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ORIGINAL ARTICLE
Year : 2021  |  Volume : 35  |  Issue : 3  |  Page : 87-91

Correlation between antral follicle count and anti-Mullerian hormone in infertile Indian women


1 Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
4 Centre of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission08-Nov-2021
Date of Acceptance16-Nov-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Shivi Jain
Associate Professor, Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_126_21

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  Abstract 


Background: Antral follicle count (AFC) and anti-Mullerian hormone (AMH) have been used as indicators of ovarian reserve in infertile women. There still exists a debate about the association between the two parameters.
Objective: The objective of the study was to find out the relationship between AFC and AMH in infertile women. Methods: This was a prospective, hospital-based, cross-sectional study, in which 1083 infertile women (aged 20–40 years) with primary infertility were included. They were divided into four age groups, i.e., Group I (20–24 years), Group II (25–29 years), Group III (30–34 years), and Group IV (35–40 years). AMH and AFC were measured on 3rd day of menstrual cycle. Pearson correlation and linear regression analysis were done to find out the relationship between age, AFC, and AMH. Statistical analysis was done using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). A P < 0.05 was considered statistically significant.
Results: There was modest negative correlation of AFC with age (r = −0.476, P < 0.001). AMH showed strong negative correlation with age (r = −0.844, P < 0.001) and modest positive correlation with AFC (r = 0.400, P < 0.001). For separate age groups also, statistically significant correlations (P < 0.05–P < 0.001) were noted between age, AFC, and AMH. Age explained 22.7% variation in AFC and 71.2% variation in AMH.
Conclusion: There was a significant correlation between AMH and AFC in infertile women. AFC showed a continuous decline with increasing age. However, AMH increased with age till third decade of life and showed negative correlation with AFC. Thereafter, AMH started decreasing with age and showed positive correlation with AFC.

Keywords: Anti-Mullerian hormone, antral follicle count, primary infertility


How to cite this article:
Jain S, Shukla RC, Jain M, Singh U, Singh TB. Correlation between antral follicle count and anti-Mullerian hormone in infertile Indian women. J Med Soc 2021;35:87-91

How to cite this URL:
Jain S, Shukla RC, Jain M, Singh U, Singh TB. Correlation between antral follicle count and anti-Mullerian hormone in infertile Indian women. J Med Soc [serial online] 2021 [cited 2022 Jul 3];35:87-91. Available from: https://www.jmedsoc.org/text.asp?2021/35/3/87/347642




  Introduction Top


Assessment of ovarian reserve is important for the management of infertility. The ovarian reserve tests consist of both biochemical tests and ultrasound imaging of the ovaries. Anti-Mullerian hormone (AMH) among the biochemical parameters and antral follicle count (AFC) among the sonographic ones hold prime importance.[1] The researchers worldwide have compared the two parameters to find out which one was better and unfortunately led to conflicting results.[2],[3],[4] Some claimed that AMH was a better marker for ovarian reserve than AFC because it was simpler and remained relatively constant throughout the menstrual cycle.[5] While others opined that concentration of AMH actually varied during the menstrual cycle and fluctuations in its level paralleled the fluctuations in AFC.[6],[7] Therefore, AFC being cheaper and direct quantitative marker of ovarian reserve, should be considered a reasonable alternative to AMH if done in experienced hands.[1],[2] Therefore, the primary objective of this study was to determine the correlation between AMH and AFC in infertile women. The secondary objective was to compare the relationship between AMH and AFC in different age groups of infertile women.


  Materials and Methods Top


This cross-sectional study was performed at the Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. The study was done in accordance with the declaration of Helsinki guidelines on good clinical practice and after approval of the institute ethical committee. The females with primary infertility (n = 1438) were prospectively recruited from the outpatient department of the Department of Obstetrics and Gynaecology where they underwent investigation for subfertility or were undergoing assisted conception treatment.

The inclusion criteria were: regular menstrual cycle (length: 25–35 days) with <5 days' difference between cycles, age 20–40 years, no hirsutism, serum luteinizing hormone (LH)/follicle stimulating hormone (FSH)<2, and presence of both ovaries (3). The exclusion criteria were a history of hormone administration in the previous 6 months, pelvic inflammatory disease or ovarian surgery, ovarian endometrioma, premature ovarian failure, uterine malformations or uterine pathology, known systemic, metabolic, and endocrine disease including hyperandrogenism. Although women with polycystic ovarian (PCO) syndrome (PCOS) were excluded on the basis of clinical and biochemical criteria, those having only PCO morphology on ultrasound (presence of ≥12 follicles, 2–9 mm in diameter, and/or increased ovarian volume [>10 ml]) were included.[8] Women with poor ultrasound visualization of ovaries, because of retrouterine or abnormal position and the presence of at least one of cysts ≥20 mm, were excluded retrospectively. Finally, 1083 infertile females were included in the study. The subjects were further divided into four age groups, i.e., Group I (20–24 years), Group II (25–29 years), Group III (30–34 years), and Group IV (35–40 years) [Table 1]. Informed consent was obtained from all the subjects.
Table 1: Comparison of mean antral follicle count and mean anti-mullerian hormone in different age groups of infertile women (n=1083)

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All the relevant clinical data of the study subjects including biometry were acquired. The hormonal assays and transvaginal ultrasound were done on the 2nd or 3rd day of the menstrual cycle. Among the biochemical parameters, LH, FSH, triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone, free testosterone, and prolactin levels were documented. The serum AMH was measured using Gen II AMH Enzyme-linked Immunosorbent Assay (ELISA; Beckman Coulter, USA). All sonographic measurements were performed by the same investigator using a 7.5-MHz transvaginal transducer (Diagnostic ultrasound, iU22, Philips Medical System, California, United States). Thorough survey of each ovary was done by scanning from the outer to the inner margin. All follicles having adequate morphology as described for a healthy follicle (i.e., 2–10 mm size range of well-defined anechoic cysts with smooth margins and absence of internal septations or nodularity) were measured and counted in each ovary.[9] The sum of both the counts was labeled as the AFC. Follicular size was measured using the internal diameters of the area. The mean of two perpendicular measurements was taken as the follicular size.

Statistical analysis

Descriptive statistics was calculated in the form of mean ± standard deviation. Student's t-test/Mann–Whitney U test was applied to find out the significant difference in the mean values between the groups. Pearson correlation and linear regression analysis were done to find out the relationship between the study variables. The statistical analysis was done by SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). A P < 0.05 was considered statistically significant at two-tailed test.


  Results Top


A total of 1083 infertile females were included in the study. Out of these, there were 231 (21.4%) females in Group I, 336 (31.0%) in Group II, 246 (22.7%) in Group III, and 270 (24.9%) in Group IV. The mean age of 1083 women was 29.72 ± 5.73 years, mean BMI was 24.05 ± 2.32 kg/m2, mean AFC was 11.91 ± 6.02 follicles, and mean AMH was 2.51 ± 1.25 ng/ml. The mean AFC and mean AMH of different age groups have been shown in [Table 1]. There was a modest negative correlation of AFC with age (r = −0.476, P < 0.001). AMH showed strong negative correlation with age (r = −0.844, P < 0.001) and modest positive correlation with AFC (r = 0.400, P < 0.001). The correlation between age, AFC, and AMH in different age groups has been shown in [Table 2]. Age explained 22.7% variation in AFC and 71.2% variation in AMH.
Table 2: Correlation between age, antral follicle count, and anti-Mullerian hormone in different age groups of infertile women (n=1083)

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  Discussion Top


This study comprised 1083 infertile women having primary infertility with a mean age of 29.72 ± 5.73 years and mean BMI of 24.05 ± 2.32 kg/m2. We also included the women having polycystic ovaries on ultrasound but with normal clinical and biochemical parameters, thus ruling out PCOS.[2],[10] The mean AFC of the subjects was 11.91 ± 6.02 follicles and their mean AMH was 2.51 ± 1.25 ng/ml. In a study by Göksedef et al.,[11] the infertile women (n = 141) had age <45 years, mean age of 29.18 ± 5.54 years, and mean AMH of 2.23 ± 1.90 ng/ml, comparable to ours. However, they observed lower mean AFC (8.35 ± 2.83 follicles) than us. This was potentially explained by the fact that they included only 2–6 mm antral follicles, compared to 2–10 mm size used in our study. Moreover, they included subjects with both primary and secondary infertility, while we included the ones with the former only. Scheffer et al.[12] who studied infertile women (n = 132) with relatively higher mean age of 35.7 ± 3.84 years, used 3–12 mm as the criterion to define antral follicles and so got higher value of mean AFC (14.68 ± 4.2 follicles) than us and Göksedef et al. both Geetha[13] studied 50 cases (primary infertility) and 50 controls, but noted lower mean AFC of the infertile group than ours (6.67 ± 1.688 vs. 11.91 ± 6.02, respectively). This was likely to be due to the exclusion of the subjects with PCO morphology in their study. Thus, the differences in the values of mean AFC in infertile females in various studies were not only due to the variation in region, ethnicity, and selection criteria of the study population but also due to the lack of fixed definition of AFC, pertaining to the size of the antral follicles.

We noted modest positive correlation (r = 0.400, P < 0.001) between AMH and AFC [Figure 1]. Similarly, Göksedef et al.[11] also noted a correlation of 0.467 (P < 0001) between the two. Other investigators, however, noted positive but strong correlation between the two parameters.[4],[12],[14],[15] Scheffer et al.[12] in their study on 132 infertile females aged 24–48 years, noted the correlation of 0.81 (P < 00001) between AMH and AFC. Barbakadze et al.[3] conducted a study comprising 112 infertile females and found a strong positive correlation of AMH with AFC (r = 0.71, P = 0.0001). This was similar to the findings of Bala et al.[14] and Fanchin et al.[15] who also noticed strong positive correlations (r = 0.641, P < 0.001; r = 0.74, P < 0.0001, respectively) between the two parameters. Both the study groups used the same sample size (n = 75) but with the age range of 30–40 years in the former and 25–40 years in the latter. In the current study, the correlations between AMH and AFC were also calculated in different age groups and were found to be significant but weak [Table 2]. Contrary to this, Barbakadze et al.[3] observed significant and modest correlation between AMH and AFC in all the age groups, i.e., r = 0.57 (P < 0.0001) in <35 years, r = 0.69 (P < 0.0001) in 35–40 years, and r = 0.47 (P < 0.002) in 41–46 years. This could partially be due to the differences in the age range used for classifying the age groups and also the number of study subjects in each age group.
Figure 1: Relationship between serum anti-mullerian hormone and antral follicle count in infertile women

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We noticed strong negative correlation of AMH with age (r = −0.844, P < 0.001), an observation similar to that made by Barbakadze et al. (r = −0.67, P < 0.0001).[3] Contrary to these findings, weak negative correlations of r = −0.34 (P < 0.01), r = −0.18 (P = 0.03) and r = −0.22 (P < 0.04) were observed by Scheffer et al.,[12] Göksedef et al.,[11] and Fanchin et al.,[15] respectively. Among the age groups also, we found strong negative correlation (P < 0.001) between AMH and age, except in Group I (20–24 years) where we observed strong but positive correlation (r = 0.991, P < 0.001) between the two parameters [Table 2]. This indicated that AMH increased with increase in the age of a woman till 25–29 years, after which it started decreasing as the age advanced [Figure 2]. Similar observation had been reported for healthy females (majority was proven fertile) by Fong et al.[16] Wiweko et al.[17] prepared age-related nomogram for AMH in 1616 infertile women and observed its decline starting between 34 and 35 years of age. Barbakadze et al.,[3] however, did not find significant correlation between AMH and age in any age group, which might be due to small sample size in their study.
Figure 2: Relationship between serum anti-mullerian hormone and age in infertile women

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The prime reason for these wide variations in the statistical analysis involving AMH is the fact that different investigators have used different AMH assays which yield different levels of AMH.[18],[19],[20],[21],[22] Scheffer et al.,[12] Barbakadze et al.,[3] and Wiweko et al.[17] have used the AMH Generation II assay (AMH Gen II assay) like us. On the other hand, Bala et al.[14] and Fanchin et al.[15] have used ultrasensitive ELISA, while Diagnostic Systems Lab assay has been utilized by Göksedef et al.[11] This is an important point to be considered while interpreting the AMH level and using it to initiate the treatment in the needy.

In this study, there was a modest negative correlation of AFC with age (r = −0.476, P < 0.001) [Figure 3], similar to that observed by Barbakadze et al. (r = −0.55, P < 0.0001), and Göksedef et al. (r = −0.40, P < 0.0001).[3],[11] However, Scheffer et al.[12] noted a relatively weak negative correlation between the two parameters (r = −0.34, P < 0.00001). These observations, however, unanimously indicate toward the decline of AFC with increasing age of the infertile women. Among the age groups, we noted weak negative correlation between AFC and age (P < 0.05 to P < 0.001) [Table 2]. Barbakadze et al.[3] found significant correlation between the two parameters (P < 0.03) only in <35 years age group and that was also weak (r = −0.35) like ours.
Figure 3: Relationship between antral follicle count and age in infertile women

Click here to view


In our study, 22.7% variation in AFC and 71.2% variation in AMH were explained by age. Barbakadze et al.[3] found comparable results for AFC (27%), but age explained lower percentage of variation in AMH (22%) in their study. Loy et al.[23] observed much lower variation in AFC (10.1%) and AMH (14.3%) explained by age. These observations suggested that the presence of factors other than age such as genetic, nutritional, and environmental also might be affecting these ovarian reserve markers, especially AMH. The greater discrepancy for AMH than for AFC once again pointed toward existence of considerable differences between different AMH assays that posed hindrance toward uniform interpretation of AMH values across the borders. This fact needs to be carefully understood for proper counseling and management of a woman with infertility. Efforts should be made in future for establishing a universally acceptable AMH assay having standard reference values and uniform results.

There were some drawbacks in our study that need to be mentioned. First, it was a single-centre, tertiary hospital-based study and so the results could not be generalized at the community level. Second, it was a cross-sectional study, and so the correlation analysis could not be assessed at different points of time in a particular woman. Third, the sample size among the four age groups was relatively small. Fourth, differences in the correlation between AMH and AFC were not studied on the basis of the size of the antral follicles.


  Conclusion Top


There was a significant correlation between AMH and AFC in infertile women. AFC showed a continuous decline with increasing age. However, AMH increased with age till third decade of life and showed negative correlation with AFC. Thereafter, AMH started decreasing with age and showed positive correlation with AFC. Due to the fact that different AMH assays can yield different levels of AMH, a combined approach including the two parameters will lead to better case management and avoid giving unnecessary stress to a woman.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Practice Committee of the American Society for Reproductive Medicine Electronic address: [email protected]; Practice Committee of the American Society for Reproductive Medicine. Testing and interpreting measures of ovarian reserve: A committee opinion. Fertil Steril 2020;114:1151-7.  Back to cited text no. 1
    
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Bozdag G, Calis P, Zengin D, Tanacan A, Karahan S. Age related normogram for antral follicle count in general population and comparison with previous studies. Eur J Obstet Gynecol Reprod Biol 2016;206:120-4.  Back to cited text no. 2
    
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Barbakadze L, Kristesashvili J, Khonelidze N, Tsagareishvili G. The correlations of anti-mullerian hormone, follicle-stimulating hormone and antral follicle count in different age groups of infertile women. Int J Fertil Steril 2015;8:393-8.  Back to cited text no. 3
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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