Serum Anti-mullerian Hormone as a Predictor of Metaphase Ii Oocyte Yield During Controlled Ovarian Stimulation in a Private Fertility Clinic in Nairobi, Kenya

Abstract

Background: Treatment of infertility is a major global problem which has remained a challenge in many ways. The cornerstone of in vitro fertilization (IVF), which forms the end point in care of infertile couples, is controlled ovarian stimulation (COS). However, predictability of outcomes has remained elusive despite identification of several biomarkers. Metaphase II (MII) oocytes are the mandatory prerequisite to IVF. However, there appears to be no relevant studies that focus on prediction of MII outcomes as an indicator of the potential for fertilization in patients that are undergoing IVF. This study focuses on the value of serum AMH in predicting MII oocyte outcomes in women undergoing COS. Objective: To determine the role of serum AMH as a predictor of Metaphase II (MII) oocyte yield during controlled ovarian stimulation in a private fertility clinic in Nairobi. Methodology: Retrospective descriptive cohort study that compared the processes in ovarian stimulation (OS) that culminate in production of MII oocytes in subjects with normal and low serum AMH. It was done at a private fertility clinic in Nairobi. Odds ratios (OR) and p values were used to compare the outcomes of OS between the two groups. Results: Among those who had normal serum AMH levels, 17(28.2%) were aged more than 35 years as compared to19 (73.1%) among those who had low serum AMH (OR 0.1, 95%CI 0.1-0.4, p value <0.001). Normal response (5 to 14 follicles) on day 5 predominated in both groups but it was more preponderant among those with low AMH (normal AMH with 34 (57.6%) of the patients compared with 17 (65.4%) among those with low AMH, OR 0.7, CI 0.3-1.9, p<0.001). However, hyper response (>15 follicles) occurred in 23 (39.0%) and 1 (3.8%) respectively (OR 15.9, CI 2.0-126.1, p<0.001) for normal and low serum AMH respectively. The pattern was similar on day 7 follicular count. Normal total oocyte harvest (5 - 14) occurred in 24 (40.7%) of patients with normal serum AMH compared to 9 (34.6%) among those with low AMH (OR 1.3, 95% CI 0.5 – 3.4, p value 0.597); while 24 (40.7%) and 1 (3.8%) of those with normal and low serum AMH respectively had > 15 oocytes (OR 17.0, 95% CI 2.2 – 135.2, p value <0.001). There were 19 (73.1%) of patients with low serum AMH who had low MII oocyte yield compared to 16 (27.1%) in patients with normal serum AMH (OR 0.3, 95% CI 0.1-0.8, p value 0.014) and this difference persisted after controlling for age. Among those with normal serum AMH, 30 (50.8%) had MII oocyte yield between 5 to 14 oocytes compared to 7 (26.9%) of patients with low serum AMH

(OR 2.8, 95% CI 1.0-7.7, p value 0.040) whereas 13 (22.1%) of patients with normal serum AMH had MII oocyte yield of more than 15 oocytes compared to none in patients with low serum AMH. The sensitivity, specificity, positive and negative predictive values of serum AMH as a predictor of MII oocyte yield were 86.0%, 54.3%,72.96% and 73.1% respectively. The trend was similar for total oocyte harvest. Conclusion: Serum AMH is a qualitative and quantitative predictor of MII oocyte yield as well as the preceding total oocyte harvest and follicular count. Hence, the levels of serum AMH can be used to provide counselling on possible outcomes of COS.