The Value Of Anti-M(u|")llerian Hormone Evaluating Ovarian Reserve Decline And The Effect Of Gynecological Operation On Ovarian Reserve

Ovarian reserve (OR) is used to determine the growth and development of follicles in ovarian cortex and the capacity of the ovary to provide oocytes that are capable of fertilization, which are described by the quantity and quality of follicles remained in ovary, representing the potency of oocyte generation (pregnancy potency) and female hormone production (to determine the menopause age), respectively. The declined fertility or premature menopause ascribed to the reduced quantity or quality of remaining follicles that could be recruited towards maturation is defined as declined ovarian reserve (DOR). The incidence of DOR tends to be higher in young women at their childbearing age in recent years. DOR is a gradual process of development affected by multiple factors with varied individual differences. The incidence of DOR varies greatly and is influenced by the age and various external factors. The clinical manifestation features and the pathogenic factors of DOR would be discussed in the part 1 of the study, as introduction and background to the subsequent in-depth analysis.Currently, the major indicators for OR evaluation used in the clinical practice include age, serum levels of sexual hormones and cytokines, such as basal follicle stimulating hormone (FSH), estradiol (E2), luteinizing hormone (LH), FSH/LH, progesterone, INHB, Ovarian B ultrasound examination is also often used for OR estimation by measuring basal antral follicle count (AFC), ovarian volume, and peak systolic velocity (PSV) of ovarian artery blood flow. However, there is limitation for each of them as OR indicator. Therefore, it is still lack of a stable, sensitive, and convenient method (or indicator) for early diagnosis of DOR. Anti-Mullerian hormone (AMH) as one of novel indicator for OR evaluation has been validated in recent years with wide attentions. It is mainly produced by ovarian granulosa cells of small follicles and preantral follicles, and serum AMH level could reflect the primordial follicle pool reserves directly, which has been considered to be a reliable indicator to predict ovarian reserve. In the part 2 of the study, serum level of AMH was analyzed to investigate its capacity to reflect OR and to predict DOR. Meanwhile, the critical values of serum AMH level were explored with the objective to facilitate diagnosis of DOR at early stage, in order to protect ovarian function.Currently, the potential effect on ovarian function by various types of gynecological surgeries has been the concern for both clinical doctors and patients; on the other hand, the laparoscopic operation has been widely accepted with the advantages of minimized surgical trauma and rapid postoperative recovery, and the effects on ovarian function by laparoscopic operation and the effective methods to assess the effect on ovarian function after invasive treatment have been the hot topics of clinical practitioners. In the part 3 of the study, the sensitivity and superiority of serum AMH for postoperative DOR diagnosis were examined, and the effect of various laparoscopic operations on OR was tested by comparative research, with the objectives of screening and intervening postoperative DOR at early stage, meanwhile, to help clinical doctors selecting the appropriate mode of surgical in order to preserve ovarian function.Part Ⅰ:Clinical research on DORObjective:To explore the clinical features of DOR and provide clinical evidence for further study.Methods:The retrospective study was conducted with the clinical information from 150 patients of DOR who were presented to Wuxi Maternal and Child Health-Care Hospital (Wuxi, China) with the complaint of menstrual disorder between October 2012 and February 2014. The clinical information including menstruation condition, basal hormone levels, and B ultrasound scanning images was collected from each patient.ResultsClinical features of DORAll 150 patients of DOR had the manifestation of menstrual disorder with varied disease onset age; 11,23,51, and 65 patients had menstrual disorder onset between 20 and 25 years old,25 and 30 years old,30 and 35 years old, and 35 and 40 years old, respectively, suggesting the majority patients had menstrual disorder onset older than 30 years (77.3%). And there were 20,53,45, and 32 patients with the manifestation of menorrhagia, oligomenorrhea, menstrual period prolonged and menstrual period shortened, respectively. The further inquiry indicated that 65.4% patients had initial menstruation change of shortened menstrual period. There were no significant difference between patients and control cohorts with respects to age, body mass index (BMI), and age of menarche, indicating the satisfied comparability between two groups.Ovarian morphology alteration of DOR under ultrasound examinationThe uterus size and PVS of ovarian artery blood flow of DOR patients were smaller than that of control cohort (39.63 ± 12.89 vs.42.12 ± 20.25 cm3; 9.04 ± 2.77 vs. 11.26 ± 2.03 cm/s), and the average size of ovary and AFC were also significantly smaller than that of control cohort (3.23 ± 1.26 vs.5.64 ± 2.18 cm3; 3.27 ± 1.63 vs 7.35 ± 2.70). The color Doppler ultrasound images showed that DOR patients had relatively smaller uterus with thinner endometrium, and the images of ovaries were not clear enough with uneven signals; additional, the average size of ovaries was less than 4 cm. In the current study, there were 113 (75.3%) patients with the average size of ovary less than 4 cm, and there were only 37 (24.7%) patients with the average size of ovary larger than 4 cm. The number of basal antral follicles of DOR patients were countable, usually less than four. In the current study, there were 96 (64.0%) DOR patients with AFC less than four, while 37 (36%) patients with AFC more than four. Just partial ovarian blood flow could be revealed by CDFI, and the signals were usually weak.Association factors analysis for DORThere were no significant difference between DOR patients and control cohort regarding to precedence, age of menarche, age of first pregnancy, mode of anti-conception, times of abortion, and history of endometriosis. Whereas, there were significant differences between two groups in terms of menopause age of mother, smoking, alcohol drinking, sleep quality, income, education level, profession, satisfied degree of sexual activity, history of pelvic inflammation, history of gynecological surgeries, history of parotiditis, and concurrence with autoimmune diseases; the menopause age of mother, history of gynecological surgeries, and autoimmune diseases were the high risk factors for OR.ConclusionThe patients with menstrual disorder, especially those with menopause age of mother less than 45 years old, with history of gynecological surgery and concurrent with autoimmune disease were the patients of high risk for DOR. The ovary size and AFC should be under surveillance of B ultrasound; meanwhile, the serum hormones should be measured to diagnose DOR as early as possible in order to protect ovarian function by clinical intervenes.Part 2. AMH to evaluate OR and to predict DORObjective:To investigate the capability of AMH for OR evaluation and DOR prediction.Methods:The serum samples were obtained from 172 patients of menstrual disorder and 65 healthy women with regular menstrual cycles; the serum AMH and basal hormones level were measured; meanwhile, AFC, average ovary volume, and ovarian artery blood flow were determined by B ultrasound. The correlation between serum AMH and age, FSH level, AFC, and ovary volume was analyzed. The alteration of serum AMH level during menstrual cycle was examined, and the critical values of AMH for DOR prediction were determined.ResultsCorrelation between AMH and ageOne hundred and ten women with regular menstruation and normal ovary morphology were divided into five groups according to age ranged between 20 and 25,25 and 30,30 and 35,35 and 40, and above 40 years, respectively. The serum level of AMH was decreased along the aging, and the average level of AMH at age between 20 and 25 years was significantly higher than that of other ages; while, the serum level of AMH at age above 40 years was significantly lower than that of other ages. Serum level of FSH and INHB showed similar tendency to the age as that of AMH to the age. However, only serum level of AMH showed vertical drop tendency between age 25 and 30 years,30 and 35 years, and 35 and 40 years.Correlation between serum AMH and AFC, mean ovary volume (MOV), and serum FSHIt was suggested by the study with 64 women of Chinese Han nationality with age ranged between 20 and 43 years that AFC was correlated to multiple indicators with the correlation strength from strong to weakness of AMH, MOV, age, inhibin B, FSH/LH, and FSH, respectively. Whereas, there was no significant correlation between AFC and serum level of E2, LH, and ovarian artery blood flow. The correlation strength between AMH and AFC was stronger than the others (R=0.70, P < 0.001). Besides, AMH was also significantly correlated with MOV, age, INHB, and FSH/LH with the correlation coefficient of R=0.59 (P<0.0001), R=-0.43 (P< 0.001), R=0.46 (P<0.001), and R=-0.40 (P<0.001), respectively; whereas, there was no correlation between serum AMH and serum FSH, E2, LH, and ovary artery.Alteration of serum AMH in the menstruation cycleThe fasting blood samples were obtained every other day from 15 women with age ranged between 28 and 38 years, from the first or second day of menstruation period until the third or fourth day of next menstruation period, to determine the serum level of AMH, Inhibin B, FSH, LH, E2, and progesterone. It was found that there was almost no fluctuation in terms of serum level of AMH with maximum of 3.9 ± 1.3 ng/ml and minimum of 3.4 ± 1.1 ng/ml, and there was no significant difference between the maximum and minimum; whereas, the fluctuation remained in the other indicators with varied degree.Serum AMH to predict DOR and its critical valuesAFC less than five was utilized as DOR diagnosis criterion in the current study; and 125 DOR patients and another 46 women with normal OR as control were recruited into the study. It was shown that the area under the receiver operating characteristic (ROC) curve (AUC value) of AMH, INHB, FSH, and FSH/LH was all significantly larger than the reference AUC value (P< 0.05), with AUC value of 0.82,0.79,0.74, and 0.78, respectively; in addition, AUC value of AMH was significantly greater than that of INHB, FSH, and FSH/LH (P< 0.05).The ROC analysis indicated that 1.59 ng/ml of serum AMH might be the most optimal critical value for diagnosis of DOR, with the sensitivity and specificity of 86.7% and 82.3% respectively. If 53 ng/ml of serum INHB was utilized as critical value for diagnosis of DOR, the sensitivity and specificity were of 74.9% and 66.7% respectively. Therefore, the prediction capability of serum AMH for DOR was superior to that of INHB.ConclusionSerum AMH as one novel indicator for OR is associated with AFC, and the serum level decrease along with age of individual people. And the serum level remains to be stable during the whole menstruation period.The capability of serum AMH to predict OR was demonstrated superior to the other indicators such as FSH/LH, FSH, E2 and INHB. AFC< 6 could be used as criterion for diagnosis of DOR for the patients with age ranged between 22 and 48 years. The sensitivity and specificity of serum AMH for DOR diagnosis were 86% and 78%, respectively with the critical value of 1.05 ng/ml.Part 3. AMH to evaluate the effect of gynecological laparoscopic operation on ORObjectives:To explore serum AMH as indicator for DOR after gynecological laparoscopic operations on ovary, fallopian tube, and uterus; and toe analyze the potential effect of each mode of operation on OR.Methods:Seventy-five patients of ovarian endometriosis cyst who underwent laparoscopic oophorocystectomy in Wuxi Maternal and Child Health-Care Hospital between October 2012 and February 2014 with the age ranged between 20 and 45 years were selected. Nighty-six patients of hysteromyoma with the age ranged between 37 and 47 years, including 33,32, and 31 patients who underwent laparoscopic myomectomy, laparoscopic hysterectomy, and laparoscopic subtotal hysterectomy, respectively, between October 2012 and February 2014 were selected. And 90 patients of fallopian pregnancy with the age ranged between 20 and 40 years, including 30 patients of each underwent laparoscopic ’core pulling’ salpingectomy, conventional laparoscopic salpingectomy, and laparoscopic windowing and resection of tubal pregnancy, respectively. The serum level of AMH, FSH, LH, E2, and INHB were measured before operation, six weeks and six months after operation, respectively. Meanwhile, AFC, MOV, and PVS were monitored by ultrasound.ResultsAMH to evaluate the effect of laparoscopic ovarian endometriosis cystectomy on OR Serum level of AMH was progressively decreased significantly after laparoscopic ovarian endometriosis cystectomy operation six months compared with that of preoperation (preoperation 1.81±0.82 ng/ml; postoperation six weeks 1.39±0.61 ng/ml; and postoperation six months 10.81±0.35 ng/ml, P< 0.001). In addition, the percentage of postoperative serum AMH decrease was more significantly in the patients underwent bilateral ovarian cysts operation compared with that in the patients underwent unilateral ovarian cyst operation (65.4% vs.54.3%, P< 0.05). Similarly, the percentage of postoperative serum AMH decrease was more significantly in the patients with maximum diameter of ovarian cysts larger than 5 cm compared with those with maximum diameter of ovarian cysts less than 5 cm (66% vs.42.5%, P< 0.01). And the percentage of postoperative serum AMH decrease was more in the patients with the number of cysts≥ 3 that that in the patients with the number of cysts < 3, though there was no statistical significance (65.9% vs.57.2%, P> 0.05). However, there was no significant alteration regarding to the serum level of FSH, LH, E2, INHB, and PVS before and after operation at various time points.The multivariate statistical analysis indicated that the basal AMH level was the only independent factor influencing decrease of AMH after operation (P< 0.001, OR= 3.6895% confidence interval 1.66-8.14). Whereas, the number, size, and location of ovarian cysts were not the independent influencing factors for postoperative serumAMH decrease.AMH to evaluate the effect of laparoscopic tubal operation on ORThe serum level of AMH was significantly decreased three months after conventional laparoscopic salpingectomy compared with preoperative serum AMH level (preoperative AMH 2.15±0.64 ng/ml vs. three months postoperative AMH 1.65±0.67 ng/ml, P< 0.05). Whereas, there was no significant difference between preoperation and three months postoperation regarding to serum level of AMH by either laparoscopic’core pulling’ salpingectomy or laparoscopic windowing and resection of tubal pregnancy (P> 0.05). And there was no significant alteration regarding to the serum level of FSH, LH, E2, INHB, and PVS before and after operation at various time points.AMH to evaluate effect of laparoscopic uterine operation on ORThere was no significant difference between preoperative serum AMH level and postoperative serum AMH level, regardless the postoperative six weeks or six months by laparoscopic myomectomy (preoperative 1.42±0.65 ng/ml, one month postoperative 1.31±0.53 ng/ml, six months postoperative 1.33±0.61 ng/ml, P> 0.05). The progressive decrease of serum AMH after operation six weeks and six months was observed in the patients underwent laparoscopic total hysterectomy (TLH) and laparoscopic subtotal hysterectomy (LSH).Serum AMH level was decreased from preoperative 1.18±0.93 ng/ml to postoperative six weeks of 0.45±0.39 ng/ml and postoperative six months of 0.14±0.01 ng/ml, respectively (P< 0.05) by TLH; and serum AMH level was decreased from preoperative 1.17±0.11 ng/ml to postoperative six weeks of 1.01±0.10 ng/ml and postoperative six months of 0.48±0.54 ng/ml, respectively (P< 0.05) by LSH.The decrease percentage of serum AMH level from preoperation to six weeks postoperation by TLH was higher than that by LSH though there was no statistical significance (17.44±38.79% vs.13.30±22.34%, P= 0.987); whereas, the decrease percentage of serum AMH level from preoperation to six months postoperation by TLH was higher than that by LSH (37.43±37.63% vs.27.02±23.00%, P= 0.017).And there was no significant alteration regarding to the serum level of FSH, LH, E2, INHB, and PVS before and after operation at various time points.Conclusion1, Laparoscopic ovarian endometriosis cystectomy was shown adverse effect on OR six months after operation. And serum AMH decrease was more remarkable after operation for patients who had cyst≥ 5 cm or bilateral cysts than the patients who had cyst< 5 cm or unilateral cyst. And preoperative basal serum level of AMH was the only independent factor influencing the postoperative AMH decrease.2, Laparoscopic’core pulling’ salpingectomy and laparoscopic windowing and resection of tubal pregnancy were demonstrated to be no adverse effect on OR three months after operation; whereas, the conventional laparoscopic salpingectomy was demonstrated the adverse effect on OR.3, Laparoscopic myomectomy was demonstrated to be no significant effect on ovarian function; however, both laparoscopic total hysterectomy and subtotal hysterectomy showed adverse effect on ovarian function, and the adverse effect was severe by laparoscopic total hysterectomy than that by laparoscopic subtotal hysterectomy.4, Serum AMH was superior to serum FSH, LH, E2, AFC, MOV, and PVS regarding to evaluate the effect of laparoscopic ovarian invasive surgery on OR.