The correlation of the antral follicle count and Serum anti-mullerian hormone.
ABSTRACT To compare the value of the basal serum anti-Müllerian hormone (AMH) level with most of the established ovarian reserve tests.
A total of 141 infertile women was studied prospectively. On cycle day 3, serum levels of AMH, inhibin B, estradiol (E), FSH and LH levels were measured, and the number of early antral follicles (2-6 mm in diameter) estimated at ultrasound scanning to compare the strengths of hormonal-follicular correlations.
The mean age of the participants was 29.18±5.54. The mean AMH and total AFC on day 3 were 2.23±1.90 ng/ml and 8.35±2.83, respectively. Serum AMH levels were more tightly correlated (p<0.001) with number of the early antral follicle count (r=0.467, p<0.0001) than age and serum levels of FSH (r=-0.400, p<0.001; r=-0.299, p<0.001 respectively). No correlation was detected between serum levels of inhibin B, E2, and LH (r=0.154, p=0.06; p=0.31; r=-0.085 and r=0.067, p=0.42) and AFC.
Serum AMH levels showed a strong correlation with AFC, and also this correlation is stronger than the other ovarian reserve parameters.
- [Show abstract] [Hide abstract]
ABSTRACT: The objective of the study is to determine and compare the levels of Anti-Mullerian hormone (AMH) and estradiol (E2) in serum and follicular fluid (FF) on the day of oocyte pick up (OPU) with the cycle parameters and the outcome of in vitro fertilization (IVF) treatment. The long stimulation protocol was used in 37 (86%) women; the microdose flare-up protocol was used in 6 (14%) women. Concentrations of AMH and E2 were measured in serum and FF of 43 women undergoing IVF treatment on the day of OPU. Significant positive associations were observed between serum AMH concentrations and the total number of oocytes retrieved (r=0.343, p=0.024). Serum AMH and FF AMH levels on the day of OPU were significantly increased in the group of women who achieved clinical pregnancy (p=0.017, p=0.028). For serum AMH, a cut-off level of 1.64 ng/ml was used for the prediction of clinical pregnancy; for FF AMH, a cut-off level of 3.8 ng/ml was used for the prediction of clinical pregnancy. Serum AMH and FF AMH levels were significantly and positively correlated with implantation rate (r=0.401, p=0.008; r=0.317, p=0.039). No significant correlation was found between serum and FF AMH concentrations and fertilization rate. Serum AMH and FF AMH concentrations are positively correlated with implantation and clinical pregnancy rates.Journal of the Turkish German Gynecological Association. 01/2012; 13(1):21-6.
The correlation of the antral follicle count and
Serum anti-mullerian hormone
Serum anti-mülleryan hormon ve antral folikül sayısı ilişkisi
Address for Correspondence / Yazışma Adresi: Uzm. Dr. Behiye Pınar Göksedef, Haseki Eğitim ve Araştırma Hastanesi, Kadın Doğum Kliniği, 34394 Aksaray, İstanbul, Turkey
Phone: +90 212 529 44 00 e.mail: firstname.lastname@example.org
Behiye Pınar Göksedef, Nurettin Idiş, Hüsnü Görgen, Yaprak Rüstemoğlu Asma, Murat Api, Ahmet Çetin
Haseki Teaching and Research Hospital, Obstetrics and Gynecology, Istanbul, Turkey
Objective: To compare the value of the basal serum anti-Müllerian
hormone (AMH) level with most of the established ovarian reserve
Material and Methods: A total of 141 infertile women was studied
prospectively. On cycle day 3, serum levels of AMH, inhibin B, estra-
diol (E), FSH and LH levels were measured, and the number of early
antral follicles (2-6 mm in diameter) estimated at ultrasound scanning
to compare the strengths of hormonal-follicular correlations.
Results: The mean age of the participants was 29.18±5.54. The mean
AMH and total AFC on day 3 were 2.23±1.90 ng/ml and 8.35±2.83, re-
spectively. Serum AMH levels were more tightly correlated (p<0.001)
with number of the early antral follicle count (r=0.467, p<0.0001) than
age and serum levels of FSH (r=-0.400, p<0.001; r=-0.299, p<0.001
respectively). No correlation was detected between serum levels of
inhibin B, E2, and LH (r=0.154, p=0.06; p=0.31; r=–0.085 and r=0.067,
p=0.42) and AFC.
Conclusion: Serum AMH levels showed a strong correlation with
AFC, and also this correlation is stronger than the other ovarian re-
serve parameters. (J Turkish-German Gynecol Assoc 2010; 11: 212-5)
Key words: Anti-mullerian hormone; ovarian reserve; antral follicle count
Received: 9 October, 2010 Accepted: 22 November, 2010
Amaç: Bu çalışmada basal serum bazal anti-Müllerian hormone
(AMH) seviyesinin diğer sık kullanılan over rezerv testleri ile karşılaş-
Gereç ve Yöntemler: Toplam 141 infertil kadın çalışmaya alındı.
Üçüncü gün serum AMH, inhibin B, östradiol (E2), FSH ve LH seviyele-
ri ölçümü ve ultrasonografik olarak erken antral folikül (2-6 mm çaplı)
sayımı yapılarak hormonal-foliküler korelasyon değerlendirildi.
Bulgular: Olguların ortalama yaşı 29.18±5.54 idi. Ortalama AMH
ve total AFC sırasıyla 2.23±1.90 ng/ml ve 8.35±2.83 olarak saptandı.
Serum AMH seviyesi ile erken antral folikül sayısı arasındaki korelas-
yon (r=0.467, p<0.0001), yaş ve serum FSH düzeyileri ile erken antral
folikül sayısı arasındaki korelasyondan (sırasıyla; r=-0.400, p<0.001;
r=0.299, p<0.001) daha güçlü idi (p<0.001). Serum inhibin B, E2,
ve LH seviyeleri ile AFC arasında korelasyon saptanmadı (r=0.154,
p=0.06; p=0.31; r=–0.085 and r=0.067, p=0.42).
Sonuç: Serum AMH seviyesi, AFC ile sıkı bir biçimde ilişkilidir ve aynı
zamanda bu ilişki diğer over rezervi değerlendirme parametrelerin-
den daha güçlüdür. (J Turkish-German Gynecol Assoc 2010; 11: 212-5)
Anahtar kelimeler: Anti-mülleryan hormon; over reservi; antral fo-
Geliş Tarihi: 09 Ekim 2010
Kabul Tarihi: 22 Kasım 2010
Ovarian reserve is described as the quantity of the ovarian fol-
licular cohort and quality of the oocytes (1). The assessment
of the ovarian reserve needs for identification of the response
of controlled ovarian stimulation (COH). This assessment
facilitates appropriate pretreatment counseling and modifi-
cation of an individual›s treatment protocol in an attempt to
maximize their potential response. Assessing an individual’s
ovarian reserve includes age, estradiol (E2) and basal follicle-
stimulating hormone (FSH) levels. Antral follicle count, serum
inhibin B levels, ovarian volume, and vascular resistance have
also been studied as markers of ovarian reserve. The antral
follicle count (AFC) have been widely used as the ovarian
reserve test, due to convenience of the ultrasonographic
tools usage. Follicle counts can be performed easily with the
help of the high quality resolution of the sonographic systems
(2-10). Although there are well-known difficulties to obtain
correct AFC such as high inter-observer differences and ana-
tomical variations (3), it has been suggested that the ability
of AFC to predict poor response might be significantly better
than basal FSH. Thus, AFC has been considered the “test of
first choice” by some investigators (2, 11).
Recently; serum anti-Mullerian hormone (AMH) has been
commonly studied as a potential new test for ovarian reserve.
AMH, also known as Mullerian-inhibiting substance, is a
dimeric glycoprotein that belongs to the transforming growth
factor-β family (12-15). Antimullerian hormone is secreted by
small antral follicles and in reproductive-aged women and
it is expressed by granulosa cells of the ovary (16). In the
ovary, AMH inhibits initial primordial follicles recruitment and
decreases the sensitivity of preantral and small antral follicles
to FSH and hence suggesting its role in intrafollicular and
interfollicular coordination of follicle development (17, 18).
Recently it has been shown that the higher AMH levels were
associated with the greater numbers of retrieved oocytes and
improved embryo morphology in the IVF cycles (10, 15, 19, 20).
There has been a controversary between the corelation of
the AFC and the other ovarian reserve tests such as age, AMH,
basal FSH, E2 and inhibin-B. Therefore, the aim of this study is
to investigate the correlation between AFC and age, AMH, basal
FSH, Estradiol (E2), LH and inhibin-B levels in a selected popu-
lation of women who were referred for the fertility treatment.
Materials and Methods
A total of 141 patients who were evaluated prior to their first treat-
ment cycle were prospectively included into our study based
on the following criteria: regular menstrual cycles (21-35 days),
presence of both ovaries, age less than 45 years. Subjects were
excluded if they had abnormal uterine bleeding, evidence of
endocrine disorders (normal thyroid stimulating hormone, pro-
lactin, testosterone and androstenedione), suboptimal visualiza-
tion of the ovary by transvaginal ultrasonography, an ovarian cyst
or follicle measuring 20 mm or more in diameter and a history
of ovarian surgery. The Institutional Review Board approval and
written informed consent were achieved for this study. On the
third day of the spontaneous cycle, all patients had a transvaginal
scan by the same investigator (N.I) using a GE General logiq 400
pro (GE medical systems, Korea CO., LTD. Sungdam Shi, KS)
5MHZ ultrasound probe to assess the number of antral follicles,
measuring 2-6 mm, as described previously (3). Each ovary was
measured in three planes and ovarian volume was calculated
using the prolate ellipsoid formula (V=D1xD2xD3x0.523). D1, D2
and D3 are being the three maximal longitudinal, antero-posteri-
or and transverse diameters, respectively (21). On the same day,
a venous blood sample was obtained for the measurement of
AMH, FSH, LH, E2 and inhibin B.
Measurement of serum AMH levels was performed using the
MIS/AMH enzyme-linked immunosorbent assay kit DSL (diag-
nostic systems laboratories, Inc./USA). Inhibin B was measured
using the Inhibin B enzyme-linked immunosorbent assay kit
(Diagnostic System Lab, Inc./USA). FSH, LH and E2 levels were
assessed in plasma with the AxSYM immunoanalyser (Abbott
Laboratories, Abbott Park, IL, USA).
Statistical analysis was performed using SPSS (version 13.0;
SPSS, Inc., Chicago, IL). The data was expressed by means and
the standard deviations. Relationship between two different
continuous variables was assessed by Pearson Correlation. The
Fisher r to z-test was used to determine if the coefficient of cor-
relation (r) was significantly different from zero. A p<0.05 was
considered as statistically significant.
The mean age of the participants was 29.18±5.54 (range
23-44) and 69.5% (n=98) of the patients had primary infertility.
The mean AMH and total AFC on day 3 were 2.23±1.90 and
8.35±2.83, respectively. Table 1 summarizes age, BMI mean of
the FSH, LH, E2, AMH, inhibin B and total AFC and the mean
ovarian volume of the participants.
Correlations of the number of antral follicles, the mean ovarian
volume, AMH and the others ovarian reserve parameters are
shown in Table 2. Unlike, inhibin B, serum levels of E2, and LH
(r=0.154, p=0.06; p=0.31; r=-0.085 and r=0.067, p=0.42), those
of age, AMH, and FSH were significantly correlated with the
number of early antral follicles on cycle day 3.
It is noteworthy that the correlation between number of early
antral follicles and serum AMH levels (r=0.467, p<0.0001) was
significantly stronger (p<0.0001) than age and serum levels
of FSH (r=-0.400, p<0.001; r=-0.299, p<0.001 respectively).
In addition to this, serum AMH levels showed a stronger cor-
relation (p<0.001) with the mean ovarian volume (r=0.373,
p<0.0001) than did those of age (r=-0.182, p=0.03), inhibin B
(r=0.180, p=0.03), E2 (r=0.079, p=NS), FSH (r=-0.276, p=0.001)
and LH (r=-0.005, p=NS). Incidentally, serum AMH levels were
significantly correlated with those of age (r=-182, p=0.03),
inhibin B (r=0.259, p=0.002) and FSH (r=-0.290, p<0.001), but
not with those of E2 and LH.
Table 1. The demographics and FSH, LH, E2, AMH, Inhi-
bin B, and AFC and the mean ovarian volume on day 3 of
Inhibin B (pg/ml)
Total AFC (n)
Mean ovarian volume
Table 2. Correlations of the number of antral follicles, the mean ovarian volume, AMH and the others ovarian reserve parameters
Inhibin B (pg/ml)
The Mean Ovarian
r p p r p
J Turkish-German Gynecol Assoc 2010; 11: 212-5
Göksedef et al.
Relationship of AMH and AFC213
The count of the number of antral follicles by ultrasonography
is the best predictor for the quantitative aspect of ovarian reserve
(22). There is no consensus on identification of the antral follicles
(2), however several evidence based studies suggested to select
the follicles as antral follicles based on a diameter measurement
as 2 to 10 mm. (3-10). It has been reported that human antral
follicles measuring <6 mm express the greatest amount of AMH,
and that levels decline with antral follicles increase in size (23).
Two to six mm antral follicles were defined as AFC in our study.
We observed that serum AMH levels are strongly related to early
AFC, with a significance that was remarkably stronger than age,
serum levels of inhibin B, E2, FSH and LH. Similar results were
found by the previous published studies about the relationship
between AMH and antral follicle count and the coefficients of
correlation were reported as stronger (0.71-0.74) than present
study (0.46) (24, 25). The correlation of AMH and the different
sizes of antral follicle was studied previously; the best correla-
tion was found between AMH and >5 to 6 mm size of AFC and
correlation coefficient (r) was reported as low as 0.41. These
different results may be explained by the lack of an international
assay standard for AMH measurements.
In our results; a negative relationship was observed between
FSH and total AFC and the ovarian volume. These data confirms
the hypothesis of a stimulating role of FSH on granulosa cells
on the antral follicle, caused by the dependency of FSH levels
on the negative feedback from E2 and possible different regula-
tion of AMH as compared with other hormonal parameters.
Although little is known about FSH effects on AMH expression
during the early follicular phase, it can be presumed that this
hormone is less FSH-sensitive than inhibin B and E2.
On the contrary of previous reports; no correlations were
detected between total AFC and inhibin B and E2 levels in this
study. This result could be explained by the modulator role of
FSH for inhibin B and E2. During the luteal-follicular transition,
the secretion of inhibin B and E2 by the early antral follicles
modulates their own stimulation by FSH (26, 27). This implies
that inhibin B and E2 levels depend not only on the bulk of active
granulosa cells available, as represented by follicular number
and sizes, but also on their stimulation by FSH. There are poten-
tial advantages of using AMH over AFC or the other parameters
because AMH can be measured throughout the cycle , in con-
trast to the other parameters, which can only be determined
in the early follicular phase (28, 29). Therefore, AMH may rep-
resent a more independent and reliable marker of early antral
follicle activity than inhibin B and E2, and FSH on cycle day 3.
As a conclusion, our results indicate that serum AMH levels are
strongly related with ovarian follicular status during the early
follicular phase, and also this relationship is more significant
than other ovarian reserve parameters. These results also
indicate that, serum AMH measurement is better predictor for
the number of early antral follicles than conventional hormone
measurements. This point may be helpful to refine future
clinical applications of AMH measurements in routine infertil-
ity work-up for evaluating the fertility potential and monitoring
Conflict of interest
No conflict of interest is declared by authors.
1. te Velde ER, Scheffer GJ, Dorland M, Broekmans FJ & Fauser BC.
Developmental and endocrine aspects of normal ovarian aging.
Molecular and Cellular Endocrinology 1998; 145: 67-73.
Hendriks DJ, Mol BW, Bancsi LF, te Velde ER, Broekmans FJ,
Antral follicle count in the prediction of poor ovarian response
and pregnancy after in vitro fertilization: a meta-analysis and
comparison with basal follicle-stimulating hormone level, Fertil
Steril 2005; 83: 291-301.
Bancsi LF, Broekmans FJ, Eijkemans MJ, de Jong FH, Habbema
JD, te Velde ER. Predictors of poor ovarian response in in vitro
fertilization: a prospective study comparing basal markers of
ovarian reserve, Fertil Steril 2002; 77: 328-36.
Chang MY, Chiang CH, Hsieh TT, Soong YK, Hsu KH. Use of the
antral follicle count to predict the outcome of assisted reproductive
technologies, Fertil Steril 1998; 69: 505-10.
Nahum R, Shifren JL, Chang Y, Leykin L, Isaacson K, Toth TL.
Antral follicle assessment as a tool for predicting outcome in IVF-
is it a better predictor than age and FSH?, J Assist Reprod Genet
2001; 18: 151-5.
Haadsma ML, Bukman A, Groen H, Roeloffzen EM, Groenewoud
ER, Heineman MJ et al. The number of small antral follicles (2-6
mm) determines the outcome of endocrine ovarian reserve tests
in a subfertile population, Hum Reprod 2007; 22: 1925-31.
Sharara FI, McClammrock HD. Antral follicle count and ovarian
volume predict IVF outcome, Fertil Steril 2000; 74: 176- 80.
Hsieh YY, Chang CC, Tsai HD. Antral follicle counting in predicting
the retrieved oocyte number after ovarian hyperstimulation, J
Assist Reprod Genet 2001; 18: 320-4.
Frattarelli JL, Levi AJ, Miller BT, Segars JH. A prospective assessment
of the predictive value of basal antral follicles in in vitro fertilization
cycles, Fertil Steril 2003; 80: 350-5.
10. Jayaprakasan D, Deb S, Batcha M, Hopkisson J, Johnson I, Campbell
B, et al. The cohort of antral follicles measuring 2-6 mm reflects the
quantitative status of ovarian reserve as assessed by serum levels
of anti-Müllerian hormone and response to controlled ovarian
stimulation. Fertil Steril, Epub 2010; 94: 1775-81.
11. Avril C, Antral follicle count and oocyte quality, J Gynecol Obstet
Biol Reprod 2006; 35: 42-3.
12. Van Rooij IA, Tonkelaar I, Broekmans FJ, Looman CW, Scheffer GJ,
de Jong H et al., Anti-mullerian hormone is a promising predictor
for the occurrence of the menopausal transition, Menopause 2004;
13. Van Rooij IA, Broekmans FJ, Scheffer GJ, Looman CW, Habbema
JD, de Jong H et al. Serum antimullerian hormone levels best
reflect the reproductive decline with age in normal women with
proven fertility: a longitudinal study, Fertil Steril 2005; 83: 979-87
14. 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
15. Seifer DB, Mac Laughlin DT, Christian BP , Feng B, Shelden RM.
Early follicular serum mullerian-inhibiting substance levels are
associated with ovarian response during assisted reproductive
technology cycles, Fertil Steril 2002; 77: 468-71.
16. Baarends WM, Uilenbroek JT, Kramer P , Hoogerbrugge JW, van
Leeuwen EC, Themmen AP et al. Anti-müllerian hormone and anti-
müllerian hormone type II receptor messenger ribonucleic acid
expression in rat ovaries during postnatal development, the estrous
cycle, and gonadotropin-induced follicle growth, Endocrinology
1995; 136: 4951-62.
17. Durlinger LL, Gruijters MJG, Kramer P , Karels B, Kumar TR, Matzuk
MM et al. Anti-Mullerian hormone attenuates the effects of FSH on
follicle development in the mouse ovary, Endocrinology 2001; 142:
J Turkish-German Gynecol Assoc 2010; 11: 212-5
Göksedef et al.
Relationship of AMH and AFC
18. Durlinger LL, Gruijters MJG, Kramer P Karels B, Ingraham HA,
Nachtigal MW et al. Anti-Mullerian hormone inhibits initiation of
primordial follicle growth in the mouse ovary, Endocrinology 2002;
19. Ficicioglu C, Kutlu T, Baglam E, Bakacak Z. Early follicular
antimüllerian hormone as an indicator of ovarian reserve, Fertil
Steril 2006;85: 592-6.
20. Silberstein T, MacLaughlin DT, Shai I, Trimarchi JR, Lambert-
Messerlian G, Seifer DB et al. Müllerian inhibiting substance levels
at the time of HCG administration in IVF cycles predict both ovarian
reserve and embryo morphology, Hum Reprod 2006; 21: 159-63.
21. Sharara FI, McClamrock HD. The effect of aging on ovarian volume
measurements in infertile women. Obstet. Gynecol.,1999; 94, 57-60.
22. Scheffer GJ, Broekmans FJ, Looman CW, Blankenstein M, Fauser
BC, de Jong FH et al. The number of antral follicles in normal
women with proven fertility is the best reflection of reproductive
age. Hum Reprod 2003: 18: 700-6.
23. Weenen C, Laven JS, von Bergh AR, Cranfield, M, Groome NP ,
Visser JA et al., Anti-Mullerian hormone expression pattern in the
human ovary: potential implications for initial and cyclic follicle
recruitment. Mol Hum Reprod 2004; 10: 77-83.
24. de Vet A, Laven, JS, de Jong FH, Themmen AP , Fauser BC.
Antimullerian hormone serum levels: a putative marker for ovarian
aging. Fertil. Steril 2002: 77: 357-62.
25. Fanchin R, Schonäuer LM, Righini C, Guibourdenche R, Taieb J.
Serum anti-Müllerian hormone is more strongly related to ovarian
follicular status than serum inhibin B, estradiol, FSH and LH on day
3. Hum Reprod 2003; 18: 323-7.
26. Welt CK, Martin KA, Taylor AE, Lambert-Messerlian GM, Crowley
WF, Jr, Smith JA, et al. Frequency modulation of follicle-stimulating
hormone (FSH) during the luteal-follicular transition: evidence for
FSH control of inhibin B in normal women. J. Clin. Endocrinol.
Metab. 1997; 82: 2645-52.
27. Mais V, Cetel NS, Muse KN, Quigley ME, Reid RL, Yen SS. Hormonal
dynamics during luteal-follicular transition. J. Clin. Endocrinol.
Metab 1987: 64; 1109-14.
28. JK Hehenkamp, CWN Loomans, APN Themmen, FH de Jong, ER
te Velde, FJM Broekmans. Anti-Mullerian hormone levels in the
spontaneous menstrual cycle do not show substantial fluctuation, J
Clin Endocrinol Metab 2006; 10: 4057-63.
29. A. La Marca, G. Stabile, AC Artenisio, A Volpe. Serum anti-Mullerian
hormone throughout the human menstrual cycle, Hum Reprod
2006; 21: 3103-7.
J Turkish-German Gynecol Assoc 2010; 11: 212-5
Göksedef et al.
Relationship of AMH and AFC215