DRG INTERNATIONAL, INC.Where medical needs meet innovation

Note: Unless otherwise stated in our catalog or other company documentation accompanying DRG International, Inc. product(s), these assay kits are intended for research use only (RUO) in the United States.

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03/04/2014

AMH BEYOND IVF: RAISING THE BAR IN REPRODUCTIVE HEALTH DIAGNOSTICS

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What is AMH?

• 140 kDa glycoprotein• produced during normal

embryogenesis by the Sertoli cells of the embryonic testis

• causes involution of the Müllerian duct in developing males. It inhibits female gonadogenesis by inducing apoptosis of target gonadal cells

• TGF-β super family hormone with paracrine control functions in folliculogenesis

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AMH: Direct Measure of Ovarian Reserve

Antonio Lamarca chart

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Research on AMH, including potential clinical utility, is increasing rapidly

IVF / Ovarian response and OHSS

POF

POA

POI

Oncofertility

Ovarian surgery

Gonadotoxicity

Menopause

PCOS

Granulosa cell tumors

Hypogonadotropic hypogonadism

Non-obstructive azoospermia

Neonatal gender determination

What’s next?

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Primary Research Areas

Click icon to add picture

Reproductive function and pregnancy complications• Comprehensive line of

assays to TGF-beta superfamily hormones that play key roles in folliculogenesis

• Classical and novel maternal screening markers for chromosomal anomalies, preeclampsia, IUGR, and gestational diabetes

Reproductive Function• AMH • Inhibin A• Inhibin B• Total Inhibin• Follistatin• Activin A

Pregnancy• Inhibin A• AFP• I-hCG• Unconjugated

Estriol (UE3)• PAPP-A• PAPP-A2

Coming soon! • IGFs / BPs

• Activin B • Activin AB

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Predictability of AMH

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Predictability of AMH

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AMH is not cycle-day dependent

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FSH indirect, cycle day dependent

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FSH is a Surrogate Marker of Ovarian Reserve

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Simple utility of direct ovarian markers

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Introduction to PCOS• Polycystic ovary syndrome (PCOS) is one of the most

common endocrine disorders among females.• PCOS affects 6-12% of women of reproductive age. • In a population like India, that number represents >50 million

females with PCOS in varying degrees of severity, largely influenced by obesity.

• PCOS is comprised of a number of different medical conditions which can sometimes make definitive diagnosis difficult.

• The one common finding that determines PCOS is polycystic ovaries. This makes AMH an important biochemical feature of PCOS.

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Learning Objectives

After this session participants will be able to:

1. explain polycystic ovary syndrome,

2. explain the most common criteria for diagnosing PCOS,

3. discuss AMH as a marker of PCOS, and

4. describe the benefits of assessing AMH for the diagnosis of PCOS.

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What is Polycystic Ovary Syndrome (PCOS)

• A condition in which a woman has an imbalance of female (and male) sex hormones.• menstrual cycle changes, • cysts in the ovaries, • difficulty getting pregnant / infertility, and • other health changes.

• Ovaries unable to release mature, competent oocyte.  • PCOS is typically diagnosed in women in their 20s or 30s; it also

affects teenage girls. The symptoms often begin when a girl's periods start.

• Enlarged ovaries containing numerous small cysts can be detected by ultrasound, but polycystic ovaries alone do not confirm the diagnosis though.

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Symptoms• Most common includes changes in

the menstrual cycle: amenorrhea or irregular periods (MCL and heaviness)

• PCOS can cause virilization• Body hair on chest, belly, and face• Decreased breast size• Enlargement of the clitoris (rare)• Thinning of the hair on the head, i.e.,

male-pattern baldness• Voice gets deeper

• Skin changes:• Acne that gets worse• Dark or thick skin markings and

creases around the armpits, groin, neck, and breasts

• Obese

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Polycystic Ovary MorphologyAntral follicles can be seen lining the periphery of the ovary, appearing as a 'string of pearls' on ultrasound examination.

In PCOS, these antral follicles are in a state of arrested development due to a disruption of normal folliculogenesis. These follicles 2-8mm in size produce the highest concentrations of AMH.

PCO defined by one or both ovaries having 12 or more 2-8 mm follicles and/or an ovarian volume of >10ml

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Health conditions associated with PCOSWomen with PCOS are more likely to develop:

Infertility

Insulin resistance

Type 2 diabetes

Weight gain and obesity

Metabolic Syndrome

High blood pressure

High cholesterol

Cardiovascular diseases

Inflammation

Endometrial cancer

Breast cancer (slightly increased risk)

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Elevated AMHin PCOSFIG. 1. Box-and-whisker plots showing the values of serum AMH (1ng/ml 7.14 pmol/liter) and 2- to 5-mm follicle number in patients with PCOS (n 59) and in controls (n 45). Horizontal small bars represent the 10–90th percentile range, and the boxes indicate the 25th-75th percentile range. The horizontal line in each box corresponds to the median.

PASCAL PIGNYET.AL The Journal of Clinical Endocrinology & Metabolism 88(12):5957–5962

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AMH in PCOSAnti-Müllerian hormone (AMH) before and 5 years after in anovulatory and ovulatory group and control subjects

Fertility and SterilityVolume 98, Issue 4 , Pages 1043-1046, October 2012

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Literature Suggested Patient Stratification

AMH (pmol/L)

AMH (ng/mL)

Status DxAFC

(approx)Tx

50 7.00PCOS

50 Antagonist Control Agonist Trigger

40 5.60 40

30 4.20 3020 2.80 2415 2.10 1810 1.40 12

7 0.98 105 0.70 Reduced

ResponseSub-

fertility7

Flare agonist

1 0.14Neglible Infertility

2 Flare Agonist / Tertiary actions

Normal Response

High ResponseAntagonist Control hCG

Agonist Trigger

Fertility Long Down-regulation Agonist Control

Optimal Fertility

• Individualization of treatment based on subjective ovarian response categories

• Treatment strategies should be designed to minimize risk while maximizing oocyte yield

• The suggested AMH / antral follicle count (AFC) thresholds are based on the correlation of AMH and AFC and the associated response obtained from literature.

• These are not population specific, and this should be an important consideration.

Adapted from: Nelson. Biomarkers of ovarian response. Fertil Steril 2013.

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Differences between commercial assays Feature DRG International, Inc. Other Commercially Available AssayCapture Ab specific for a linear epitope on the pro

region not impacted by cleavagedirected against the mature (or is it Pro?) region, which appears to be a conformational epitope impacted by different sample collection and handling conditions and/or naturally occurring protein processing

Detection Ab specific for a linear epitope on the mature region not impacted by cleavage

directed against the mature region and a conformational epitope, which appears to be impacted by changes in sample conditions and cleavage, or both

Specificity Human specific Antibodies derived against rec human AMH, but have significant cross-reactivity with many species (especially bovine, chicken, rat, mouse, pig, etc.)

Calibration (Ag) rec human AMH, mammalian (CHO cell)-derived

Bovine serum AMH

Interference None known Complements, and heterophilic antibodies (animal IgG, especially bovine)

Dilution Dilutes linearly from >75ng/mL to Limit of Detection

Do not dilute. Company reports to not dilute over 10 ng/mL because the samples will over recover. Affects PCOS and neonatal gender determinations.

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Summary of PCOS• Polycystic ovary syndrome affects between 6 and 12% of all women of reproductive

age worldwide. Some geographies report as high as 18% prevalence!

• Over 70% of PCO / PCOS women are undiagnosed!

• PCOS can be treated, if diagnosed. Periodic checks, repeat diagnostic testing is prescribed.

• According to the Revised Rotterdam Criteria (most common criteria used for assessment of PCOS) a patient must demonstrate two out of the three listed criteria: 

• Oligo- or amenorrhea• hyperandrogenism, and • evidence of polycystic ovary (usually determined by ultrasound).

• Common finding that determines PCOS is polycystic ovaries, which makes AMH an

important biochemical feature of PCOS.

• Because AMH is produced by the granulosa cells of ovary, elevated AMH levels indicate a polycystic ovary even when an accurate antral follicle count cannot be obtained, and in the absence of hyperandrogenism and/or anovulation.

• AMH is consistently >2x greater in PCOS than in non-PCO age-matched controls

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Conclusion• The DRG International, Inc. assay

methods offer clear analytical and clinical performance advantages over other commercially available assays.

• The DRG International, Inc. assay addresses the challenges raised regarding the reliability of AMH testing due to interferences and lab-to-lab variability presumably due to sample handling.

• The increased sensitivity and accuracy throughout the wide-physiological range of AMH makes the DRG International, Inc. assay useful for broader applications in gynecological assessment of patients.

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