1. 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

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

3. 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

4. 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

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

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

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

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

9. 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

10. 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

11. STUDY DESIGN
This was a cross-sectional and comparative study

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

25. ≤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

26. Receiver operative xtic curve

27. 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

28. ROC

29. Degree of accuracy

31. 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

32. Multiple Linear Regression Model

33. 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

34. 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

35. 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.

36. conclusion
Thank you