Ovarian reserve testing is important before planning IVF cycle, ovulation induction, family planning reasons, before and after chemotherapy and radiotherapy. Ovarian reserve testing such as AMH may help also in diagnosis of granulosa cell tumors and amenorrhea.
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Ovarian reserve 2
1. Dr. Azmi Saleh Abdrbo
FRCOG
El-Amal IVF Center
Ovarian reserve
2. Ovarian reserve
Population of nongrowing follicle wthin ovary: acyclic
ovarian activity(primordial follicles)
Population of small gorwing follicles responsive to FSH
(Ovulatory potential)
Quantity and quality of primordial follicle at a given age.
Indirect measure of future fertility,onset of menopause
El-Amal IVF Center
3. Ovarian reserve
Ovarian reserve
Plan fertility preservation
Fertility outcome
Response to ovarian stimulation
Predict pregnancy rate
Monitor fertility decline
Fertility after chemotherapy and cancer treatment
El-Amal IVF Center
4. Ovarian reserve AMH
D.Diagnosis of PCO ,amenorrhea
Family planning :ovarian reserve screening
Ovarian surgery
Granulosa cell tumors
Menopause and POI
El-Amal IVF Center
11. AMH variability
AMH: glycoprotein secreted by Granulosa cells in small
gowoing follicle up to 8mm
Older studies: stable at any point in menstrual cycle
Recent studies: minor varation in level(no change)
El-Amal IVF Center
Anderson 2006m, Nelson 2010 –Hadlow etal 2013
12. AMH variability
Marker of preantral and smal antral follicle up to 8mm
Reflect primordial follicle pool size(indiectly)
AMH: suppressed during pregnancy and prolonged
GNrHa , O C
El-Amal IVF Center
Anderson 2006m, Nelson 2010 –Hadlow etal 2013
13. Ovarian reserve
AMH: suppressed during pregnancy and prolonged
GNrHa , O C
AMH may not retain its accuracy as predictor of ovarian
reseve in OC users
El-Amal IVF Center
Anderson 2006m, Nelson 2010 –Hadlow etal 2013
17. Ovarian reserve:AMH
AMH in diagnosis
PCO morphology,
Andrgen excess,
Anovulation
PCOS:more than 5ng/ml to 8,4ng/ml,correlated to andrgen
level
AMH correlates TO AFC in PCO
PCO: AMH level and metformin treatment
El-Amal IVF Center
18. Ovarian reserve:AMH
AMH in diagnosis
PCOS:
AMH may replace AFC in the future
High AMH(8.4ng/ml) may help in diagnosis of PCO in
adolucent since Ultrasound scan may be difficult or not
accurate
May help to plan AMH based protocol for ovulation
induction : clomiphene
El-Amal IVF Center
19. Ovarian reserve:AMH
AMH in diagnosis amenorrhea
In hypogonadal Hypogonadism :FSL,LH low
AMH is low than normal
Hypergonadal Hypogonadism: AMH undectable
Granulosa cell tumors very heigh levels
Premature ovarian failure AMH may be undectable
El-Amal IVF Center
20. Ovarian reserve:AMH
AMH in diagnosis
Granulosa cell tumor difficult to diagnose
Ultrasound :Solid cystic mass
Granulosa cell tumors(GCT)AMH : very heigh levels
Granulosa cell tumors require prolonged follow up
Both Inhibin and AMH are sensetive marker for GCT
In J cancer 2015
El-Amal IVF Center
21. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Pretreatment and post treatment levels chemotheapy
Prediction of ovarian function after chemotjerapy
Incorporated in Guidelines of childhood cancer treatmnt
Research on the best protocol of chemotherapy
Human Reprod 2015
El-Amal IVF Center
22. Ovarian reserve:AMH
Research on the best protocol of chemotherapy
GNRH agonist works well with cyclophosamide based
protocol to avoid ovaruian damage from chemotherapy
Radiotherapy: mointoring of ovarian function
Ovarian surgery : which technique is good?
Uterine artery embolization and AHM level( no significant
effect)
Minim Invasive 2015
El-Amal IVF Center
23. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Ovarian surgery
Endometriosis:effect of endometrioma surgery on AMH
Ovarian function after total hysterectomy Vs supracervical
hysterectomy
J minim Invasive Gynecol 2015
El-Amal IVF Center
24. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Predict ovarian reserve decline in autoimmune diseases
SLE and other autoimmune disorders
Auto immune thyroiditis
Rev Bras Reumatol 2014 J Assist Reprod Genet 2015
El-Amal IVF Center
25. Ovarian reserve:AMH
AMH in diagnosis(monitor fertility decline)
Treatment of ectopic pregnancy with methotroxate
decreases AMH and AFC
Eur J Obstet Gynecol Reprod Biol 2014
El-Amal IVF Center
26. Ovarian reserve: AMH
AMH limitations
No international satandard assay
Does not provide direct measurement of primordial follicle
pool
Age and genetics other biomarkers should be taken in
cosideration in the prediction of future fertility
May not be accurate In patient taking OC
Racial variantions
El-Amal IVF Center
27. Ovarian reserve:AMH
AMH in diagnosis: predictions of menopause Why?
Menopause: End of natural fertlity
Plan career,
Decision on the wish to have childern
Family planning
Fecundability(probability of concieving in low and high
AMH both low fecundability
El-Amal IVF Center
28. Ovarian reserve:AMH
Predicting remaining reproductive life span(model)
AMH undectable 5 years before final menstrual cycle
Intrpretation in the contex of age,genetics,enviroment
0.2ng/ml median age to menopause 6 ys (gp 40-45ys)
But about 10 ys in age gp 35-39ys
El-Amal IVF Center
29. Ivf outcome and AMH
Low AMH<0.47ng/ml is associated with poor
prognosis for IVF outcome
AMH>2ng good outcome
Lehmann et al J Assist Reprod Genet 2014
El-Amal IVF Center
30. Oocyte quality and age
Age=Quality
Ovarian reserve test=Quantity
Age: Miscarriage rate
Age: Obesity and oocyte quality
Weight reduction and oocyte quality
Nelson et al Hum Reprod update 2013
El-Amal IVF Center
31. Birth rate and age
Nelson et al Hum Reprod update 2013
El-Amal IVF Center
32. Miscarrage rate and age
Nelson et al Hum Reprod update 2013
El-Amal IVF Center
34. Oocyte quality and age
Age=Quality
Age: Obesity and oocyte quality
Weight reduction and oocyte quality
Nelson et al Hum Reprod update 2013
El-Amal IVF Center
37. Ovarian reserve
AFC strongly correlated to AMH
AMH combined with AF:increase sensitivity and
specificy
Predict oocyte yield during COS
Identify good prognosis patients for ivf
Response prediction in Ovarian stimulation:OHSS
Predicts poor responders
El-Amal IVF Center
Hadlow et al fertil steril 2013
38. Ovarian reserve
Why to predict ovarian response
Avoid iatrogenic complication
Ovulation protocol strategy
Agonist protocol VS Antagonist protocol
Flare protocol VS MNC
El-Amal IVF Center
39. Ovarian reserve:AMH
Why Predict Ovarian response
AFC >=40,AMH>=5.6ng/ml- or 40pmol-antagonist control
agonist triger
AFC 24-40or AMH 2.8-5.6ng/ml or20-40pmol antagonist
control hcg,agonist triger
AFC 10-24,AMH 1--2.8ng or 7-20 pmol Long agonist
control
AFC 2-10,AMH <0.1- 1ng/m1 or -7pmol Flare agonist
El-Amal IVF Center
Nelson S in fertil Steril 2013
41. Ovarian reserveAMH
AMH Vs AFC Ovarian response:Starting Dose
AMH is better in predicting hyporesponse
AFC is better in predicting hyperresponse
El-Amal IVF Center
42. Improving oocyte quality and
age
Age=Quality
Age: Obesity and oocyte quality
Weight reduction and oocyte quality
Nelson et al Hum Reprod update 2013
El-Amal IVF Center
43. Avoiding age related decline in
oocyte quality
Oocyte cryopreservation(Social freezing)
Assess embryo quality: aneuploidy screen
DHEA? Testosterone skin batch
Growth hormone?
Vit E Conenzyme Q?
Nelson et al 2013 Hum Reorod Update
El-Amal IVF Center
44. conclusion
AMH is follicle gatekeeper. AMH and AFC are the best
markers of ovarian reserve, age is the best marker for
oocyte quality. Maximizing oocyte yield for all patient is no
longer an appropriate stimulation strategy. ORT allows
pretreatment patient counseling, individualization of
stimulation strategy, increased cost effectiveness,
enhanced safety. AMH may be used in assessing ferility
preservation , chemotherapy ovarian surgery. AMH may be
used as a biomarker in diagnosis of endocrine disorders’
autoimmune disorders
El-Amal IVF Center
