الفهرس 
ANTI-MULLERIAN HORMONEOnly 14 pages are availabe for public view
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Abstract
Women egg supply begins to be depleted before birth, and continues until menopause, the rate of egg loss essentially constant over women’s life span, although several reports have detected an accelerated rate of loss at around 37 years on average, this means that at the beginning of every menstrual cycle, a relatively fixed proportion of all the remaining eggs becomes recruitable i.e., sensitive to gonadotropins, given that overall number of eggs in younger women is higher than at later years.
Ovarian reserve refers to the size of the non growing, or resting primordial follicle population, which presumably determines the number of growing follicles and the “quality” or reproductive potential of the oocytes.
Although age is the best predictor of ovarian reserve, approximately 10% of women have an accelerated loss of ovarian reserve by their mid 30s, whereas others respond to controlled ovarian hyper stimulation and achieve pregnancies despite their advanced age. Because of these imperfect correlations between chronological age and ovarian biological age, assays have been developed to assist in the predictor of ovarian responsiveness to controlled ovarian hyper stimulation.
The number of primordial follicles in the ovary, correlated well with the number of growing follicles, counted by transvaginal sonography in the early follicular phase. So the decreasing size of the antral follicle cohort with age is a reflection of the decreasing primordial follicle pool. We used this principle to measure ovarian reserve, defined as the total number of follicles which can be stimulated under maximal ovarian stimulation with FSH.
Studies about IVF stimulations have suggested that AMH as such represents ovarian quantitative reserve test
Evidence is accumulating that AMH, in contrast to FSH, E2, and inhibin B, can be used as a cycle independent marker
In female, AMH is exclusively produced by granulose cells of preantral (primary and secondary) and small antral follicles from birth up to menopause. After follicles differentiate from the primordial to the primary stage, production of AMH starts, and it continues until the follicles have reached the antral stages, with diameters of 2-6 mm The number of the small antral follicles is related to the size of the primordial follicle pool With the decrease in the number of the antral follicles with age, AMH production appears to become diminished and it invariably will become undetectable at and after menopause
B.STUDY:
This study was conducted in Ain shams maternity hospital it included 50 patients who are eligible for treatment by assisted reproduction.
All the patients underwent:
A. Full history taking.
B. Physical examination and assessment of body mass index.
C. Day 3 FSH, LH, TSH and prolactin level
D. Day 3 AMH and early follicular phase TV/US for detection of AFC in both ovaries.
For the purpose of this study, we analyzed the basal serum AMH on cycle day 3 and antral follicular count was measured by adding number of follicles with mean follicular diameter 2-10 mm in both ovaries.
Each patient was followed up for the outcome of IVF stimulation according to number of oocytes ready for retrieval and/or embryos available for transfer on day 3.
c.RESULTS:
Serum sample was taken from all included women at day 3 of the IVF cycle for detecting serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, thyroid releasing hormone (TSH) and anti-müllerian hormone (AMH). TVS was performed to all included women on the same cycle day for recording the antral follicle count (defined as no. of follicles measuring 2-8 mm at cycle day 3). After induction of ovulation during the IVF cycle, oocytes were retrieved, IVF was done; no. of embryos available for transfer was counted.
There were highly significant good negative correlation between age and AMH at cycle day 3 (r=-0.704, p<0.001), antral follicle count at cycle day 3 (r=-0.702, p<0.001) and no. of embryos available for transfer (r=-0.525, p<0.001). There were a highly significant good positive correlation between AMH at cycle day 3 and both antral follicle count (r=0.869, p<0.001) and no. of embryos available for transfer (r=0.815, p<0.001) (Figures 3-8).
There were no significant correlations between measured parameters and serum levels of FSH, LH, prolactin and TSH.
Regression analysis of all measured parameters as predictors of the no. of embryos available for transfer showed that only age, cycle day 3 AMH and cycle day 3 antral follicle count are the significant predictors, with the latter being the most significant predictor (adjusted R2 values were 0.276, 0.664, 0.842, respectively). None of the other parameters, including serum FSH, LH, prolactin and TSH measured at cycle day 3, was a significant predictor of no. of embryos ready for transfer.
ROC curves were constructed for detecting the best cutoff values for measured parameters as predictors of successful outcome (set as presence of ≥ 4 embryos available for transfer) [figure-9]. Serum levels of FSH, LH, prolactin and TSH measured cycle day 3 were poor predictors, and no cutoff values for these parameters with satisfactory sensitivity and specificity were found.
Concerning age, the best cutoff value was 35.5 years, above which there is high likelihood of unsuccessful outcome (sensitivity 87%, specificity 61%). The best cutoff value for cycle days 3 AMH was 2.85 ng/dl (sensitivity 82%, specificity of 89%). The best cutoff value for cycle day 3 antral follicle count was 8 (sensitivity 82%, specificity 100%).