The effect of environmental stressors on anti-mullerian hormone levels in Lebanese women: a retrospective study.

Fertility, the natural capacity to conceive and sustain a pregnancy, is a cornerstone of reproductive health and plays a vital role not only in individual well-being but also in family formation and broader demographic stability. Its significance extends beyond biological function, influencing psychological health, social identity, and even population dynamics, making the ability to preserve and assess fertility a priority in both clinical and public health contexts [ 1 ]. Infertility, defined as the inability to conceive after 12 months of unprotected intercourse, is estimated to affect between 8–12% of reproductive-aged couples worldwide [ 2 ]. Anti-mullerian hormone (AMH), a dimeric glycoprotein produced by the granulosa cells in ovarian follicles, is the most widely used measure of functional ovarian reserve [ 3 ]. In other words, AMH reflects the size of one’s remaining follicle pool, thereby serving as a proxy for reproductive capacity. It has shown clinical utility in predicting the success of in-vitro fertilization, diagnosis of polycystic ovary syndrome (PCOS) and premature ovarian failure (POF) [ 4 ]; elevated AMH level is a hallmark of PCOS, while decreased levels are a sensitive indicator of POF [ 5 , 6 ]. More recently, AMH has been adopted in establishing a PCOS diagnosis [ 5 ], shown utility in the assessment of ovarian reserve in infertile patients, and assisted in guiding fertility care for women in this subgroup [ 7 ]. Fertility, and as a consequence AMH, are affected by multiple factors including medical, environmental and genetic factors. For example, AMH levels gradually decline with older age and are negatively affected by chemotherapy, history of ovarian surgery, use of oral contraceptive pills (OCPs), obesity, presence of BRCA mutation and possibly Vitamin D deficiency [ 8 ]. Given that stress has demonstrated negative effects on reproductive health and ovarian reserve, it follows that it adversely affects AMH levels [ 8 ]. Since October 2019, Lebanon has been engulfed in a multipronged crisis that has been cited as one of the top three most severe economic collapses since the mid-nineteenth century [ 9 ]. This has pushed more than 50% of the population into poverty and staggering inflation coupled with severe local currency depreciation that led to a tremendous curtailment of purchasing power. It has also had other devastating impacts; the resulting fuel shortages and inflation impacted access to essential services such as electricity, clean water, food, and healthcare [ 10 ]. The economic collapse was further exacerbated by political instability, the external shock of COVID-19 pandemic, and the catastrophic Port of Beirut explosion in August of 2020 [ 10 , 11 ]. These compounding national and international events caused considerable stress, resulting in a substantial mental health burden. Elbejjani et. al assessed the mental health challenges of the Lebanese population during the first COVID-19 lockdown using multiple validated scales, and reported depressive and anxiety symptoms as being among the highest worldwide [ 12 ]. Furthermore, deteriorating living conditions were further exacerbated by the 2020 Beirut blast which occurred in a densely populated area of the city leaving thousands injured [ 13 ], and approximately 218 dead [ 14 ]. In a survey of 2078 survivors of the blast, one-third met the criteria for post-traumatic stress disorder, and 80% screened positive for depression. Notably, women of lower socioeconomic status who were closest to the site of the explosion were most affected [ 15 ]. A stressor is defined as any physical or psychological stimulus that leads to physiological or behavioral changes (also known as stress response) mediated by the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic-adrenal-medullary (SAM) axis [ 16 ]. Prolonged and repetitive exposure to stressors results in lasting neuroendocrine changes leading to detrimental effects on female reproductive health (including ovarian reserve, fertility, and fecundity) [ 17 ]. Increasing concentrations of glucocorticoids (reaching ‘stress’ levels) lead to direct inhibition of the hypothalamic release of gonadotropin-releasing hormone (GnRH), consequently disrupting the hypothalamic-pituitary-ovarian (HPO) axis [ 18 ]. Animal studies have demonstrated that stress levels of glucocorticoids prevent an increase in estrogen secretion and the subsequent luteinizing hormone (LH) surge, negatively impacting follicular maturation and release, as reported in a sheep model [ 19 ]. Chronic psychological stress resulted in the downregulation of AMH protein expression in mouse ovaries [ 20 ]. Higher levels of perceived psychosocial stress led to lower levels of AMH in infertile [ 21 ] women, sub-fertile [ 22 ] women, and female childhood cancer survivors [ 23 ]. In turn, some reproductive health disorders may themselves increase susceptibility to stress and elevate the risk of adverse mental health outcomes. For instance, 17% of women with PCOS have a diagnosis of depression, and 41% report anxiety symptoms [ 24 ]. Similarly, many patients with infertility experience anxiety and depressive symptoms, with the prevalence of depression among them reported to be as high as 52% [ 25 ]. Premature ovarian insufficiency (POI) is also associated with vulnerability to stress with higher odds of depression [OR: 3.33] and anxiety [OR: 4.89] [ 26 ]. Research on stress in the context of reproductive outcomes recognizes multiple measures of ‘stress’, including exposure to acute stressful events, living in stressful environments, or heightened susceptibility to stress [ 27 ]. In a cross-sectional study of infertile women, exposure to chronic lifetime psychosocial stressors (such as history of abuse or substance use) was more strongly associated with a decline in ovarian reserve relative to increased ‘current stress’ levels [ 28 ]. This underscores the need for careful evaluation of onset, chronicity, and pattern of stress exposure to better contextualize and measure its effect on reproductive health outcomes. Comprehensive national studies specifically tracking AMH levels in Lebanon since 2019 are lacking. As an alternative, fertility clinics and reproductive health centers often conduct their own assessments to provide individualized treatment plans. As such, this study employs a retrospective approach to trace the trend in AMH levels in a population of reproductive-aged Lebanese women in a tertiary healthcare center in the country’s capital, Beirut, in the setting of compounding national and international events that caused significant disruptions to daily life.

Table 1 depicts subjects’ demographic information such as age and marital status, as well as baseline lab values. Both groups exhibited homogeneity in terms of demographic information and baseline laboratory values, rendering them comparable. The significance of differences in mean AMH levels before and after stressful events, between different age groups, and in patients with any history of receiving assisted reproductive technology is shown in Table 2 . The mean AMH level in individuals who had not experienced the stressful events (2.52 ± 2.94 ng/mL) was slightly greater than that in those with exposure to all three stressful events (2.12 ± 1.99 ng/mL), however the p-value was not significantly different (p = 0.061). *P-value<0.05 was considered significant When stratified by age, participants below 35 years old had significantly higher AMH levels (2.66 ± 2.75 ng/mL) compared to those aged 36–40 years old (1.64 ± 1.74 ng/mL, p-value < 0.01). Furthermore, individuals with a history of ART exhibited significantly lower AMH levels (1.76 ± 1.82 ng/mL) compared to those without such history (2.45 ± 2.62 ng/mL, p = 0.011). Although patients with hormonal disorders such as hypothyroidism and hyperprolactinemia were excluded at the start of the study, patients with PCOS and DOR were not. A diagnosis of PCOS is established when an individual exhibits at least two of the following criteria: clinical or biochemical hyperandrogenism, polycystic appearance of ovaries, and oligo-anovulation [ 27 ]. Fig 1 depicts the secondary analysis done to control for the effect of PCOS, DOR, POF, and infertility on AMH levels within the sample. When controlling for PCOS cases, a significant difference in AMH levels between the two groups was observed (p = 0.004), where the mean AMH in the pre-stressful events group (7.92 ± 4.87) was nearly twice as much as that of the post-stressful events group (4.18 ± 3.71). These findings remained significant after Bonferroni correction (adjusted α = 0.0125). Regarding subjects with DOR and POF, both groups did not yield significant results when controlled for (p = 0.59; p = 0.29 respectively). P < 0.05 was considered significant. Among subjects with primary infertility, the mean AMH was significantly higher pre-stressful events (2.69 ± 2.04 compared to 1.74 ± 1.25 post-stressful events; p = 0.008), while subjects with secondary infertility showed no significant differences in mean AMH level (1.59 ± 2.25 in the pre-stressful events group compared to 1.88 ± 1.58 post-stressful events; p = 0.57). Fig 2 focuses on comparisons of AMH levels after excluding subgroups from the entire sample. Excluding DOR showed a significant decrease in AMH level post-stressful events (p = 0.012) after Bonferroni correction (adjusted α = 0.0125). After excluding subjects with secondary infertility from the sample, a decline in AMH levels is observed after stressful events (from 2.66 ± 3.01 to 2.14 ± 2.03, p = 0.026), though it is not considered significant after adjusting the level of significance (adjusted α = 0.0125). The other subgroups did not exhibit significant changes in mean AMH levels, further verifying the results displayed in Fig 1 . P < 0.05 was considered significant.

Women with pre-existing reproductive health conditions experience a higher vulnerability to stressors, such as women with PCOS and primary infertility. Individuals with such conditions are more likely to experience significant declines in AMH levels and by extension, ovarian reserve following stressful events. These findings highlight the need for a holistic approach to reproductive health, one that considers both physical and emotional factors to better understand and support fertility outcomes.

Ethical approval was obtained from the American University of Beirut Institutional Review Board (IRB) prior to conducting the study (IRB ID BIO-2023–0229). Medical records of patients at the American University of Beirut Medical Center were retrospectively reviewed via the electronic medical record system. The records reviewed were taken from the period January 1, 2018, until June 30, 2023; the period of stressful events was defined as the period from February 1, 2020, to December 1, 2020. Medical records with AMH levels taken during this period were excluded to better homogenize the post-stress group, enable a more accurate comparison of AMH levels, and eliminate potential bias from the stress itself. Patients between the ages of 18 and 40 years, with AMH levels tested at the American University of Beirut Medical Center and available on their medical record within the specified time period were included. Women outside the specified age range, those with known hormonal disorders, and women undergoing active treatment for malignancy at the time the AMH level was taken were excluded. Since this study was a retrospective chart review, the data was pre-existing, and no patients were contacted for information nor was there new data collected prospectively. As such, consent to participate was not required as per the requirements of the institutional review board at the American University of Beirut, and a waiver for patient consent was granted prior to conducting the study. A sample of 563 patient records were initially reviewed by the authors from November 15, 2023 until February 29, 2024. Of the original 563, 26 subjects were excluded due to having a history of hormonal disorders or were receiving treatment for hormonal disorders. The final number of records reviewed and included in the analysis was 537, with 254 subjects enrolled in the control (pre-stressful events) group and 283 enrolled in the exposure (post-stressful events) group. Authors accessing the medical records were able to view information that could identify individual participants during data collection. Patients’ results for serum AMH, Follicle Stimulating Hormone (FSH), LH, Estradiol, Prolactin, Thyroid Stimulating Hormone (TSH), and Vitamin D levels were collected to assess baseline hormonal measures. AMH levels were measured using electrochemiluminescence immunoassay (ECLIA). Relevant obstetrical and gynecological history was retrieved. This included the patients’ pregnancy history, history of infertility, history of assisted reproductive technology (ART), and history of gynecological pathologies such as endometriosis, PCOS, and POI. Any history of intrauterine insemination, in vitro fertilization, or intracytoplasmic sperm injection was considered as a positive ART history. Confounding factors affecting the gynecological history such as age, BMI, personal or family history of POF were also collected. The results were calculated using SPSS version 24 statistical software package (IBM, USA). Demographic characteristics were summarized using descriptive statistics. Independent samples t -tests were performed to confirm that the pre- and post-stressful events groups were comparable with respect to demographic variables. Independent t-test was carried out to assess the differences in AMH means between the pre- and post-stressful events groups. Specific confounding factors that could affect AMH level, including PCOS, POF, diminished ovarian reserve (DOR), and a diagnosis of infertility were controlled for and examined via independent t-test to evaluate their effect on the results of each group both individually and collectively. Given multiple comparisons, we applied a Bonferroni correction to adjust the significance threshold to p  < 0.0125.