Dr. Kenneth Egwuda MBBS, PGA-ART(Lon), ESGE(Belg.),FMAS,FWACS,FMCOG A COMPARATIVE ANALYSIS OF ANTI-MULLERIAN HORMONE AND FOLLICLE STIMULATING HORMONE IN ASSESSMENT OF OVARIAN RESERVE Dr. Kenneth Egwuda MBBS, PGA-ART(Lon), ESGE(Belg.),FMAS,FWACS,FMCOG

Authors Egwuda, K.; Onuh, SO.; Ekwempu, CC.; Shuaibu, SI., Kamolideen, AA; Ojima, SC

AMH/FSH A patient's ovarian reserve (OR) determines prognostic chances of fertility treatments and her treatment options Best possible assessments of OR, therefore, represent a core issue in modern infertility care

OR In human in-vitro fertilization (IVF), the identification of variables able to predict ovarian responsiveness to exogenous gonadotropins guides the clinician on individualizing treatment protocols, optimizing results and reducing complications

AMH Value Ranges (ng/ml) optimal fertility ------------ 4.0 – 6.8 Satisfactory fertility -------- 2.2 – 4.0 Low fertility ------------------ 0.3 – 2.2 Very low fertility ------------ 0.0 – 0.3 High level---------------------- >6.8 5/12/2019 AMH VS FSH IN OR

FSH Value Range (miu/ml) Very low Reserve ---------- <2 Satisfactory ----------------- 3 - 10 Depleted --------------------- ≥ 12 Ovarian failure ------------- ≥ 25

objectives To evaluate basal anti-müllerian hormone as compared to follicle stimulating hormone as a marker for ovarian reserve and responsiveness

Objective To determine whether AMH is a better marker of ovarian reserve and responsiveness than FSH

Study Type This was a hospital based study that was carried out in Fertile Aid Clinic, DEDA Hospital Abuja and a private hospital in Jos

Study Population The study population comprised of clients who had the indication for In-vitro fertilization and Embryo Transfer (IVF-ET) or Assisted Reproductive Technology (ART), had been counselled, consented and scheduled for a treatment cycle

STUDY DESIGN This was a cross-sectional and comparative study

INCLUSION CRITERIA < 40 years, having regular, menstrual cycles every 21–35 days having both ovaries present no current or past diseases affecting ovaries, gonadotrophin, sex steroid secretion, clearance or excretion they were also not on any form of hormonal therapy their ovaries were adequately visualized at transvaginal ultrasound scanning

ETHICAL CONSIDERATION This study was approved by the Research and Ethical Committees of the institution where it was conducted and the Federal Capital Development Authority. Informed consent was obtained from the clients before enrolment into the study. The laboratory analysis of baseline serum Anti-Mullerian Hormone was paid for by the researchers

methodology Stored basal menstrual cycle day three serum samples of 112 women was evaluated for AMH and FSH and compared to the number of oocytes retrieved A correlation analysis, ROC curve and analysis of variance were performed to determine the level of accuracy between AMH and FSH in predicting the ovarian reserve and responsiveness

OUTCOME MEASURED total number of follicles ≥ 17mm in diameter before administration of hCG the total number of oocytes retrieved AMH levels FSH levels Duration of stimulation Age BMI

AMH/FSH For the purpose of this study, serum AMH levels <2.2 ng/ml shall be taken as an abnormal level while serum levels >2.2 ng/ml is satisfactory. Serum FSH levels between 3-10 miu/ml will be regarded as normal/satisfactory while levels >10 miu/ml will be regarded as abnormal

TABLE: 1 Characteristics of Subjects   Minimum Maximum Mean Std. Deviation Age 20 45 31.3 6.7 Parity 3 0.5 0.8 Weight 55.2 117.4 78.8 13.8 Height 1.5 1.8 1.6 0.1 BMI 20.9 45.9 29.5 5.2 FSH 2.1 17.8 5.9 2.6 LH 0.3 17.3 3.1 AMH 16.6 3.7 3.0 AFC 1 22 10.4 5.5 Number of Follicles ≥17mm before HCG 3.5 Number of Oocytes 7.5 Amp 2 6 1.4 Duration of Stimulation 4 15 9.9 1.7 Total Dose 300 5850 2583.4 1136.5 TABLE: 1 Characteristics of Subjects

≤3 Oocytes >3 Oocytes 0.162 0.906 0.772 Variable AUC SE 95% CI   ≤3 Oocytes >3 Oocytes Variable AUC SE 95% CI P-Value Age 0.162 0.049 0.067,0.257 0.0001 0.838 0.743,0.933 0.002 BMI 0.337 0.070 0.199,0.476 0.034 0.663 0.524,0.801 FSH 0.228 0.064 0.103,0.353 0.0002 0.772 0.647,0.897 0.0003 AMH 0.906 0.038 0.832,0.980 0.094 0.020,0.168

Receiver operative xtic curve

COMPARISON OF PERFORMANCE OF KEY VARIABLES It was observed that for the prediction of ≤3 oocytes (poor response), Anti-Mullerian Hormone provided the largest Area Under the Curve (AUC) with a value of 0.91 on the Receiver Operating Procedure Curve, which implied an excellent balance of sensitivity and specificity for the number of oocytes ≤ 3 (P<0.05) relative to FSH which showed AUC of 0.228; P<0.05

ROC

Degree of accuracy

AMH/FSH FSH show a higher level of sensitivity for levels of Oocyte >3 oocytes retrieved. Interestingly, AMH showed a higher overall accuracy (82.1%) even for normal responders

Multiple Linear Regression Model

model A model developed based on the different variable that could predict the number of oocytes retrieved in an IVF treatment cycle. Though the model looks positive, AMH appeared to be the only significant predictor of the number of oocytes retrieved as compared to other independent variables including FSH. Anti-Mullerian Hormone was also seen to have the largest contribution (4.210) to the model since it has the highest coefficient of 0.538

conclusion Conventional evaluation of ovarian reserve requires specific menstrual cycle day serum evaluation of oestradiol, FSH, and LH. The accuracy of these analytes may be decreased dramatically by exogenous hormone (gonadotropin-releasing hormone agonists, gonadotropin-releasing hormone antagonists, hormonal contraceptives), endogenous hormones (elevated oestradiol levels because of a functional ovarian cyst), and timing of sample acquisition

conclusion studies have shown that AMH results are not influenced significantly by menstrual cycle day, oestradiol, contraceptives, or gonadotropin-releasing hormone agonists. Because AMH offers added convenience and its predictive value parallels or exceeds conventional analytes testing with FSH, age, and inhibin B, AMH appears to represent a compelling tool for the assessment of ovarian reserve. Use of AMH testing is likely to improve ovarian reserve assessment in infertile patients.

conclusion Thank you