Traditional endocrine evaluation (gonadotropins, inhibin B, and estradiol) remains as the preferred diagnostic tool for this condition, but AMH appears to be a promising marker of ovarian response in idiopathic HH patients with induced menstrual cycles [70]
Traditional endocrine evaluation (gonadotropins, inhibin B, and estradiol) remains as the preferred diagnostic tool for this condition, but AMH appears to be a promising marker of ovarian response in idiopathic HH patients with induced menstrual cycles [70]. treatment with alkylating gonadotoxic brokers. Lastly, its usefulness has been proposed in the diagnosis of polycystic ovarian syndrome (PCOS) and ovarian granulosa cell tumors and in the evaluation of patients with hypogonadotropic hypogonadism. == 1. Introduction == Anti-Mllerian hormone (AMH), also known as Mllerian inhibiting material, is essential for the involution of the Mllerian ducts (the anlagen of the internal female genitalia) in the male fetus [13]. Male sex differentiation is completely dependent on the normal development of testes that produce ample amounts of testosterone and AMH. The two hormones, produced by Leydig cells and Sertoli cells, respectively, represent two unique pathways in male sex differentiation. Testosterone is responsible for the differentiation of the Wolffian ducts, the urogenital sinus, and the external genitalia. By contrast, AMH does not have any known function in female fetal organogenesis. Determination of the serum AMH concentration is used in various ways in clinical pediatrics to determine the presence of testicular tissue in patients with cryptorchidism, suspected anorchia, or more severe Disorders of Sex Development (DSD). Also, AMH may be used as a marker of premature ovarian insufficiency (POI). It has FG-2216 been proposed as a marker in polycystic ovarian syndrome (PCOS) [4], as a tumor weight marker in ovarian granulosa cell tumors [5] and, lastly, in hypogonadotropic hypogonadism [6]. This paper gives a brief overview of the physiology of AMH and seeks to give clinicians a tool when interpreting results from different assays. The aim is to simplify the use of AMH in clinical pediatrics. == 2. Expression and Regulation of AMH == AMH is usually produced by Sertoli and granulosa cells in the male and female, respectively. AMH is usually a member FG-2216 of the TGF-family and is encoded by theAMHgene, which contains 5 exons [7] and is located on chromosome 19 p13.3 [8] (seeFigure 1for an iconography of the gene). The hormone binds to the specific AMH type II receptor (AMH-RII), which is usually encoded by a gene found on chromosome 12 p13 (seeFigure 1for an iconography of the gene) [9]. The receptor is a single transmembrane protein with serine-threonine kinase activity, and it is present on the cell membrane of target organs (including the mesenchymal cells of the Mllerian ducts, the granulosa cells of the ovary, and the Sertoli and Leydig cells of the testis) [10]. == Figure 1. == Mutations of theAMHgene (Case 1) and theAMH-RIIgene (Case 2) in two families with boys presenting with PMDS. Two missense mutations in exons 1 and 2 (substitution of alanine by proline and of tyrosine by cysteine, resp.) were found in theAMHgene in two brothers presenting with AMH-negative PMDS. A homozygous missense mutation in exon 9 (substitution of aspartic acid by tyrosine) in theAMH-RIIgene was found in two brothers presenting with AMH-positive PMDS. Several genes play FG-2216 a role in the regulation of AMH production from Sertoli cells. TheSRYgene, for example, is important for the activation ofSOX9, which together with steroidogenic factor 1 (SF1) and DAX1 directly stimulates the expression ofAMHin the fetal testes [14,15]. == 3. Male and Female Serum FG-2216 AMH Reference Ranges == We have previously reported serum AMH reference ranges for males and females throughout the entire lifespan measured on the Immunotech Coulter assay [11,12], (Figure 2). At birth, male cord blood has FG-2216 high levels of AMH (mean 148 pmol/L), whereas AMH is undetectable (54%) or very low (95% CI: <216) in cord sera from female infants. At three months of age, AMH levels increase markedly in both sexes, although the concentrations in females (mean 13 pmol/L) remain much lower compared to concentrations in male infants (mean 1047 pmol/L). During childhood, AMH levels are relatively stable in both sexes, boys having approximately 35 times higher levels than girls. == Figure 2. == Serum AMH in 1953 healthy subjects (926 females and 1027 males) according to age. Females: red circles, males: blue circles. Longitudinal values during infancy are connected with grey lines. The red and blue curves represent the female and male reference ranges, respectively (median, 2SD). The figure was redrawn from our previously published data using Immunotech Coulter enzyme immunometric assay in all subjects [1113]. Please note the logarithmicy-axis. They-axes for the DSL and Gen II assays were created using the following formulas: AMH (IOT) pmol/L = 2.0 AMH (DSL) ug/L 7.14 pmol/ug and AMH (IOT) pmol/L = HDAC6 0.74 AMH (Gen II) ug/L 7.14 pmol/ug. Until pubertal onset, AMH is consequently a sensitive and specific marker of Sertoli cell activity. With the onset of testosterone synthesis in male puberty, serum AMH levels decline rapidly (mean 50.
