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Clomifene administration when AMH is low

Clomifene citrate (Clomid) has been the first-line treatment for nearly 50 years for women suffering from infertility due to very irregular or complete lack of ovulation and have normal estrogen levels. It has the advantage of being taken in tablet form and being relatively cheap. Clomifene will induce ovulation in 75-80% of suitable women and about half of these conceive. The chances for conception following clomifene treatment are influenced by a number of factors. These include body mass index (BMI), LH concentrations, insulin levels and, of course, female age. The higher the value of each of these factors, the lower the chance, statistically, of pregnancy and subsequent live birth.

Anti-Mullerian hormone (AMH) has become a new addition to this equation. AMH is produced by the small follicles in the ovary (mainly those between a size of 2-9mm) and reflects the number of such follicles in the ovaries. Women with polycystic ovaries have about 6-times the number of such follicles in their ovaries compared to women with normal ovaries and it therefore no surprise that their AMH levels are high. Recent research suggests that AMH may interfere with the normal process by which ovulation occurs by disrupting the action of FSH which is vital for the growth of follicles pre-destined to ovulate. By producing a discharge of FSH clomifene may restore the balance and, by overcoming the deleterious actions of AMH, is capable of inducing ovulation. While all this is still theoretical rather than proved, it does seem that the higher the AMH level, the less the chance of success in inducing ovulation with clomifene.

This adds to the supposition that, regarding polycystic ovary syndrome (PCOS), the higher the AMH levels, the more small follicles in the ovary, the more serious the symptoms. This holds true for the degree of ovulatory disturbance and the consequences of high androgen production by the ovaries. The AMH concentration may also well be an indicator of the chances of successfully inducing ovulation with Clomid.

Roy Homburg, Anil Gudi, Amit Shah

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