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Antimüllerian Hormone in Patients with Hypogonadotropic Hypogonadism

Service d’Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre (J.Y., B.C., P.C., G.S.), 94270 Kremlin Bicêtre and Unité de Recherches sur l’Endocrinologie du Développement (INSERM U 493), Ecole Normale Supérieure (R.R., N.J.) 92120 Montrouge, France

Address all correspondence and request for reprints to: Gilbert Schaison, M.D., Service d’Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre 94270 Kremlin Bicêtre, France.

	Abstract

Top Abstract Introduction Patients and Methods Results Discussion References

 
Antimüllerian hormone (AMH) is produced by immature Sertoli cells until pubertal maturation. At puberty, elevation of serum testosterone correlates with a decrease in serum AMH. To further investigate the hormonal control of AMH secretion, serum AMH levels were measured in 20 normal men (20–60 yr), in 12 patients (19–30 yr) with congenital hypogonadotropic hypogonadism (CHH), and in 18 patients (19–65 yr) with acquired hypogonadotropic hypogonadism (AHH) either untreated or during testosterone or human chorionic gonadotropin (hCG) therapy. Mean serum AMH levels in normal adult men were low (20 ± 4.9 pmol/L). In untreated CHH patients, mean serum AMH levels were significantly higher than in normal men (292 ± 86 pmol/L, P < 0.001) and were similar to those previously reported in prepubertal boys. In men with AHH, mean serum AMH levels were also significantly increased (107 ± 50 pmol/L; P < 0.01) when compared with healthy men but were less than in men with CHH. In addition, in 10 patients treated for prostate cancer, a modest but significant increase of serum AMH (from 11.4 ± 5.7 pmol/L to 49 ± 9.9 pmol/L; P < 0.01) was observed 12 months after suppression of the gonadal axis with the GnRH agonist Triptorelin (3.75 mg IM once a month).

Plasma testosterone (T) and serum AMH levels were measured at baseline and at 3 and 6 months in 10 HH patients (6 CHH and 4 AHH) treated with hCG (1500 IU/twice weekly for 6 months) and in 8 HH (4 CHH and 4 AHH) patients treated with T (T enanthate 250 mg/3 weeks for 6 months). hCG treatment induced an increase of plasma T (from 1.0 ± 0.7 to 11 ± 2.4 and 19 ± 4.8 nmol/L, at 3 and 6 months respectively) associated with a dramatic decrease of serum AMH (from 314 ± 93 to 56 ± 30 and 17 ± 4.3 pmol/L). The similar increase in plasma T levels (from 1.4 ± 1.0 to 15.6 ± 4.2 and 23 ± 6.2 ng/mL) obtained with exogenous T induced a lesser decrease of serum AMH (from 221 ± 107 pmol/L to 114 ± 50 and 66 ± 17 pmol/L, at 3 and 6 months respectively).

In conclusion, high plasma AMH levels in CHH patients are related to the absence of pubertal maturation of Sertoli cells. The high AMH levels in AHH and its increase after Triptorelin-induced gonadotropin deficiency suggest that the suppression of AMH is a reversible phenomenon. Finally, the inhibition of AMH production by Sertoli cells is induced by intratesticular T.

	Introduction

Top Abstract Introduction Patients and Methods Results Discussion References

 
ANTIMÜLLERIAN hormone (AMH), also known as Müllerian inhibiting substance (MIS), is a testicular hormone, secreted by immature Sertoli cells and responsible for the regression of Müllerian ducts in male fetuses (1). The timing of the expression of the AMH gene is now well known (1, 2). AMH is the earliest secretory product of the Sertoli cells in the fetal testis. It is synthesized during fetal and post-natal life and decreases progressively thereafter until puberty. In previous studies, it has been shown that elevation of plasma testosterone (T) correlates with a decrease in serum AMH levels during normal or central precocious puberty (3, 4). This inverse relationship between T and AMH is also present in boys with gonadotropin-independent precocious puberty (3), suggesting that testosterone, and not gonadotropin, is implicated in AMH downregulation.

AMH is measurable in human serum and has diagnostic applications in pediatric endocrinology as a specific marker of immature Sertoli cell number and function (5, 6, 7). In the present study, the aims were 1) to study AMH secretion in adult men with untreated hypogonadotropic hypogonadism (HH); 2) to evaluate the reversibility of AMH suppression in post-pubertal men; and 3) to specify in the human the inhibitory effect of intratesticular testosterone on AMH secretion. A sensitive and specific enzyme linked immunosorbent assay (ELISA) was used to measure serum AMH in patients with congenital or acquired HH, either untreated or during T or human chorionic gonadotropin (hCG) therapy.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Discussion References

 
Subjects

Twelve untreated men age 19–30 yr with congenital hypogonadotropic hypogonadism (CHH), either idiopathic (n = 6) or due to Kallmann’s syndrome (n = 6), were selected at the time of in-patient admission for diagnosis and choice of therapy. The diagnosis criteria for CHH included the following: failure to undergo spontaneous puberty, low testicular volume, and normal cranial imaging of the hypothalamic-pituitary area. Patients were considered to have Kallmann’s syndrome if anosmia was also present. In addition, all patients had low plasma T levels and low gonadotropin plasma levels with apulsatile LH profile. Basal and stimulated levels of cortisol and of other anterior pituitary hormones in response to CRH, GHRH, and TRH were normal.

Eighteen men (age range, 19–65 yr) with acquired HH (AHH) and hypopituitarism were studied. The pituitary deficiency was the consequence of hypothalamic or nonfunctional pituitary tumors treated by surgery and/or radiotherapy. All these patients received replacement thyroxine and hydrocortisone therapy before entry in the study. None had received GH replacement therapy or exogenous T before admission.

Ten patients (age range, 60–69 yr old) treated for prostate cancer with the GnRH agonist Triptorelin (Ipsen-Biotech, Paris, France) were studied. Normal volunteers included twenty men, 19–60 yr of age, whose reproductive parameters (testicular volume, plasma LH, FSH, and testosterone levels) were normal. Clinical and laboratory characteristics of patients and controls are given in Table 1.

Study design

In untreated HH patients testicular volume was measured using the Prader orchidometer (Pharmacia, St. Quentin en Yvelines, France).

At in-patient admission, a blood sample was drawn in all hypogonadal subjects to determine baseline serum AMH and plasma T levels before begining hCG or T therapy.

Ten HH patients (4 AHH and 6 CHH) received hCG therapy (1500 U, im, twice weekly) for 6 months. Blood samples for measurement of serum AMH and plasma T levels were drawn at 3 and 6 months of hCG treatment.

Eight other HH patients (4 AHH and 4 CHH) received testosterone treatment (Tenanthate, Schering, Zys-lez-Lannoy, France, 250 mg, im, at 3-week intervals). Blood samples for measurement of serum AMH and plasma T levels were drawn at 3 and 6 months of T treatment.

In the ten eugonadal patients treated for prostate cancer, blood samples for measurement of serum AMH and T levels were drawn before and 12 months after functional suppression of the gonadal axis with the GnRH agonist Triptorelin (3.75 mg DTrp-6, im, once a month).

Assays

Plasma T levels were measured by RIA after chromatography on a celite column as previously described (8). Serum AMH levels were measured by enzyme-linked immunosorbent assay, as previously described (3); the lower limit of detection was 0.4 ng/mL, inter- and intraassay coefficients of variation were 13.8% and 7.04%, respectively.

Statistical analyses

The data are presented as the mean ± SD. Differences were considered statistically significant when P < 0.05. For comparison between groups, the nonparametric rank order test of Kolmogorov-Smirnov was used (9). The nonparametric Wilcoxon rank order paired test was used to compare serum AMH levels before and after hCG and T treatments in HH patients and to compare serum AMH levels before and after Triptorelin treatment in eugonadic patients with prostate cancer. Spearman’s rank correlation procedure was carried out to define serum AMH that correlated significantly with testicular volume.

	Results

Top Abstract Introduction Patients and Methods Results Discussion References

 
Serum AMH levels in normal men and in HH patients

In normal adult men, mean serum AMH levels were low (20 ± 4.9 pmol/L). In untreated CHH patients, the increase in serum AMH levels was highly significant compared to normal men (292 ± 86 pmol/L, P < 0.001) (Fig. 1).

View larger version (47K): [in this window] [in a new window]   Figure 1. Mean (±SD) serum AMH levels in normal men and in patients with congenital and acquired hypogonadotropic hypogonadism (HH). *, P < 0.001 compared with normal men; **, P < 0.01 compared with normal men; T, mean plasma testosterone levels (nmol/L) (±SD); TV, mean testicular volume (mL) (±SD) .

Correlation between serum AMH and testicular volume in HH patients

As shown in Fig. 2, a negative and significant correlation was observed between serum AMH levels and testicular volume in untreated HH patients. Subjects with CHH had lower testicular volume and higher serum AMH levels than subjects with AHH.

View larger version (14K): [in this window] [in a new window]   Figure 2. Negative correlation between serum AMH levels and testicular volume in HH patients (P < 0.001).

As expected, the functional suppression of the gonadal axis with DTrp-6 in patients with prostate cancer induced a dramatic decrease of mean plasma T levels (from 17 ± 3.8 nmol/L to 2.1 ± 1.0 nmol/L). A modest but significant increase of serum AMH levels was observed in all patients after 12 months of treatment (from 11.4 ± 5.7 pmol/L to 49 ± 9.9 pmol/mL; P < 0.01) (Fig. 3).

View larger version (18K): [in this window] [in a new window]   Figure 3. Serum AMH in eugonadic patients with prostate cancer before and 12 months after functional suppression of the gonadal axis with the GnRH agonist Triptorelin. T, mean plasma testosterone levels (nmol/L) (±SD).

In ten patients with HH (6 CHH and 4 AHH), after 3 months of hCG treatment, mean plasma T levels increased from 1.0 ± 0.7 nmol/L to 11 ± 2.4 nmol/L, and serum AMH decreased in all patients, from 314 ± 93 pmol/L to 56 ± 30 pmol/L, (82 ± 9% inhibition), P < 0.01 (Fig. 4A). A further decrease of serum AMH levels was observed when hCG therapy was continued for 6 months. At that time, mean plasma T levels were 19.4 ± 4.8 nmol/L, and mean serum AMH levels (17 ± 4.3 pmol/L) were not significantly different from those observed in normal men (Fig. 4A).

View larger version (24K): [in this window] [in a new window]   Figure 4. A, Effect of 6-month hCG treatment on serum AMH levels in ten HH patients; B, Effect of 6-month T therapy on serum AMH levels in eight HH patients; T, mean plasma testosterone levels (nmol/L) (±SD).

	Discussion

Top Abstract Introduction Patients and Methods Results Discussion References

 
In the present study, AMH secretion was assessed in adult men with HH. This pathological model was convenient to further evaluate the role of T in the regulation of testicular AMH production in the human. The high levels of serum AMH levels in adults with CHH contrasted with the very low levels observed in postpubertal normal men. CHH is characterized by the absence of gonadotropin secretion and testicular testosterone production. Therefore, physiological inhibition of AMH secretion at age of puberty was impaired, and serum AMH levels remained elevated, as observed in normal prepubertal boys (3, 4, 6). This result confirms our previous data concerning the regulation of AMH secretion by androgens (3). During male puberty, serum AMH and testosterone levels show a significant negative correlation. In addition, serum AMH is abnormally elevated in patients with defects in androgen synthesis or with an androgen insensitivity syndrome indicating that the absence of testosterone inhibition results in AMH upregulation (10). It has been shown that serum AMH is low when plasma T levels are higher than 7 nmol/L (3). In fact, the best negative and significant correlation was observed between serum AMH levels and testicular volume in untreated HH patients. Patients with AHH usually have a less complete form of gonadotropin deficiency and a larger testicular size than CHH patients. Therefore, the lower AMH levels observed in AHH patients could be explained by the partial gonadotropin activity and some persistent testicular T secretion resulting in higher intratesticular T concentration.

The interest of measuring serum AMH in AHH was to evaluate the reversibility of the postpubertal suppression of AMH secretion. The high serum AMH levels in these patients suggest that the pubertal maturation of Sertoli cells is a reversible phenomenon. This result was confirmed by the increase in AMH levels observed in eugonadal patients whose gonadotropin secretion was functionally suppressed by Triptorelin. The modest increase of AMH in those patients older than 60 yr of age can be related to the long-term suppression of AMH secretion, the failure of the GnRH agonist to achieve a complete suppression of the testicular testosterone production (11), or a decreased ability of their sertolian cells to secrete AMH.

A dramatic decrease of serum AMH levels was observed in hCG treated HH patients. The decrease was also significant in HH patients treated with exogenous testosterone. These results confirm the inhibitory role of T on testicular AMH secretion in men. However, the decrease of serum AMH levels was less important in T-treated than in hCG-treated HH patients, despite similar peripheral plasma T levels. The main difference between hCG and T treatments might be the intratesticular T levels (12). Therefore, the complete inhibition of testicular AMH secretion induced by hCG was probably related to the higher intratesticular testosterone levels induced by this gonadotropin. A high intratesticular T concentration is required for the inhibition of AMH secretion as well as for initiation and maintainance of spermatogenesis (13). The Sertolian androgen binding protein binds T and may decrease its availability (14), explaining why exogenous T is unable to display the same degree of inhibition of AMH secretion. The rise in concentration of testicular T is an early event in the pubertal development of the testis (15). It has been shown in normal male mice that, 25 days before serum T increases, the intratesticular T concentration is already elevated when serum AMH declines to pubertal levels (16). Thus, in men as in rodents, intratesticular T acting as a paracrine factor via the androgen receptor present in Sertoli cells is the main inhibitor of AMH secretion.

In conclusion, in adult men with either CHH and AHH, the physiological down regulation of testicular AMH secretion is absent owing to the lack of normal testicular T production. The suppression of AMH is a reversible phenomenon, as observed in patients with AHH. The inhibition of AMH production is induced by the direct paracrine effect of intratesticular T.

	Acknowledgments

 
We are very grateful to Dr J. Blumberg (Ipsen-Biotech) for providing us with plasmas from patients treated for prostate cancer with the GnRH agonist Triptorelin.

Received February 23, 1999.

Revised May 7, 1999.

Accepted May 10, 1999.

	References

Top Abstract Introduction Patients and Methods Results Discussion References

 

1. Lee MM, Donahoe PK. 1993 Mullerian inhibiting substance: A gonadal hormone with multiple functions. Endocr Rev. 14:152–164.[Abstract/Free Full Text]
2. Rey R. 1998 Endocrine, paracrine, and cellular regulation of postnatal antimüllerian hormone secretion by Sertoli cells. Trends Endocrinol Metab. 9:271–276.[CrossRef][Medline]
3. Rey R, Lordereau-Richard I, Carel JC, et al. 1993 Antimüllerian hormone and testosterone serum levels are inversely related during normal and precocious pubertal development. J Clin Endocrinol Metab. 77:1220–1226.[Abstract]
4. Lee MM, Donahoe KP, Silverman LB, et al. 1996: Mullerian inhibiting substance in humans. Normal levels from infancy to adulthood. J Clin Endocrinol Metab. 81:571–576.
5. Lee MM, Donahoe KP, Silverman LB, et al. 1997 Measurements of serum müllerian inhibiting substance in the evaluation of children with nonpalpable gonads. N Eng J Med. 336:1480–1521.[Abstract/Free Full Text]
6. Josso N, Legeai L, Forest MG, Chaussain JL, Brauner R. 1990 An enzyme linked immunoassay for antimüllerian hormone: a new tool for the evaluation of testicular function in infants and children. J Clin Endocrinol Metab. 70:23–27.[Abstract/Free Full Text]
7. Rey R, Belville C, Nihoul-Fekété C, et al. 1999 Evaluation of gonadal function in 107 intersex patients by means of serum anti-müllerian hormone measurement. J Clin Endocrinol Metab. 84:627–631.[Abstract/Free Full Text]
8. Scholler R, Nahoul K, Castanier M, Rotman J, Salat-Baroux J. 1984 Testicular secretion of conjugated and unconjugated steroids in normal adults and in patients with varicocele. J Steroid Biochem. 20:203–215.[CrossRef][Medline]
9. Siegel S. 1956 Nonparametric statistic for behavioural sciences. Tokyo: McGraw-Hill; 127–136.
10. Rey R, Mebarki F, Forest MG, et al. 1994 Antimüllerian hormone in children with androgen insensitivity. J Clin Endocrinol Metab. 79:960–964.[Abstract]
11. Schurmeyer Th, Knuth VA, Freischen CW, Sandow J, Akhtar FB, Nieschlag E. 1984 Suppression of pituitary and testicular function in normal men by constant gonadotropin-releasing hormone agonist infusion. J Clin Endocrinol Metab. 59:19–24.[Abstract/Free Full Text]
12. Weinstein RL, Kelch RP, Jenner MR, Kaplan SL, Grumbach MM. 1974 Secretion of unconjugated androgens and estrogens by the normal and abnormal human testis before and after human chorionic gonadotropin. J Clin Invest. 53:1–6.
13. Schaison G, Young J, Pholsena, Nahoul K, Couzinet B. 1993 Failure of combined follicle-stimulating hormone-testosterone administration to initiate and/or maintain spermatogenesis in men with hypogonadotropic hypogonadism. J Clin Endocrinol Metab. 77:1545–1549.[Abstract]
14. Roberts KP, Zirkin BR. 1993 Androgen binding protein inhibition of androgen-dependent transciption explains the high minimal testosterone concentration required to maintain spermatogenesis in the rat. Endocr J. 1:41–47.
15. Pasqualini T, Chemes H, Rivarola MA. 1981 Testicular testosterone levels during puberty in cryptorchidism. Clin Endocrinol (Oxf). 15:545–554.[Medline]
16. Al-Attar L, Noel K, Dutertre M, et al. 1997 Hormonal and cellular regulation of sertoli cell antimüllerian hormone production in the postnatal mouse. J Clin Invest. 100:1335–1343.[Medline]

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