Nomograms for AMH using LMS model.

Ovarian reserve tests are valuable for evaluation of female fertility, and to formulate appropriate treatment strategies for infertile women. Antral follicle count (AFC) and Anti-Mullerian hormone (AMH) are most reliable markers of ovarian reserve which are related inversely to age. There are many factors that affect ovarian reserve like race, ethnicity, fertility status, BMI or any chronic illness. We conducted this study to find outage specific nomograms for AMH and AFC among fertile and Infertile Indian women, to find out any variations between fertile and Infertile ovarian reserves at various centiles, to define the age cut-off of decline in AMH and AFC among fertile and Infertile Indian women and to find correlation between AMH and AFC. It was a prospective cross sectional single centre study conducted at a tertiary hospital of northern India from March 2017 to February 2022. Fertile healthy women were recruited from family planning clinic, oocyte donors and subfertile women from Gynaecology and ART clinic. AMH was done using ELISA, Beckmann Coulter Gen II assay and AFC was done using TVS with high frequency probe (9.0 MHZ, Voluson,S-6, GE Healthcare, USA) by trained personnel. R Statistical Programming Language was used for statistical modelling and visualization. Age-specific AFC centile chart and AMH centile chart were generated using GAMLSS (Generalized Additive Models for Location Scale and Shape) package available in R Statistical Computing Language. A Non-linear decline in ovarian reserves among fertile, while linear among infertile women was seen. Centiles defined for both groups with a faster decline in infertile women. Age cut off for decline in AMH and AFC in fertile women approximately 31 years using ROC analysis and Age cut off for decline in AMH and AFC in infertile women is approximately 34 years. There seems to be a good correlation between AFC and AMH. We need to counsel women to consider child bearing well before ovarian reserves decline (31–34 years).

卵巢储备检测对于评估女性生育能力、为不孕女性制定合理的治疗策略具有重要临床价值。窦卵泡计数（Antral follicle count, AFC）与抗米勒管激素（Anti-Mullerian hormone, AMH）是目前最为可靠的卵巢储备标志物，二者水平均与年龄呈负相关。影响卵巢储备的因素众多，包括种族、族群、生育状态、体重指数（Body Mass Index, BMI）以及各类慢性疾病等。本研究旨在构建适用于印度育龄与不孕女性的AMH及AFC年龄特异性列线图，明确不同百分位数下育龄与不孕女性卵巢储备的差异，确定印度育龄及不孕人群AMH与AFC水平下降的年龄阈值，并分析AMH与AFC之间的相关性。

本研究为前瞻性横断面单中心研究，于2017年3月至2022年2月在印度北部一所三级医院开展。研究对象招募自计划生育门诊的健康育龄女性、卵母细胞捐赠者，以及妇科与辅助生殖技术（Assisted Reproductive Technology, ART）门诊的不孕女性。AMH检测采用贝克曼库尔特Gen II酶联免疫吸附试验（Enzyme-Linked Immunosorbent Assay, ELISA）试剂盒；AFC检测由经过专业培训的人员采用高频探头（9.0 MHz，Voluson S-6，通用电气医疗集团，美国）行经阴道超声（Transvaginal Sonography, TVS）完成。

本研究采用R统计编程语言进行统计建模与可视化，通过R语言内置的位置、尺度和形状的广义可加模型（Generalized Additive Models for Location Scale and Shape, GAMLSS）包，生成了年龄特异性的AFC百分位数图表与AMH百分位数图表。

研究结果显示：育龄女性的卵巢储备呈非线性下降趋势，而不孕女性则呈线性下降趋势；两组均构建了对应的百分位数区间，且不孕女性的卵巢储备下降速度更快。通过受试者工作特征（Receiver Operating Characteristic, ROC）分析，育龄女性AMH与AFC水平下降的年龄阈值约为31岁，不孕女性约为34岁。此外，AFC与AMH之间存在良好的相关性。

临床实践中应建议女性在卵巢储备水平下降（31~34岁）前尽早考虑生育计划。