Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
AMH & OVARIAN RESERVE
DR SUNDAR NARAYANAN M.D , DLS,
D.ART
REPRODUCTIVE ENDOCRINOLOGIST &
GYNEC ENDOSCOPIC SURGEON
SUB FERTILITY - FACTS
 The one of the area in gynaecology with increasing
demand
 One in six couples have difficulty con...
AGE WISE FERTILITY
 20-25 2.8% infertile
 30-34 10% infertile
 35-39 33% infertile
 40-45 86% infertile
AGE - DECLINE OF OOCYTES
MISCARRIAGE RATE
Age 30: 7-15%
Age 31-34: 17-21%
Age 35-39: 17-28%
Age 40: 40-52%
ANEUPLOIDY
 10% of eggs are aneuploidic in young women
 30% at the age of 40
 50 % at the age of 43
 Nearly all the eg...
OVARIAN RESERVE
 Age related decline in female fertility well
recognised
Starts at 30,
rapid decline after 37,
virtual...
(teVelde and Pearson 2002)
OVARIAN RESEVE
 There is considerable individual variation in the
age of menopause and, subseq...
OTHER FACTORS
 BMI (Sedentary life style / high calorie diet)
 Ovarian diseases (endometriosis, PID)
 Ovarian neoplasm
...
OVARIAN RESERVE
 Criteria used to assess ovarian function and to
subject sub fertile patients for ovarian
stimulation are...
TESTING FOR OVARIAN
RESERVE
 Hormone analysis
 Ultrasound techniques
 Dynamic testing
 Anatomical testing (ovarian bio...
HORMONE ANALYSIS
 Follicle Stimulating Hormone (FSH)
 Oestradiol
 Progesterone
 Inhibin B
FOLLICLE STIMULATING
HORMONE (FSH)
 Usually measured Day 2 or 3 of cycle
 Women with > 10 IU/l poor response to ART
 Wo...
SERUM OESTRADIOL
 E2 alone of little value to asses ovarian reserve
 Combined E2 and FSH levels – better than E2
alone.
...
PROGESTERONE
 Early LH surge and elevation of P4 suggested
sign of poor ovarian reserve
 Doesn’t have any independent ro...
INHIBIN B
 Hetero dimeric protein similar to AMH
 Levels > 45 pg/ml – poor response to induction
 High false positive r...
ANTRAL FOLLICULAR COUNT
 Count of total follicles measuring 2 to 5mm in
both ovaries on Day 2/3 of periods.
 Some correl...
AFC
 So far, assessment of the number of antral
follicles by ultrasonography, the antral follicle
count (AFC), best predi...
OVARIAN DOPPLER
 Trans-vaginal pulse Doppler can assess
ovarian blood flow
 Some suggestion that high vascularity in
lat...
CLOMOPHENE CHALLENGE TEST
 Baseline FSH, LH & E2 followed by CC
100mg/day from Days 5 to 9
 Measure E2, FSH and LH on Da...
OVARIAN BIOPSY
 Counting the number of primordial follicles on
ovarian biopsy is an attractive concept.
 More invasive f...
ANTI-MULLERIAN HORMONE
AMH
 AMH is a glycoprotein
 Appears in females at puberty
 Produced by granulosa cells of pre-antral and
small antral f...
AMH
 Not cycle dependant-can be measured any day
 Less cycle to cycle variation than FSH.
 Not altered by hormonal ther...
AMH
 Therefore, a serum marker that reflects the
number of follicles that have made the transition
from the primordial po...
AMH
Age-specific
quantiles
Age (y)
25 30 35 40 45 50
0
AMH
(pmol/L)
10
25th
50th
75th
90
50
40
30
20
10
70
AMH BLOOD LEVEL
 High (often PCOS) Over 3.0 ng/ml
 Normal Over 1.0 ng/ml
 Low Normal Range 0.7 - 0.9 ng/ml
 Low 0.3 - ...
AMH – NORMAL RANGE
AMH
 Increasing age means a decreasing AMH level.
 Lower AMH levels at any age predicts a poor
response to ART.
 High A...
CONCLUSION
 Anti mullerian hormone(AMH) alone or better in
combination with antral follicular count (AFC) is a
better ind...
THANK YOU
Upcoming SlideShare
Loading in …5
×

Amh and ovarian reserve

1,235 views

Published on

role of amh in fertility

Published in: Health & Medicine
  • Be the first to comment

Amh and ovarian reserve

  1. 1. AMH & OVARIAN RESERVE DR SUNDAR NARAYANAN M.D , DLS, D.ART REPRODUCTIVE ENDOCRINOLOGIST & GYNEC ENDOSCOPIC SURGEON
  2. 2. SUB FERTILITY - FACTS  The one of the area in gynaecology with increasing demand  One in six couples have difficulty conceiving  Age at which women getting married gradually increasing  Progressive decline in sperm quality
  3. 3. AGE WISE FERTILITY  20-25 2.8% infertile  30-34 10% infertile  35-39 33% infertile  40-45 86% infertile
  4. 4. AGE - DECLINE OF OOCYTES
  5. 5. MISCARRIAGE RATE Age 30: 7-15% Age 31-34: 17-21% Age 35-39: 17-28% Age 40: 40-52%
  6. 6. ANEUPLOIDY  10% of eggs are aneuploidic in young women  30% at the age of 40  50 % at the age of 43  Nearly all the eggs are aneuploidic at the age of 45
  7. 7. 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
  8. 8. (teVelde and Pearson 2002) OVARIAN RESEVE  There is considerable individual variation in the age of menopause and, subsequently, also in the age of subfertility. Hence, chronological age alone is a poor indicator of reproductive aging, and thus of the ovarian reserve.
  9. 9. OTHER FACTORS  BMI (Sedentary life style / high calorie diet)  Ovarian diseases (endometriosis, PID)  Ovarian neoplasm  Pelvic surgery  POF (? genetic / immunological)
  10. 10. OVARIAN RESERVE  Criteria used to assess ovarian function and to subject sub fertile patients for ovarian stimulation are still a matter of much debate  Various biochemical and ultrasonographic markers are used to investigate the ovarian reserve in candidates for ART
  11. 11. TESTING FOR OVARIAN RESERVE  Hormone analysis  Ultrasound techniques  Dynamic testing  Anatomical testing (ovarian biopsy)
  12. 12. HORMONE ANALYSIS  Follicle Stimulating Hormone (FSH)  Oestradiol  Progesterone  Inhibin B
  13. 13. FOLLICLE STIMULATING HORMONE (FSH)  Usually measured Day 2 or 3 of cycle  Women with > 10 IU/l poor response to ART  Women aged more than 30 with one value of FSH > 14 IU/l do worse on IVF  Variation from month to month  Lab wise variation in values due to different techniques.  Spurious fall after hormone therapy.
  14. 14. SERUM OESTRADIOL  E2 alone of little value to asses ovarian reserve  Combined E2 and FSH levels – better than E2 alone.  E2 of > 80 pg/ml day 3 pre IVF cycle- higher cancellation rate
  15. 15. PROGESTERONE  Early LH surge and elevation of P4 suggested sign of poor ovarian reserve  Doesn’t have any independent role in assessment of ovarian reserve
  16. 16. INHIBIN B  Hetero dimeric protein similar to AMH  Levels > 45 pg/ml – poor response to induction  High false positive rate  Not widely used nowadays.
  17. 17. ANTRAL FOLLICULAR COUNT  Count of total follicles measuring 2 to 5mm in both ovaries on Day 2/3 of periods.  Some correlation with ovarian response but only at low threshold  If AFC < 5- significantly worse outcome.  Inter observer variation is a limitation.
  18. 18. AFC  So far, assessment of the number of antral follicles by ultrasonography, the antral follicle count (AFC), best predicts the quantitative aspect of ovarian reserve (Scheffer, et al., 2003)
  19. 19. OVARIAN DOPPLER  Trans-vaginal pulse Doppler can assess ovarian blood flow  Some suggestion that high vascularity in late follicular phase good prognostic sign  No clinical value at present
  20. 20. CLOMOPHENE CHALLENGE TEST  Baseline FSH, LH & E2 followed by CC 100mg/day from Days 5 to 9  Measure E2, FSH and LH on Day 9 to 11  Exaggerated FSH after CC bad prognostic sign  Along with other tests like FSH or GNRH agonist stimulation no better inference than basal values
  21. 21. OVARIAN BIOPSY  Counting the number of primordial follicles on ovarian biopsy is an attractive concept.  More invasive for a routine clinical screening.
  22. 22. ANTI-MULLERIAN HORMONE
  23. 23. AMH  AMH is a glycoprotein  Appears in females at puberty  Produced by granulosa cells of pre-antral and small antral follicles  Physiological function- prevent excessive follicle recruitment
  24. 24. AMH  Not cycle dependant-can be measured any day  Less cycle to cycle variation than FSH.  Not altered by hormonal therapy.  Not altered even after downregulation with GNRH agonist.
  25. 25. AMH  Therefore, a serum marker that reflects the number of follicles that have made the transition from the primordial pool into the growing follicle pool, and that is not controlled by gonadotropins, would benefit both patients and clinicians. In recent years, accumulated data indicate that anti-Müllerian hormone (AMH) may fulfill this role. (Visser, et al., 2006)
  26. 26. AMH Age-specific quantiles Age (y) 25 30 35 40 45 50 0 AMH (pmol/L) 10 25th 50th 75th 90 50 40 30 20 10 70
  27. 27. AMH BLOOD LEVEL  High (often PCOS) Over 3.0 ng/ml  Normal Over 1.0 ng/ml  Low Normal Range 0.7 - 0.9 ng/ml  Low 0.3 - 0.6 ng/ml  Very Low Less than 0.3 ng/ml
  28. 28. AMH – NORMAL RANGE
  29. 29. AMH  Increasing age means a decreasing AMH level.  Lower AMH levels at any age predicts a poor response to ART.  High AMH levels – candidates prone for OHSS.
  30. 30. CONCLUSION  Anti mullerian hormone(AMH) alone or better in combination with antral follicular count (AFC) is a better indicator of ovarian reserve than any other hormonal or sonographic markers available at present.  Also a good predictor of response to ovulation induction both poor as well as excessive response.
  31. 31. THANK YOU

×