Everything You Need to Know About AMH and Ovarian Reserve
I often have patients coming to me concerned about their ovarian reserve. Either they got a test result that they weren’t happy about or they aren’t ready for kids yet and are worried about their future fertility. Either way, testing your ovarian reserve can provide valuable information about a person's fertility potential and help with family planning.
What does ovarian reserve testing look like?
Cycle day 3 FSH, LH, Estradiol. These hormones are tested via blood work on day 3 of your menstrual cycle. Together, they can tell us how well your ovaries are responding.
AMH. A blood test taken at any time in your cycle. Anti-müllerian hormone, or AMH, is secreted by the ovaries and can give us an idea of your ovarian reserve, or how many eggs you have left.
Antral Follicle Count (AFC). This is an ultrasound done in the first part of your menstrual cycle that counts how many follicles are developing on each ovary.
We can’t understand the whole picture of ovarian reserve without all three of these tests. In this blog, we are going to dive a bit deeper into AMH.
Average AMH values
25 years old: 3.0 ng/mL.
30 years old: 2.5 ng/mL.
35 years old: 1.5 ng/mL.
40 years old: 1 ng/mL.
45 years old: 0.5 ng/mL.
AMH Interpretation:
High AMH: >4 ng/mL
Normal AMH: 1-4 ng/mL
Low AMH: 0.5-1 ng/mL
Very low AMH: <0.5 ng/mL
Low AMH or very low AMH means you have diminished ovarian reserve, regardless of your age.
Causes of low AMH:
Endometriosis (especially endometriomas and surgery to remove endometriomas)
Ovarian surgery
Smoking or drug use
Menopause
Premature ovarian failure (in this case FSH will also be high)
Genetics
Cancer or the effects of cancer treatments, including radiation and chemotherapy
Hypothalamic amenorrhea
Does a low AMH effect my ability to conceive naturally? Nope. Studies show that for people with regular menstrual cycles (between 24-35 days), low AMH is not correlated with reduced fertility. AMH is a useful marker for fertility clinics to gauge how you may respond to an IVF cycle (and what dosage of stimulation medication to give you), but it is not a good predictor of whether or not you will be able to conceive naturally. Studies show that the clinical pregnancy rate of those with normal, low, and very low AMH levels were statistically similar. However, the time to pregnancy was longer in the very low group compared to the normal group (on average 13 months compared to 7 months). Therefore, AMH as a quantitative but not a qualitative marker of ovarian reserve and therefore does not reflect a person’s ability to become pregnant.
Does a low AMH effect my ability to conceive via IVF? Maybe. IVF clinics use AMH values as a factor when determining how well you might respond to an IVF cycle and your risk of ovarian hyperstimulation. The higher the AMH you have, the greater the chance you will retrieve more eggs. If you are freezing your eggs or going through IVF, AMH can help estimate how many eggs you can retrieve in a cycle.
Do some medications affect my AMH? Yes. Hormonal contraception that prevents ovulation and/or introduces hormones into the body do affect AMH levels. They typically appear lower than they normally are (by about 30%). This is why I recommend patients wait at least 6 months after discontinuing hormonal birth control before testing AMH values to avoid a false low result. The drug Clomid, or clomiphene citrate, used in fertility treatments, can temporarily decrease AMH levels. There is also some evidence that metformin can lower AMH levels.
Do people with endometriosis often have low AMH? Yes. This is likely due to the inflammatory component of endometriosis harming the ovaries as well as potential surgery on the ovaries to remove endometriomas. I typically recommend my endometriosis patients test their AMH levels before, and 6-12 months after surgery to keep an eye on ovarian reserve levels.
How often should I test my AMH levels? If you want to have children but you aren’t ready yet, I would definitely recommend testing your AMH (along with FSH, LH, and estradiol) starting at age 30 and every year after that (until you conceive). It’s important to be aware of your reserve and be able to pinpoint any problems sooner rather than later. Otherwise, if you are currently trying to conceive, I might recommend testing your AMH levels every 6-12 months depending on your goals and treatment plan.
What if I have low AMH but a normal AFC? Some people have normal antral follicle counts despite a low AMH. This is definitely a positive factor in predicting fertility. In this case, you will likely have a better response to IVF. AFC is just as an important factor for determining ovarian response as AMH for IVF.
Does a low AMH mean I have premature ovarian insufficiency? Premature ovarian insufficiency, or POI, is when your ovaries stop working before the age of 40 and you enter into premature menopause. These patients will have VERY low AMH levels along with HIGH FSH levels. A low AMH alone is not enough to diagnose POI.
Is a high AMH a problem? By itself, no. If it’s accompanied by other abnormal test results and reproductive symptoms, it may point towards a diagnosis of PCOS, or polycystic ovarian syndrome.
Does a high AMH mean I have PCOS? Possibly. If you have high AMH as well as irregular or absent periods (more than 35 days each cycle), OR high androgens shown through blood work (like high testosterone, androstenedione, or DHEA-S) or symptoms (like acne or hirsutism), then you qualify for the diagnosis of PCOS.
Why do people with PCOS have high AMH? Because those with PCOS often have more than the usual amount of follicles (little fluid filled cysts on the ovaries that house the eggs) due to stalling of the ovulation process, they have more follicles to secrete the hormone AMH.
Why do people correlate low AMH with infertility? Because AMH tends to decrease with age, and fertility naturally becomes reduced as we age, people tend to assume they go hand in hand. However, this is not the case. Age is the most significant determination factor for egg quality and infertility, not AMH.
Does a low AMH mean my other results may be off? Not necessarily. Low AMH often corresponds with a lower antral follicle count (which may mean less eggs are retrieved), but it does not automatically mean you will have high FSH or altered estradiol levels.
Does low AMH increase my risk of miscarriage? Low AMH levels could potentially be associated with a heightened likelihood of experiencing a miscarriage. According to research, women who conceived naturally and had a very low AMH level (equal to or below 0.4 ng/mL) displayed a twofold increase in the rate of miscarriage compared to those with a sufficient AMH level (1.0 ng/mL or higher). This elevated risk was observed during the 6th to 7th week of pregnancy. The study's findings propose that diminished ovarian reserve, as indicated by a low AMH level, may heighten the risk of miscarriage regardless of a woman's age.
Can my AMH levels fluctuate? There is some evidence that AMH levels fluctuate slightly throughout the menstrual cycle and are higher in the follicular phase. I typically recommend my patients get them tested around the same time of their cycle each time for consistency. However, in my experience, this fluctuation isn’t enough to change our treatment plan.
Is there anything I can do to increase my AMH? Not really. Although I’ve seen slight increases a handful of times, your AMH values are not able to be increased. However, this is never the goal with my patients. We can’t change the amount of eggs you have, but we CAN have a positive impact on the quality. And THAT is the most important part for fertility. Some studies show that supplementing with DHEA and vitamin d can mildly increase AMH levels.
Does low AMH mean I have poor egg quality? No. Age is the most significant determination factor for egg quality, not AMH. Low AMH is most often seen in women of older reproductive age, so it often corresponds with poorer egg quality. But a 25 year old woman with low AMH can still have great egg quality.
Does low AMH mean I will enter menopause sooner? Maybe. It depends on your age and AMH levels. A 30 year old with an AMH of 1 ng/ml could potentially enter menopause earlier (perhaps in their early 40’s instead of late 40’s), but it’s difficult to estimate. If you have low AMH along with high FSH, there is a greater likelihood of premature ovarian insufficiency and premature menopause.
Many factors influence AMH levels, ovarian reserve, and egg quality. A comprehensive plan to improve fertility must include a variety of factors including diet and lifestyle modifications, exercise, stress reduction, and key supplementation.
Ways to support egg quality.
Avoid endocrine disruptors (like plastic and artificial fragrance)
Supplements: omega 3 fatty acids, vitamin d, melatonin and myoinositol powder, CoQ10, DHEA, l-carnitine,
Reduce stress
Regular exercise
Get enough sleep
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