Anti-Müllerian hormone (AMH) is a polypeptide, member of the transforming growth factor-
In healthy female fetus, this protein is detected in umbilical cord. Measurement of AMH in different stages of life shows that serum level of AMH decreases during the first four years and then it would increase linearly during the next four years and the serum level will not change during puberty and adolescence.
During reproductive age, AMH is secreted from granulosa layer cells of primary follicles which are developed from primordial follicles. AMH is secreted from small antral and preantral follicles which are less than 4 mm. Secretion of AMH reduces during follicle maturation and in follicles which are more than 8 mm AMH is not secreted anymore; therefore AMH serum level is constant during menstruation cycle [
The number of primordial follicles shows the ovarian age and storage. Computation of primordial follicles is impossible but follicles count during phase of development can lead to approximate number of primordial follicles and ovarian age [
Evaluation of ovarian storage is an essential step for treatment of infertility.
There are several methods for evaluation of ovarian storage such as antral follicular count (AFC) which is done by ultrasonography [
Other methods are measuring estrogen, FSH, and inhibin B serum levels with some restrictions such as time limitation for evaluation of the serum levels [
Serum level of AMH is associated better with a decline of oocytes/follicles over time. AMH serum level can be measured at any time of cycle and the serum level is not affected by consumption of oral contraceptive pills (OCP), against serum level of FSH and other markers [
Premature ovarian failure is one of the causes of infertility which is described as a decline in ovarian function and ovarian response to FSH and reduction of estrogen level [
Serum level of AMH decreases or cannot be detected in patients with POF (Table
AMH blood level.
AMH blood level | Interpretation |
---|---|
Over 3.0 ng/mL | High (often PCOS) |
Over 1.0 ng/mL | Normal |
0.7–0.9 ng/mL | Low normal range |
0.3–0.6 ng/mL | Low |
Less than 0.3 ng/mL | Very low |
One of the benefits of AMH serum level measurement is to identify patients with risk factors of POF such as family history of POF, history of chemotherapy and radiation to pelvic region, and history of autoimmune diseases [
Besides, patients with POF are prone to be involved with adverse effects of menopausal state; therefore early detection of POF can lead to primary prevention of these adverse effects such as osteoporosis and cardiovascular diseases [
The aim of this paper is to compare the sensitivity and specificity of AMH and FSH in detection of POF in patients with menstrual disorders diagnosed as primary ovarian failure in Jahrom city.
The study was initiated after approval of Research and Ethics Committee of Jahrom University of Medical Sciences; after clarifying the study protocol, written consent was obtained from the participants.
This is a descriptive study on 96 women who were referred to Dr. Rasekh Clinic due to menstrual disorders and history of infertility for one year.
Initially medical history and demographic information were assessed.
Blood was collected on Day 3 (3rd of menstrual cycle), and serum was immediately separated by centrifugation for 6 min at room temperature. Serum AMH and FSH were measured by electrochemiluminescence immunoassay.
Exclusion criteria of the study are having history of autoimmune disease, radiation to pelvis, polycystic ovarian syndrome, and other medical or surgical disorders which are causes of menstrual disorders such as endometriosis, thyroid disease, and pelvic inflammatory disease. Inclusion criteria of the study are women with abnormal vaginal bleeding who are less than 40 years old, women who have decreased volume size of ovary or reduction of follicular numbers and size below normal range, and women with family history of premature ovarian failure: Normal size of ovary = 2.5–5 cm in length and 1.5 to 3 cm in width and depth. Volume of ovary (mL) = length (cm) × width (cm) × depth (cm) × 0.52. Normal count of ovary: 3–6 mm.
Data were analyzed by SPSS for Windows (version 21.0.0; SPSS, Inc., Chicago, IL, USA). Then evaluation of binary classifier for determination of specificity and sensitivity was done.
Serum level of AMH measured on Day 3 in women with abnormal vaginal bleeding for diagnosis of POF shows that sensitivity of this test in diagnosis of POF is 80% and specificity is 78.89%. Diagnostic accuracy of this test is 78.95%. Positive predictive value of AMH in diagnosis of POF is 17.39% and negative predictive value of AMH in diagnosis of POF is 98.61%.
Sensitivity of FSH in diagnosis of POF is 28.57% and specificity of FSH in diagnosis of POF is 78.65%. Diagnostic accuracy of this test is 71.84%.
Positive predictive value of FSH in diagnosis of POF is 17.39% and negative predictive value of FSH in diagnosis of POF is 87.5% (Figure
Area under the curve.
Area | Std. error | Asymptotic sig. | Asymptotic 95% confidence interval | |
---|---|---|---|---|
Lower bound | Upper bound | |||
0.796 | 0.107 | 0.027 | 0.586 | 1.005 |
ROC curve shows that most of the cases that are diagnosed as POF also have positive serum level of AMH. ROC curve determines high sensitivity of serum level of AMH in diagnosis of POF (significance 0.027). Area in ROC curve shows that possibility of diagnosing POF with AMH serum level is 79.6%.
Sensitivity of AMH in diagnosis of POF was more than that of FSH but both tests had almost equal specificity. Many scientists focused on relation of AMH level in diagnosis of POF but did not compare the specificity and sensitivity of AMH and FSH.
Diagnostic accuracy of AMH is more than FSH such that there is significant difference between the two tests (
On the other hand, Dewailly et al. showed in their study that the value of AMH in the diagnosis of PCOS remains controversial, but it may replace AFC in the future [
Early diagnosis of reduction of ovarian storage can prevent expensive ways in treatment of infertile woman and in women who are susceptible to POF. As sensitivity of AMH in diagnosis of POF is more than FSH and specificity is equal, AMH is a better marker of POF but both tests can confirm each other having more reliable prediction. Also, oocytes freezing, ovarian tissue freezing, and embryo freezing are recommended for those who are at risk of POF.
The authors declare that they have no competing interests.
The authors would like to thank Jahrom University of Medical Science.