Lack of Serum Anti-Mullerian Hormone Responses After Recombinant Human Chorionic Gonadotropin Stimulation in Women With Polycystic Ovary Syndromeby Heidi Cook-Andersen, Sandy S. Chuan, Kevin Maas, Marcus A. Rosencrantz, H. Irene Su, Mark Lawson, Helen D. Mason, R. Jeffrey Chang

The Journal of Clinical Endocrinology & Metabolism


Lack of Serum Anti-Mullerian Hormone Responses

Following Recombinant Human Chorionic

Gonadotropin Stimulation in Women with Polycystic

Ovary Syndrome

Heidi Cook-Andersen1, Sandy S. Chuan1, Kevin Maas1, Marcus A. Rosencrantz1,

H. Irene Su1, Mark Lawson1, Helen D. Mason2, and R. Jeffrey Chang1 1Department of Reproductive Medicine, University of California, San Diego, LA Jolla California 92093; 2Clinical Development Sciences and Basic Medical Sciences, St. George’s University of London, London

SW17 ORE, United Kingdom

Context: Polycystic ovary syndrome (PCOS) is an anovulatory disorder characterized by excess androgen production and increased luteinizing hormone (LH) secretion. Serum anti-Mullerian hormone (AMH) is also elevated in this disorder. Women with PCOS exhibit a positive correlation between AMH and LH levels and recent in vitro data demonstrate that LH can directly stimulate

AMH production by granulosa cells from women with PCOS.

Objective: To directly test whether LH increases AMH production in women with PCOS in vivo by assessing responses after recombinant human chorionic gonadotropin (r-hCG) stimulation.

Design: Prospective study.

Setting: Research center at an academic medical center.

Participants: Women with PCOS (n  28) and normal controls (n  29).

Interventions:Blood sampleswere obtainedbefore and 24hours after intravenous administration of 25 mcg r-hCG.

Main Outcome Measures: Basal and stimulated serum AMH, androstenedione (A4), testosterone (T), and 17-hydroxyprogesterone (17-OHP) levels.

Results: Baseline AMH levels in women with PCOS were greater than in normal controls and correlated with levels of LH as well as A4, T and 17-OHP. A rise of serum AMH levels was not observed following r-hCG administration in women with PCOS or normal ovaries.

Conclusion: These findings are in contrast to in vitro evidence demonstrating AMH secretion by granulosa cells of PCOS women in response to LH stimulation and suggest AMH regulation in vivo is complex and that theelevated serumAMH inwomenwithPCOS is not adirect effect of theexcess

LH production characteristic of PCOS.

It has been well documented that womenwith polycysticovary syndrome (PCOS) have elevated serum levels of anti-Mullerian hormone (AMH) (1–11). AMH is a member of the transforming growth factor-ß superfamily of peptides and is producedbygranulosa cells (GCs)of growingpreantral and early antral follicles. Several studies have shown thatAMHlevels are strongly correlatedwith antral follicle number. Accordingly, increased circulating AMH inwomenwithPCOShas generally been attributed tohigh antral follicle numbers associated with this disorder.

ISSN Print 0021-972X ISSN Online 1945-7197

Printed in U.S.A.

Copyright © 2014 by the Endocrine Society

Received July 16, 2014. Accepted October 2, 2014.



E n d o c r i n e R e s e a r c h doi: 10.1210/jc.2014-2948 J Clin Endocrinol Metab 1

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Despite these observations, the precise mechanism of increasedAMHproduction inwomenwithPCOSremains unknown. AMH levels in women with PCOS have generally been found to correlate positively with circulating

A4 and T levels and anovulation and negatively with serum FSH and BMI (4, 7, 9, 10, 12–18) although a few studies have not found these associations (17, 19, 20). In addition, studies evaluating the effects of FSH, androgens, or insulin on AMH levels have had either negative or inconsistent findings (2, 3, 9, 16, 20–23).

Recently, however, a large amount of accumulating data, both in vitro and in vivo, strongly suggests that LH acts to stimulateAMHproduction.Direct LH stimulation of GCs isolated from antral follicles from unstimulated ovaries from women with PCOS resulted in a 4-fold increase in AMH production by the GCs; no significant increase was seen fromGCs from normal ovaries (22). Similar increases in AMH expression were also seen after in vitro LH stimulation of luteinized GCs from oligo/anovulatory women with PCOS, but again not from GCs from normal ovaries (21, 24). In addition, a close examination of the circadian variation in hormone production in PCOS and normal women revealed a significant positive covariation between AMH and LH levels (but not other hormone measures) and that the circadian secretion of AMH and LH was linked, with a failure of LH and AMH levels to drop overnight in women with PCOS as observed in controls (25).Many other studies have also demonstrated a positive correlation between serumAMH levels and LH levels in women with PCOS (2, 15, 17, 20, 26, 27) although this correlation was not found in some studies (8, 9). Despite the strong in vitro evidence that LH stimulates

AMH production and the associative correlations that link these hormones, the possibility of adirect causal effect of LH on AMH production has not been directly tested in women with PCOS.

In the current study, we sought to determine whether

LH stimulation of AMH production, as clearly observed in vitro, can also be detected in vivo by assessing serum

AMH and androgen responses to r-hCG stimulation in women with PCOS and normal women.

Subjects and Methods


Twenty-eightwomenwithPCOSand29normalwomenwere recruited. PCOS subjects exhibited clinical and/or biochemical evidence of hyperandrogenism and were either oligomenorrheic or amenorrheic. Oligomenorrhea was defined as irregular menstrual bleeding occurring less than six times a year. Each PCOS subject had an antral follicle count per ovary of greater than 12, with no follicle that exceeded 9 mm in diameter and the vast majority being 2–5 mm in size. Normal women also had no follicles greater than 10 mm in diameter. Three-dimensional ultrasonography was performed for a subset of the subjects (12

PCOS and 10 controls) before beginning the study in order to obtain a more accurate antral follicle count than is possible with 2D-ultrasound for calculation of AMH levels per antral follicle.