Amh and ovarian reserve

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AMH & OVARIAN RESERVE DR SUNDAR NARAYANAN M.D , DLS, D.ART REPRODUCTIVE ENDOCRINOLOGIST & GYNEC ENDOSCOPIC SURGEON

Transcript of Amh and ovarian reserve

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AMH & OVARIAN RESERVE

DR SUNDAR NARAYANAN M.D , DLS, D.ARTREPRODUCTIVE ENDOCRINOLOGIST & GYNEC ENDOSCOPIC SURGEON

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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

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AGE WISE FERTILITY

20-25 2.8% infertile

30-34 10% infertile

35-39 33% infertile

40-45 86% infertile

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AGE - DECLINE OF OOCYTES

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MISCARRIAGE RATE

Age 30: 7-15%

Age 31-34: 17-21%

Age 35-39: 17-28%

Age 40: 40-52%

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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

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OVARIAN RESERVE Age related decline in female fertility

well recognisedStarts at 30,rapid decline after 37, virtually zero at 43.

Due to decrease in Oocyte quantityOocyte quality

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(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.

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OTHER FACTORS

BMI (Sedentary life style / high calorie diet)

Ovarian diseases (endometriosis, PID)

Ovarian neoplasm

Pelvic surgery

POF (? genetic / immunological)

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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

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TESTING FOR OVARIAN RESERVE

Hormone analysis

Ultrasound techniques

Dynamic testing

Anatomical testing (ovarian biopsy)

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HORMONE ANALYSIS

Follicle Stimulating Hormone (FSH)

Oestradiol

Progesterone

Inhibin B

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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.

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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

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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

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INHIBIN B

Hetero dimeric protein similar to AMH

Levels > 45 pg/ml – poor response to induction

High false positive rate

Not widely used nowadays.

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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.

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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)

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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

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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

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OVARIAN BIOPSY

Counting the number of primordial follicles on ovarian biopsy is an attractive concept.

More invasive for a routine clinical screening.

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ANTI-MULLERIAN HORMONE

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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

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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.

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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)

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AMH

Age-specificquantiles

Age (y)25 30 35 40 45 50

0

AMH(pmol/L)

10

25th

50th

75th

90

50

40

30

20

10

70

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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

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AMH – NORMAL RANGE

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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.

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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.

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THANK YOU