Comparing AMH, AFC and FSH for predicting high ovarian response in women undergoing antagonist protocol

COMPARING AMH, AFC AND FSH FOR PREDICTING HIGH OVARIAN RESPONSE IN WOMEN UNDERGOING ANTAGONIST PROTOCOL Nguyen Xuan Hoi 1 , Nguyen Manh Ha 2 1 National Obstetrics and Gynecology Hospital

COMPARING AMH, AFC AND FSH FOR PREDICTING HIGH OVARIAN RESPONSE IN WOMEN UNDERGOING ANTAGONIST

PROTOCOL

Nguyen Xuan Hoi 1 , Nguyen Manh Ha 2

1 National Obstetrics and Gynecology Hospital, 2 Hanoi Medical Unviversity The aim of this study was to assess the predictive values of AFC, AMH and FSH in predicting high ovarian response during in - vitro fertilization (IVF) We recruited 600 IVF patients who were receiving GnRH antagonist therapy and recombinant FSH for ovarian stimulation High ovarian response during IVF was de-fined as > 15 oocytes retrieved AMH, FSH and AFC levels were assessed on cycle day 2 We found that the AMH threshold value for high ovarian response was 4.04 ng/ml with a sensitivity of 73% and a specificity of 61% The AFC threshold value for high ovarian response was 10.5, with a sensitivity of 78.7% and a speci-ficity of 52% The FSH threshold value for high ovarian response was 6.14 (IU/L) with a sensitivity of 53.2% and a specificity of 72.7% The area under the curve (AUC) of AMH, AFC and FSH were 71%, 65%, 62.7%, respectively Conclusions: AMH was the best marker for predicting high ovarian response during IVF, fol-lowed by AFC and FSH.

Keywords: AMH, FSH, AFC, high ovarian response, GnRH antagonist

Corresponding author: Nguyen Xuan Hoi, National

Obstet-rics and Gynecology Hospital

E-mail: doctorhoi@gmail.com

Received: 20 October 2016

Accepted: 10 December 2016

I INTRODUCTION

A high ovarian response to ovarian

stimula-tion during in-vitro fertilizastimula-tion (IVF) has been

associated with increased cancellation rates,

compromised pregnancies, and live birth rates

[1] A high ovarian response also increases

the risk for development of ovarian

hyper-stimulation syndrome (OHSS) OHSS is an

excessive response to ovarian stimulation,

characterized by increased vascular

permea-bility and ovarian enlargement Moderate and

severe forms of OHSS may occur in 3% to

10% of all IVF cycles and the incidence may

reach 25% among women undergoing IVF

treatment [2] Thus, early identification of

po-tential high responders is necessary to enable

individualization of the ovarian stimulation treatment regimen and to counsel patients about the risk of OHSS Factors used to pre-dict ovarian stimulation include markers of ovarian reserve such as follicle stimulating hormone (FSH) and antral follicle count (AFC) Recently, anti - Müllerian hormone (AMH) has been used as a reliable indicator of ovarian reserve [3; 4] Determining an AMH threshold is important in order to identify women who are at risk of high ovarian response and OHSS [5] Some studies have shown that AMH is an accurate biomarker for predicting OHSS [6; 7] Others have compared the predictive values of AMH, AFC and FSH for ovarian response In controlled ovarian hyperstimulation, AFC has been found to be a better predictor of ovarian response than AMH [8; 9] However, the predictive values of AMH, FSH and AFC in IVF women undergoing the antagonist protocol are not fully understood

This study was designed to assess the

predictive values of AFC, AMH, and FSH in

predicting high ovarian response during IVF

II SUBJECTS AND METHODS

1 Subjects

Female members of infertile couples

undergoing IVF antagonist treatment at the

National Assisted Reproductive Technology

Center were eligible to participate in this study

The research was conducted at the National

Assisted Reproductive Technology Center in

Vietnam All patients in this study met the

selection criteria and voluntarily agreed to

participate

Inclusion criteria

Patients between the ages of 18 - 45

cur-rently receiving ovarian stimulation with a

gonadotropin - releasing hormone (GnRH)

antagonist protocol and recombinant FSH at

the National Assisted Reproductive

Technolo-gy Center were included in the study

Exclusion criteria

Patients who had undergone other

stimula-tion regimens, such as the long protocol and

the agonist protocol, or who had participated

in egg donation, were ineligible to participate

2 Methods

This prospective study was conducted at

the National Hospital of Obstetrics and

Gyne-cology in Vietnam from October 2014 to June

2015 The study included 600 IVF patients

receiving the GnRH antagonist protocol with

recombinant FSH The starting dose of

recom-binant FSH was based on patient age, AMH

level, and AFC level Human chorionic

gonadotrophin (hCG) was administered when

there were ≥ 2 follicles of ≥ 18 mm Oocyte retrieval was conducted 36 hours after hCG administration.The criteria for ovarian

respon-se was barespon-sed on the number of oocytes retrie-ved [10] High ovarian response was defined

as more than 15 oocytes retrieved

Measurement of AFC, AMH, and FSH

To determine AMH and FSH levels, eligible subjects had 3 mL of blood drawn on day 2 of their menstrual cycle and just prior to FSH stimulation Serum separation was done within one hour after blood collection Serum was stored at –20°C and then transferred to testing laboratories within 24 hours after blood sampling Serum AMH levels were determined using the AMH Gen II assay (Beckman Coulter, Texas, USA; lowest detection limit 0.08 ng/mL) and the FSH level was deter-mined using the electrochemiluminescence method (Roche, Mannheim, Germany; assay sensitivity 0.100 mIU/mL) To determine AFC levels, eligible subjects underwent transvagi-nal 2-dimensiotransvagi-nal ultrasounds (7.5MHz, Aloka, Japan) on day 2 of their cycle Total AFC level was measured by including all follicles of 2

-10 mm in both ovaries

3 Research ethics

Research subjects were informed about the goals of the study and voluntarily agreed

to participate All personal information was be kept confidential The study protocol was approved by National Hospital of Obstetrics and Gynecology

III RESULTS

1 Patient characteristics and ovarian stimulation outcomes

600 patients were eligible to participate in

the study Demographic and clinical data,

in-cluding basal AFC, AMH, and FSH, were as

follows:

The average age of participants was 31.7 ±

5.2, with the group of 30 - 34 year olds

accounting for 42% of the patients The

youngest patient was 18 years old and the

oldest was 45 years old

54.7% of patients had primary infertility,

while 45.3% had secondary infertility The

av-erage duration of infertility was 5.0 ± 3.2

years, with 52.2% having less than 5 years of

infertility 33 patients had an infertility duration

of more than 10 years 44.2% of patients had

unexplained infertility

Characteristics of AFC, AMH, basal

FSH, and E2

The lowest AFC value was 1, the highest

AFC value was 30 and the average AFC value

was 13.0 ± 10.8 In terms of AMH level, the

lowest AMH level was 0.2, while the highest

AMH level was 23.6 and the average AMH

level was 4.57 ± 3.25

The lowest basal FSH level was 0.09, the

highest FSH level was 15.00 and the average

FSH level was 5.97 ± 4.56

Finally, the lowest E2 level was 1.54, the

highest E2 level was 174.00 and the average

E2 level was 36.22 ± 19.00

Ovarian stimulation and cycle outcomes

The average number of total rFSH doses

was 1971,2 ± 753,4 IU, with the lowest dose at

400 IU and the highest dose at 6750 IU

Duration of ovarian stimulation was 9.84 ±

1.16 days The shortest duration of ovarian

stimulation was eight days, while the longest

was 15 days

The average number of follicles ≥ 14mm

was 12.09 ± 5.74 Te lowest number of folli-cles was 3 follifolli-cles, while the highest number

of follicles was 30 follicles Finally, oocytes retrieved per trigger averaged to 13.21 ± 6.66, with a range from 0 - 30 oocytes

Results of ovarian response

Poor response accounted for 4.7% of participants (28 patients in total), normal response accounted for 62.3% of participants (374 patients in total), and high response accounted for 33% of participants (198 pa-tients in total)

2 Comparing the predictive value of AMH, AFC, and FSH for predicting high ovarian response

Our data showed that an AFC threshold of

8 had a sensitivity of 78.7% and a specificity of 52% for predicting high ovarian response The AFC value was highly correlated with the num-ber of oocytes retrieved that reflex ovarian reserve, with a correlation coefficient of r = 0.34 (p < 0.001) AFC had a weak correlation with high ovarian response (r = 0.167,

p < 0.05), indicating their poor value as indica-tor for high ovarian response

In terms of FSH, our study found that the FSH threshold to predict high ovarian re-sponse was 6.14 (IU/L), with 53.2% sensitivity and 72.7% specificity

We could not determine the predictive value of E2, since there were no statistical differences between E2 concentration among the 3 groups We also found no correlation between the concentration of E2 and the num-ber of oocytes retrieved

* The predictive value of AMH for high ovarian response

Table 1 The predictive value of AMH for high ovarian response

High ovarian response (> 15 oocytes retrieved) Threshold value Sensitivity Specificity

AMH (ng/ml)

The AMH threshold to predict high ovarian response was 4.04 ng/ml, with 73% sensitivity and 61% specificity

The predictive value of AFC for high ovarian response

Table 2 The predictive value of AFC for high ovarian response

High ovarian response (> 15 oocytes retrieved) Threshold value Sensitivity Specificity

AFC

An AFC threshold of 8 had a sensitivity of 78.7% and a specificity of 52% for predicting high ovarian response

The predictive value of FSH for high ovarian response

Table 3 The predictive value of FSH with high ovarian response

High ovarian response (> 15 oocytes retrieved) Threshold value Sensitivity Specificity

FSH (IU/L)

The FSH threshold to predict high ovarian response was 6.14 (IU/L), with 53.2% sensitivity and 72.7% specificity

Comparing the predictive value of AMH, AFC and FSH for predicting high ovarian response

Table 4 AMH, AFC and FSH thresholds to predict high ovarian response

High ovarian response (> 15 oocytes retrieved) Threshold value Sensitivity Specificity AUC

AMH had the best predictive value in determining which women would have high ovarian response, followed by AFC and finally FSH, as demonstrated by each measurement’s sensitivity and specificity

Figure 1 Receiver operating characteristics (ROC) curves for AMH, FSH and AFC in

predicting high ovarian response

Multivariate analysis for predictive factors of high ovarian response

Table 5 Multivariate analysis for predictive factors of high ovarian response

Predictive factors

High ovarian response (n = 198 patients)

The adjusted odds ratio (OR) of having a high ovarian response based on AMH ≥ 4.04 ng/ml was 2.69, as compared with AMH < 4.04 ng/ml (95% CI, p < 0.001) Conversely, the OR of having

a high ovarian response based on AFC ≥ 10.5 was 2.67, as compared with AFC < 10.5 (95% CI,

p < 0.001) Finally, the OR of having a high ovarian response based on FSH ≤ 6,14 IU/l was 2.11,

as compared with FSH > 6.14 IU/l (95% CI, p < 0.001)

IV DISCUSSION

Our results showed that AMH and AFC are

good predictors of high ovarian response in

women undergoing the GnRH antagonist

protocol AMH appears to be a superior

predictor to AFC, since we found that the area

under the curve for AMH (AUC = 71%) was

larger than the area under the curve for AFC (AUC = 65%) AMH is more highly correlated

to the number of oocytes retrieved at pick - up (r = 0.338) than AFC (r = 0.167) We found no correlation between FSH and E2 and the number of oocytes retrieved, indicating that

these factors are not predictors of high ovarian

response These results are in agreement with

previous studies [11; 12]

Recent studies have suggested that the

use of AMH as a marker of ovarian response

has clinical advantages when assessing

ovarian reserve A meta-analysis with data

from more than 20 studies concluded that

AMH was a more accurate and robust

biomarker of ovarian response in IVF than

FSH, LH, E2 and inhibin B [13]

Our findings are in agreement with

previous studies which found that the

combi-nation of AFC and AMH enhances prediction

of ovarian response However, there are

limited data and conflicting results in the

literature with regards to comparing AMH and

AFC to predict the number of oocytes

retrieved Ficicioglu et al revealed that the

level of AMH, as an indicator of ovarian

reserve, is more sensitive and specific than

AFC, with an AUC for AMH of 92% and for

AFC of 78% [12] On the contrary, Mutlu et al

measured basal levels of AMH, FSH and AFC

in 192 patients prior to IVF treatment and

demonstrated that AFC is better than AMH at

predicting poor ovarian response [14] The

AUC values from this study were 93%, 86%

and 75% for AFC, AMH, FSH, respectively,

indicating that in our study, AFC was better at

predicting poor ovarian response Similarly,

Kwee et al found the AUC for AFC and AMH

demonstrating that AFC seemed to perform

slightly better than AMH for predicting

hyperresponse [15]

Recently, Fleming et al reviewed the

cur-rent evidence evaluating individualized ovarian

stimulation protocols using AMH concentration

as a predictive marker for ovarian response They concluded that AMH is the most reliable marker of ovarian reserve [16] Moreover, AMH has a number of obvious clinical advantages, since AMH levels vary less across different menstrual cycles, within one menstrual cycle, during a pregnancy period, and when undergoing GnRH agonist treatment [13] This variation is often seen with other ovarian biomarkers [13] AMH can be assessed at any time point during the menstrual cycle, whereas AFC and other biomarkers have to be measured at the start

of the menstrual cycle AFC can be used as a prognostic indicator of ovarian response in patients with a history of ovarian surgery, or in patients with endometriosis in the ovaries So far, AMH has been found to be a useful, convenient, and promising marker to assess ovarian reserve and to predict ovarian response

The real value of the above information lies

in its ability to help predict a female patient's required dose of rFSH In our study, the target for ovarian stimulation was set at 7 – 15 oocytes at retrieval Seven or more oocytes are considered to give a reasonable chance (∼25%) of pregnancy, and the risk of developing moderate/severe ovarian hyperstimulation syndrome (OHSS) is low in patients with ≤ 15 oocytes Severe OHSS was most frequent in patients with high ovarian reserve and who were given high rFSH doses In contrast, in patients with low ovarian reserve and who were treated with low or medium doses of rFSH, fewer or no oocytes were retrieved, cycles were cancelled, and the proportion of oocytes retrieved below the stimulation target was higher In these patients, high doses of rFSH may be appropriate

In summary, clinical practitioners should

use AMH and AFC to assess ovarian reserve

in ovarian stimulation, to both increase the

efficiency of the number of oocytes obtained at

retrieval and to decrease the risk of

develop-ing OHSS in IVF

V CONCLUSION

In conclusion, our study provides additional

data to support the clinical value of AMH and

AFC in predicting high ovarian response in

protocol AMH seems to be a better predictor

(AUC = 71%) than AFC (AUC = 65%) The

sensitivity and specificity for AMH in predicting

high ovarian response were 73% and 61%,

respectively, while the sensitivity and

specific-ity for AFC were 78.7% and 52.0%,

respec-tively FSH has no predictive value in

determining high ovarian response (r = 0.10

and p > 0.05)

ACKNOWLEDGEMENTS

We would like to express our deepest

gratitude to all staff from the National ART

center at the National Hospital of Obstetrics

and Gynecology in Vietnam

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