Iranian Society of Gynecology Oncology

Document Type : Original Research Article


Department of Obstetrics and Gynecology, College of Medicine, University of Al-Qadisiyah, Al-Diwaniyah Province, Iraq


Background: Endocrine disorders like polycystic ovarian syndrome affect reproductive-age women. It causes infertility and has several clinical symptoms. Clomiphene citrate ovulation induction is a first-line treatment. Serum anti-Mullerian hormone can indicate positive pregnancy outcomes in women with this disease, however this is controversial. To assess the value of anti-Mullerian hormone (AMH) as an anticipator of ovary response to clomiphene citrate in patients with “polycystic ovary syndrome (PCOS).
Methods: A cross-sectional study of 50 women diagnosed with Rotterdam-based polycystic ovarian syndrome by two gynecologists was conducted. The Maternity and Pediatric Teaching Hospital in Diwaniyah Province, Iraq, conducted the study from August 1, 2022, to May 15, 2023, at the obstetrics and gynecology department. Women with diabetes or hypertension were excluded from the trial. These women sought medical treatment for infertility and received clomiphene citrate to induce ovulation. The findings of hCG urine and blood testing divided women into positive and negative biochemical pregnancy groups.
Results: The mean FSH of all recruited women was 5.19±1.14 IU/L, with no significant difference between pregnant and non-pregnant women (p = 0.849). AMH levels were significantly lower in pregnant women compared to non-pregnant women (p< 0.001). The mean AMH was 6.97±2.88 ng/ml for all enrolled women. ROC curve research determined the optimal AMH cutoff value for predicting positive biochemical pregnancy: ≤6.5 ng/ml with 100% sensitivity, 67.7% specificity, and 80.9 % accuracy.
Conclusion: Serum anti-Mullerian hormone accurately predicts pregnancy success in PCOS women taking clomiphene citrate to induce ovulation.


Main Subjects

1. Ndefo UA, Eaton A, Green MR. Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches. Pharm Ther. 2013;38(6):336-55. [PMID] [PMCID]
2. Sadeghi HM, Adeli I, Calina D, Docea AO, Mousavi T, Daniali M, et al. Polycystic Ovary Syndrome: A Comprehensive Review of Pathogenesis, Management, and Drug Repurposing. Int J Mol Sci. 2022;23(2):583. [DOI:10.3390/ijms23020583] [PMID] [PMCID]
3. Zeng LH, Rana S, Hussain L, Asif M, Mehmood MH, Imran I, et al. Polycystic Ovary Syndrome: A Disorder of Reproductive Age, Its Pathogenesis, and a Discussion on the Emerging Role of Herbal Remedies. Front Pharmacol. 2022;13:874914. [DOI:10.3389/fphar.2022.874914] [PMID] [PMCID]
4. Spritzer PM, Barone CR, Oliveira FB. Hirsutism in Polycystic Ovary Syndrome: Pathophysiology and Management. Curr Pharm Des. 2016;22(36):5603-13. [DOI:10.2174/1381612822666160720151243] [PMID]
5. Rababa'h AM, Matani BR, Yehya A. An update of polycystic ovary syndrome: causes and therapeutics options. Heliyon. 2022;8(10):e11010. [DOI:10.1016/j.heliyon.2022.e11010] [PMID] [PMCID]
6. Abbott DH, Dumesic DA, Levine JE. Hyperandrogenic origins of polycystic ovary syndrome-implications for pathophysiology and therapy. Expert Rev Endocrinol Metab. 2019;14(2):131-43. [DOI:10.1080/17446651.2019.1576522] [PMID] [PMCID]
7. Abruzzese GA, Silva AF, Velazquez ME, Ferrer MJ, Motta AB. Hyperandrogenism and Polycystic ovary syndrome: Effects in pregnancy and offspring development. WIREs Mech Dis. 2022;14(5):e1558. [DOI:10.1002/wsbm.1558] [PMID]
8. Chang S, Dunaif A. Diagnosis of Polycystic Ovary Syndrome: Which Criteria to Use and When? Endocrinol Metab Clin North Am. 2021;50(1):11-23. [DOI:10.1016/j.ecl.2020.10.002] [PMID] [PMCID]
9. Smet ME, McLennan A. Rotterdam criteria, the end. Australas J Ultrasound Med. 2018;21(2):59-60. [DOI:10.1002/ajum.12096] [PMID] [PMCID]
10. Abdalqader MM, Hussein SS. Metastatin as a Marker for Hyperandrogenemia in Iraqi Women with Polycystic Ovary Syndrome. Obstet Gynecol Int. 2020;2020:5216903. [DOI:10.1155/2020/5216903] [PMID] [PMCID]
12. Giri A, Joshi A, Shrestha S, Chaudhary A. Metabolic Syndrome among Patients with Polycystic Ovarian Syndrome Presenting to a Tertiary Care Hospital: A Descriptive Cross-Sectional Study. JNMA J Nepal Med Assoc. 2022;60(246):137-41. [DOI:10.31729/jnma.7221] [PMID] [PMCID]
13. Cunha A, Póvoa AM. Infertility management in women with polycystic ovary syndrome: a review. Porto Biomed J. 2021;6(1):e116. [DOI:10.1097/j.pbj.0000000000000116] [PMID] [PMCID]
14. Sawant S, Bhide P. Fertility Treatment Options for Women With Polycystic Ovary Syndrome. Clin Med Insights Reprod Health. 2019;13:1179558119890867. [DOI:10.1177/1179558119890867] [PMID] [PMCID]
15. Melo AS, Ferriani RA, Navarro PA. Treatment of infertility in women with polycystic ovary syndrome: approach to clinical practice. Clinics (Sao Paulo). 2015;70(11):765-9. [DOI:10.6061/clinics/2015(11)09]
16. Dennett CC, Simon J. The role of polycystic ovary syndrome in reproductive and metabolic health: overview and approaches for treatment. Diabetes Spectr. 2015;28(2):116-20. [DOI:10.2337/diaspect.28.2.116] [PMID] [PMCID]
17. Practice Committee of the American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril. 2013;99(1):63. [DOI:10.1016/j.fertnstert.2012.09.023] [PMID]
18. Sahmay S, Aydogan Mathyk B, Sofiyeva N, Atakul N, Azemi A, Erel T. Serum AMH levels and insulin resistance in women with PCOS. Eur J Obstet Gynecol Reprod Biol. 2018;224:159-64. [DOI:10.1016/j.ejogrb.2018.03.007] [PMID]
19. Artini PG, Obino MER, Sergiampietri C, Pinelli S, Papini F, Casarosa E, et al. PCOS and pregnancy: a review of available therapies to improve the outcome of pregnancy in women with polycystic ovary syndrome. Expert Rev Endocrinol Metab. 2018;13(2):87-98. [DOI:10.1080/17446651.2018.1431122] [PMID]
20. Morley LC, Tang T, Yasmin E, Norman RJ, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2017;11(11):Cd003053. [DOI:10.1002/14651858.CD003053.pub6] [PMID] [PMCID]
21. Xu XL, Deng SL, Lian ZX, Yu K. Estrogen Receptors in Polycystic Ovary Syndrome. Cells. 2021;10(2):459. [DOI:10.3390/cells10020459] [PMID] [PMCID]
22. Tang ZR, Zhang R, Lian ZX, Deng SL, Yu K. Estrogen-Receptor Expression and Function in Female Reproductive Disease. Cells. 2019;8(10):1123. [DOI:10.3390/cells8101123] [PMID] [PMCID]
23. Vyrides AA, El Mahdi E, Giannakou K. Ovulation induction techniques in women with polycystic ovary syndrome. Front Med (Lausanne). 2022;9:982230. [DOI:10.3389/fmed.2022.982230] [PMID] [PMCID]
24. Nishii S, Ezoe K, Nishihara S, Onogi S, Takeshima K, Karakida S, et al. Association between endometrial thickness before ovulation, live birth, and placenta previa rates in clomiphene citrate-treated cycles. AJOG Glob Rep. 2023;3(1):100161. [DOI:10.1016/j.xagr.2023.100161] [PMID] [PMCID]
25. Montenegro IS, Kuhl CP, Schneider RA, Zachia SA, Durli I, Terraciano PB, et al. Use of clomiphene citrate protocol for controlled ovarian stimulation impairs endometrial maturity. JBRA Assist Reprod. 2021;25(1):90-6. [DOI:10.5935/1518-0557.20200056] [PMID] [PMCID]
26. Unfer V, Facchinetti F, Orrù B, Giordani B, Nestler J. Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials. Endocr Connect. 2017;6(8):647-58. [DOI:10.1530/EC-17-0243] [PMID] [PMCID]
27. Nuttall FQ. Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutr Today. 2015;50(3):117-28. [DOI:10.1097/NT.0000000000000092] [PMID] [PMCID]
28. Sachdeva G, Gainder S, Suri V, Sachdeva N, Chopra S. Prediction of Responsiveness to Clomiphene Citrate in Infertile Women with PCOS. J Reprod Infertil. 2019;20(3):143-50.
29. Xi W, Yang Y, Mao H, Zhao X, Liu M, Fu S. Circulating anti-mullerian hormone as predictor of ovarian response to clomiphene citrate in women with polycystic ovary syndrome. J Ovarian Res. 2016;9:3. [DOI:10.1186/s13048-016-0214-2] [PMID] [PMCID]
30. Gülşen MS, Ulu İ, Yıldırım Köpük Ş, Kıran G. The role of anti-Müllerian hormone in predicting clomiphene citrate resistance in women with polycystic ovarian syndrome. J Gynaecol Endocrinol. 2019;35(1):86-9. [DOI:10.1080/09513590.2018.1499085] [PMID]
31. Vagios S, Sacha CR, Hammer KC, Dimitriadis I, James KE, Bormann CL, et al. Response to ovulation induction treatments in women with polycystic ovary syndrome as a function of serum anti-Müllerian hormone levels. J Assist Reprod Genet. 2021;38(7):1827-33. [DOI:10.1007/s10815-021-02217-x] [PMID] [PMCID]
32. Bordewijk EM, Weiss NS, Nahuis MJ, Kwee J, Lambeek AF, van Unnik GA, et al. Gonadotrophins or clomiphene citrate in women with normogonadotropic anovulation and CC failure: does the endometrium matter? Hum Reprod. 2020;35(6):1319-24. [DOI:10.1093/humrep/deaa052] [PMID] [PMCID]
33. Moazami Goudarzi Z, Fallahzadeh H, Aflatoonian A, Mirzaei M. Laparoscopic ovarian electrocautery versus gonadotropin therapy in infertile women with clomiphene citrate-resistant polycystic ovary syndrome: A systematic review and meta-analysis. Iran J Reprod Med. 2014;12(8):531-8.
34. Toosy S, Sodi R, Pappachan JM. Lean polycystic ovary syndrome (PCOS): an evidence-based practical approach. J Diabetes Metab Disord. 2018;17(2):277-85. [DOI:10.1007/s40200-018-0371-5] [PMID] [PMCID]
35. Karnatak R, Agarwal A, Asnani M, Singh R. The Effect of Insulin Resistance on Ovulation Induction With Clomiphene Citrate in Non-polycystic Ovary Syndrome (PCOS) Women. Cureus. 2022;14(7):e27433. [DOI:10.7759/cureus.27433] [PMID] [PMCID]
36. Moolhuijsen LME, Visser JA. Anti-Müllerian Hormone and Ovarian Reserve: Update on Assessing Ovarian Function. J Clin Endocrinol Metab. 2020;105(11):3361-73. [DOI:10.1210/clinem/dgaa513] [PMID] [PMCID]
37. Bedenk J, Vrtačnik-Bokal E, Virant-Klun I. The role of anti-Müllerian hormone (AMH) in ovarian disease and infertility. J Assist Reprod Genet. 2020;37(1):89-100. [DOI:10.1007/s10815-019-01622-7] [PMID] [PMCID]
38. Hager M, Hörath S, Frigo P, Koch M, Marculescu R, Ott J. Changes in serum markers of patients with PCOS during consecutive clomiphene stimulation cycles: a retrospective study. J Ovarian Res. 2019;12(1):91. [DOI:10.1186/s13048-019-0564-7] [PMID] [PMCID]
39. Hestiantoro A, Negoro YS, Afrita Y, Wiweko B, Sumapradja K, Natadisastra M. Anti-Müllerian hormone as a predictor of polycystic ovary syndrome treated with clomiphene citrate. Clin Exp Reprod Med. 2016;43(4):207-14. [DOI:10.5653/cerm.2016.43.4.207] [PMID] [PMCID]