|Year : 2014 | Volume
| Issue : 1 | Page : 32-35
Anti-mullerian hormone, follicular phase follicle stimulating hormone and antral follicular count as predictors of ovarian response in assisted reproductive technique cycles
Avantika Vaze-Parab1, Pratima Bhatt2, Mandakini Parihar3, Pratibha Baldawa1
1 Gynaecologist, Obstetrician and Infertility Consultant independently, Mumbai, Solapur, India
2 Embryologist, ART Centre, Nova IVI Fertility Clinic, Mumbai, India
3 Mandakini IVF Center, Chembur, Mumbai, India
|Date of Web Publication||14-Feb-2014|
Gynaecologist, Obstetrician and Infertility Consultant independently, Mumbai, Solapur
Source of Support: None, Conflict of Interest: None
Aim: Aim of the study is to correlate Serum Anti-Mullerian Hormone (AMH) levels, Follicular phase Follicle stimulating Hormone (FSH) levels and Antral Follicular Count (AFC) with ovarian response in ART (Assisted reproductive Techniques) cycles. Materials and Methods: Seventy patients undergoing ART cycles for various factors were included in the study. They were divided in two groups according to number of oocytes retrieved at ovum pick up procedures. Four or less number of oocytes were considered as poor response (n=32) and more than four oocytes were considered as good response (n=38). Two groups were compared for their Age, Duration of Marriage, Follicular phase FSH, AMH levels, pregnancy rates and cycle cancellation rate. Results: We found that the age and duration of infertility were not statistically different in two groups. AMH value in poor responders was 1.20ng/ml and in good responders it was 3.38 ng/ml with statistically significant difference (p< 0.05). The difference in FSH levels (7.36 Vs5.99) and AFC (5 Vs 12) was statistically significant. Pregnancy rate in poor responder group was very low as compared to good responders (6.25 Vs 18.42). In good responders none of the cycle got cancelled whereas in poor responders group five cycles got cancelled (15.63%) either due to failure to retrieve mature oocytes or failed fertilization due to poor quality of oocytes. Conclusion: It appears that AMH serum Levels baseline FSH and antral follicular count are associated with ovarian response in ART cycles and can be served as markers for ovarian reserve.
Keywords: Anti-Mullerian Hormone, Antral Follicular Count, FSH, Ovarian Reserve
|How to cite this article:|
Vaze-Parab A, Bhatt P, Parihar M, Baldawa P. Anti-mullerian hormone, follicular phase follicle stimulating hormone and antral follicular count as predictors of ovarian response in assisted reproductive technique cycles. IVF Lite 2014;1:32-5
|How to cite this URL:|
Vaze-Parab A, Bhatt P, Parihar M, Baldawa P. Anti-mullerian hormone, follicular phase follicle stimulating hormone and antral follicular count as predictors of ovarian response in assisted reproductive technique cycles. IVF Lite [serial online] 2014 [cited 2022 Jan 18];1:32-5. Available from: http://www.ivflite.org/text.asp?2014/1/1/32/127090
| Introduction|| |
Ovarian reserve is currently defined as the number and quality of the follicles left in the ovary at any given time. Ovarian reserve can be considered normal in conditions where stimulation with the use of exogenous gonadotrophins will result in the development of at least 8-10 follicles and the retrieval of a corresponding number of healthy oocytes at follicle puncture. 
Over the past two decades, a number of so-called ovarian reserve tests have been studied for their ability to predict outcome of in vitro fertilization (IVF) in terms of oocyte yield and occurrence of pregnancy. These include baseline follicle stimulating hormone (FSH) levels, Anti-mullerian hormone (AMH), Serum inhibin levels, ovarian volume and antral follicular count (AFC). The aim of the present study is to correlate the serum AMH, Follicular phase FSH and AFC with the ovarian response in assisted reproductive technique (ART) cycles.
| Materials and Methods|| |
It is a retrospective study of 70 patients undergoing IVF cycles at our IVF Center in a period from January 2010 to January 2012. Levels of FSH were determined on the morning of either day 2 or day 3 of menstruation (follicular phase). AMH values were obtained according to the patients' convenience. AFC was checked by transvaginal scan in follicular phase at our clinic. All the patients included were of primary or secondary infertility seeking treatment. The etiology was polycystic ovaries, tubal factor, male factor, endometriosis and unexplained infertility. Stimulation protocol used was Antagonist (78%), Agonist (16%) and ultra-long (6%) protocol with gonadotropins. Monitoring was carried out by transvaginal Ultrasound. Inj. Human chorionic gonadotropin (HCG injection) (10,000 units) was given when follicle size is 18 mm. Ovum pick-up was done 35 h after inj. HCG. Follicular fluid was screened by embryologist and intracytoplasmic sperm injection (ICSI) was performed on mature oocytes. USG guided Embryo transfer was done on Day 2/3. Blood test for beta human chorionic gonadotropin (β-HCG) was done 14 days after transfer.
The primary outcome measure of the study was the number of oocytes retrieved. Poor ovarian response was defined as fewer than four oocytes at follicle puncture or absence of follicular growth in response to ovarian hyperstimulation.  Secondary outcome measures were chemical pregnancy that was defined as a serum β-HCG >50 mIU/mL, 2 weeks after IVF or ICSI. Cycle cancellation refers to the cycles where no Embryo transfer was performed due to failure to retrieve any oocyte or failed fertilization.
The study was divided into two subgroups according to the number of oocytes retrieved. Those with four or less oocytes retrieved were considered as poor responders and those with more than four oocytes retrieved were considered as good responders. Age, Baseline FSH, AMH, AFC was compared in both groups. Pregnancy rates and cycle cancellation rates were calculated in both groups.
After data collection, data entry was done in Excel. Data analysis was performed with the help of SPEE Software Version 15 and Sigmaplot Version 11. Qualitatively data is presented with the help of mean, standard deviation, median and interquartile range. Comparisons in study groups are done with the help of Mann-Whitney test and unpaired t-test as per results of Normality test. P < 0.05 is taken as a significant level.
| Results|| |
A total of 70 patients were included in this study. They were divided in two groups depending on the ovarian response (<4 oocytes and more than 4 oocytes). They were compared for age, duration of infertility, baseline FSH, AMH, AFC. Clinical pregnancy rate and cycle cancellation rate were studied in both groups.
We found that the age and duration of infertility were not statistically different in two groups [Table 1] and [Table 2]. AMH value in poor responders was 1.20 ng/ml and in good responders it was 3.38 ng/ml [Table 3]. And the difference was statistically significant (P < 0.05). FSH in poor responders was 7.36 and in good responders it was 5.99 [Table 4]. The AFC in poor responders was 5 and in good responders it was 12 [Table 5]. The difference was statistically significant (P < 0.05).
|Table 2: Comparison of duration of marriage of poor and good responders |
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Pregnancy rate in poor responder group was very low when compared to good responders (6.25 vs. 18.42) [Table 6]. In good responders none of the cycle got cancelled, whereas in poor responders group five cycles got cancelled (15.63%) either due to failure to retrieve mature oocytes or failed fertilization due to poor quality of oocytes [Table 7].
| Discussion|| |
Decreased Ovarian Reserve is a condition of decreased fertility owing to a reduction in the overall quantity and quality of the oocytes.  It is associated with the greatest use of medications during IVF cycles and with the least successful outcomes. 
Our results demonstrated that poor ovarian response in IVF cycles was highly correlated with low serum AMH levels, high baseline FSH levels and Low AFC. It is associated with low pregnancy rates and high cycle cancellation rates.
Dehghani-Firouzabadi et al. demonstrated that serum AMH levels were highly correlated with the number of antral follicles, HCG day follicles count and the number of retrieved oocyte than did E2, FSH, or LH on day 3 of the cycle. In good responders, with increasing AMH levels, the antral follicle, the growing follicle and oocyte retrieval counts would also increase.  van Rooij et al. investigated whether serum AMH levels can predict ovarian response during first IVF treatment cycles. They observed a high correlation of AMH with ovarian response, as expressed by the number of oocytes retrieved. Ovarian response during exposure to high levels of gonadotrophins can be considered to be a measure of the selectable cohort of antral follicles. As this number of antral follicles appears to be related to the size of the primordial follicle pool, ovarian response can be regarded as a reflection of the ovarian reserve. 
Broekmans et al. systematically reviewed all ovarian reserve tests. They found that accuracy in response prediction, however, will only be high if the false positives are prevented by using extreme threshold levels, implicating that only minor percentages of abnormal tests will be found and many future poor responders will pass unrecognized. They suggested that that the use of the test as a method to deny treatment to assumed ovarian aged women should be declined and as a consequence the test should not be applied on a regular basis and should only be used for counseling or screening purposes.  Singer et al. demonstrated statistical association between FSH and AMH in assessing ovarian reserve. Using FSH and AMH in combination will improve the evaluation of ovarian reserve.  A study by Gleicher et al. showed abnormal FSH and abnormal AMH at all ages is associated with significantly reduced oocyte yield. 
In a study by Holte et al., Pregnancy rates and live-birth rates were positively associated with AFC in a log-linear way. Pregnancy and live-birth rates are log-linearly related to AFC. Polycystic ovaries, most often excluded from studies on ovarian reserve, fit as one extreme in the spectrum of AFC; a low count constitutes the other extreme, with the lowest ovarian reserve and poor treatment outcome. The findings remained statistically significant also after adjustment for the number of oocytes retrieved, suggesting this measure of ovarian reserve comprises information on oocyte quality and not only quantity.  Kline et al. demonstrated chronological age, ovarian volume, FSH, inhibin were significantly associated with AFC. 
| Conclusion|| |
It appears that AMH serum Levels baseline FSH and AFC are associated with ovarian response in ART cycles and can be served as markers for ovarian reserve. Furthermore, with respect to significant difference in chemical pregnancy outcome, serum levels of AMH may be used as a marker for predicting the chemical pregnancy rate. However further studies with large sample size are needed.
| References|| |
|1.||Fasouliotis SJ, Simon A, Laufer N. Evaluation and treatment of low responders in assisted reproductive technology: A challenge to meet. J Assist Reprod Genet 2000;17:357-73. |
|2.||van Rooij IA, Broekmans FJ, te Velde ER, Fauser BC, Bancsi LF, de Jong FH, et al. Serum anti-Müllerian hormone levels: A novel measure of ovarian reserve. Hum Reprod 2002;17:3065-71. |
|3.||Buyuk E, Seifer DB, Younger J, Grazi RV, Lieman H. Random anti-Müllerian hormone (AMH) is a predictor of ovarian response in women with elevated baseline early follicular follicle-stimulating hormone levels. Fertil Steril. 2011;95:2369-72. |
|4.||Kumbak B, Oral E, Kahraman S, Karlikaya G, Karagozoglu H. Young patients with diminished ovarian reserve undergoing assisted reproductive treatments: A preliminary report. Reprod Biomed Online 2005;11:294-9. |
|5.||Dehghani-Firouzabadi R, Tayebi N, Asgharnia M. Serum level of anti-mullerian hormone in early follicular phase as a predictor of ovarian reserve and pregnancy outcome in assisted reproductive technology cycles. Arch Iran Med 2008;11:371-6. |
|6.||Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update 2006;12:685-718. |
|7.||Singer T, Barad DH, Weghofer A, Gleicher N. Correlation of antimüllerian hormone and baseline follicle-stimulating hormone levels. Fertil Steril 2009;91:2616-9. |
|8.||Gleicher N, Weghofer A, Barad DH. Discordances between follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) in female infertility. Reprod Biol Endocrinol 2010;8:64. |
|9.||Holte J, Brodin T, Berglund L, Hadziosmanovic N, Olovsson M, Bergh T. Antral follicle counts are strongly associated with live-birth rates after assisted reproduction, with superior treatment outcome in women with polycystic ovaries. Fertil Steril 2011;96:594-9. |
|10.||Kline J, Kinney A, Kelly A, Reuss ML, Levin B. Predictors of antral follicle count during the reproductive years. Hum Reprod 2005;20:2179-89. |
| Authors|| |
Dr.Avantika Vaze- Parab , M.S.(Obstetrics and Gynaecology) is a practicing gynaecologist in Mumbai with special interest in Reproductive Endocrinology and Assisted Reproductive Techniques and working in this field for past three years.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]