CC BY-NC-ND
0Middle East Fertility Society Journal (2016) 21, 91-95
Middle East Fertility Society Middle East Fertility Society Journal
www.mefsjournal.org www.sciencedirect.com
ORIGINAL ARTICLE
Anti-Miillerian hormone and luteinizing hormone for prediction of spontaneous ovulation after laparoscopic ovarian drilling in clomiphene-resistant polycystic ovary syndrome
CrossMark
Mohamed Rezk *, Mohamed Emarh, Alaa Alhalaby
Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Egypt
Received 28 August 2015; revised 13 September 2015; accepted 14 September 2015 Available online 17 October 2015
KEYWORDS
AMH; LH; PCOS; LOD
Abstract Objectives: Correlation between pre-ovarian drilling anti-Mullerian hormone (AMH) and luteinizing hormone (LH) levels and subsequent spontaneous ovulation following the procedure.
Methods: Prospective observational study including 113 primary infertility, clomiphene resistant patients with polycystic ovary syndrome (PCOS) in the department of Obstetrics and Gynecology, Menoufia University Hospital, Egypt. The selected patients were directed to have laparoscopic ovarian drilling (LOD). Ovulation was diagnosed by serial follow-up ultrasonography in the subsequent cycles confirmed by day 21 progesterone. AMH and LH assays were done before and 3 months after the procedure. Receiver operator characteristic (ROC) curve was used to correlate between patients' characteristics and hormonal profile and spontaneous ovulation following LOD.
Results: Using ROC to assess the prognostic value of AMH and LH, it was found that AMH p 8.5 ng/ml was associated with no ovulation after LOD (sensitivity 74% and specificity 69%, with area under the curve (AUC) of .797 and p-value < 0.001). Also, LH p 15.2 IU/l was associated with no ovulation after LOD (and sensitivity of 71% and specificity of 73% with AUC of .792 and p-value < 0.001).
Conclusions: Pre-drilling AMH and LH levels could be useful predictors of spontaneous ovulation after LOD. Further larger studies are warranted to confirm these findings. © 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).
* Corresponding author at: 25 Yasin Abdelghafar Street, Shibin Elkom, Menoufia, Egypt. Mobile: +20 1006237186. E-mail address: m_rezk9207@yahoo.com (M. Rezk). Peer review under responsibility of Middle East Fertility Society.
1. Introduction
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders and the leading cause of anovulatory infertility in women of reproductive age (1).
http://dx.doi.org/10.1016/j.mefs.2015.09.003
1110-5690 © 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
In most cases ovulation can be induced with clomiphene citrate (CC) which constitutes one of the first-line treatments for ovulation induction in these patients. But, approximately 25% of patients fail to ovulate and require alternative treatment (2).
The second possible line of therapy after resistance to CC demonstrated in women with PCOS is exogenous gonadotropins or laparoscopic ovarian drilling (LOD), both modalities have a comparable live birth and miscarriage rate (3-5).
Anti-Miillerian hormone (AMH) is produced by the granulose cells of early developing follicles in the ovary and seems to be able to inhibit the initiation of primordial and FSH-induced follicle growth (6). A number of studies have shown serum AMH levels to be increased in women with PCOS (7,8).
The reported ovulation rate after LOD varies between 50% and 90% (9), and there is some disparity between hormonal improvement and ovulation rate following LOD (10).
Identifying predictors of success of LOD is an important issue for improving its outcome and avoiding unnecessary surgery with possible risks of diminishing the ovarian reserve and other surgical complications in patients who are likely to be LOD non-responders (11).
The aim of this study was to assess the correlation between pre-ovarian drilling AMH and LH levels and subsequent spontaneous ovulation following the procedure.
2. Materials and methods
A prospective observational study was designed taking 113 primary infertility, clomiphene resistant patients, admitted to the Department of Obstetrics and Gynecology, Menoufia University Hospital, Menoufia, Egypt, in the period between April 2012 and April 2015.
The institutional review board approved the study protocol and an informed consent was obtained from all patients prior to commencing the study.
Figure 1 Shows ROC curve of AMH level and spontaneous ovulation.
Figure 2 Shows ROC curve of LH and spontaneous ovulation.
We compared ovulation before and after drilling in each patient and correlated that with her pre-drilling LH and AMH levels. Our aim was to find a cutoff for both hormones that may predict spontaneous ovulation.
Diagnosis of PCOS was based on the NIH criteria, as follows: the two following criteria are present: oligo/anovulation and clinical and/or biochemical signs of hyperandrogenemia. Clomiphene citrate resistance was defined as the absence of developing follicles after ovarian stimulation with 150 mg clomiphene citrate/day given for five days beginning with the 2nd day of the menstrual cycle. Patients were stimulated with clomiphene for a minimum of three and a maximum of six cycles (12). A normal semen analysis, normal uterine cavity and bilateral tubal patency were other criteria of inclusion.
Patients with FSH > 15mIU/ml, medical disorders as diabetes mellitus and hypertension, contraindications for laparoscopy, endocrine disorders: hyperprolactinemia (prolactin P 22 ng/dl), thyroid disorders, Cushing's syndrome and acromegaly and patients having organic pelvic disease (endometriosis, leiomyoma, PID, endometrioma or ovarian cyst) upon laparoscopy as well as husband semen abnormalities (severe oligospermia) were excluded from the study.
Patients baseline blood samples were obtained before laparoscopic ovarian drilling (2-3 days after the commencement of spontaneous or progesterone induced menstrual bleeding) to assess serum levels of FSH, LH, AMH, testosterone, androstenedione and sex hormone binding globulins (SHBG). The free androgen index (FAI) was calculated using the formula testosterone X 100/SHBG.
The second blood sample was obtained in the early follicu-lar phase (days 2-3) of the menstrual cycle after 3 months of the operation to measure only serum AMH and LH.
AMH assay was done using commercial ELISA kits (immunotech, Beckman-coulter UK Ltd., High Wycombe, Buckinghamshire, UK), according to the manufacturer, and the sensitivity of the assay is .24 ng/ml. The intra- and inter-assay variabilities were, 5% and 8%, respectively.
Radioimmunoassays were used to determine serum levels of LH (Autodelfia; Wallac Oy, Turku, Finland), the intra- and inter-assay coefficients of variation for LH were 4.5% and 10.4% respectively; FSH (Enzymun ES700; Bohringer Mannheim, Mannheim, Germany), testosterone (Immunotech, Westbrook, ME, USA), androstenedione (Immunotech, Westbrook, ME, USA) and progesterone (Immunotech, Westbrook, ME, USA). Normal values of hormonal levels were as follows: FSH = 3-13 IU/l, LH = 1.5-12 IU/l, Androstenedione = 0.6-3 ng/ml and Testosterone = 0.2-0.9 ng/ml.
LOD was performed using three-puncture technique by the same surgeon. The laparoscope was introduced through a sub-umbilical incision. After assessment of the pelvic structures and tubal patency, an insulated needle connected to a unipolar electrocautery with four to six cautery points 3-4 mm in diameter with a current of 30 watts for 4-5 s, was created in each ovary applied through the laparoscopic insulated needle.
Post-operative ovulation was diagnosed by serial follow-up ultrasonography in the subsequent cycle confirmed by day 21 progesterone. If no menses occurred within 6 weeks, withdrawal bleeding was done and the patients were followed up for 3 months and considered as non-ovulatory. Patients were categorized into two groups, ovulatory and non-ovulatory groups based upon occurrence of spontaneous ovulation following LOD for comparison.
2.1. Statistical analysis
Data were collected, tabulated, and statistically analyzed by computer using SPSS version 16 (SPSS Inc, Chicago, IL, USA), and two types of statistics were done:
1. Descriptive statistics
Quantitative data are expressed to measure the central tendency of data and diversion around the mean, mean (x) and standard deviation (SD).
2. Analytic statistics
Student's t-test was used for comparison of normally distributed variables while Mann-Whitney test was used for comparison of non-normally distributed variables.
Multiple logistic regression analysis for patients' characteristics and hormonal profile was used to determine the independent predictors of success of LOD.
Receiver-operating characteristic (ROC) curve analysis was used to evaluate the prognostic value of serum AMH and LH levels with cutoff levels were determined at the maximum levels of sensitivity and specificity.
All these tests were used as tests of significance as follows: P value 6 0.05 was considered statistically significant and P value 6 0.001 was considered statistically highly significant.
3. Results
Table 1 reveals the patients' characteristics. No significant difference was observed between the two groups regarding age, body mass index, duration of infertility, menstrual cycle pattern, hirsutism, acne and ultrasonic evidence of polycystic ovaries (P > 0.05).
Table 2 shows the hormonal profile of the two groups, and there was a highly significant difference between pre- and postoperative AMH and LH levels in the spontaneous ovulation group (P < 0.001) in comparison with non-ovulation group. No significant difference was observed between the two groups regarding other hormones levels (P > 0.05).
Table 3 shows the multiple logistic regression analysis of patients' characteristics and hormonal profile among the participants using ROC to assess the prognostic value of AMH and LH, and it was found that AMH p 8.5 ng/ml was associated with no ovulation after LOD (sensitivity 74% and specificity 69%, with area under the curve (AUC) of .797 and p-value < 0.001). Also, LH p 15.2 IU/l was associated with no ovulation after LOD (and sensitivity of 71% and specificity of 73% with AUC of .792 and p-value < 0.001). Other patients'characteristics and hormonal levels were non-significant (Figs. 1 and 2).
Table 1 Patients' characteristics.
Variable Group 1 Group 2 Student's t-test P-value
Spontaneous ovulation (n = 78) Non-ovulation (n = 35)
Age (in years) 20 ± 3.9 21 ± 4.2 1.23 >0.05
BMI 23 ± 4.6 25 ± 3.9 2.24 >0.05
Duration of infertility 1.3 ± 0.7 1.5±.6 1.47a >0.05
Menstrual cycle pattern" 0.13b
-Regular 11(14.1%) 6(17.1%) >0.05
-Oligomenorrhea 60(76.9%) 25(71.4%)
-Amenorrhea 7(9%) 4(11.5%)
Hirsutism 24(30.7%) 12(34.2%) 0.15b >0.05
Acne 17(21.8%) 8(22.8%) -0.13b >0.05
Ultrasound evidence of PCO 72(92.3%) 30(85.7%) 0.75b >0.05
BMI = body mass index, PCO = polycystic ovaries.
a Mann-Whitney test.
b Chi square.
c Menstrual pattern definition: regular cycles: cycle length between 21 and 35 days; oligomenorrhea: cycle length between 35 days and
6 months; amenorrhea: absence of the menstrual period for >6 months.
Table 2 Hormonal profile of the participants.
Variable Group 1 Group 2 Student's t-test P-value
Spontaneous ovulation (n = 78) Non-ovulation (n = 35)
(Mean ± SD) (Mean ± SD)
Serum LH (IU/l)
-Preoperative 12.7 ± 4.2 18.4 ± 3.7 6.24 P < 0.001
-Postoperative 8.8 ± 3.1 14 ± 2.1 9.03 P < 0.001
P < 0.001 P < 0.001
Serum FSH (IU/l) 5.3 ± 1.4 5.5 ± 1.2 0.73 >0.05
Serum testosterone (ng/ml) 0.8 ± 0.4 0.7 ± 0.2 1.4 >0.05
Serum androstenedione (ng/ml) 3.6 ± 1.1 3.4 ± 1.3 0.84 >0.05
Free androgen index 8.2 ± 5.2 8.4 ± 5.1a 0.19 >0.05
Serum AMH (ng/ml)
-Preoperative 6.2 ± 2.6 12.6 ± 4.7 9.29 P < 0.001
-Postoperative 5.2 ± 0.8 9.6 ± 2.4 14.5 P < 0.001
P < 0.001 P < 0.001
a Mann-Whitney test.
Table 3 Multiple logistic regression analysis of patients' characteristics and hormonal profile among the participants (total no 113).
AUC Sensitivity (%) Specificity (%) Cut-off value P-value
Age .601 63 69 - >0.05
BMI .569 55 61 - >0.05
AMH .797 74 71 8.5 ng/ml <0.001
LH .792 71 73 15.2 IU/l <0.001
Testosterone .541 54 58 - >0.05
FAIa .536 52 57 - >0.05
AUC = area under the curve, BMI = body mass index, AMH = = anti-MUllerian hormone, LH = luteinizing hormone.
a FAI = free androgen index.
4. Discussion
In our study, we have used multiple logistic regression analysis to determine an independent predictor of ovulation following LOD. Age, BMI, duration of infertility, androgen levels and FAI were found to be of no significance while both AMH and LH seemed to be good predictors of spontaneous ovulation following LOD in women with PCOS.
In a previous retrospective study including 200 patients with anovulatory infertility due to PCOS who underwent LOD, the influence of the various patients' pre-operative characteristics on the ovulation and pregnancy rates after LOD was evaluated. Marked obesity (BMI > 35), marked hyperan-drogenism (serum testosterone concentration >4.5nmol/l), and/or long duration of infertility in women with PCOS seem to predict resistance to LOD (13). None of our included patients were morbidly obese, have marked hyperandrogenism or older than 35 years.
In this study, we found that AMH p 8.5 ng/ml was associated with no ovulation after LOD (sensitivity 74% and specificity 69%, with area under the curve (AUC) of .797 and p-value < 0.001). Also, LH p 15.2 IU/l was associated with no ovulation after LOD (and sensitivity of 71% and specificity of 73% with AUC of .792 and p-value < 0.001).
A previous smaller study was conducted in UK to measure circulating AMH before laparoscopic ovarian diathermy (LOD) to evaluate its prognostic value for an ovulatory response and to investigate AMH changes after LOD to further
explore the effects of LOD. This study included anovulatory women with PCOS undergoing LOD (n = 29) or receiving clomiphene citrate (n = 18). Plasma AMH concentrations were measured before and 1 week after treatment. Further measurements of AMH were made at 3- and 6-month follow-up. AMH was found to be a useful predictor of no ovulation after LOD with area under the curve of 0.804 (P = 0.025). Using a cutoff of 7.7 ng/ml, AMH had a sensitivity of 78% and a specificity of 76% in the prediction of no ovulation after LOD (14). However, the small sample size of the LOD group (n = 29) as well as the use of LOD as a first-line method of ovulation induction rather than CC-resistant PCOS women is important limitation of that study (11).
Failure of LOD in women with relatively high levels of AMH may be due to severity of the PCOS condition in these women. It is possible that the extent of follicle destruction by LOD in these women was not enough to reduce intra-ovarian AMH to a level consistent with resumption of ovulation (14,15).
Inability to follow-up patients for longer periods and to record pregnancy and live-birth rates was the main limitation of our study.
Future research should explore the use of dose adjusted LOD in relation to the serum levels of AMH and to extend the period of follow-up.
From the results obtained in this clinical study, we conclude that women with clomiphene resistant PCOS who are candidates for LOD may benefit from pre-drilling measurement of serum AMH and LH. Women with high pre-operative serum
AMH (p 8.5 ng/ml) and/or high pre-operative serum LH (p 15.2 IU/l) may have lower success rates of LOD in terms of spontaneous ovulation and possibly pregnancy rates.
Conflict of interests
We certify that no actual or potential conflict of interests in relation to this article exists.
Acknowledgments
The authors would like to acknowledge the contribution of the residents and nursing staff of the operating room and Clinical Pathology Department of Menoufia University Hospital.
References
(1) Franks S, Mason HD, Polson DW, Winstpon RML, Margara R, Reed MJ. The mechanism and management of ovulatory failure in women with polycystic ovary syndrome. Hum Reprod 1988;3:431-4.
(2) Homburg R. Clomiphene citrate - end of an era? A mini-review. Hum Reprod 2005;20(8):2043-51.
(3) Sastre ME, Prat MO, Checa MA, Carreras RC. Current trends in the treatment of polycystic ovary syndrome with desire for children. Ther Clin Risk Manage 2009;5(2):353-60.
(4) Delbaere A, Smits G, Olatunbosun O, Pierson R, Vassart G, Costagliola S. New insights into the pathophysiology of ovarian hyperstimulation syndrome. What makes the difference between spontaneous and iatrogenic syndrome? Hum Reprod 2004;19 (3):486-9.
(5) Farquhar C, Lilford RJ, Marjoribanks J, Vandekerckhove P. Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2007;18(3):CD001122.
(6) Durlinger AL, Gruijters MJ, Kramer P, Karels B, Kumar TR, Matzuk MM, Rose UM, de Jong FH, Uilenbroek JT, Groote-goed JA, Themmen AP. Anti-Mullerian hormone attenuates the effects of FSH on follicle development in the mouse ovary. Endocrinology 2001;142(11):4891-9.
(7) Fanchin R, Schonauer LM, Righini C, Frydman N, Frydman R, Taieb J. Serum anti-Mullerian hormone dynamics during controlled ovarian hyperstimulation. Hum Reprod 2003;18:328-32.
(8) La Marca A, Volpe A. Anti-Mullerian hormone (AMH) in female reproduction: is measurement of circulating AMH a useful tool? Clin Endocrinol (Oxf) 2006;64:603-10.
(9) Abdel Ghadir A, Khatim MS, Mowafi RS, Alnaser HMI, Alzaid HGN, Shaw RW. Ovarian electrocautery versus human meno-pausal gonadotropins and pure follicle stimulation hormone therapy in the treatment of the patients with polycystic ovarian disease. Clin Endocrinol 1990;33:585-92.
(10) Balen AH, Jacobs HS. A prospective study comparing unilateral and bilateral laparoscopic ovarian diathermy in women with the polycystic ovary syndrome. Fertil Steril 1994;62:921-5.
(11) Hashim Hatem Abu. Predictors of success of laparoscopic ovarian drilling in women with polycystic ovary syndrome: an evidence-based approach. Arch Gynecol Obstet 2015;291:11-8.
(12) Thessaloniki. ESHRE/ASRM-sponsored PCOS consensus workshop Group: consensus on infertility treatment related to poly-cystic ovary syndrome. Hum Reprod 2008;23:462-77.
(13) Amer S, Li TC, Ledger WL. Ovulation induction using laparo-scopic ovarian drilling in women with polycystic ovarian syndrome: predictors of success. Hum Reprod 2004;19:1719-24.
(14) Amer SA, Li TC, Ledger WL. The value of measuring anti-Mullerian hormone in women with anovulatory polycystic ovary syndrome undergoing laparoscopic ovarian diathermy. Hum Reprod 2009 Nov;24(11):2760-6.
(15) Elmashad AI. Impact of laparoscopic ovarian drilling on anti-Mullerian hormone levels and ovarian stromal blood flow using three-dimensional power Doppler in women with anovulatory polycystic ovary syndrome. Fertil Steril 2011;95:2342-6.
