Non-equivalence of anti-Müllerian hormone automated assays—clinical implications for use as a companion diagnostic for individualised gonadotrophin dosing

STUDY QUESTION Can anti-Müllerian hormone (AMH) automated immunoassays (Elecsys® and Access) be used interchangeably as a companion diagnostic for individualisation of follitropin delta dosing? SUMMARY ANSWER The Access assay gives systematically higher AMH values than the Elecsys® assay which results in over 29% of women being misclassified to a different follitropin delta dose. WHAT IS KNOWN ALREADY Follitropin delta is the first gonadotrophin to be licenced with a companion diagnostic, the Roche Elecsys® AMH Plus assay. Alternative automated AMH assays including the Beckman Coulter Access immunoassay are considered to provide similar results, but clarification of their suitability as an off-licence companion diagnostic for follitropin delta is required. STUDY DESIGN, SIZE, DURATION We systematically searched the existing literature for studies that had measured AMH using both automated assays in the same cohort of women. Individual paired patient data were acquired from each author and combined with unpublished data. PARTICIPANTS/MATERIALS, SETTING, METHODS We identified five eligible prospective published studies and one additional unpublished study. A 100% response from the authors was achieved. We collected paired AMH data on samples from 848 women. Passing–Bablok regression and Bland–Altman plots were used to compare the analytical performance of the two assays. The degree of misclassification to different treatment categories was estimated should the Access AMH be used as a companion diagnostic instead of the Elecsys AMH in determining the dosing of follitropin delta. MAIN RESULTS AND THE ROLE OF CHANCE The Passing–Bablok regression shows a linear relationship (Access = −0.05 + 1.10 × Elecsys). The Access assay systematically gave higher values by an average of 10% compared with the Elecsys assay (slope = 1.10, 95% CI: 1.09 to 1.12). The average of the difference between the two assays was 2.7 pmol/l. The 95% limits of agreement were −11.7 to 6.3. Overall 253 (29.3%) women would have received an inappropriate follitropin delta dose if the Beckman Coulter Access assay was used. Specifically, a substantial proportion of women (ranging from 49% to 90% depending on the AMH category) would receive a lower dose of follitropin delta based on the Access AMH assay. Up to 10% (ranging from 2.5% to 10%) of women with high ovarian reserve would have been misclassified to a greater dose of follitropin delta based on the Access AMH assay. LIMITATIONS REASONS FOR CAUTION We compared the values of the two principal automated assays, extrapolation of our findings to other automated AMH assays would require similar comprehensive examination. WIDER IMPLICATIONS OF THE FINDINGS An international standard for the calibration of the automated AMH assays is warranted to facilitate efficient use of AMH as a companion diagnostic. The variable calibration of alternative automated AMH assays may adversely impact on the performance of the follitropin delta dosing algorithm. STUDY FUNDING/COMPETING INTEREST(S) No formal funding has been received for this study. SI is funded by a UK Medical Research Council skills development fellowship (MR/N015177/1). SMN has received speakers fees, travel to meetings and participated in advisory Boards for Beckman Coulter, IBSA, Ferring Pharmaecuticals, Finox, Merck Serono, Merck and Roche Diagnostics. SMN has received research support from Ansh laboratories, Beckman Coulter, Ferring Pharmaceuticals and Roche Diagnostics

Les follicules antraux (maitrise de leur croissance et production d'hormone anti-müllérienne chez la femme)

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Valeur prédictive du dosage sérique de la FSH au 3ème jour d'un cycle "semi-naturel" en fécondation in vitro

PARIS-BIUM (751062103) / SudocCentre Technique Livre Ens. Sup. (774682301) / SudocSudocFranceF

Mesure automatique du follicule ovarien à l'aide de la technologie Sono AVC (faisabilité, précision et reproductibilité d'une approche novatrice)

La pratique de l échographie est un art difficile avec des variabilités intra et inter-opérateurs pouvant fausser les conclusions. L apport de nouveaux logiciels en échographie 3D permet déjà d améliorer la fiabilité et la reproductibilité des mesures.Nous avons testé sur la taille des follicules ovariens, le logiciel SonoAVC®, successeur du VOCAL®, permettant le calcul immédiat et automatique du volume, et qui améliorerait la fiabilité et reproductibilité et offrirait un gain de temps. Après des rappels sur le follicule pré ovulatoire, sur le monitorage de l ovulation et sur l échographie en 3D, nous rapportons 2 études sur la fiabilité par rapport au volume réel et la reproductibilité de cet outil en cycle naturel et en cycle stimulé. Nos résultats tendent à rendre obsolète la classique mesure du diamètre en 2D et laisse entrevoir une possible simplification du monitorage pour le praticien et pour les patientes. Des études sont en cours pour envisager d autres utilisations.Ultrasound examination is a difficult procedure with an high intra observer variability, which can lead to misdiagnosis. New softwares, especially those used for three-dimentionnal ultrasound scan, can improve the reability and the reproductibility of our measurements. We have experimented a new software, SonoAVC, that is a improved evolution of VOCAL, for the ovarian follicle measurement. This software allows a automated and immediate volume calculation. After recalls about pre ovulatory follicle, about ovulation monitoring, and about 3D ultrasound technology, we report two preliminary studies based on the reability and the reproduccibility of the calculation of the ovarian follicle size, using the SonoAVC software during natural and stimulated cycle. As compared to the usual two dimentionnal ultrasound measurement, three dimentionnel measurement of the folliclesize using a SonoAVC software, is easier and more precise; As compared to the VOCAL calculation, this procedure appears faster. Hence, SonoAVC calculation procedure could become, in the future, a major tool for the ovulation monitoring of patients in assisted reproductive technology programs.ST QUENTIN EN YVELINES-BU (782972101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Elévation prématurée de la progestérone en stimulation ovarienne (influence du type de gonadotrophine)

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

Régulation de la croissance folliculaire et de la production d'hormone anti-Müllérienne chez la femme

L hormone anti-Müllerienne (AMH), une glycopréotéine exclusivement produite par les cellules de la granulosa (CG) des follicules ovariens de la femme, est un marqueur unique de du statut folliculaire ovarien. Contrairement à l inhibine B, l estradiol et la FSH, l AMH est produite par un large éventail de follicules allant des follicules primaires aux follicules à petit antrum. Cependant, les mécanismes précis régulant la production d AMH par les CG restent mal connus. Nous avons montré que la sélection folliculaire précoce au cours de la phase de transition lutéo-folliculaire, un phénomène fréquemment retrouvé chez les femmes ayant un vieillissement ovarien, caractérisé par la présence d au moins un follicule surdéveloppé au cours de la phase folliculaire précoce, n altérait pas la puissance de la relation entre le compte folliculaire antral et les concentrations sériques d AMH. En revanche, cette situation perturbait significativement celle entre le nombre de follicules antraux et les taux sériques de FSH, d inhibine B et d estradiol. Nous avons par la suite mis en évidence, en utilisant un nouvel outil, nommé Follicular Output RaTe (FORT), que le pourcentage de follicules qui répondent effectivement à la FSH exogène en atteignant la maturation pré-ovulatoire, était négativement et indépendamment lié aux taux sériques d AMH, ce qui va dans le sens de l hypothèse d un effet inhibiteur de l AMH sur la sensibilité des follicules à la FSH. Ensuite, nous avons regardé si la production d AMH par ovaire et par follicule était altérée chez les femmes n ayant plus qu un seul ovaire suite à une ovariecomie unilatérale. En effet, tout indique que chez ces femmes, des réarrangements majeurs de la folliculogenèse sont mis en place pour maintenir une fonction ovarienne malgré la perte brutale d une partie du pool folliculaire. Ainsi, par une analyse extensive et comparative de la folliculogenèse utilisant des marqueurs hormono-folliculiares, nous n avons pu mettre aucune modification significative chez les femmes avec un ovaire unique, comparativement aux contrôles. A l aide du modèle précédemment utilisé, nous avons constaté une augmentation de la sensibilité des follicules antraux à la FSH exogène, évaluée par le FORT, chez des femmes avec un seul ovaire, comparativement aux femmes avec 2 ovaires. Ces résultats supportent l hypothèse d une augmentation de la sensibilité folliculaire à la FSH, qui pourrait faire partie des possibles mécanismes compensatoires en jeu dans le maintien d une folliculogenèse efficace chez les femmes ayant eu une ovariectomie unilatérale.Finalement, à l aide de 2 approches complémentaires, in vitro and in vivo, nous avons montré que la FSH et l AMPc stimulaient la transcription de l AMH, et que la LH avait un effet additif. Nous avons montré que les gonadotrophines et l AMPc agissaient à travers la protéine kinase A et la P38 MAP Kinase, impliquant notamment les facteurs de transcription GATA binding factor-4 et le steroidogenic factor-1. Par ailleurs, nous avons également mis en évidence que l expression d AMH pouvait être régulée de manière différentielle par l estradiol, en fonction du type de récepteur aux estrogènes exprimés par les CG. Ainsi, la chute d expression de l AMH au sein des CG des follicules matures, qui expriment essentiellement ERb, est probablement liée à un effet de l estradiol. En résumé, ces travaux de thèse ont permis d apporter de nouvelles données sur la régulation de la croissance folliculaire et sur la production d AMH chez la femme.Anti-Müllerian hormone (AMH), a glycoprotein that is exclusively produced by the granulosa cells (GC) of ovarian follicles in the adult female, is a unique biomarker of ovarian follicular status. In contrast with inhibin B, estradiol and FSH, AMH is produced in a wide range of follicles that goes from the primary to the small antral stages of folliculogenesis. However, the precise mechanisms that drive AMH expression by GC remain poorly understood.We showed that untimely and/or accelerated antral follicle growth during the luteal follicular transition, a phenomenon that is frequent in ovarian-aged women and that is characterized by the presence of at least one overdeveloped antral follicle during the first days of the follicular phase does not alter the strength of the relationship between antral follicle count and serum AMH levels but does affect the relationship between serum FSH, inhibin B and estradiol levels and the number of antral follicles. The heftiness of AMH in relation to advanced antral follicle growth provides a further explanation for the reported stronger association between serum AMH levels and antral follicle counts as compared with the other hormonal markers of the ovarian fertility status. We subsequently demonstrated, using an innovative tool, the Follicular Output RaTe (FORT), that the percentage of follicles that effectively respond to exogenous FSH by reaching pre-ovulatory maturation is negatively and independently related to serum AMH levels, which is in keeping with the hypothesis that AMH inhibits follicle sensitivity to FSH. Given this hypothesis, we wondered if per-ovary and per-follicle AMH production could be altered in patients having a single ovary as a result of unilateral oophorectomy. Indeed, all indicate that major rearrangements of folliculogenesis occur to preserve and maintain ovarian function despite the abrupt halving of follicular stockpile in these patients. We performed an extensive and comparative evaluation of the folliculogenesis using homono-follicular markers failing to show major changes in unilaterally oophorectomized when compared with control women. Using the same model, we demonstrated an increased antral follicle responsiveness to exogenous FSH, as assessed by FORT, in normo-ovulating unilaterally oophorectomized women undergoing controlled ovarian hyperstimulation. These results support the hypothesis that increased FSH sensitivity ranks among the possible compensating mechanisms at stake in the maintenance of successful folliculogenesis after unilateral oophorectomy.Finally, using complementary approaches, in vitro and in vivo, we showed that FSH and cAMP enhance AMH transcription, and LH has an additive effect. Gonadotropins and cAMP act through protein kinase A and p38 MAPK signaling pathways and involve the GATA binding factor-4 and steroidogenic factor-1 transcription factors, among others. The expression profile of AMH and the dynamics of serum AMH after gonadotropin stimulation have been interpreted as a down-regulating effect of FSH upon AMH production by GC. We also demonstrated that AMH expression can be differentially regulated by estradiol depending on the estradiol receptors by GC. Therefore the decrease in AMH expression by GC of mature follicles, which mainly express ERb, is likely due to the effect of estradiol.In short, this Ph.D. work offers new insight into the regulation of the follicular growth and AMH production in woman.PARIS11-SCD-Bib. électronique (914719901) / SudocSudocFranceF

Relação entre os níveis séricos do hormônio anti-Mulleriano, inibina B, estradiol e hormônio folículo estimulante no terceiro dia e o status folicular ovariano Relationship of serum anti-Müllerian hormone, inhibin B, estradiol and FSH on day 3 with ovarian follicular status

OBJETIVO: examinar a hipótese de que o nível sérico do hormônio anti-Mülleriano (HAM) reflete o status folicular ovariano. MÉTODOS: Desenho: estudo prospectivo. Pacientes: foram incluídas 101 candidatas à FIV-TE submetidas à estimulação ovariana controlada com agonista de GnRH e FSH. Depois de atingir a supressão da hipófise e antes da administração de FSH (dia basal), os níveis séricos de HAM, inibina B e FSH foram avaliados. O número de folículos antrais foi determinado pela ultra-sonografia (dia basal) (folículo antral precoce; 3-10 mm). RESULTADOS: as médias do nível sérico de HAM, inhibina B, E2, P4 e FSH (dia basal) foram 3,4±0,14 ng/mL, 89±4,8 pg/mL, 34±2,7 pg/mL, 0,22±0,23 ng/mL e 6,6±0,1 mUI/mL, respectivamente, e a média do número de folículos antrais precoces foi 17±0,39. O nível sérico do HAM foi negativamente correlacionado com a idade (r= -0,19, pPURPOSE: to examine the hypothesis that serum anti-Müllerian hormone (AMH) levels reflect the ovarian follicular status. METHODS: Design: prospective study. Patients: we studied 101 IVF-ET candidates undergoing controlled ovarian hyperstimulation with GnRH agonist and FSH. After the achievement of pituitary suppression and before FSH administration (baseline), serum AMH, inhibin B, and FSH levels were measured. The number of antral follicles was determined by ultrasound at baseline (early antral follicles; 3-10 mm). RESULTS: at baseline, median serum levels of AMH, inhibin B, E2, P4 and FSH were 3.42±0.14 ng/mL, 89±4.8 pg/mL, 34±2.7 pg/mL, 0.22±0.23 ng/mL and 6.6±0.1 mIU/mL, respectively, and the mean number of early antral follicles was 17±0.39. Serum levels of AMH were negatively correlated with age (r=-0.19, p<0.04), and positively correlated with number of antral follicles (r=0.65, p<0.0001), but this did not apply to serum levels of either inhibin B, E2 or FSH. CONCLUSION: the data demonstrate an association between AMH and antral follicular counts. Therefore, AMH is probable a biomarker of ovarian follicular status