title: Clinical pregnancy in a woman with idiopathic hypogonadotropic hypogonadism and low AMH: utility of ovarian reserve markers in IHH.
abstract: OBJECTIVE
  Serum anti-mullerian hormone (AMH) has been proposed as a useful marker of ovarian reserve that is cycle-independent and predictive of outcome in assisted reproduction cycles. However, there is evidence that AMH production is gonadotropin-dependent, and that under the influence of FSH, growing follicles contribute to circulating AMH levels. Therefore, AMH testing may not be universally reflective of the primordial follicle pool in certain conditions. We demonstrate that in patients with idiopathic hypogonadotropic hypogonadism (IHH) and deficient gonadotropin production, AMH and antral follicle count (AFC) may not be reliable markers of ovarian reserve.
  
  
  METHODS
  Case report.
  
  
  METHODS
  Fertility clinic at a tertiary academic hospital.
  
  
  METHODS
  A 30-year-old nulligravid patient with IHH who presented for fertility treatment with low FSH (0.3 IU/L), LH (0.1 IU/L), estradiol (77 pmol/L) and AMH levels (0.65 pmol/L), and an unmeasurable AFC.
  
  
  METHODS
  A three-month course of priming with oral micronized 17β-estradiol, followed by daily injections of human menopausal gonadotropins (hMG).
  
  
  METHODS
  AMH level and follicular development.
  
  
  RESULTS
  After 60 days of stimulation with hMG, the patient's AMH level increased to a peak of 1.27 pmol/L. After 102 days of stimulation, her estradiol level rose to 480 pmol/L and a 19 mm dominant follicle was detected. The patient successfully conceived with intrauterine insemination.
  
  
  CONCLUSIONS
  Ovarian reserve testing in patients with IHH can be challenging due to the contracted appearance of the ovaries and deficient FSH production. In these patients, AMH levels may underestimate ovarian reserve due to the lack of FSH-dependent growing follicles. When treated with a long course of hMG, these patients may exhibit increased AMH levels and demonstrate adequate follicular development.
authors.affiliation: Centre for Fertility and Reproductive Health, Mount Sinai Hospital, 7th floor, 250 Dundas Street West, Toronto, ON, M5T 2Z5, Canada, cryssie.chan@mail.utoronto.ca.
authors.forename: Crystal
authors.initials: C
authors.lastname: Chan
authors.forename: Kimberly
authors.initials: K
authors.lastname: Liu
mesh_terms: D000328:Adult; D054304:Anti-Mullerian Hormone / Q000097:blood*; D015415:Biomarkers / Q000097:blood*; D004958:Estradiol / Q000097:blood; D005260:Female; D005298:Fertility / Q000502:physiology; D005307:Fertilization in Vitro / Q000379:methods; D005640:Follicle Stimulating Hormone / Q000097:blood; D006062:Gonadotropins / Q000097:blood; D006801:Humans; D007006:Hypogonadism / Q000097:blood*; D006080:Ovarian Follicle / Q000502:physiology; D065851:Ovarian Reserve / Q000502:physiology; D010062:Ovulation Induction / Q000379:methods; D011247:Pregnancy
chemical_list: D015415:Biomarkers; D006062:Gonadotropins; D004958:Estradiol; D054304:Anti-Mullerian Hormone; D005640:Follicle Stimulating Hormone
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