Reviewer ’s report  
 
Title: Age-dependent changes in anti -Müllerian hormone levels i n Lebanese females: correlation 
with basal FSH and LH levels and LH/FSH ratio: a cross -sectional study  
 
Version: 1 Date: 18 Apr 2020  
 
Reviewer: Rodolfo Alberto Rey  
 
Reviewer's report:  
 
The revised version of th e manuscript by Racoubian and colleagues has addressed most of the 
issues previously raised. However, there issues that still need re -writing since incorrect 
affirmations persist, especially those related with the history and physiology of AMH.  
 
It is sad  to read so many articles in Gynaecology journals referring to AMH as if it had been 
discovered recently. My view is that authors have the obligation of learning the background of 
the subject they address in an article, and unfortunately this seems to be t he exception for authors 
writing articles on AMH in Gynaecological Endocrinology.  
 
Indeed, although AMH became popular in female Reproductive Endocrinology in the years 
2000's, the protein was already recognised in the 1970's and called AMH, or also MIS (M üllerian 
inhibiting substance) or MIF (factor), and the human gene was cloned by Richard Cate and 
colleagues and published in the journal Cell in 1986 (Isolation of the bovine and human genes 
for Müllerian inhibiting substance and expression of the human g ene in animal cells. Cate RL, 
Mattaliano RJ, Hession C, Tizard R, Farber NM, Cheung A, Ninfa EG, Frey AZ, Gash DJ, Chow 
EP, et al. Cell. 1986 Jun 6;45(5):685 -98. doi: 10.1016/0092 -8674(86)90783 -x. PMID: 3754790).  
 
The indisputable physiological action of AMH is related to Müllerian duct regression in the male 
foetus, as overwhelmingly shown by the description of PMDS (the genetic condition in humans 
and other mammals with AMH or AMHR2 mutations) and knockout mice models with 
mutations of the Amh gene or it s promoter, the Amhr2 gene or the genes encoding the various 
type 1 receptors. The phenotypes leave no doubt that AMH is indispensable for Müllerian 
regression (the only evident phenotype). Other actions of AMH within the testes, ovaries, 
hypothalamus, pit uitary, etc. are putative, and might only represent minor actions, redundant 
with that of other proteins, since no major phenotypes in these organs have been observed in 
patients with mutations of the AMH or AMHR2 genes.  
 
 
To help avoiding inaccurate statem ents or citations in the Introduction, these are my suggestions:  
 
1. Page 4, line 13: I suggest replacing with:  
 
Anti-Müllerian hormone (AMH) is 140 kDa disulfide -linked homodimeric glycoprotein, 
belonging to transforming growth factor -β (TGF -β) superfamil y (Cate et al 1986. Isolation of the 
bovine and human genes for Müllerian inhibiting substance and expression of the human gene in 
animal cells. Cell. 1986 Jun 6;45(5):685 -98. doi: 10.1016/0092 -8674(86)90783 -x. PMID: 
3754790), is essential factor involved in the regression of Müllerian ducts in the male fetus 
(reviewed in Josso N. WOMEN IN REPRODUCTIVE SCIENCE: Anti -Müllerian hormone: a 
look back and ahead. Reproduction. 2019 Dec;158(6):F81 -F89. doi: 10.1530/REP -18-0602. 
PMID: 30844753). AMH is produced in high amounts by Sertoli cells in males from testicular 
differentiation up to puberty, and in lower amounts by granulosa cells of primary and small 
antral follicles in females from the second half of intrauterine life up to menopause (Rey R et al. 
AMH/MIS: what we know already about the gene, the protein and its regulation. Mol Cell 
Endocrinol. 2003 Dec 15;211(1 -2):21 -31. doi: 10.1016/j.mce.2003.09.007.PMID: 14656472, 
AND Kuiri -Hänninen T et al. Postnatal developmental changes in the pituitary -ovarian axis i n 
preterm and term infant girls. J Clin Endocrinol Metab. 2011 96(11):3432 -9. doi: 
10.1210/jc.2011 -1502. PMID: 21900380). The main role of AMH is the regulation of foetal male 
sex differentiation, while other roles in ovarian follicle development and elsew here have been 
described (reviewed in ref. Josso 2019 cited above).  
 
2. Replace ref. 4 with Josso N, di Clemente N, Gouédard L. Anti -Müllerian hormone and 
its receptors.Mol Cell Endocrinol. 2001 Jun 20;179(1 -2):25 -32. doi: 10.1016/s0303 -
7207(01)00467 -1. PM ID: 11420127.  
 
3. Replace ref. 5. with ref. 4 (Mullen 2018).  
 
4. Paragraph line 29: once again, the relationship between AMH and GnRH still needs to 
be fully proven, and it has no major relevance for this manuscript. I suggest deleting the text:  
The role of AMH in the hypothalamic -pituitary -gonadal axis regulation remains not fully 
understood [1,6]. It was recently reported that GnRH lowers serum AMH levels, and thus is 
negatively correlated with gonadotrophin levels [6], thereby highlighting a ro le for GnRH as an 
important regulator of AMH levels and activity.  
 
5. Page 5, line 46: the paragraph has been rewritten, and previously existing accurate 
statements have been deleted. This is not a major problem, but citations need to be revised. For 
insta nce, ref. 20 no longer applies here.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your com ments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your  comments to the authors.  
 
Yes 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in you r comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscrip t, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for  any patents  relating to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interests?  
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is y es to any, please give details below.  
 
I have received royalties for the AMH ELISA.  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted for publicat ion, my named report 
including any attachments I upload will be posted on the website along with the authors' 
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CC-BY license ( http://creativecommons.org/licenses/by/ 4.0/). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal