Anti-Müllerian Hormone:

By: Saleha EssopWellington SCL

An Eggciting Introduction

Overview

•What is AMH?•Application/Uses•How its measured and compares with other labs•Case studies•Limitations

https://giphy.com

What is AMH?

•A glycoprotein part of the transforming growth factor family.•In males: Produced by immature sertoli cells.

Important in sex differentiation.•In females: Produced by granulosa cells of primary and secondary

follicles.

Two Main Functions in Females:•Regulates the number of primordial follicles that begin maturation. •Prevents the recruitment of non-dominant follicles during FSH-mediated selection.

Anatomy & Physiology. Provided by: OpenStax CNX. Located at:

http://cnx.org/contents/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@8.25.

Fleming, Richard & Seifer, David & Frattarelli, John & Ruman, Jane. (2015). Assessing ovarian response: antral follicle count versus anti-Müllerian hormone

Folliculogenesis

Application

•Important marker in the assessment of ovarian reserve in women undergoing fertility counselling.•AMH reflect the number of small follicles entering the growth phase of their life cycles which is suggestive of the number of primordial

follicles that still remain in the ovary.

AMH levels can:•Predict the response to ovarian stimulation in fertility treatment•Predict the age of menopause•Help in the diagnosis of Polycystic ovarian syndrome (PCOS) and ovarian failure

Silveira, Juliano Coelho da et al. “Isolation and Analysis of Exosomal MicroRNAs from Ovarian Follicular Fluid.”

Application

Other tests in assessing ovarian reserve include:•FSH•Oestradiol•Progesterone (6-8 days before menstruation)

•FSH and oestradiol must be measured during the early follicular phase because they are part of the pituitary-ovarian feedback system.•Less sensitive in early stages of reduced ovarian reserve.•AMH not part of the pituitary-ovarian feedback system therefore it can be measured at any time.

https://mindthegraph.com/profile/mindthegraph2/menstrual-cycle#/

Other Uses

Evaluation of intersex disorders:•Persistent Mullerian Duct Syndrome: Affects males that have normal male reproductive organs and genitalia as well as a uterus and fallopian tubes.•AMH levels can help achieve targeted mutation analysis of the gene for AMH.

AMH can also help in distinguishing between:•Cryptorchidism: One or both testes fail to descend from the abdomen.And•Anorchism: Genetic male born without testes.

As a tumour marker:•Aids in diagnosis and management of granulosa cell tumours.

https://giphy.com

Measurement

Roche AMH Immunoassay•18 min assay •Sandwich electrochemiluminescence•Serum or lithium heparin plasma•Sample stability: 3 days at RT, 5 days at 2-8°C or 6 months at -20°C •Measuring range: 0.07-164 pmol/L

Measurement

•70 Samples collected and analysed•Results compared to CHL’s method (Beckman-Coulter)

•R² value: 0.9877

Measurement

Reference Intervals

Age (yrs) AMH (pmol/L)

18-25 18-45

26-30 8-30

31-35 8-30

36-40 5-25

41-45 1-8

Females:

Expected ranges: (25 – 75th percentiles)

· If AMH >30 pmol/L consider Polycystic Ovary Syndrome (PCOS) or if markedly

elevated, granulosa cell tumour of the ovary. If on ART, elevated AMH indicates risk

of possible ovarian hyperstimulation. Fertility

assessment should consider the full clinical context.

Limitations

AMH stability during a menstrual cycle•Some reports suggest AMH is highest during the follicular phase and lowest in the luteal phase.•A study done at the University of Messina proved that there are fluctuations in AMH levels, however the differences were not clinically significant.

A. La Marca, G. Stabile, A.Carducci Artenisio, A. Volpe, Serum anti-Mullerian hormone throughout the human menstrual cycle.

Limitations

Contraceptive Use•A study found that there was a 30% decrease in AMH in cases of prolonged contraceptive use.•Temporary suppression.•2 months after contraceptives stopped, AMH levels increased.•Possible need for timing of AMH levels in this case.

Serum AMH at baseline and after 5 weeks and 9 weeks of administration of contraceptives.

Antonio La Marca, Valentina Grisendi, and Georg Griesinger, “How Much Does AMH Really Vary in Normal Women?,”

Examples

Example 1A 35 year-old woman with an AMH level of 20 pmol/L. This means she has an average number of eggs left in her ovaries. Average means she is likely to go through menopause at around 51-52 and she is likely to have children until she is 41. She is also likely to get an average number of eggs in an IVF cycle.

https://www.fertilityassociates.co.nz/news-and-blog/amh-understanding-the-

results-dr-mary-birdsall/

Examples

Example 2A 35 year-old woman with an AMH level of 10 pmol/L. Her level sits on the 25th centile and so she is likely to go through menopause at around 49. She is also probably going to produce fewer eggs if she did an IVF cycle and so she would need a higher dose of ovarian stimulation drugs.

https://www.fertilityassociates.co.nz/news-and-blog/amh-understanding-the-results-dr-mary-

birdsall/

Case Study

A 29 year-old woman who was seen at a reproductive medicine clinic with a 2 year history of secondary subfertility.•No significant medical history.•FSH, oestradiol, progesterone and AMH levels were done.•Ultrasound done to identify any abnormalities.•AMH: 99.54 pmol/L.•Suspicious area on left ovary seen on ultrasound and MRI.•Other tumour markers like CA-125, HCG and AFP were all normal.•Laparotomy confirmed presence of 10 cm mass on left ovary.•Histology examination confirmed GCT.•One month after surgery AMH levels dropped to 39.09 pmol/L.•Six months after surgery she was able to conceive through IVF.

MRI View of Tumour

Umranikar, Aarti & Saran, Mili & Brook, Nick & Singh, Neeta & Fowler, Darren & Cheong, Ying. (2013). Role of Anti-Müllerian Hormone in Diagnosing Granulosa Cell Tumor: A Case Report

Summary

AMH is a useful marker of ovarian reserve where it can:•Predict response to IVF•Provide a time frame for women to have children

Stability of AMH has the advantage over traditional assessments of FSH, oestradiol and progesterone measurements.

Minor limitations: contraceptive use easily overcome with correct information and timing.

Roche assay has shorter test time but same accuracy as other methods.

https://giphy.com

References

•Antonio La Marca, Valentina Grisendi, and Georg Griesinger, “How Much Does AMH Really Vary in Normal Women?,” International Journal of Endocrinology, vol. 2013, Article ID 959487, 8 pages, 2013.

•S. Lie Fong, P.J. Lugtenburg, I. Schipper, A.P.N. Themmen, F.H. de Jong, P. Sonneveld, J.S.E. Laven, Anti-müllerian hormone as a marker of ovarian function in women after chemotherapy and radiotherapy for haematological malignancies, Human Reproduction, Volume 23, Issue 3, March 2008, Pages 674–678

•C. Gnoth, A.N. Schuring, K. Friol, J. Tigges, P. Mallmann, E. Godehardt, Relevance of anti-Mullerian hormone measurement in a routine IVF program, Human Reproduction, Volume 23, Issue 6, June 2008, Pages 1359–1365.

•A. La Marca, G. Stabile, A.Carducci Artenisio, A. Volpe, Serum anti-Mullerian hormone throughout the human menstrual cycle, Human Reproduction, Volume 21, Issue 12, Dec 2006, Pages 3103–3107

•Fleming, Richard & Seifer, David & Frattarelli, John & Ruman, Jane. (2015). Assessing ovarian response: antral follicle count versus anti-Müllerian hormone. Reproductive BioMedicine Online. 31. 10.1016/j.rbmo.2015.06.015.

•Bungum, Leif et al. “The Impact of the Biological Variability or Assay Performance on AMH Measurements: A Prospective Cohort Study With AMH Tested on Three Analytical Assay-Platforms.” Frontiers in endocrinology vol. 9 603. 16 Oct. 2018, doi:10.3389/fendo.2018.00603

•H.W.R. Li, B.P.C. Wong, W.K. Ip, W.S.B. Yeung, P.C. Ho, E.H.Y. Ng, Comparative evaluation of three new commercial immunoassays for anti-Müllerian hormone measurement, Human Reproduction, Volume 31, Issue 12, 1 December 2016, Pages 2796–2802, https://doi.org/10.1093/humrep/dew248

•Demirdjian, Gaiane & Bord, Stephanie & Lejeune, Caroline & Masica, Ryan & Rivière, Dominique & Nicouleau, Lucie & Denizot, Philippe & Marquet, Pierre-Yves. (2016). Performance characteristics of the Access AMH assay for the quantitative determination of anti-Müllerian hormone (AMH) levels on the Access* family of automated immunoassay systems. Clinical Biochemistry. 49. 10.1016/j.clinbiochem.2016.08.005.

•Umranikar, Aarti & Saran, Mili & Brook, Nick & Singh, Neeta & Fowler, Darren & Cheong, Ying. (2013). Role of Anti-Müllerian Hormone in Diagnosing Granulosa Cell Tumor: A Case Report. Clinical Ovarian and Other Gynecologic Cancer. 5. 10.1016/j.cogc.2012.12.001.

References