Essay Submitted by

1
Anti-Mullerian Hormone (AMH) in Female
Reproduction (Part I)

• Essay Submitted by
• Mohamed D. Mansy
• Specialist of Obstetrics and Gynecology
• Ministry of Health Population (MOHP) Port Said
• 2009

2

• Under supervision of
• Prof. Dr Mahmoud Farouk Midan
• Professor and Head of
• Obstetrics and Gynecology Department
• Faculty of medicine, Al-Azhar university,
  Damietta.
• Dr. Khattab Abd Elhalem Omar Khattab
• Assist. Professor of Obstetrics and Gynecology
• Faculty of medicine, Al-Azhar university,
  Damietta.
• Dr. Rashed Mohamed Rashed
• lecturer in Obstetrics and Gynecology
• Faculty of medicine, Al-Azhar university,
  Damietta.

3
Introduction
4

• At the early stages of development in mammals,
  fetuses of both sexes have two pairs of ducts
  the Wollfian and the Müllerian ducts. In the
  1940s, Alfred Jost showed that a testicular
  product different from testosterone was
  responsible for the regression of Müllerian ducts
  in the male fetus.

5

• This product was called 'hormone inhibitrice'.
• Twenty three years ago the human gene for
  anti-Müllerian hormone (AMH) was isolated and
  sequenced.
• (Cate, et al., 1986)

6

• There is considerable individual variation in the
  age of menopause and, subsequently, also in the
  age of subfertility. Hence, chronological age is
  a poor indicator of reproductive aging, and thus
  of the ovarian reserve.
• (teVelde and Pearson 2002)

7

• To assess an individuals ovarian reserve,
  early follicular phase serum levels of FSH,
  inhibin B and estradiol (E2) have been measured.
  Inhibin B and E2 are produced by early antral
  follicles in response to FSH, and contribute to
  the classical feedback loop of the
  pituitary-gonadal axis to suppress FSH secretion.

8

• So far, assessment of the number of antral
  follicles by ultrasonography, the antral follicle
  count (AFC), best predicts the quantitative
  aspect of ovarian reserve
• (Scheffer, et al., 2003)

9

• However, measurement of the AFC requires an
  additional transvaginal ultrasound examination
  during the early follicular phase.

10

• Therefore, a serum marker that reflects the
  number of follicles that have made the transition
  from the primordial pool into the growing
  follicle pool, and that is not controlled by
  gonadotropins, would benefit both patients and
  clinicians. In recent years, accumulated data
  indicate that anti-Müllerian hormone (AMH) may
  fulfill this role.
• (Visser, et al., 2006)

11
AIM OF THE WORK
12

• To review the update in Anti-Müllerian Hormone in
  Female Reproduction.

13
Subjects and Method
14

• This review depends on searching trusted
  websites as, Cochrane library, RCOG site, Green
  Top guideline, ACOG, Pub Med, Obgyn.net, etc. and
  most recent obstetrics and gynecology (national
  and international) books, journals and
  editorials.

15
Review of Literature
16
Review of Literature
AMH and Its Expression in the Ovary
17

• AMH is a member of the transforming growth
  factor-beta (TGF-ß) superfamily. AMH is a
  homodimeric disulfide-linked glycoprotein with a
  molecular weight of 140 kDa (kilo Dalton, which
  is atomic mass unit). The gene is located on the
  short arm of chromosome 19 in humans, band 19p
  133
• (Al-Qahtani, et al., 2005)

18

• AMH, produced by the Sertoli cells of the fetal
  testis, induces the regression of the Müllerian
  ducts, the anlagen of the female reproductive
  tract (Josso, et al., 1993).
• In the absence of AMH, Müllerian ducts of both
  sexes develop into the uterus, the Fallopian
  tubes and the upper part of the vagina
  (Behringer, et al., 1994).

19

• However, after birth, this sex-dimorphic
  expression pattern is lost and AMH is also
  expressed in granulosa cells of growing follicles
  in the ovary.

20

• Expression in the ovaries has been observed as
  early as 36 weeks' gestation in humans.
• Expression also is highest in granulosa cells of
  preantral and small antral follicles, and
  gradually diminishes in the subsequent stages of
  follicle development.

21

• AMH is no longer expressed during the
  FSH-dependent final stages of follicle growth. In
  addition, AMH expression disappears when
  follicles become atretic.

22

• Interestingly, two major regulatory steps of
  folliculogenesis,
• initial follicle recruitment.
• cyclic selection for dominance.
• (McGee, and Hsueh, 2000)

23

• In women, AMH expression can first be observed in
  granulosa cells of primary follicles, and
  expression is strongest in preantral and small
  antral follicles (4mm). AMH expression disappears
  in follicles of increasing size and is almost
  lost in follicles larger than 8 mm, where only
  very weak staining remains, restricted to the
  granulosa cells of the cumulus.
• (Weenen, et al., 2004)

24

• This expression pattern suggests that, also in
  man, AMH may play a role in initial recruitment
  and in the selection of the dominant follicle
  (Visser, 2003).

25

• The results of a study by Modi D, et al. (2006)
  in both human and monkeys strongly favor the
  regulatory roles of MIS in the folliculogenesis
  particularly in the process of follicular growth
  and differentiation.

26

• Based on the expression profiles and the results
  of some in vitro studies, it seems likely that
  the roles of MIS in ovarian functions in the
  rodents and primates may differ.

27

• AMH in the primate ovary may exert its effects in
  a larger temporal window initiating from the
  primordial follicle growth to terminal granulosa
  cell differentiation.

28

• The presence of MIS in the granulosa cells and a
  small subset of oocytes in the fetal ovary, point
  towards its additional role during fetal ovarian
  development that needs to be explored.
• (Modi, et al., 2006)

29
Figure (2) Expression of Mullerian inhibiting
substance (MIS) mRNA in the developing human ovary

• A is in situ hybridized 18-week-old fetal ovary,
  B is fetal ovary at 13 weeks showing week
  expression in the somatic (presumably
  pregranulosa) cells (gc) the oocytes (o) are MIS
  negative. C is ovary of a fetus at 16 weeks
  showing a developing follicle. D and E are
  ovaries at 18 and 20 weeks of development
  respectively showing developing primordial
  follicles (pf) and naked oocytes (o). Oocyte
  showing strong MIS expression is marked () in D.
  F is fetal ovary at 23 weeks of development
  showing a group of well-defined primordial
  follicles. G is fetal testis at 16 weeks of
  gestation as positive control. H is 16-week-old
  fetal ovary hybridized with a sense probe.

30
Figure (3) Mullerian inhibiting substance (MIS)
mRNA in the neonatal ovary
(A) Newborn human ovary containing primordial
follicles showing MIS expression in the granulosa
cells of primordial follicles. (B) Expression of
MIS in the growing follicles in a newborn ovary.
Note the increase in expression in the primary
(pr) and secondary (s) follicles, and a marginal
drop in the antral (ant) follicles. (C) Enlarged
view of the primary and large secondary
follicles. (D) Negative control.
31
Figure (4) Cellular localization of Mullerian
inhibiting substance (MIS) transcripts during
folliculogenesis in the human ovary.
(A) Primordial follicles. (B) Primary follicles.
(C) Secondary follicle. (D) Large antral
follicle. (E) Cumulous granulosa cells and the
oocyte (o) of a large antral follicle. (F) The
mural cells (arrow) and the theca (tc) layer of
the same. Note the difference in the intensity of
the staining of MIS mRNA in these cells. (G) An
atetric follicle and a secondary follicle
(arrow). (H) Corpus luteum that is negative for
MIS mRNA. (IK) Photographs of human cumulous
oocyte complex (COC) stained for MIS mRNA I is
low magnification of the COC showing staining in
the granulosa cells while the oocyte (o) has no
staining J is higher magnification of the
granulosa cells note the staining only in the
periphery (cytoplasm) no nuclear signals are
evident K shows the granulosa cells (gc) closest
to the oocyte (o) do not show MIS expression.
Negative control is shown in L.
32

• It has been demonstrated that oocytes from early
  preantral, late preantral and preovulatory
  follicles up-regulate AMH mRNA levels in
  granulosa cells, in a fashion that is dependent
  upon the developmental stage of the oocyte.
• (Salmon, et al., 2004)

33

• The pattern of MIS expression during fetal
  life and in adulthood suggests its roles in
  follicular formation and the autocrine/paracrine
  regulation of adult folliculogenesis.
• (Modi, et al. ,2006)

34
Table (1)Comparison of AMH expression in the
adult ovary
35
Review of Literature
Receptors for AMH
36

• AMH uses a heteromeric receptor system consisting
  of a single membrane spanning serine threonine
  kinase receptors called type I and type II. The
  type II receptor (AMHRII) imparts ligand binding
  specificity and the type I receptor mediates
  downstream signalling when activated by the type
  II receptor.

37

• The human gene for AMHRII was isolated in 1995
  (Imbeaud, et al., 1995). It is located on
  chromosome 12 and is made up of 11 exons spread
  over more than 8 kbp (kilo Base pair).
• The AMHRII messenger is expressed by AMH target
  organs, namely the Müllerian ducts, and the
  gonads.

38

• Loss of function mutations in the type II
  receptor as well as the AMH ligand itself are
  causes of persistent Müllerian duct syndrome in
  humans
• (Imbeaud, et al., 1994).

39
Review of Literature
The Role of AMH in Ovarian Physiology
40

• The activation of primordial follicles and the
  pace of follicular development are regulated by
  both positive and negative factors. AMH is
  considered as a negative regulator of the early
  stages of follicular development

41
Figure (7) Role of AMH in human
folliculogenesis.

• Progressing stages of folliculogenesis are
  depicted. AMH is produced by the small growing
  (primary and preantral) follicles in the
  postnatal ovary and has two sites of action. It
  inhibits initial follicle recruitment (1) and
  inhibits FSH-dependent growth and selection of
  preantral and small antral follicles (2).

42

• Studies suggests that, the presence of AMH acts
  as a brake on the activation of primordial
  follicles and the growth of preantral follicles.
  Both in vitro and in vivo studies have shown that
  follicles are more sensitive to FSH in the
  absence of AMH.

43

• The presence of AMH in the granulosa cells and a
  small subset of oocytes in the fetal ovary, point
  towards its additional role during fetal ovarian
  development.
• (Modi, et al., 2006)

44
Review of Literature
Clinical Utility of AMH Measurement
45

• AMH levels in women are lower than in men
  throughout life. In women, AMH serum levels can
  be almost undetectable at birth.
• (Rajpert-De Meyts, et al., 1999)

46

• Evaluating Fertility Potential Serum AMH levels
  correlate with the number of early antral
  follicles with greater specificity than Inhibin
  B, Oestradiol, Follicle Stimulating Hormone and
  Luteinizing Hormone on cycle day 3. Thus, serum
  AMH may reflect ovarian follicular status better
  than these hormone markers.Measuring Ovarian
  Aging Diminished ovarian reserve, associated
  with poor response to IVF, is signaled by reduced
  baseline serum AMH concentrations. AMH would
  appear to be a useful marker for predicting
  ovarian aging and the potential for successful
  IVF.

47

• Predicting Onset of Menopause The duration of
  the menopausal transition can vary significantly
  in individuals and reproductive capacity may be
  seriously compromised prior to clinical
  diagnosis. AMH can predict the occurrence
• of the menopausal transition.Assessing
  Polycystic Ovary Syndrome Serum AMH levels are
  elevated in patients with polycystic ovary
  syndrome and may be useful as a marker for the
  extent of the disease.

48
Table (2) AMH Reference ranges.
Laboratory Guide 2009
49
Review of Literature
AMH as a Marker of Ovarian Reserve in Ageing
Women
50

• It is well known that with increasing age there
  is a decline in female reproductive function due
  to the reduction in the ovarian follicle pool and
  the quality of the oocytes.

51

• Many studies suggest AMH as a novel measure of
  ovarian reserve. Serum AMH levels show a
  reduction throughout reproductive life.
• Undetectable AMH levels after spontaneous
  menopause have been reported
• (LaMarca, et al., 2005a).

52

• Ovariectomy in regularly cycling women is
  associated with disappearance of AMH in 3-5 days,
  demonstrating that circulating AMH is exclusively
  of ovarian origin.
• (Long, et al., 2000 LaMarca, et al., 2005a).

53

• Eighty one, women were prospectively studied for
  4 years (mean age 396 and 436 at the beginning
  and at the end of the study, respectively). It
  was found that AFC did not change over time
  whereas AMH, FSH and inhibin B changed
  significantly.
• (Scheffer, et al., 1999).

54

• the quantitative aspect of ovarian aging is
  reflected by a decline in the size of the
  primordial follicle pool. Direct measurement of
  the primordial follicle pool is impossible.
  However, the number of primordial follicles is
  indirectly reflected by the number of growing
  follicles
• (Scheffer, et al., 1999)

55

• Hence, a factor primarily secreted by growing
  follicles will reflect the size of the primordial
  follicle pool. Since AMH is expressed by growing
  follicles up to selection (Durlinger, et al.,
  2002a), and can be detected in serum (Lee, et
  al., 1996), it is a promising candidate.

56

• In young normal ovulatory women, early follicular
  phase hormone measurements at 3-year intervals
  revealed that serum AMH levels decline
  significantly whereas serum levels of FSH and
  inhibin B and the number of antral follicles do
  not change during this interval
• (deVet, et al., 2002)

57

• Changes in serum AMH levels occur relatively
  early in the sequence of events associated with
  ovarian aging. Substantially elevated serum
  levels of FSH are not found until cycles have
  already become irregular
• (Burger, et al., 1999).

58

• Furthermore, compared to other ovarian reserve
  markers, only serum AMH level showed a mean
  longitudinal decline over time. Taken together,
  these data strongly suggest that serum levels of
  AMH can be used as a marker of ovarian aging.

59

• The usefulness of serum AMH levels as a measure
  of the ovarian reserve was recently shown in
  young women after treatment for childhood cancer.

60

• With respect to other known markers, AMH seems to
  better reflect the continuous decline of the
  oocyte/follicle pool with age
• (VanRooij, et al., 2004).

61

• However, AMH was the only marker of ovarian
  reserve showing a mean longitudinal decline over
  time both in younger women (lt 35 years) and in
  women over 40 years.

62

• The decrease in AMH with advancing age may be
  present before changes in currently known
  ageing-related variables, indicating that serum
  AMH levels may be the best marker for ovarian
  ageing and menopausal transition
• (Hale and Burger, 2008).

63
thank you
64
(No Transcript)