2013

39. AMH in Pediatric Reproductive Endocrinology
AMH has numerous applications in clinical paediatrics.
It is required for the physiologic involution of Mullerian ducts in male
foetuses.
Since AMH is the product of the Sertoli cells in the testes of males, a
positive assay is evidence of testes being present in cryptorchidism and
disorders of sex development.
 In females, AMH can help localize the source of virilization: raised levels
are found in testicular tissue induced virilization while levels are normal in
congenital adrenal hyperplasia.
In children treated for ovotestis, AMH can identify the presence of
testicular tissue before and after surgical intervention.
M. Lindhardt Johansen, C. P. Hagen, T. H. Johannsen et al., “Anti-mullerian hormone and its clinical use in pediatrics with special emphasis on disorders of
sex development,” International Journal of Endocrinology, vol. 2013, Article ID 198698, 10 pages, 2013.
Josso N, Rey RA, Picard JY. Anti-müllerian hormone: a valuable addition to the toolbox of the pediatric endocrinologist. Int J Endocrinol. 2013;2013:674105

40. AMH in Paediatric Reproductive Endocrinology
It is also useful in Klinefelter syndrome as its levels reflect the degree of
testicular dysfunction in this condition.
Turner syndrome patients are especially likely to undergo accelerated
depletion of ovarian follicles and monitoring of AMH is an excellent
indicator of premature ovarian insufficiency in these patients.
 It is also being investigated as a test for differentiating hypogonadotropic
hypogonadism from constitutional pubertal delay.
Thus, AMH has established itself as a truly versatile marker in paediatric
reproductive endocrinology.
L. Aksglaede, P. Christiansen, K. Sørensen et al., “Serum concentrations of Anti-M¨ullerian Hormone (AMH) in 95 patients with Klinefelter syndrome with or
without cryptorchidism,” Acta Paediatrica, International Journal of Paediatrics, vol. 100,no. 6, pp. 839–845, 2011.
A. Visser, A. C. S. Hokken-Koelega, G. R. J. Zandwijken, A. Limacher, M. B. Ranke, and C. E. Fl¨uck, “Anti-Mullerian hormone levels in girls and adolescents with
Turner syndrome are related to karyotype, pubertal development and growth hormone treatment,” Human Reproduction, vol. 28, no. 7, pp. 1899–1907, 2013.

41. AMH in prediction of age at menopause
Declining AMH levels indicate gradual decrease in reproductive
capacity with age, hence it may be considered as a potential marker
for menopause.
A recent study showed that every fall of AMH level by 0.10 ng/mL
was related with a 14% increased risk of early menopause (p<0.001).
 Another study reported that the combination of AMH and age was
more reliable predictor of early menopause than age alone.
Bertone-Johnson ER, Manson JE, Purdue-Smithe AC, Steiner AZ, Eliassen AH, Hankinson SE, et al. Anti-Mullerian hormone levels and incidence of early natural menopause in a
prospective study. Hum Reprod. 2018;33:1175–82.
Depmann M, Eijkemans MJ, Broer SL, Tehrani FR, Solaymani-Dodaran M, Azizi F, et al. Does AMH relate to timing of menopause? Results of an individual patient data meta-
analysis. J Clin Endocrinol Metab. 2018;

42. AMH in prediction of age at menopause
Women above age of 40 with low AMH levels have shown
improvements in ovarian reserve markers with DHEA
supplementation.
DHEA therapy has reported improvement in ovarian function,
pregnancy rates, and decreased embryo aneuploidy and miscarriage
rate in infertile women predicted to have early menopause with low
AMH.
Gleicher N, Barad DH. Dehydroepisterone (DHEA) supplementation in diminished ovarian reserve (DOR). Reprod Biol Endocrinol 2011;9:67
Sing V, Thakur P, Agrawal S, Anjum B. Role of DHEA in diminished Ovarian reserve, systematic review. World J. Pharmaceut. Res. 2015;4:2488-507.

43. Conclusion
AMH is a signalling molecule of central importance for follicular
recruitment and growth.
In recent years, serum AMH has proven effective in evaluation of
ovarian disorders in women, right from childhood to menopause
M. Dayal , Shreshtha S, Chaurasia A, Singh U. Anti-Mullerian Hormone: A New Marker of Ovarian
Function. The Journal of Obstetrics and Gynecology of India (March–April 2014) 64(2):130–133.
Shrikhande L, Shrikhande B, Shrikhande A. AMH and Its Clinical Implications. J Obstet Gynaecol
India. 2020 Oct;70(5):337-341. doi: 10.1007/s13224-020-01362-0. Epub 2020 Aug 19. PMID:
33041549; PMCID: PMC7515982.

44. Conclusion
Its strong correlation with follicle numbers and high negative
predictive value for premature ovarian insufficiency make it an
attractive tool in the infertility specialist’s armamentarium.
 It also aids in individualization of ART protocols, thus minimizing
iatrogenic effects as well as cost.

45. Conclusion
With cancer survival improving and quality of life in survivors gaining
importance in reproductive age women, serum AMH has been found
to be useful in predicting ovarian reserve after completion of cancer
therapy and can help physicians inform their patients regarding their
risk of premature ovarian insufficiency.
AMH lends itself to utilization as a diagnostic marker in PCOS due to
the fact that its levels remain stable across cycles and are
independent of oral contraceptive use.
It also has significant scope in assisting the diagnosis of disorders of
sexual development in clinical paediatrics.

46. The more you give, the more you
will get.
Then life will become a sheer dance
of love.
H. H. Sri. Sri. Ravishankar
The Art of Living
Thank you

47. My World of
sharing happiness!
shrikhandedrlaxmi@gmail.com
Dr. Laxmi Shrikhande
Shrikhande Fertility Clinic
Ph-8805577600 / 8805677600