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Relationship of Antral Follicle Count and Anti-Mullerian Hormone with Ovarian Response in Infertile Women
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Shamim Mosallami1    , Moghadaseh Jahanshahi *2 , Fatemeh Sadat Hosseini3 , Somayeh Livani4 , Sima Besharat5 |
1- Medical Student, Research Student Committee, Golestan University of Medical Sciences, Gorgan, Iran.
2- Assistant Professor of Infertility, Clinical Research Development Unit (CRDU), Sayyad Shirazi Hospital, Golestan University of Medical Sciences, Gorgan, Iran. , mogh.jahanshahi@gmail.com
3- Assistant Professor of Reproductive Biology, Clinical Research Development Unit (CRDU), Sayyad Shirazi Hospital, Golestan University of Medical Sciences, Gorgan, Iran.
4- Associate Professor of Radiology, Clinical Research Development Unit (CRDU), Sayad Shirazi Hospital, Golestan University of Medical Sciences, Gorgan, Iran.
5- Associate Professor of Biomedical Sciences (By Research), Golestan Research Center of Gastroenterology and Hepatology, Jorjani Clinical Sciences Research Institute, Golestan University of Medical Sciences, Gorgan, Iran. |
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Keywords: Infertility, Female [MeSH], Anti-Mullerian Hormone [MeSH], Ovarian Follicle [MeSH]
Article ID: Vol27-36 |
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Type of Study: Original Articles |
Subject:
Reproduction & Infertility
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Abstract: (12 Views) |
Extended Abstract
Introduction
Infertility assessment in women is indicated when pregnancy is not achieved after one year of unprotected intercourse for women under the age of 35, or after 6 months for those aged 35 and older, despite overall physical health.
Assisted reproductive technology (ART) procedures represent a widely utilized therapeutic intervention. However, infertility and suboptimal fertility rates within ART procedures may be attributed to the hormonal fluctuations induced by ovarian stimulation. A diminished ovarian reserve leads to a reduced response to gonadotropin stimulation, consequently resulting in a lower yield of retrieved oocytes. The success rate of ART procedures significantly declines with advancing maternal age; specifically, older women exhibit a lower number of retrieved oocytes, fewer available embryos, and reduced implantation rates compared to their younger counterparts. Furthermore, the incidence of embryo fragmentation is positively correlated with increased maternal age.
Serum anti-Müllerian hormone (AMH) levels and antral follicle count (AFC) are crucial predictors of ovarian reserve and treatment response.
One of the significant factors limiting the success of in vitro fertilization (IVF) is poor ovarian response, which is observed in 10-15% of women undergoing IVF treatment. Therefore, it is essential to assess the ovarian reserve prior to initiating ART procedues. Ovarian reserve, defined as the functional potential of the ovaries, reflects both the quantity and quality of the oocytes within the ovary.
Several studies have proposed the measurement of ovarian volume and AFC as practical tests for determining ovarian reserve. Furthermore, serum levels of follicle-stimulating hormone (FSH) and Inhibin B may also be considered alternative options for assessing ovarian reserve. AMH has been established as a key biomarker for predicting ovarian response prior to the implementation of ART. AMH is secreted by developing follicles that contain oocytes. Therefore, it serves as an indicator of the quantity and quality of oocytes produced during a menstrual cycle. This hormone is secreted by the ovarian granulosa cells, and its levels gradually decline following maturation and eventually become undetectable at menopause. Through AMH II receptors expressed in theque-granulosa cells, AMH exerts direct or indirect roles across multiple phases of folliculogenesis, spanning from the primordial stage to the FSH-sensitive follicular stages. AMH secretion may reflect the activity of pre-antral and small antral follicles. Consequently, AMH serves as a reliable marker for evaluating fertility potential and ovarian response in IVF. Currently, measuring serum levels of AMH is recognized as the most accurate test for determining ovarian reserve, demonstrating sensitivity and specificity comparable to AFC, while surpassing FSH, estradiol, luteinizing hormone (LH), and Inhibin B. Estradiol, FSH, and Inhibin B exhibit low sensitivity during the early stages of diminished ovarian reserve. These three hormones function within a feedback loop, and their serum concentrations are interdependent. Furthermore, serum fluctuations in these hormones occur relatively late in the reproductive aging process-typically when the ovarian reserve has reached a critical threshold and the probability of conception has significantly declined. Conversely, AMH serum levels remain stable throughout the menstrual cycle and are not influenced by gonadotropin-releasing hormone (GnRH) agonists or oral contraceptives.
This study was conducted to determine the relationship of AFC and AMH levels with ovarian response in infertile women referring to the Nahal Infertility Center in Gorgan, Iran.
Methods
This descriptive-analytical study was conducted on 50 women (mean age = 33.88±5.32 years, age range = 18-43 years) undergoing ART procedures at Nahal Infertility Center, Shahid Sayad Shirazi Hospital, in 2020.
Following the acquisition of informed consent, serum levels of AMH, FSH, LH, complete blood count (CBC), liver function tests (LFTs), thyroid function tests (TFTs), blood urea nitrogen (BUN), creatinine (Cr), and prolactin (PRL) were measured using enzyme-linked immunosorbent assay (ELISA), while FSH levels were specifically determined via radioimmunoassay (RIA). Transvaginal ultrasound was performed on the third day of the menstrual cycle to determine the AFC. Additionally, a checklist was prepared for all participants at the study's inception to record demographic data and primary research variables (including FSH, AMH, LH, AFC, polycystic ovary syndrome [PCOS], height, and weight) through interviews and clinical assessments.
Results
The mean duration of infertility was 4.8±2.8 years. Thirty-three women (66%) had primary infertility, and in 35 cases (70%), the cause of infertility was related to female factors.
The mean and standard deviation serum levels of AMH and AFC were 4.8±4 ng/ml and 9±5 ng/ml, respectively.
A total of 45 participants (90%) received the antagonist treatment protocol, while only 5 (10%) were treated with the agonist protocol. Poor ovarian response was observed in 4 cases (8%). Additionally, 31 individuals (62%) demonstrated a normal response to treatment, whereas 15 cases (30%) exhibited a robust response to treatment.
AMH levels revealed no significant correlation with body mass index (BMI) and age. However, AMH levels were significantly higher in cases with a greater AFC (P<0.026). Furthermore, AFC showed no statistically significant correlation with serum levels of LH, FSH, PRL, or thyroid-stimulating hormone (TSH).
The mean values of AMH and AFC were compared across poor, normal, and robust ovarian response groups, categorized based on the number of retrieved oocytes. Each of the investigated indices (AMH and AFC) demonstrated a significant correlation with ovarian response, showing significantly higher values in the normal and robust ovarian response groups (P<0.002 and P<0.014, respectively).
Among the causes of infertility, endometriosis was identified in 18 cases (36%). Other etiologies included male factor infertility in 15 cases (30%), poor ovarian response in 16 cases, PCOS in 5 cases (10%), and tubular abnormalities in 4 cases (8%).
Conclusion
According to the findings of the present study, both AFC and AMH were identified as predictors of ovarian response. While patients with a history of ovarian and uterine pathologies were excluded from this study, other similar studies that did not apply such exclusion criteria suggest that AMH may not predict ovarian response in women undergoing IVF as accurately as AFC. Consequently, several studies have regarded AFC assessment as a more reliable tool for predicting ovarian response, particularly in patients with endometriosis. Furthermore, prior research has demonstrated the superiority of AFC over AMH in predicting the number of retrieved oocytes.
In the present study, the mean levels of AMH and AFC were within the normal range, indicating that the majority of the study population possessed an adequate ovarian reserve. Furthermore, the significant correlation found between AMH and AFC suggests that both markers may influence ovarian response. Conversely, AFC had no significant correlation with the mean serum levels of LH, FSH, and TSH; however, other studies have reported both positive and negative significant correlations between AFC and FSH serum levels.
Among the causes of female infertility, the highest frequencies were attributed to endometriosis and poor ovarian response. The prevalence of endometriosis as a causative factor (36%) underscores the critical importance of diagnosing and managing this disorder. Furthermore, the presence of other etiologies, such as male factors and fallopian tube abnormalities, reinforces the multifactorial nature of infertility and the necessity for a comprehensive therapeutic approach. In this study, the majority of infertile women were treated with a GnRH antagonist protocol. Notably, in 92% of cases, the ovarian response rate-assessed via oocyte count through transvaginal ultrasound-was categorized as normal or robust. The response to treatment protocols revealed a robust response in 30% and a poor response in 8% of patients, indicating that the selected protocols were generally effective for this population.
FSH and AMH serve as biomarkers for pregnancy and successful pregnancy outcomes in infertile women following IVF and intracytoplasmic sperm injection (ICSI). In our study, AMH was identified as a predictor of ovarian response.
Ethical Statement
This study was approved by the Ethics Committee at Golestan University of Medical Sciences (IR.GOUMS.REC.1400.097).
Funding
This article has been derived from the doctoral dissertation (approval code: 112094) by Shamim Mosallami in Doctor of Medicine (MD) at the School of Medicine, Golestan University of Medical Sciences.
Authors' Contributions
Shamim Mosallami: Project execution, Data collection, Drafting of the initial manuscript, Approval of the final manuscript.
Moghadaseh Jahanshahi (M.D): Project administration and design, Data analysis, Interpretation of the results, Drafting of the initial manuscript, Approval of the final manuscript.
Fatemeh Sadat Hosseini (M.D): Project administration and design, Data analysis, Interpretation of the results, Drafting of the initial manuscript, Approval of the final manuscript.
Somayeh Livani (M.D): Project administration and design, Project execution, Data analysis, Interpretation of the results, Drafting of the initial manuscript, Approval of the final manuscript.
Sima Besharat (M.D, Ph.D): Project administration and design, Data analysis, Interpretation of the results, Drafting of the initial manuscript, Approval of the final manuscript.
Conflicts of Interest
No conflicts of interest.
Acknowledgement
The authors would like to thank the Clinical Research Development Unit of Sayad Shirazi Hospital, Golestan University of Medical Sciences, as well as the Vice-Chancery for Research and Technology at Golestan University of Medical Sciences for their support.
Key Message: AFC and AMH can be considered reliable predictors of ovarian response in infertile women during treatment. |
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Mosallami S, Jahanshahi M, Hosseini F S, Livani S, Besharat S. Relationship of Antral Follicle Count and Anti-Mullerian Hormone with Ovarian Response in Infertile Women. J Gorgan Univ Med Sci 2025; 27 (4) :54-62 URL: http://goums.ac.ir/journal/article-1-4557-en.html
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