Dynamics Of Hormonal Profile And AMH During Spontaneous Follicular Development In PCOS Women And Its Clinical Significance

Part Ⅰ Dynamics of Hormonal Profile during Spontaneous Follicular Development in PCOS women and its clinical significanceBackground:Polycystic ovary syndrome(PCOS)is a complex hormone disorder characterized by reproductive,endocrine and metabolic abnormalities.It is characterized by hirsutism(abnormal secretion of ovarian androgens),irregular menstruation,and infertility(sparse ovulation or anovulation),with a incidence of 6-16%.Its clinical manifestations and biochemical characteristics are’ highly heterogeneous,and its endocrine characteristics are hyperluteinizing hormone/follicle stimulating hormone(LH/FSH),hyperandrogenism(HA),hyperinsulinemia(INS).In Anovulatory Sterility patients,30%to 60%of them are PCOS.Oligoovulation or anovulation is an important feature of polycystic ovary syndrome.Follicular development is characterized by stagnation of follicular development,absence of dominant follicles and/or persistent anovulation.PCOS patients with a rare menstrual cycle are characterized by severe ovulation disorders.However,the cause of ovarian dysfunction and ovulation dysfunction in women is unknown.To date,the mechanism of follicular dysplasia in PCOS patients and its relationship remain unclear.In PCOS patients,the number of preantral and antral follicles was significantly increased.Most of these follicles stopped growing when they reached 4-7mm,resulting in inferior follicle formation and anovulation.Follicular arrest in PCOS is different from that in normal ovaries in healthy follicles and atresia follicles.Under certain conditions and time periods,follicles in PCOS only grow at a standstill and are not completely apoptotic or atrophic.This may explain that some PCOS patients may have sparse spontaneous ovulation or even pregnancy.For unknown reasons,PCOS has advantages.Follicles sometimes escape the inhibitory factors in the ovary and grow until ovulation,and then form corpus luteum.Because of the low incidence of ovulation,untreated PCOS can cause pregnancy,but the pregnancy rate is lower than that of normal women.For these patients,it is a complex process to start from preantral follicles to mature follicles.Whether hormones play a dominant role in the initiation of sinus follicles and how they change throughout the development of follicles are poorly understood.Objective:To analyze the process of spontaneous follicular development and the changes of sex hormones in PCOS patients with oligomenorrhea,and to analyze the possible factors of follicular dysplasia,so as to provide theoretical basis for further exploring the mechanism of follicular development and the next treatment of ovulation induction in patients with PCOS.Methods:From March 2014 to April 2015,the study consisted of 34 volunteer reproductive women between 22 and 34 years old.All subjects were selected from the Outpatient Department of Gynaecology and Obstetrics in Liaocheng People’s Hospital.The diagnosis of PCOS was based on the Rotterdam criteria.Oligomenorrhea was defined as a cycle length>35 days.The women were divided into two groups:the oligo-ovulation group(n=22)and the anovulation group(n=12).Non-activated antral follicle was defined as anovulation over 60 days.Overnight fasting blood samples were collected from all subjects in the early follicular phase(days 2-3)after spontaneous menstruation,and transvaginal ultrasounds were performed.Age,Body Weight(BW),Body Mass Index(BMI),E2,FSH,LH,T,PRL,P concentrations,Fasting Blood Glucose(FBG),Fasting Insulin(FINS),and Homeostasis Model Assessment for Insulin Resistance(HOMA-IR)were measured on day 2-3 of spontaneous menstrual bleeding.HOMA-IR=(fasting plasma glucose(mmol/L)X fasting plasma insulin(mIU/L))/22.5.Then serum E2,LH,FSH,T concentrations and follicular development were measured every 3-7 days.When follicular diameter(d)reached 10 mm,the concentration of E2,LH,FSH and T was measured every 2-3 days until mature follicles were ovulated,and the concentration of E2,LH,FSH and T was detected again on the first day and the seventh day after ovulation.Hormone values at five monitoring points were analyzed in the oligo-ovulation group:menstrual cycle(Mc)2-3 days(T1),dominant follicle selection(d at 10 mm,T2),mature follicle stage(d≥18mm,T3),first day(Dl)and seventh day(D7)after ovulation.Hormone values at two monitoring points in the anovulation group were analyzed:the second to third day(T4)of the menstrual cycle,about 60 days(T5).Non-activated antral follicle was defined as anovulation over 60 days.Results:(1)Patients characteristics:There was no noteworthy variation in BM,BMI and age between the groups.There was no significant difference between the groups in FBG(P=.066).The PCOS women with oligo-ovulation had lower FINS and HOMA-IR values compared with the other group(P=0.009 and P=0.003,respectively).(2)The days of ovulation:In oligo-ovulation PCOS women,the mean days of ovulation were 37(28-42.5)days.It takes 29(21-38)days for d<5 mm,3.0(2.5-4)days for 9<d<14 mm,and 3.0(2.0-3.0)days for 14<d<22 mm.It indicates that the time required for follicle recruitment and selection is the longest in the course of spontaneous development of follicles.When follicles are collected and selected,the time needed for follicular growth to mature is similar to that of normal menstrual cycle.(3)Dynamics of hormonal profile during spontaneous follicular development:In oligo-ovulation group,the basal LH concentration(5.98mIU/mL)was slightly higher than the FSH concentration(4.94 mIU/mL).When the follicular development diameter was about 10 mm,the concentration of LH was 7.32 mIU/mL,which was higher than that of basal LH(5.98 mIU/mL).FSH(5.36 mIU/mL)at this stage was also higher than basal FSH(4.94 mIU/mL).The increased FSH activated aromatase system,promoted androgen synthesis and secretion of E2,and promoted dominant follicles.Selection and induction of granulosa cells to produce LH receptors suggest that LH and FSH synergy make follicular dominance.The serum E2 level was 59.15 pg/ml,which was higher than the basal E2(42.49 pg/ml),suggesting follicular dominance.Then E2 had a very fast growth trend.At the follicular diameter>18 mm,the level of E2 was 238.53 pg/ml.At the same time,the peak of E2 and LH appeared(24.85 mIU/mL).The peak of LH promoted the final maturation and ovulation of oocytes.We monitored the level of E2 in mature follicular development,which was basically consistent with that of normal women in the same period of E2.The E2 levels of D1 and D7 were 125.67 pg/ml and 203.44 pg/ml,which accorded with the changes of E2 in normal menstrual women.In oligo-ovulation group,the T concentration(0.67 ng/ml)was higher than the basal T concentration(0.59 ng/ml)when the follicular development diameter was about 10 mm,suggesting that the substrate of synthesis and secretion of E2 increased.Under the combined action of FSH and LH,the follicle was transformed into E2 and the follicle became dominant.At the follicular diameter>18 mm,the concentration of T is 0.66 ng/ml.In anovulatory group,sinus follicles were not activated,FSH concentration did not change significantly;the basic serum T(0.79 ng/ml),LH(110.52 mlU/mL)was significantly higher than the basic serum T(0.59 mlU/mL)and LH(5.98 mlU/mL)in anovulatory group(P<0.05);at 60 days of menstruation,T(0.78 ng/ml),LH(1.0.36 mlU/mL)there was no difference in concentration between T and LH.Serum E2 levels were 35.14 and 59.32pg/nl respectively on the second and 60 days of menstruation.Conclusion:(1)some PCOS patients with spontaneous menstrual cycle have spontaneous ovulation,and their development is related to their own characteristics.(2)The increase of body mass index aggravates insulin resistance and abnormal glucose metabolism in PCOS patients,resulting in abnormal follicular development and ovulation disorders.(3)In the process of spontaneous follicular development in PCOS,the collection and selection of sinus follicles need a relatively long time,but after collection and selection,the mature time is similar to that of follicular development in normal menstrual cycle.(4)In the stage of follicular recruitment,the increase of FSH level,especially the increase of LH level,initiated the superiority of follicles.(5)High levels of LH,T,FSH and LH in anovulatory patients may be one of the causes of follicular dysplasia.Part Ⅱ Dynamics of Anti-Miillerian Hormone during Spontaneous Follicular Development in PCOS women and its clinical significanceBackground:Anti-Mullerian hormone(AMH)is a member of the transforming growth factor-β(TGF β)superfamily.In females,the AMH is mainly secreted by the granulose cells of the ovarian early developing follicles.The concentration of AMH in serum is thought to reflect the size of follicular pool.In hyperandrogenism and/or anovulation PCOS,high AMH serum concentration was increased.At present,as an independent marker,AMH has good diagnostic and predictive potential.Many scholars suggest that AMH be used as a diagnostic criterion for PCOS or as asupplement to the Rotterdam PCOS diagnostic criteria.In ovarian stimulation,the level of AMH helps to assess the potential response of the ovary to avoid OHSS.AMH can also reflect the PCOS phenotype and the severity of symptoms.AMH participates in FSH dependent periodic follicle recruitment,and decreases inprimordial,dominant and atresia follicles.It plays an important role in the initiation and selective growth of follicles.The mechanism of AMH in regulating follicular selection and maturation has also been hypothesized in some studies that it inhibits follicular development and may play an important role in the pathogenesis of anovulatory polycystic ovary syndrome.The level of AMH was higher in PCOS women than in ovulation women.It has been proved that the serum AMH level of PCOS patients is significantly higher than that of normal people.AMH may be involved in the occurrence and development of follicular abnormalities in PCOS,and is related to the disorder of sex hormone synthesis.However,the exact regulatory mechanism needs further study.Objective:To analyze the expression of AMH in spontaneous follicular development of patients with oligomenorrhea PCOS,to analyze the different expression of AMH in patients with PCOS(including oligo-ovulation and anovulation),to explore the relationship between the expression level of AMH and hormones,clinical indicators of patients and its clinical significance.It will provide new clinical evidence for the clinical treatment and follicular development of PCOS patients.The use of AMH as a diagnostic marker for PCOS or as a predictor of spontaneous ovulation in PCOS with oligomenorrhea may provide new insights.Methods:From March 2014 to April 2018,the study consisted of 75 volunteer reproductive women between 22 and 34 years old.Oligomenorrhea was defined as a cycle length>35 days.The women were divided into two groups:the oligo-ovulation group(n=43)and the anovulation group(n=32).Serum AMH concentration was measured on D2-3 of the menstrual cycle(T1),at selection of the dominant follicle(T2),the time of mature follicle(T3)in oligo-ovulation PCOS women,whereas in anovulatory PCOS women,it was taken at two time points(T4=on D2-3 of the menstrual cycle;T5=on approximately day 60 of the menstrual cycle).Non-activated antral follicle was defined as anovulation over 60 days.Ovary volume formula:0.5*length*width*thickness.Ovarian volume(OV)was defined as the average ovarian volume obtained from both ovaries,the number of antral follicles counted(AFC)in both ovaries,and the AMH/AFC ratio was calculated.AMH to AFC ratio(AMH/AHC)was used as a surrogate marker for average AMH production per follicle,i.e.follicular AMH outputResults:(1)Ovarian characteristics:OV(13.40[3.13]and AFC(40.09[7.60]in anovulatory group were significantly higher than OV(9.07[2.74 ml]and AFC(30.93[5.45]in the oligo-ovulation group(P<0.001,P<0.001,respectively).The AMH/AFC ratio in anovulatory group was 0.30(+ 0.09),which was higher than that in oligo-ovulationgroup(0.22±0.07)(P<0.001).(2)Changes of AMH in two groups at different time periods:The serum AMH concentration in anovulatory group was 12.26(+4.99ng/mL)on the 2nd-3rd day of menstruation,which was significantly higher than that in the oligo-ovulation group(6.94(+2.98ng/mL)at the same period(P<0.001).During spontaneous follicular development,there was no significant change in AMH concentration(P= 0.624)in the oligo-ovulation group,and there was no difference about AMH levels in the anovulation group during menstruation(P=0.379).(3)Predictive efficiency of AMH,OV,AFC and different combinations on spontaneous ovulation in PCOS patients with oligomenorrhea:AMH cut-off value 8.15ng/ml showed 84.4%sensitivity and 76.7%specificity;OV cut-off value 10.41ml,sensitivity 75%,specificity 83.7%;AFC AUC 0.845,cut-off value 35.5,sensitivity 84.4%,specificity 76.7%..AUC of OV + AFC was 0.903,sensitivity was 90.6%,specificity 81.3%;AUC of AMH + OV was 0.873,sensitivity 87.5%,specificity 76.7%;AUC of AMH + AFC + OV was 0.903,sensitivity 87.5%,specificity 83.4%.(4)Correlation between AMH concentration and different variables:There was a strong positive correlation between AMH and AFC and OV in the oligo-ovulation group(P<0.001,P=0.019,respectively).But there was no correlation with T(r=0.242,P=0.119).There is a strong positive correlation between OV and T(r=0.364,P= 0.016).There was a significant positive correlation between AMH and AFC in the anovulation group(r=0.929,.P<0.001).There was a correlation between AMH and OV(r=0.751,P<0.001),AMH and T(r=0.548,P=0.001),and a positive correlation with body mass index(r=0.598,P=0.005),but no correlation with LH(r =0.042,P=0.818).There was a negative correlation between AMH and FSH(r=-0.145,P=0.040).Conclusion:(1)In PCOS women,there was no significant change in AMH concentration during spontaneous follicular development(2)There is a positive correlation between serum AMH value and T value in anovulatory patients,and a negative correlation between AMH value and FSH value.AMH,FSH and T value may coordinate to interfere with the occurrence and development of follicles.(3)When AMH concentration was>8.15 ng/mL,OV>10.41ml and AFC>35.5,it was speculated that PCOS is likely to have anovulation.(4)Recommended use of OV+AFC,AMH+OV+AFC can improve the predictive efficiency of spontaneous ovulation in PCOS patients.(5)AMH can be used as one of the diagnostic indicators of PCOS,and has a good predictive value for spontaneous ovulation in PCOS patients.