`The Relation between Follicular Fluid Anti-Müllerian Hormone (AMH), Oocyte Maturation and Embryo Development in Intracytoplasmic Sperm Injection (ICSI) Cycles

Abstract

Placing the human ovum with spermatozoa outside the women and transferring the resulting embryo to her uterus is a relatively recent and rapidly evolving approach to overcome human fertility problems. The first reports of implantation and pregnancy following the use of this technique in human were published during the 1970s. Since then, the techniques known as in vitro fertilization (IVF) and embryo transfer (ET), have resulted in new insights into gamete interactions and early embryonic development, as well as numerous pregnancies. However, IVF tends to be less successful for the treatment of male factor infertility than the treatment of tubal factor infertility (Tourney et al., 1992).

Intracytoplasmic sperm injection (ICSI) is now one of the most successful and viable techniques in assisted fertilization (Nagy et al., 1995). In those who have no identifiable or correctable causes, ICSI provides new hope for infertility (Chow et al., 2006). Human oocyte maturation is considered as the reinitiation and completion of the first meiotic division from the germinal vesicle stage (prophase I) to metaphase II, and the accompanying cytoplasmic maturation necessary for fertilization and early embryonic development. The cytoplasm of the oocyte is of key interest in oocyte maturation. The best way to improve embryo quality is to improve oocyte quality. (Kwang et al., 1998).

Oocyte quality affects early embryonic survival, the establishment and maintenance of pregnancy and fetal development. Quality, or developmental competence, is acquired during folliculogenesis as the oocyte grows, and during the period of oocyte maturation (Krisher, 2004). Determination of oocyte and embryo quality are one of the most important goals of embryologists in human IVF. Several methods are employed for determining oocyte and embryo quality(Revelli et al., 2009). Biochemical characteristics of the follicular fluid play an important role in the prediction of oocyte quality, fertilization and ultimately the embryo quality in noninvasive methods (Revelli et al., 2009). Anti-mullerian hormone (AMH) is one member of transforming growth factor (Das et al., 2008). AMH plays a fundamental role in gonadal differentiation during fetal period and inhibits the formation of mullerian ducts in male fetus (La Marca et al., 2009). AMH is secreted by the ovarian granulosa cells into blood flow and follicular fluid in adult female, although its concentration is much higher in the follicular fluid (La Marca et al., 2009). AMH production is independent of FSH and inhibits FSH-induced follicular growth (Ebner et al., 2006). It also has a direct autocrine paracrine effect on the granulosa cells, oocyte function and embryo quality (Silberstein et al., 2006). Follicular fluid anti-mulerian hormone (FF AMH) level is probably a marker of the qualitative and quantitative activity of granulose cells (Feyereisen et al., 2006). Although some studies have showed the relationship between the level of serum AMH, and quality of oocyte and embryo(Ebner et al., 2006)., there are few studies about the relationship existing between these factors and FF AMH level (Feyereisen et al., 2006).

This study aimed to assess the relation between follicular fluid AMH, oocyte maturation, fertilization and emberyo grading. Eighty five Infertile women with unexplained infertililty undergoing ICSI, were recruited from Ain Shams University Maternity Hospitals (ART unit) assisted reproductive technology unit, during the period between December 2012 to October 2014. Each patient’s follicular fluid sample was collected from one follicle with a diameter greater than 18 mm, The AMH level of every respective follicular fluid was measured using a second-generation ELISA, Oocytes was evaluated and graded, the fertilization of each oocyte was assessed using a microscope 18-20 hours following IVF following IVF, and quality of embryo was assessed before embryo transfer by the embryo score. Our study found that, the age of the studied population ranged from 22 to 35 years old, the mean age was 31.2±3.3years, while the duration of infertility ranged from1.5 to 18 years, with mean duration 7.8±4.4 years, also the body mass index ranged from 22 to 43, the mean BMI was28.8±4.3. In this study, the FF AMH (follicular fluid) level per follicle ranged from 1.1 to 5.8 ng/ml, the mean level was 3.1±1.3 ng/ml. We also found the antral follicular count (AFC) ranged from 3 to 20 follicle, the mean number was 9.9±3.4 follicles.The duration of ovarian stimulation ranged from 8 to 21 days , the mean duration was 12.1±2 days.The mean dose of HMG was 49.5±13.4 ampoules, the mean time to oocyte retrieval was14.1±2days. In this study the number of retrieved oocyte ranged from 0 to 22 oocyte per patient, with mean number 8.4±5 oocyte were retrieved, while the number of produced embryos per patient ranged from 0 to 12 embryo with mean number 4.7±3.2 embryo. Most of the patients 56 (65.9%) had 1ry infertility while 29 patient (34.1%) had 2ry infertility. The majority of the produced oocytes were grade MII maturation 53 oocyte (63.9%) , while GV and MI were ( 12 ,18 ) oocyte (14.5 , 21.7)% respectively, also 88.7% of the produced oocyte were fertilized and 11.3% were not fertilized ,most of the produce embryos 58.7% were grade 1 maturation while grade 2,3,4 represente (15.9,14.3,11.1)% respectively. We found no significant correlation between FF AMH and age , duration of infertility , BMI (body mass index ) and other hormonal profile. We found negative correlation between FF AMH, duration of ovarian stimulation and time to Oocyte retrieval. But there was positive correlation between FF AMH ,oocyte maturation, fertilization, number of produced embryos and embryo grading. Oocytes are more likely to be fertilized when follicles are able to make high concentrations of AMH in the follicular fluid. Thus, AMH could be a prediction marker for fertilization. In our study there was highly significant correlation between FF AMH and successful fertilization with p-value 0.0001. FF AMH with cut-off value >1.2 ng/ml could be used as single independent factor for prediction of successful fertilization. FF AMH associated with MII oocyte was significantly higher compared with GV, MI oocyte, with p-value <0.001. FF AMH with cut-off value >3.4 ng/ml could be used as single independent factor for prediction of production of MII Oocytes. FF AMH level associate grade I embryo was significantly higher compared with grade II-IV, with p-value 0.006. FF AMH with cut-off value >4 ng/ml could be used as single independent factor for prediction of grade I embryo