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 conceiving

 Age at which women getting married gradually

increasing

 Progressive decline in sperm quality

 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 eggs are aneuploidic at the age of 45

OVARIAN RESERVE
 Agerelated 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
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.

(teVelde and Pearson 2002)

OTHER FACTORS

 BMI (Sedentary life style / high calorie diet)

 Ovarian diseases (endometriosis, PID)

 Ovarian neoplasm

 Pelvic surgery

 POF (? genetic / immunological)

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
TESTING FOR OVARIAN
RESERVE

 Hormone analysis

 Ultrasound techniques

 Dynamic testing

 Anatomical testing (ovarian biopsy)

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

 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.

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
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
INHIBIN B

 Hetero dimeric protein similar to AMH

 Levels > 45 pg/ml – poor response to induction

 High false positive rate

 Not widely used nowadays.

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.

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)

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

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
OVARIAN BIOPSY

 Counting the number of primordial follicles on ovarian

biopsy is an attractive concept.

 More invasive for a routine clinical screening.

ANTI-MULLERIAN HORMONE
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
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.
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)

AMH
Age-specific
quantiles
90
70
AMH
(pmol/L) 75 th

50

40

30
50th
20
25 th

10
10
0
25 30 35 40 45 50
Age (y)
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

AMH – NORMAL RANGE
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.

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.
THANK YOU