AMH and measuring Ovarian reserve Professor W Hamish Wallace Consultant Paediatric Oncologist Edinburgh Scotland UK hamish.wallace@nhs.net
Ovarian Reserve?
The Wallace-Kelsey Model (Five parameter asymmetric double-gaussian cumulative curve) Wallace &Kelsey (2010) PloS ONE ESHRE Lille 2012
Ovarian reserve: Conception to Menopause Wallace &Kelsey (2010) PloS ONE
Percentage of NGF population remaining with increasing age Wallace &Kelsey (2010) PloS ONE
Ovarian reserve: Conception to Menopause Bella Anna Wallace &Kelsey (2010) PloS ONE
Prediction of Ovarian Reserve (AMH) Anti Mullerian Hormone (AMH) is an important product of the adult ovary produced by the granulosa cells of small growing follicles AMH has little variation across and between menstrual cycles AMH is the best currently available marker of the number of small-growing follicles in the ovary But there was no validated reference model for AMH available Anderson Nelson Wallace (2011) Maturitas
A validated model of serum antimullerian hormone (AMH) from conception to menopause Kelsey et al. PLoS ONE 2011
AMH: Normogram from birth to menopause The green and blue lines are the 68% and 95% prediction limits for the model Kelsey et al. PLoS ONE 2011
AMH in childhood cancer 3 AMH (ng/ml) 2.5 1.5 1.0 ** 0.5 0.0 22 girls age 0.3-15yr 17 prepubertal ** *** *** 1 3 Brougham et al 2012 JCE&M ** 2 0 AMH (ng/ml) AMH (ng/ml) 2.0 Medium/low risk Pre End Recovery High risk 2 1 0 Pre * ** End Recovery
AMH in 3 girls with cancer 1.0 3.0 Age 1.2; neuroblastoma AMH (ng/ml) 0.8 2.0 0.6 0.4 1.0 0.2 0.0 0 25 50 75 0.0 Age 2.4; rhabdomyosarcoma 0 50 100 150 200 Weeks 2.0 Age 14.6: Hodgkin s lymphoma 1.5 1.0 0.5 0.0 0 50 100 Weeks 150 Brougham et al 2012 JCE&M
Summary AMH is detectable before puberty AMH falls rapidly during cancer treatment in both pre-pubertal and pubertal girls AMH levels recover in those patients at low/medium risk of gonadotoxicity AMH fails to recover in those at high risk. This could be indicative of future reproductive impairment Brougham et al 2012 JCE&M
Pretreatment anti-müllerian hormone predicts for loss of ovarian function after chemotherapy for early breast cancer. sensitivity 98.2% specificity 80.0% for correct classification of amenorrhoea n=75 Anderson and Cameron 2011 JCE&M Anderson et al 2013 Eur J Cancer
EuroNet-PHL-C1 Dirk Fertility Interim Analysis for EuroNet-PHL After discussion in Leipzig - 2015-10-23 - Hamish Girls with Wallace Richard Anderson & Christine MauzKörholz 2015-11-04
Analysis Set Fertility in Girls 2111 patients in study 1098 boys 1013 girls 439 No fertility assessment 574 girls At least one PG form 15
AnyPB NoPB Total A 13 33 46 B 7 0 7 CH 19 13 32 CZ 22 0 22 D 213 114 327 DK 3 4 7 E 21 25 46 F 189 57 246 GB 22 119 141 Missing Fertility Data AnyPG NoPG Total by Country 13 33 46 A B CH CZ D DK E F GB IRL N NL PL S SK SLO Sum 7 19 22 213 3 21 189 22 1 14 4 26 11 9 0 574 0 13 0 114 4 25 57 119 21 3 13 12 14 10 1 439 7 32 22 327 7 46 246 141 22 17 17 38 25 19 1 1013 Dear Dirk This is because in the UK this was a study that was separately consented for (outside of the trial itself) - called the Fertility Study with its own Information Sheets and ICFs which was under the wings of Hamish. According to my understanding it had to be separate to the main C1 trial in UK because of all the ethical issues surrounding the information collected in the context of a treatment protocol. Therefore the issue is not one of a backlog of data but in fact a low level of recruitment to this separate Fertility Study. Kind regards Janis 16
Analysis Set Fertility in Girls II 574 girls At least one PG form 407 girls PG form at staging 373 patients PB form at FU 206 girls PG form both Staging and FU Note: Missing values in relevant variables further reduce sample size. 17
Valid data for Follow up FU only if more than 6 months after end of treatment including RT Not yet fully implemented treatment used 12 months since start of Valid only if girl post-pubertal:= Tanner stage (Rounded mean) 2+ for hormone analysis Assume Tanner stage does not decrease (in dealing with missing Tanner stage). Assume post-pubertal if Age at FU > 16 years If the patient has multiple valid FU PBs the latest assessment is taken. 610 FU PGs in 373 patients Alternatives: The time point nearest at 24 month after end of treatment Worst case after 6 months 18
Tanner stage and Age 19
Age at Menarche 20
FSH - Effect of taking the pill 21
LH - Effect of taking the pill 22
Oestradiol - Effect of taking the pill 23
Inhibin B - Effect of taking the pill 24
FSH (postpubertal FU ) 25
LH (postpubertal FU ) 26
Oestradiol (postpubertal FU ) 27
Inhibin B (postpubertal FU ) 28
Ovarian insufficiency Richard Anderson: suspect ovarian insufficiency if FSH > 25 IU/l while Oestradiol < 200 nmol/l 29
High FSH while low on Oestradiol 30
Suspicion of Ovarian Insufficiency OEPA OEPA-COPDAC OEPA-COPP Sum noalarm OvarianInsufficency? Sum 89 1 90 88 2 90 64 15 79 241 18 259 ############ COPP versus COPDAC ONLY 2-sample test for equality of proportions with continuity correction X-squared = 11.2827 df = 1 p-value = 0.00078 alternative hypothesis: two.sided 95 percent confidence interval: 0.064 0.271 sample estimates: prop 1 prop 2 0.190 0.022 31
EuroNet-PHL-C1 Dirk 2nd Fertility Interim for EuroNet-PHL After discussion in Leipzig 2015-10-23 Analysis Boys with Hamish Wallace Richard Anderson & Christine MauzKörholz 2015-11-03
Analysis Set Fertility in Boys 2111 patients in study 1013 girls 1098 boys 489 No fertility assessment 609 patients At least one PB form 33
Missing Fertility Data AnyPB NoPB by Country Total A B CH CZ D DK E F GB IRL N NL PL S SK SLO Sum 17 8 10 29 231 4 16 195 24 0 16 4 34 16 5 0 609 25 9 9 1 136 5 43 45 125 19 6 13 26 15 11 1 489 42 17 19 30 367 9 59 240 149 19 22 17 60 31 16 1 1098 Dear Dirk This is because in the UK this was a study that was separately consented for (outside of the trial itself) - called the Fertility Study with its own Information Sheets and ICFs which was under the wings of Hamish. According to my understanding it had to be separate to the main C1 trial in UK because of all the ethical issues surrounding the information collected in the context of a treatment protocol. Therefore the issue is not one of a backlog of data but in fact a low level of recruitment to this separate Fertility Study. Kind regards Janis 34
Analysis Set Fertility in Boys II 609 patients At least one PB form 417 patients PB form at staging 403 patients PB form at FU 214 patients PB form both Staging and FU Note: Missing values in relevant variables further reduce sample size. 35
Valid data for Follow up FU only if more than 6 months after end of treatment including RT Valid only if boy post-pubertal:= Tanner stage (Rounded mean) 4+ Assume Tanner stage does not decrease (in dealing with missing Tanner stage). Assume post-pubertal if Age at FU > 16 years If the patient has multiple valid FU PBs the latest assessment is taken. 655 FU PBs in 403 patients Alternatives: The time point nearest at 24 month after end of treatment Worst case after 6 months 36
Tanner stage and Age 37
FSH (postpubertal FU ) 38
LH (postpubertal FU ) 39
Testosterone (postpubertal FU ) 40
Inhibin B (postpubertal FU ) 41
Expected Correlation: FSH Inhibin B 42
Expected Correlation: LH - Testosterone 43
Sperm analysis OEPA OEPA-COPDAC OEPA-COPP Sum normosperm 20 not-azoosperm 8 azoosperm 21 Sum 49 6 12 2 3 3 2 0 3 18 9 18 22 Pearson's Chi-squared test Note: Possible selection: Semen analysis in high FSH (?) data: tttt X-squared = 26.6769 df = 4 p-value = 2.31e-05 44
Sperm analysis OEPA OEPA-COPDAC OEPA-COPP Sum not-azoosperm 28 azoosperm 21 Sum 49 "############ 9 15 4 0 3 18 9 18 22 COPP versus COPDAC ONLY" 2-sample test for equality of proportions with continuity correction X-squared = 14.3399 df = 1 p-value = 0.0001526 95 percent confidence interval for Note: Possible selection: Semen analysis in difference: -0.933391-0.359842 high FSH (?) 45