The document discusses the role of Anti-Müllerian Hormone (AMH) as a marker of ovarian reserve, highlighting its importance in predicting fertility outcomes and its variability in different health conditions. It covers topics such as the implications of AMH levels on fertility preservation, the effects of age and obesity on oocyte quality, and the utility of AMH in diagnosing conditions like polycystic ovary syndrome (PCOS) and granulosa cell tumors. Additionally, it outlines the limitations of AMH testing and suggests the need for individualized approaches in fertility treatments.

1. Dr. Azmi Saleh Abdrbo
FRCOG
El-Amal IVF Center
Ovarian reserve

2. Ovarian reserve
 Population of nongrowing follicle wthin ovary: acyclic
ovarian activity(primordial follicles)
 Population of small gorwing follicles responsive to FSH
 (Ovulatory potential)
 Quantity and quality of primordial follicle at a given age.
 Indirect measure of future fertility,onset of menopause
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3. Ovarian reserve
Ovarian reserve
 Plan fertility preservation
 Fertility outcome
 Response to ovarian stimulation
 Predict pregnancy rate
 Monitor fertility decline
 Fertility after chemotherapy and cancer treatment
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4. Ovarian reserve AMH
 D.Diagnosis of PCO ,amenorrhea
 Family planning :ovarian reserve screening
 Ovarian surgery
 Granulosa cell tumors
 Menopause and POI
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5. Ovarian reserve
5 months iu : millions
Menopause: 1000
450 ovulatory cycles
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6. Ovarian reserve
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Suppressors
AMH
FOXO3@
PTEN
P27
Naintainers
PDK1
rpS6
Activators
mTORC
Regulation and intiation of follicle growth

7. Ovarian reserve
Ovarian reserve
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Regulation and intiation of follicle growth

8. Ovarian reserve:AMH
AMH
Dimeric glycoprotein
Mural granulosa cells
Paracrine inhibitor
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9. Ovarian reserve
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10. Ovarian reserve
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11. AMH variability
 AMH: glycoprotein secreted by Granulosa cells in small
gowoing follicle up to 8mm
 Older studies: stable at any point in menstrual cycle
 Recent studies: minor varation in level(no change)
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Anderson 2006m, Nelson 2010 –Hadlow etal 2013

12. AMH variability
Marker of preantral and smal antral follicle up to 8mm
 Reflect primordial follicle pool size(indiectly)
 AMH: suppressed during pregnancy and prolonged
GNrHa , O C
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Anderson 2006m, Nelson 2010 –Hadlow etal 2013

13. Ovarian reserve
 AMH: suppressed during pregnancy and prolonged
GNrHa , O C
 AMH may not retain its accuracy as predictor of ovarian
reseve in OC users
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Anderson 2006m, Nelson 2010 –Hadlow etal 2013

14. Ovarian reserve:AMH
 AMH peak:
 24.5 years
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15. Ovarian reserve
AMH peak 24.5 years
NGF POP:18 MONTH
NGF recrutited :14.5 years
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16. Ovarian reserve
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17. Ovarian reserve:AMH
AMH in diagnosis
PCO morphology,
Andrgen excess,
Anovulation
PCOS:more than 5ng/ml to 8,4ng/ml,correlated to andrgen
level
AMH correlates TO AFC in PCO
PCO: AMH level and metformin treatment
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18. Ovarian reserve:AMH
AMH in diagnosis
PCOS:
AMH may replace AFC in the future
High AMH(8.4ng/ml) may help in diagnosis of PCO in
adolucent since Ultrasound scan may be difficult or not
accurate
May help to plan AMH based protocol for ovulation
induction : clomiphene
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19. Ovarian reserve:AMH
AMH in diagnosis amenorrhea
In hypogonadal Hypogonadism :FSL,LH low
AMH is low than normal
Hypergonadal Hypogonadism: AMH undectable
Granulosa cell tumors very heigh levels
Premature ovarian failure AMH may be undectable
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20. Ovarian reserve:AMH
AMH in diagnosis
Granulosa cell tumor difficult to diagnose
Ultrasound :Solid cystic mass
Granulosa cell tumors(GCT)AMH : very heigh levels
Granulosa cell tumors require prolonged follow up
Both Inhibin and AMH are sensetive marker for GCT
In J cancer 2015
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21. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Pretreatment and post treatment levels chemotheapy
Prediction of ovarian function after chemotjerapy
Incorporated in Guidelines of childhood cancer treatmnt
Research on the best protocol of chemotherapy
Human Reprod 2015
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22. Ovarian reserve:AMH
Research on the best protocol of chemotherapy
GNRH agonist works well with cyclophosamide based
protocol to avoid ovaruian damage from chemotherapy
Radiotherapy: mointoring of ovarian function
Ovarian surgery : which technique is good?
Uterine artery embolization and AHM level( no significant
effect)
Minim Invasive 2015
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23. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Ovarian surgery
Endometriosis:effect of endometrioma surgery on AMH
Ovarian function after total hysterectomy Vs supracervical
hysterectomy
J minim Invasive Gynecol 2015
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24. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Predict ovarian reserve decline in autoimmune diseases
SLE and other autoimmune disorders
Auto immune thyroiditis
Rev Bras Reumatol 2014 J Assist Reprod Genet 2015
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25. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Treatment of ectopic pregnancy with methotroxate
decreases AMH and AFC
Eur J Obstet Gynecol Reprod Biol 2014
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26. Ovarian reserve: AMH
AMH limitations
No international satandard assay
Does not provide direct measurement of primordial follicle
pool
Age and genetics other biomarkers should be taken in
cosideration in the prediction of future fertility
May not be accurate In patient taking OC
Racial variantions
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27. Ovarian reserve:AMH
AMH in diagnosis: predictions of menopause Why?
Menopause: End of natural fertlity
Plan career,
Decision on the wish to have childern
Family planning
Fecundability(probability of concieving in low and high
AMH both low fecundability
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28. Ovarian reserve:AMH
Predicting remaining reproductive life span(model)
AMH undectable 5 years before final menstrual cycle
Intrpretation in the contex of age,genetics,enviroment
0.2ng/ml median age to menopause 6 ys (gp 40-45ys)
But about 10 ys in age gp 35-39ys
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29. Ivf outcome and AMH
 Low AMH<0.47ng/ml is associated with poor
prognosis for IVF outcome
 AMH>2ng good outcome
Lehmann et al J Assist Reprod Genet 2014
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30. Oocyte quality and age
 Age=Quality
 Ovarian reserve test=Quantity
 Age: Miscarriage rate
 Age: Obesity and oocyte quality
 Weight reduction and oocyte quality
Nelson et al Hum Reprod update 2013
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31. Birth rate and age
Nelson et al Hum Reprod update 2013
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32. Miscarrage rate and age
Nelson et al Hum Reprod update 2013
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33. Oocyte quality and age
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34. Oocyte quality and age
 Age=Quality
 Age: Obesity and oocyte quality
 Weight reduction and oocyte quality
Nelson et al Hum Reprod update 2013
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35. Ovarian reserve response
predictor
AMH=AFC>FSH>age
Age
 FSH:E2
 Ovarian volume
 AFC
 AMH
 Inhibin
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36. Ovarian reserveReponse
prediction
 Age
 FSH
 Ovarian volume
 AFC
 AMH
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37. Ovarian reserve
AFC strongly correlated to AMH
AMH combined with AF:increase sensitivity and
specificy
Predict oocyte yield during COS
Identify good prognosis patients for ivf
Response prediction in Ovarian stimulation:OHSS
Predicts poor responders
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Hadlow et al fertil steril 2013

38. Ovarian reserve
Why to predict ovarian response
Avoid iatrogenic complication
Ovulation protocol strategy
Agonist protocol VS Antagonist protocol
Flare protocol VS MNC
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39. Ovarian reserve:AMH
Why Predict Ovarian response
AFC >=40,AMH>=5.6ng/ml- or 40pmol-antagonist control
agonist triger
AFC 24-40or AMH 2.8-5.6ng/ml or20-40pmol antagonist
control hcg,agonist triger
AFC 10-24,AMH 1--2.8ng or 7-20 pmol Long agonist
control
AFC 2-10,AMH <0.1- 1ng/m1 or -7pmol Flare agonist
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Nelson S in fertil Steril 2013

40. Ovarian reserveAMH
Starting
dose
AMH<0.7NG
AMH0.7-2NG
AMH>2.1-4.2ng
AMH>4,2-6.3NG
AMH>6.3NG
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41. Ovarian reserveAMH
AMH Vs AFC Ovarian response:Starting Dose
AMH is better in predicting hyporesponse
AFC is better in predicting hyperresponse
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42. Improving oocyte quality and
age
 Age=Quality
 Age: Obesity and oocyte quality
 Weight reduction and oocyte quality
Nelson et al Hum Reprod update 2013
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43. Avoiding age related decline in
oocyte quality
Oocyte cryopreservation(Social freezing)
Assess embryo quality: aneuploidy screen
DHEA? Testosterone skin batch
Growth hormone?
Vit E Conenzyme Q?
Nelson et al 2013 Hum Reorod Update
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44. conclusion
AMH is follicle gatekeeper. AMH and AFC are the best
markers of ovarian reserve, age is the best marker for
oocyte quality. Maximizing oocyte yield for all patient is no
longer an appropriate stimulation strategy. ORT allows
pretreatment patient counseling, individualization of
stimulation strategy, increased cost effectiveness,
enhanced safety. AMH may be used in assessing ferility
preservation , chemotherapy ovarian surgery. AMH may be
used as a biomarker in diagnosis of endocrine disorders’
autoimmune disorders
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