Low AMH Level, Need not to panic; find out the Solution

Anti-Mullerian Hormone (AMH) is a hormone produced by cells in small developing egg sacs (follicles) that contain an egg in a woman's ovaries. Therefore, AMH gives an indication of the number of eggs being produced during a woman's monthly cycle. The level of AMH in a woman's blood is a good indicator of her ovarian reserve and is helpful in assessing her fertility status. A low level of AMH suggests that there is a significant reduction in the remaining supply of eggs. a substance produced by granulosa cells at the earliest (primordial) stage of ovarian follicle development. Since the number of these primordial cells is linked to the number of follicles that ultimately grow into viable, fertilizable eggs, AMH levels are used to assess a woman’s remaining egg supply.

Several factors lead fertility specialists to believe that AMH is a good way of measuring ovarian reserve. Some studies in women being treated by IVF have found lower AMH levels in those who responded poorly to fertility drugs. Other tests of ovarian reserve such as FSH must be measured at particular time(s) in the menstrual cycle. One potential advantage of using an AMH test to assess ovarian reserve is that it does not seem to change over the course of the menstrual cycle, and so AMH can be tested by obtaining a blood sample at any time of the month.

For women undergoing IVF treatment, AMH results can be used to help choose the best dose of fertility medicine(s) used to stimulate the ovaries. AMH levels may help to identify women who are more likely to over-respond or hyper-stimulate during IVF treatment, and the dose of fertility medicine can be adjusted to minimize that risk. AMH may help to identify woman who have polycystic ovarian syndrome (PCOS). AMH can also help to identify women who have a lower pregnancy rate from fertility treatment.

Most common measurement of AMH levels is as follows:

High AMH                           over 3.0ng/ml

Normal AMH                     over 1.0ng/ml

Low Normal AMH            0.7-0.9ng/ml

Low AMH                            0.3-0.6ng/ml

Very low AMH                  less than 0.3ng/ml

The above values are then used to predict chances of conception with higher numbers indicating a larger ovarian reserve and as such a more promising odd of pregnancy and lower levels mirroring poor reserve and poor chances of conception.

The low AMH and Vitamin D deficiency link, mostly ignored in clinical practice and during the infertility diagnosis is nonetheless becoming a much discussed subject on infertility forums and blogs. If your vitamin D levels are low, you might get a “false” low AMH level reading and as a result receive a “false” prognosis that might send you into a self-fulfilling spiral of defeat. So if you received a low AMH diagnosis, it makes sense to start your investigation by testing your vitamin D levels. All you need is a simple blood test to determine your Vitamin D levels.  Although as recently as few years ago, levels of   20-100 ng/ml were considered normal, currently the optimal levels have been raised to 32-100 ng/ml. 

Anti-Mullerian Hormone test results are mostly useful in assessing a woman’s response to ovarian stimulation for IVF, where retrieving more eggs is thought to increase chances of pregnancy. Some study reports the case of two women with very low AMH levels who became pregnant spontaneously, the other one compared AMH levels of two groups of healthy women: obese and non-obese. The obese women, whose overall level of health and organ function may have been compromised, had lower AMH levels. And the last explores the link between Vitamin D levels and low AMH. AMH levels though they may reflect a diminishing size of the remaining ovarian pool, are also a reflection of ovarian function related to a woman’s overall level of health; Since AMH levels do not reflect egg quality, when the overall level of the woman’s health increases, chances of pregnancy increase.

Here you all of need to know about the ovarian reserve also that a woman's ovarian reserve is the amount of good quality eggs remaining in her ovaries. Although men continually produce new sperm, women are born with their lifetime supply of eggs. In other words, women do not produce new eggs and as they age their supply of eggs in their ovaries decreases. As the rate of loss of eggs varies between women, it can be difficult to predict the amount of eggs and level of fertility a woman has as she ages. Therefore, measuring ovarian reserve can be an important part of fertility evaluation and potential advantages of having your ovarian reserve measured include;

-       -  If you have decided to delay starting a family you may wish to check your ovarian reserve to confirm that   your supply of eggs is not already significantly reduced.

-         - A low ovarian reserve is one factor in identifying women who may have a low chance of success from fertility treatment.

-          - If a woman has an unusually high ovarian reserve she may have polycystic ovarian syndrome (PCOS).

-      - Measurement of ovarian reserve is helpful in deciding the best dose of medicine(s) to use during fertility treatments such as in-vitro fertilization (IVF).

A number of different blood hormone levels and ultrasound measurements have previously been used to assess ovarian reserve. However, there are potential drawbacks and inaccuracies associated with each of those tests.

These include;

-          - Follicle Stimulating Hormone (FSH) measured on day 3 of the cycle

-          - Inhibin B

-          - Antral follicle count

-          - Ovarian volume assessment

-          - Clomiphene challenge test

A common question was regarding the clinical significance of a low AMH level. “I am young and my AMH level is low”.  What does this mean?  Does a low AMH level mean I will never get pregnant? Today, because the test is so easily available, many doctors do AMH level testing in order to counsel infertile women. While a normal AMH level is reassuring, many doctors do not seem to understand what to advise their patients when their AMH level is low. While low AMH levels do suggest poor ovarian reserve, this does not mean that these patients cannot get pregnant with their own eggs. However, there are some IVF specialists who reflexively advise their patients with low AMH levels to use donor eggs as their first treatment choice!

Both doctors and patients need to remember that doctors do not treat lab results – we treat patients. Sadly, it’s so much easier to order lab tests and “fix” these rather than talk to the patient that we tend to over treat abnormal lab results such as low AMH levels.

Please remember that women with low AMH levels do get pregnant in natural way as well! This is especially true for young women with low AMH levels – in these women; a low AMH level does not correlate as well with poor fertility as compared to low AMH levels in older women!

The trouble is that when infertile women find out they have a low AMH level, this is what they start obsessing about – much like the man with a low sperm count that is exclusively focused about his sperm counts!

Please remember that an AMH level is just one piece in a complex mystery! If you do have a low AMH level, please do not panic. Remember that every problem has a solution - we just need to find the right one for you!

Here are some ground rules, which may help to what should do next.

1.    Please don’t jump to conclusions based on just one report.  Please retest from another lab – remember that not all labs are reliable!

2.    You need to collect additional evidence to confirm the diagnosis of poor ovarian reserve. One of the best ways of doing this is by checking your antral follicle count, using a vaginal ultrasound scan.

3.    it’s worth trying alternative medicines to try to improve your ovarian reserve. While these are untested and unproven, they are unlikely to cause any harm – and will give you peace of mind you did your best. You can use yourself as a personal guinea pig and run a clinical trial on yourself – this is a great way of becoming an expert patient!

Low AMH levels in young healthy women do not seem to be a predictor of reduced productive ability.  This is consistent with high egg quality in these young women, despite a reduced ovarian reserve.  Conversely, women with high AMH levels had a 40% reduction in the FR, and this persisted even after exclusion of women with irregular cycles.

So what does all this mean?  At present, routine measurement of AMH level as a “fertility check up” in young women is not useful.  It clearly shows that young women with low AMH levels did not have a decreased chance of conception compared to women with normal AMH levels.

It’s important to remember that we do have solutions to this common and frustrating problem, and that a low AMH level does not mean that your dreams of having a baby will never be fulfilled!

It’s a good idea to try IVF to see how your ovaries respond. Using donor eggs should always be second option!