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ORIGINAL ARTICLE
Year : 2020  |  Volume : 47  |  Issue : 3  |  Page : 164-167

Determination of ovarian reserve in different age groups of infertile women


1 Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir, India
2 Department of Community Medicine, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Submission25-May-2020
Date of Acceptance10-Jul-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. Shaheera Ajaz
House No. 8, Old Colony, Rawalpora, Srinagar - 190 005, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_44_20

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  Abstract 


Background: Infertility is a major global issue, and the childbearing potential can be estimated by determining the ovarian reserve. Ovarian reserve is described as a quantity of the ovarian follicles and quality of oocytes. Aims and Objectives: The objective of our study was to identify the correlations between follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-Müllerian hormone (AMH), and antral follicle count (AFC) in different age groups of infertile women and to distinguish the most reliable marker for ovarian reserve with the objective of selecting a strategy for initial stages of infertility management. Materials and Methods: In this prospective study, 101 infertile women were assessed. The study participants were divided into three age groups: 20–29 years, 30–39 years, and >40 years. FSH, LH, AMH, and AFC were done on day 2–3 of menstrual cycle. Results: A total of 101 infertile women were assessed in our study. The mean age of the participants was 33.3 ± 4.37 years and the mean infertility period was 3.36 ± 2.26 years. The mean body mass index was 23.75 ± 2.97 kg/m2. The mean FSH level was 8.18 ± 5.54 and the mean AMH was 1.98 ± 1.0. The mean AFC was 9.29 ± 5.09. There was a statistically significantly elevated negative correlation between age and AMH level (rs = -0.667, P < 0.0001) and AFC (rs = -0.64, P < 0.0001). We observed a statistically significantly positive correlation between age and FSH (rs = 0.569, P < 0.0001). The correlation analysis performed in separate groups showed that AMH and AFC showed a statistically significant positive correlation for Group I (r = 0.953, P < 0.0001), Group II (r = 0.966, P < 0.0001), and Group III (r = 0.865, P < 0.001). A statistically significant negative correlation between FSH/LH and AMH was detected only in Group II (r = -0.661, P < 0.0001) and Group III (r = -0.735, P < 0.003). A statistically significant correlation existed between FSH and AFC in Group II (r = -0.657, P < 0.000), Group III (r = -0.664, P < 0.01), as well as between age and FSH only in Group III (r = 0.551, P < 0.04). Conclusion: AMH is more reliable marker of ovarian reserve compared to FSH/LH as the correlation between AMH and AFC is strongly positive. AMH can detect decrease in ovarian reserve much earlier than FSH/LH. The use of AMH combined with AFC definitely improves the evaluation of ovarian reserve in all age groups of infertile women.

Keywords: Anti-Müllerian hormone, antral follicle count, follicle-stimulating hormone, luteinizing hormone, ovarian reserve


How to cite this article:
Wani S, Ajaz S, Rashid L, Ahmed J, Khurshid R, Ahmed A. Determination of ovarian reserve in different age groups of infertile women. J Sci Soc 2020;47:164-7

How to cite this URL:
Wani S, Ajaz S, Rashid L, Ahmed J, Khurshid R, Ahmed A. Determination of ovarian reserve in different age groups of infertile women. J Sci Soc [serial online] 2020 [cited 2021 Mar 7];47:164-7. Available from: https://www.jscisociety.com/text.asp?2020/47/3/164/307598




  Introduction Top


In today's fast-paced life, childbearing is taking a back seat, with more and more couples presenting with issues related to fertility. Infertility is a major global issue. The prevalence of infertility worldwide is approximately 10'–15'.[1] Many women present with queries regarding their childbearing potential and how long they can delay childbearing. These queries can be answered by determining the ovarian reserve of the female. Ovarian reserve is described as a quantity of the ovarian follicles and quality of oocytes.[2] This assessment facilitates appropriate pretreatment counseling and modification of individual treatment protocol in an attempt to maximize their potential response.[3] Conventionally, serum follicle-stimulating hormone (FSH), serum luteinizing hormone (LH), serum E2, serum inhibin B and serum anti-Müllerian hormone (AMH), and antral follicle count (AFC) have been used to determine ovarian reserve.[3]

Recently, identification of AMH levels has become important in the assessment of ovarian reserve.[4] FSH plays a vital role during early follicular development, while LH is involved in later stages. However, they have cyclic variability. Furthermore, the changes in serum levels of FSH and LH occur relatively late in reproductive aging process at a time when ovarian reserve is critical and chances of pregnancy are significantly reduced. Hence, FSH as a marker of ovarian reserve does not justify the purpose of testing.[3]

Ultrasonographic parameters used to measure ovarian reserve are AFC (a total of 2–10 mm antral follicles in both ovaries are measured) and ovarian volume. AFC is considered the best predictor of ovarian reserve in quantitative aspect.[3] Some investigators consider AFC as the first-choice test.[5],[6]

Over the last decade, a large number of studies examining the multiple roles of AMH have been published. It is virtually undetectable but increases gradually until puberty and remains stable throughout the menstrual cycle.[7],[8]

It is widely accepted that reduction in serum AMH is the first indication of decline in follicular reserve in ovaries. It can be measured at any time in the menstrual cycle due to its stability.[9],[10]

Aims and objectives

The objective of our study was to identify the correlations between FSH, LH, AMH, and AFC in different age groups of infertile women and to distinguish the most reliable marker for ovarian reserve with the objective of selecting a strategy for the initial stages of infertility treatment.


  Materials and Methods Top


This was a prospective study conducted at the Department of Gynaecology and Obstetrics in SKIMS, Soura, Srinagar, over a period of 3 years from March 2017 to February 2020. The study population comprised 101 infertile women who attended the outpatient department for infertility evaluation and treatment after taking clearance from the institutional ethical committee. The exclusion criteria for our study were patients with previous ovarian surgery, those with polycystic ovarian syndrome, and those with premature ovarian failure. The participants were divided into three age groups: group I: 20–29 years (n = 19), Group II: 30–39 years (n = 68), and Group III: 40 + years (n = 14).

The FSH, LH, and AMH levels were measured on day 2–3 of the cycle. AMH levels were measured by enzyme-linked immunosorbent assay. FSH levels were measured by enzyme-linked fluorescent assay. Transvaginal ultrasound was performed on day 2–3 of the cycle by a 4–10 MHz multifrequency ultrasound probe. The sum of antral follicles that measured 2–10 mm in both ovaries was taken as the AFC. AFC is a reliable marker of ovarian reserve, and a count of 8–10 is considered a predictor of normal ovarian response. Small antral follicles better represent the functional ovarian reserve. As AFC has the best discriminating potential for poor ovarian response, it may be considered the first choice for estimating quantitative ovarian reserve.[5],[9]

Statistical analysis

Statistical analysis was performed using SPSS software version 20 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp). Data were analyzed by one-way ANOVA and the Kruskal–Wallis test. Post hoc comparisons were determined by the Bonferroni test, Pearson's correlation test, and multiple linear regression analysis. The results in all the above-mentioned procedures were accepted as statistically significant when P < 5' (P < 0.05).


  Results Top


Distribution of the study population according to age groups was as follows: group I (18.8'), Group II (67.3'), and Group III (13.9'). A total of 101 infertile women were assessed in our study. The mean age of the participants was 33.3 ± 4.37 years, and the mean infertility period was 3.36 ± 2.26 years. The mean body mass index was 23.75 ± 2.97 kg/m2. The mean FSH level was 8.18 ± 5.54, and the mean AMH was 1.98 ± 1.0. The mean AFC was 9.29 ± 5.09.

[Figure 1] shows the values for AMH, FSH, and AFC, according to the study group.
Figure 1: Mean AMH, FSH, LH, and AFC values in the three age groups. AMH: Anti-Müllerian hormone, FSH: Follicle-stimulating hormone, LH: Luteinizing hormone, AFC: Antral follicle count

Click here to view


[Table 1] lists the differences between groups for the mean ± standard deviation of AMH, FSH, and AFC values. There were significantly higher AMH levels in Group I compared to Groups II and III. This value was also higher in Group II compared to Group III. AFC values were significantly higher in Group I compared to Group III, as well as in Group II compared to Group III. FSH levels were significantly higher in Group III compared to Group I and Group II.
Table 1: Differences between different age groups for the mean±standard deviation of anti-Müllerian hormone, follicle-stimulating hormone, luteinizing hormone, andantral follicle count values

Click here to view


We examined the relationships between age and ovarian reserve indicators in all the study groups. There was a statistically significantly elevated negative correlation between age and AMH level (rs = -0.667, P < 0.0001) and AFC (rs = -0.64, P < 0.0001). We observed a statistically significantly positive correlation between age and FSH (rs = 0.569, P < 0.0001).

AMH negatively correlated with LH and FSH (rs = -0.70, P < 0.0001) and positively with AFC (r = -0.977, P = 0.0001). There was a moderate negative relation between FSH and AFC (r = -0.697, P = 0.0001).

The correlation analysis performed in separate groups showed that AMH and AFC showed a statistically significant positive correlation for Group I (r = 0.953, P < 0.0001), Group II (r = 0.966, P < 0.0001), and Group III (r = 0.865, P < 0.001).

A statistically significant negative correlation between FSH/LH and AMH was detected only in Group II (r = -0.661, P < 0.0001) and Group III (r = -0.735, P < 0.003). A statistically significant correlation existed between FSH and AFC in Group II (r = -0.657, P < 0.000), Group III (r= -0.664, P < 0.01), as well as between age and FSH only in Group III (r = 0.551, P < 0.04).


  Discussion Top


There was a significantly elevated negative correlation between age and AMH levels. Therefore, AMH values reflected age-specific changes better than other indicators. This was comparable with the study of Barbakadze et al.[4] Furthermore, De Vet et al. showed that early follicular phase hormone measurement at 3-yearly intervals reveals that serum AMH levels declined significantly, whereas serum levels of FSH and LH remained unchanged during this interval.[11] Our study also revealed an elevated negative correlation between age and AFC levels. This trend was seen in the study of Barbakadze et al., who found that age had a highly significant negative correlation with AMH and AFC.[4] A study by Sharma et al. also revealed that AFC and ovarian volume decrease with age.[3] A significantly positive correlation was noted between age and FSH. A significant positive correlation between age and FSH was also seen in the study by Barbakadze et al. The study by Sharma et al. revealed that with increasing age serum levels of FSH and LH also increase. In our study, AMH negatively correlated with FSH. This was in agreement with a study conducted by Parveen et al., where a negative correlation was found between AMH and FSH.[12] This was comparable with studies conducted by Singer et al.,[13] Dorotheam et al.,[14] and Barbakadze et al.[4]

In our study, AMH related positively with AFC. This was consistent with the study of Barbakade et al.,[4] where AMH and AFC in all age groups showed a positive correlation. This was confirmed by other researchers.[15],[16] Our study revealed a moderate negative correlation between FSH and AFC.

A moderate positive relation between age and FSH was present. The correlation analysis performed in separate groups showed that AMH and AFC showed a statistically significant positive correlation for Group I, Group II, and Group III. ? The same was seen in the study by Barbakadze et al., in which there was a positive correlation among all age groups.[4] This was confirmed by other researchers.[16],[17]

A statistically significant negative correlation between FSH and AMH was detected only in Groups II and III. The same was observed in the study by Barbakedze et al., where only some groups showed a significant correlation.[4] A statistically significant correlation existed between FSH and AFC in Groups II and III. The study by Barbakadze et al. showed a correction between FSH and AFC in the elderly group only.[4] A correlation between age and FSH was present only in Group III. This was in agreement with the study by Barbakadze et al., where a significant high correlation was present in the elderly age group only.[4] Thus, AMH has higher predictability for ovarian reserve as compared to FSH and can thus detect diminution of ovarian reserve earlier.

There was a significant positive correlation between age and LH, which was comparable to the study by Sharma et al.[3] A statistically significant negative correlation was observed between LH and AMH as well as in AFC only in Groups II and III. Thus, AMH has much higher predictability for ovarian reserve compared to LH, which is comparable to the study by? Schonauercm FR et al.[17]


  Conclusion Top


AMH is more reliable marker of ovarian reserve compared to FSH and LH as the correlation between AMH and AFC is strongly positive. AMH can detect decrease in ovarian reserve much earlier than FSH and LH. The use of AMH combined with AFC definitely improves the evaluation of ovarian reserve in all age groups of infertile women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Infertility efficacy of combined clomiphene citrate and gonadotrophin therapy. Professional Med J 2011;18:195-200.  Back to cited text no. 1
    
2.
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3.
Sharma I, Jourar S, Junja S. Correlations of anti Mullerian hormone and antral follicle count in infertile women. Indian J Basic Appl Med Res 2018;7:590-8.  Back to cited text no. 3
    
4.
Barbakadze L, Kristesashvili J, Khonelidze N, Tsagareishvili G. The correlations of anti- Mullerian hormone, follicle-stimulating hormone and antral follicle count in different age groups of infertile women. Int J Fertil Steril 2015;8:393-8.  Back to cited text no. 4
    
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Hendriks DJ. Mol BW, Bancsi LF, Te Velde ER, Broekmans FJ. Antral follicle count in the prediction of poor ovarian response and pregnancy after in vitro fertilization: A meta-analysis and comparison with basal follicle – Stimulating hormone level. Fertile Steril 2005;83:291-301.  Back to cited text no. 5
    
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Awril C. Antral follicle count and oocyte quality. J Gynecol Obstet Biol Reprod (Paris) 2006;35 (5 Pt2):2s42-3.  Back to cited text no. 6
    
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Hin R, Schonauer LM, Righini C, Frydman R, Taieb J. Serum anti-Mullerian hormone dynamics during controlled ovarian Hyperstimulation. Hum Repord 2003;18:328-32.  Back to cited text no. 7
    
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Hussain M, Cahill D Akande V, Gordon U. Discrepancies between Anti-Mullerian hormone and follicle stimulating hormone in assisted reproduction. Obstet Gynecol Int 2013. p. 6.  Back to cited text no. 8
    
9.
van Rooji IA, Broekmans FJ, Scheffer Gj, Looman CW, Habbema JD, et al. Serum anti-Mullerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: A longitudinal study. Fertil Steril 2005;83:979-87.  Back to cited text no. 9
    
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Fanchin R, Schonäuer LM, Righini C, Frydman N, Frydman R, Taieb J. Serum anti-Müllerian hormone dynamics during controlled ovarian hyperstimulation. Hum Reprod 2003;18:328-32.  Back to cited text no. 10
    
11.
De Vet A, Laven JS, de Jong FH, Themmen AP, Fauser BC. Anti-Mullerian hormone serum levels: A putative marker for ovarian aging. Fertil Steril 2002;77:357-62.  Back to cited text no. 11
    
12.
Singer T, Barad DH, Weghofer A, Gleicher, N. Correlation of anti-Mullerian hormone and baseline follicle-stimulating hormone level. Fertil Steril 2009;91:2616-19.  Back to cited text no. 12
    
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Fayereisen E, Mendez Lozano DH, Taleb J, Hesters L, Frydman R, Fanchin R. Anti-Mullerian hormone: Clinical insights into a promising biomarker of ovarian follicular status. Reprod Biomed Online 2006;12:695-703.  Back to cited text no. 13
    
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Frattarelli JL, Levi AJ, Miller BT, Segars JH. A prospective assessment of the predictive value of basal antral follicles in in vitro fertilization cycles. Fertil Stail 2003;80:350-5.  Back to cited text no. 14
    
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Parveen N, Rehman D, Baloch N, Masroor K. Association of serum Mullerian inhibiting hormone with the gonadotropins in infertile women. Isra Med J 2018;10:12-5.  Back to cited text no. 15
    
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Dorotheam W, Nicka B, Mengistu YR, Robert K, Martin HR. Statistically significant changes of anti-Mullerian hormone and inhibin levels during the physiologic menstrual cycle in reproductive age women. Fertil Steril 2008;84:927-33.  Back to cited text no. 16
    
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Schonauercm FR, Righini C, Guibourdenche J, Frydman R. Strongly related to ovarian follicular status than serum inhibin B, estradiol, FSH and LH on day 3. Hum Reprod 2003;18:323-7.  Back to cited text no. 17
    


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