Introduction:
In
the present scenario of advanced infertility treatment, there is lot of
expectations and great disappointments when negative results are obtained.
Hence good markers are needed to counsel patients about the probabilities of
success and detect the poor prognostic patients so they can be counselled in
greater detail. Most cases of success depend on the number and quality of ova
produced. This in turn depends on the ovarian reserve. Ovarian reserve in the
quantification of the number of follicle that are still present that can
develop and release the ovum. As the age increases the reserve reduces. In age
more than 40 the reserve is very poor. A number of tests are available to
quantify the reserve. One of them is anti mullerian hormone.
ANTI MULLERIAN HORMONE:
Anti
Mullerian Hormone (AMH) is considered as an important marker of the ovarian
reserve. It is secreted by the granulose
cells (the cells surrounding the ovum) of the ovarian follicle. More the ova,
more is the granulose cells and so the AMH is high. Very low values indicate
exhaustion of the ova or low ovarian reserve. This is a poorer prognostic
indicator for in-vitro fertilization (IVF) success, as a low AMH levels
indicate that only few follicles will be formed and they may be of poor quality.
Conversely, high AMH levels are also
clinically significant. High AMH levels may be seen in polycystic ovarian
disease (PCOD) and it may be a predictor for ovarian hyper stimulation (OHSS)
in IVF cycles. This means excess eggs are formed leading to water retention and
rarely heart failure or even death during IVF cycles. Reliable data on AMH
levels in Indian patients are limited. This study was done to compare the AMH
levels in infertility patients presenting at our Infertility Centres in New
Delhi. The AMH levels were correlated with age and western standard (normal)
range available.
Materials and Methods:
All Indian
consecutive patients who presented for evaluation of infertility
in a one year period (2012) at our
centre were enrolled for this study. Patients not consenting for the study were
excluded. The age of the patients and demographic features were noted. Five ml
of blood was collected from the patients, and the AMH levels were estimated. The
AMH levels were compared with the western standard cut offs.
Results:
A
total of 123 infertile patients in the age
group of 20 to 51 years were tested for AMH levels. The average age is
32.40 years. The average AMH is 14.635 pmol/L.
There
were 18 patients in the age group less than 25 years, 23 patients between 25 to
29 years, 33 patients between 30 to 34 years, 36 patients in age group 35 to 39
and 14 patients more than/ equal to 40 years of age. The youngest patient was
20 years old and the eldest was 51 years. They belonged to middle and upper
socio economic status.
There was a significant inverse correlation between
AMH levels and age. With increasing age, the mean value of AMH declined.
Two tables are
given:
Table 1. Standard cut off for serum AMH LEVELS
1.
Optimal
Fertility - 28.6 - 48.5 pmol/L
2.
Satisfactory
Fertility - 15.7 - 28.6 pmol/L
3.
Low
Fertility -
2.2 - 15.7 pmol/L
4.
Very Low - 0.0 - 2.2 pmol/L
Table 2. Age-wise categorization of AMH levels
Age groups
|
Number of patients
|
Very low
|
Low
|
Satisfactory
|
Optimal
|
High
|
<25 years
|
18
|
1
|
7
|
3
|
3
|
4
|
25 – 29 years
|
23
|
3
|
15
|
4
|
1
|
0
|
30 – 34 years
|
33
|
6
|
18
|
5
|
2
|
2
|
35 – 39 years
|
36
|
9
|
21
|
3
|
2
|
1
|
> 40 years
|
14
|
11
|
3
|
0
|
0
|
0
|
It can be seen that only one third of patients in
all age groups have either satisfactory or optimal AMH levels. Even in < 25
years age group 8 of the 18 patients have either low or very low AMH levels. 85 out of 123 patients (69.1%) had levels of
AMH below 14 pmol/L. This value is considered as the critical level of ovarian
reserve for good pregnancy outcomes.
Discussion
AMH levels
are useful in predicting the likely response during the IVF
cycles, so it is useful to decide the type and dosage of medicines. AMH
estimation may also be useful predicting ovarian ageing and act as a guide in
how long a woman can delay childbearing. AMH levels may also be useful in
predicting the age of menopause. AMH levels may also serve as a useful marker
of PCOS. AMH levels are also worthwhile in estimating the reserve prior to or
following chemotherapy and ovarian surgery.
Studies
from India have shown that AMH levels and antral follicle count (AFC) correlate
with each other. Large databases from the Western population have
clearly established the values and age specific cut-offs of AMH. Such data are
limited among Indian fertile and infertile patients. We found surprisingly
lower levels of AMH among Indian infertile patients undergoing IVF. 85 out of
123 patients (69.1%) had levels of AMH less than 14 pmol/L, which is the critical
level for good pregnancy outcomes. Larger studies with more number of patients
are required to establish whether Indians really have lower levels of AMH than
published in the western literature.
To conclude, we found lower levels of AMH among
Indian infertile patients undergoing assisted productive techniques. The AMH
levels were lower across the age categories. Majority of patients did not have
optimal or satisfactory levels of AMH.
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