AMH Fertility Test : Anti-Mullerian Hormone

Anti-Mullerian Hormone (AMH): A New Test For Ovarian Reserve

AMH stands for AntiMullerian Hormone. It is also called MIS (Mullerian Inhibiting Substance).  Since Anti-Mullerian Hormone / AMH is produced directly by the ovarian follicles, AMH levels correlate with the number of residual eggs in the ovary.

AMH isproduced by the granulosa cells of the ovaries and disappears after menopause, and it is thought to the formation of ovarian follicles bymodulating the role of by FSH.

It has been documented that women with lower Anti-Mullerian Hormone / AMH have smaller ovaries and  lower antral follicular counts and produce a lower number of oocytes compared to women with higher levels.

What is a normal Anti-Mullerian Hormone/ AMH level? What is a low AMH level?

Anti-Mullerian Hormone / AMH is a good predictor of fertility reserve (the higher the better). But what is a normal value? The answer is that the AMH value varies with age and its values decline with age. We can get a good perspective on how to interpret this value:

Age n Median Yearly average decrease Mean Yearly average decrease Yearly average decrease
24 3.4 4.1
25 3.2 4.1
26 3.2 4.2
27 2.9 3.7
28 2.8 −0.2 3.8 −0.2 −0.2
29 2.6 3.5
30 2.4 3.2
31 2.2 −0.2 3.1 −0.2 −0.2
32 1.8 2.5
33 1.7 2.6
34 1.6 2.3
35 1.3 2.1
36 1.2 1.8
37 1.1 1.6
38 0.9 −0.1 1.4 −0.2 −0.2
39 0.8 1.3
40 0.7 1.1
41 0.6 1.0
42 0.5 0.9
43 0.4 −0.1 0.7 −0.1 −0.1
44 0.3 0.6
45 0.3 0.5
46 0.2 0.4
47 0.2 0.4
48 0.0 −0.1 0.2 −0.1 −0.2
49 0.1 0.1
50 0.0 0.0

Source : Fertility and Sterility  Pages 747-750, February 2011

AMH vs. FSH: which is more accurate?

Until a couple of years ago the standard for ovarian reserve testing was the Day 3 FSH level. Today, physicians seem to rely more on AMH levels as AMH measurements are considered to be more reliable because they are not cycle day dependent (can be measured on any day of the cycle, even if you are on birth control pills).  FSH level varies from cycle to cycle and AMH does not vary from cycle to cycle.

Checking Your Ovarian Reserve 

An AMH and FSH level can also be very useful for young women who want to postpone childbearing and want to check their fertility. We often see women who have not started trying to conceive and they just want us to “check their fertility”.  This is a very good idea as getting completely normal values can be very reassuring.  Testing can generate much anxiety if the results come back borderline or low.

Part of the problem with fertility testing for women who have not yet attempted pregnancy derives from the fact that these tests do not always predict fertility in absolute levels.  We often use the example of the gas gauge in your car: your tank may be half empty, or half full  , but you still have plenty of “miles to go”.

What to do when your FSH is high or your AMH is low.

First: Do not panic.   Ovarian reserve testing usually suggests different degrees of fertility. Even if your fertility testing reveals that you may be less fertile than the average person your age, this does not mean that you are completely infertile.

Studies have shown that even patients with very abnormal FSH and AMH hormone levels have a chance, albeit a small one, of having a baby, even considering the risk of miscarriages.

When you have been told that your values are abnormal it is a good idea to consult a fertility specialist as it may be a good idea to get more aggressive if you are trying to get pregnant.

Read more on Dr. Vidali’s approach to low AMH

Our Approach to “Low Ovarian Reserve”

We believe in an honest and open approach to any medical problem.  We have observed that many physicians approach this problem in two radically distinct ways: The first way is denial of the problem and the second is a knee jerk reaction to the problem, resulting in forcing the patients into egg donation after a couple of abnormal tests.

If your tests have been repeatedly abnormal, then you are indeed suffering from diminished ovarian reserve. We have seen over the years many patients who have come to us after having treatment refused by other centers and have successfully conceived using their own eggs.  We must be cognizant of the fact that these cases are infrequent but they are not miracles!

For this reason if you have been diagnosed with “low ovarian reserve” we recommend that you get a second opinion before moving on to oocyte donation.

“I have never tried to get pregnant but now I discovered that my FHS is high and my AMH is low.  Am I infertile?”

We often see women who have not started trying to conceive and they just want us to “check their fertility”. Sometimes the initial testing reveals abnormal lab levels. What we recommend in these cases is that you consider having a baby sooner rather than later.  If this is an absolute impossibility you may want to consider fertility preservation.

What is the best protocol for poor responders in IVF?: 

Long protocol – Estrogen priming, micro dose Lupron

Short protocol – Antagonist, low dose, mini IVF or Clomid plus gonadotropins?

The answer is none of the above, or any of the above! Having attended a myriad of conferences and debates and reviewed the current literature on this topic, the conclusion has always been the same!

Often patients come to see us and tell us that they have read online that a certain protocol is much better. This statement is unsubstantiated by facts.  In fact when one looks at the actual studies, the evidence is that the results are inconsistent, which basically means that there is no “best” protocol.

Many of these protocols end up being associated with certain centers.  A typical example is the estrogen priming protocol frequently used at Cornell.  At times patients read about it and ask for the protocol and we have nothing against trying it as we are open-minded physicians.

Ultimately our perspective is that if all protocols are pretty much equivalent, the reasonable way to go is minimal stimulation.  We believe that minimal stimulation is appropriate mostly for 2 reasons: 1) fewer hormones in your body and, 2) less money out of your pocket to buy expensive fertility drugs.

My AMH level is high. does this mean I have PCOS (Policystic Ovaries?)

A high AMH  is usually associated eith PCOS , but it is not diagnostic. For more information read out pcos page.

“Call us now or send us a message if you have any questions about this topic or if you want to make an appointment