THE PREDICTIVE VALUE OF SERUM CONCENTRATIONS OF
ANTI-MÜLLERIAN HORMONE FOR OOCYTE QUALITY
Fertility – Centro de Fertilização Assistida
Instituto Sapientiae – Centro de Estudos e Pesquisa em Reprodução
Assistida
Sao Paulo, Brazil
Assumpto Iaconelli Jr., Daniela P. A. F. Braga, Amanda S. Setti,
Fabio F. Pasqualotto, Rita de Cássia S. Figueira, Edson Borges Jr.
1
INTRODUCTION
Anti-Müllerian Hormone (AMH)
The Anti-Müllerian Hormone AMH
Glycoprotein
TGF-β superfamily
Growth and differentiation
Short arm of chromosome 19
2
INTRODUCTION
AMH and Sexual Differentiation
1940 - Role in male sexual differentiation (Alfred Jost)
Males
Females
Sertoli cells
Absence of AMH
Regression of the
Müllerian duct
Müllerian duct
differentiate
Male reproductive tract
Female reproductive
tract
3
INTRODUCTION
Ovarian AMH production
Expressed in granulosa cells from the pre-antral and antral follicles
Follicular
fluid and
circulation
Birth
Puberty
21 years of
age
6% a year
Menopause
4
INTRODUCTION
AMH function
Negative, restraining influence
on initial recruitment
Inhibition of cycle recruitment by
lowering follicle sensitivity to FSH
Transition from primordial into growing follicles is enhanced in the absence of
AMH, resulting in the early exhaustion of the primordial follicle pool
5
INTRODUCTION
AMH and Assisted Reproduction
Oocyte
yield
Predictive
of POR to
COS
Predictive
of HR to
COS
Cycle
cancellation
rate
Mature
oocytes
Obtained
embryos
AMH in assisted reproduction
6
INTRODUCTION
AMH and oocyte quality
AMH
serum
levels
Oocyte
quality
Low levels
(<1.66 ng/ml)
High levels
(>4.52 ng/ml)
Poor oocyte
morphology
7
OBJECTIVE
To identify a possible correlation between serum AMH concentrations and (i)
oocyte quality, (ii) embryo developmental competence and (iii) implantation
potential
8
MATERIALS AND METHODS
ICSI
408 patients
January 2011
August 2013
4488 oocytes
Blood samples
obtained on
cycle day 3
AMH - ELISA
Oocyte
morphology
evaluation
before ICSI
Day 1
Day 2
Day 3
Day 5
9
MATERIALS AND METHODS
Oocyte morphological evaluation
Cytoplasmic
colour
Vacuoles
Aggregates of
sERC
Intracytoplasmic defects
Refractile
bodies
Perivitelline
space size
Perivitelline
space
granularity
Zona pellucida
abnormalities
Shape
abnormalities
Fragmented
polar body
Extracytoplasmic defects
10
MATERIALS AND METHODS
• 8 – 10 cells
• < 15%
fragmentation
• No multinucleation
• Colourless
cytoplasm
• No inclusions
• No PVS granularity
• No ZP abnormality
Blastocyst formation
Blastocyst formation
High quality on Day 3
Embryo morphological evaluation – D3
• Blastocoel cavity
less than half the
volume of the
embryo
11
MATERIALS AND METHODS
Maternal age
Transferred
embryos
BMI
Embryos
FSH dose
AMH
levels
Fertilization
rate
Follicles
MII oocytes
Oocytes
Pearson correlation
12
MATERIALS AND METHODS
Embryo
quality on
day 2
Linear regression
analysis
Embryo
quality on
day 3
Implantation
rate
AMH levels
Binary regression
analysis
Pregnancy
Blastocyst
formation
chance
13
MATERIALS AND METHODS
Cytoplasmic
colour
Vacuoles
Aggregates of
sERC
Refractile
bodies
Perivitelline
space size
Perivitelline
space
granularity
Zona pellucida
abnormalities
Shape
abnormalities
Fragmented
polar body
Extracytoplasmic defects
Intracytoplasmic defects
Binary regression analysis
All regression models were controlled for maternal age
14
RESULTS
General Characteristics of the cycles (n=408)
Variables
Mean
SD
Min
Max
Female age (y)
37.8
3.9
28
45
Serum AMH levels (ng/ml)
1.49
1.9
0.1
12.6
Number of follicles
11.8
10.5
0
51
Number of ooctytes
8.0
7.4
0
35
Number of mature oocytes
6.2
5.9
0
30
Mature oocytes rate
76.1
23.7
0
100
Fertilization rate
69.7
26.9
0
100
Number of embryos
5.5
4.5
0
27
Transferred embryos
1.8
1.0
0
4
Implantation rate
25.5
41.9
0
100
Variables
n/N
Cycles with embryo transfer
345/408 (84.6)
Pregnancy rate per transferred cycle
99/345 (28.7)
RESULTS
Correlations between AMH levels and cycles’ characteristics
Serum AMH level
Variable
Correlation coefficient p-value
Maternal age
-0.279
<0.001
Maternal BMI
-0.203
0.065
FSH dose
0.089
0.075
Number of aspirated follicles
0.626
<0.001
Number of retrieved oocytes
0.600
<0.001
Number of mature oocytes
0.588
<0.001
Fertilisation Rate
0.595
0.048
Number of obtained embryos
0.495
<0.001
Number of obtained high-quality embryos
0.504
<0.001
Number of transferred embryos
0.221
<0.001
RESULTS
Influences of AMH levels on cycles’ outcomes
Serum AMH level
Response variable
OR
CI
p-value
Embryo quality on D2
1.01
0.96 - 1.06
0.732
Embryo quality on D3
0.98
0.65 - 2.17
0.716
Blastocyst formation
0.93
0.41 - 1.36
0.864
Pregnancy
1.30
1.13 - 1.48
<0.001
AMH level
Variable
Regression coefficient p-value
Implantation rate 0.116
0.031
RESULTS
Influences of AMH levels on oocytes’ morphology
Serum AMH level
Oocyte morphology
OR
CI
p-value
At least one oocyte defect
0.70
0.52 - 0.92
<0.001
Cytoplasmic colour
0.82
0.67 - 1.01
0.071
Vacuoles in the ooplasm
0.96
0.89 - 1.05
0.377
Aggregates of sERC
0.79
0.63 - 0.99
0.014
Refractile Bodies
0.84
0.50 - 1.42
0.460
Large PVS
0.82
0.75 - 0.90
<0.001
PVS granularity
0.87
0.83 - 0.92
<0.001
ZP abnormalities
0.80
0.69 - 0.92
<0.001
sERC: Smooth endoplasmic reticulum
perivitelline
Zona pellucida, PB: Polar Body
Shape abnormalities
0.72cluster, PVS:
0.56
- 0.94space, ZP:
0.003
DISCUSSION
Ovarian
response to
COS
OOCYTE
QUALITY
Low
oocyte
quality
≅ 40%
EMBRYO
IMPLANTATION
HYPOTHESIS
Lower serum AMH levels would have
a negative effect on oocyte and
embryo development
19
DISCUSSION
AMH
Oocyte
quality
AMH
Fertilization
rate
AMH
Embryo
quality
AMH
Blastocyst
formation
20
DISCUSSION
AMH
Oocyte
quality
AMH
AMH
Embryo
quality
Fertilization
Agreement
Disagreement
21
DISCUSSION
Follicular
fluid AMH
Oocyte
quality
Embryo
implantation
AMH
22
DISCUSSION
AMH
Oocyte
developmental
competence
Oocyte
quality
Fertilization
rate
AMH
Granulosa
cells
Earlier
follicular
stages
Low
AMH
levels
Failure in
GC
expression
Harm the
gamete
AMH
AMH
23
DISCUSSION
Follicular
fluid AMH
Fertilization
AMH
24
DISCUSSION
AMH
Embryo
quality
Disagreement
Embryo quality
Embryo quality
• Cell number
• % Fragmentation
• Symmetry
Silberstein et al.
morphological
evaluation criteria
Our morphological
evaluation criteria
•
•
•
•
Multinucleation
ZP defects
Cytoplasmic defects
PVS defects
25
DISCUSSION
Pregnancy
AMH
Implantation
Serum AMH level
AMH
Variable
Number of aspirated follicles
Number of retrieved oocytes
Number of mature oocytes
Fertilisation Rate
Number of obtained embryos
Number of obtained high-quality embryos
Number of transferred embryos
p-value
<0.001
<0.001
<0.001
0.048
<0.001
<0.001
<0.001
In patients with low AMH, the lower number of available embryos may
not compensate for oocyte deficiency
Correlation between AMH and ICSI outcomes
• Lower response to COS?
• Lower oocyte quality?
• Both?
26
CONCLUSION
Serum AMH levels may reflect quantitative and qualitative ovarian
responsiveness in women undergoing ICSI
27
STAFF
DIRECTORS
EDUCATIONAL DEPARTMENT
Assumpto Iaconelli Jr.
Sylvia Cortezzi
Edson Borges Jr.
GINECOLOGY AND ULTRASOUND
IVF LABORATORY
Adriana de Goes Soligo
Livia Vingris
Fernanda Montenegro Valente
Matheus de Castro
Carla Iaconelli
Renata Ferreira
Edir Catafesta
Rita Figueira
Fábio B. Lopes
ANDROLOGY LABORATORY
Luiz Guilherme Maldonado
Rodrigo Provenza
Rosane Rodrigues
Thais Serzedello
Wagner C. P. Busato
GENETICS
ANESTHESIA
Leila Farah
Maternidade ProMatre Paulista
Raquel Joffe
PSYCHOLOGY
NUTRITION
Rose Marie Melamed
Gabriela Halperm
NURSING/ SUPPORT
SCIENTIFIC RESEARCH DEPARTMENT
Amanda Setti
Daniela Braga
Carla Mercante
Margaret Meira
Mariana Rossini
INFORMATICS
Marcelo Baptista
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