Here Alex O'Connor, a fertility acupuncture specialist, from Essex Fertility in her Explaining the Unexplained series gives us the ins and outs of AMH.
AMH - Does It Represent Egg Reserve?
It is not unusual for a woman to contact me after a visit to an IVF clinic for a 'fertility assessment' having had her Anti-Mullerian hormone (AMH) measured. People are usually told that the AMH level indicates egg reserves and if the level is anything short of great people get very worried. AMH can be indicative of egg reserve but not egg quality, and it is not a good predictor of how readily someone will conceive; it is actually a better indicator of how someone would respond to IVF stimulation, as this article will explain.
The table below shows the typical range of AMH at different ages.
Your AMH level will change over your lifetime, it is usually quite high in your mid-twenties, and gradually declines until menopause but along the way it can go up and down as it reacts to lifestyle, nutrition, stress and medications. Some GPs will test AMH, but it others argue that it is an expensive and unnecessary test as other tests are more useful for determining what is going on with your cycle; NICE guidelines recommend AMH is not offered routinely as a test to check for premature ovarian deficiency.
Does AMH Only Go Down?
Many people assume that AMH only goes in a downwards direction, but it is much more fluid than that. The oral contraceptive pill has been shown to cause AMH to decline by up to 50%, smoking can reduce AMH and stress can also be a factor in lower AMH.
Low AMH can often be improved with diet, lifestyle and acupuncture. In an example from my own clinic, a client came to me about 8 months after stopping the oral contraceptive pill having just had had a blood test to check her AMH - the result showed it was quite low for her age. A repeat AMH blood test after two cycles of acupuncture showed it had more than doubled in that time to the top of her age range.
Ovarian surgery such as removal of an endometrioma can create scar tissue within an ovary. This can also result in a temporarily lower AMH level which can persist for few months after surgery.
AMH and PCOS
A particularly high level of AMH (over 48.5 pmol/l) is one of several indicators of Polycystic Ovarian Syndrome (PCOS). A very high level of AMH usually indicates that the ovaries have an excessive number of pre-antral follicles and small follicles because it is these follicles that secrete AMH. In normal conditions at the beginning of a cycle there are a handful of follicles on each ovary waiting to grow on, at some point in the follicular phase, one of these overtakes the rest and becomes the dominant follicle which then grows considerably and releases the egg mid cycle. If the AMH is very high, in the early part of a cycle and there are too many small follicles, the process of selection of the dominant follicle may fail to work properly. When that happens it is possible that none of the follicles manage to grow to full maturity in a natural cycle. Ovaries with lots of pre-antral and small follicles can be seen clearly on an ultrasound, these ovaries are described as polycystic ovaries.
These small follicles also secrete testosterone so if there are lots of them it can create an excess of testosterone in the system which can also interfere with ovulation. Not all cases of polycystic ovaries are accompanied by high levels of testosterone; it is also possible that the large amounts of testosterone is being converted into an excessive amount of oestrogen which is another indicator of polycystic ovaries. In a normal cycle, that oestrogen comes from the dominant follicle as it grows and matures the egg, but in a PCOS cycle the oestrogen comes from a large number of follicles, sometimes none of them large enough or mature enough to release a mature egg.
When you work with a Fertility Support Trained Acupuncturist, they will work with you to establish what is going on with your hormones and your cycle and determine whether your cycle is dominated by testosterone or oestrogen. This knowledge will help them to treat you more effectively and offer you the most appropriate advice to help correct the imbalance. As the overall balance of hormones improves, the high AMH level should return to a more normal level.
One of few benefits of PCOS comes with age. At the age where AMH is falling too low for many women, in a PCOS woman AMH is just slipping down into a more healthy range, so there can be a window in which fertility actually improve in these later years.
Is a Low AMH Good?
If AMH is very low, there will only be a few pre-antral and small follicles at the beginning of the cycle. This can impact on the success of an artificially stimulated cycle (see below). However AMH is not an indicator of egg quality and for any normal cycle only one follicle is selected as the dominant follicle and grown on to maturity, so as long as the cycle is healthy it is very possible to ovulate successfully with a low AMH. A new study has shown that as long as you are regularly ovulating, a lower AMH does not make a huge difference to your chances of conceiving. The study showed that the chances of achieving a natural pregnancy with a lower AMH stood at 62%, whereas the chances of achieving a natural pregnancy with a normal range AMH was 65%.
When an IVF clinic sees a very low AMH, they know that at the beginning of a stimulated cycle there would be very few follicles available to respond to the stimulation drugs, so they will be unable to mature and harvest a large number of eggs.
AMH and Ovarian Reserve
AMH is often cited as a measurement that corresponds well with ovarian reserve. Alternative factors that suggest ovarian reserve are high Follicle Stimulating Hormone (FHS) or low Antral Follicle Count. In reality all three of these markers should be checked before making a diagnosis of reduced ovarian reserve, but of the three, an Antral Follicle Count is the most reliable marker. Even with a low ovarian reserve, it is still possible to conceive naturally if the hormones are well balanced and the egg and sperm quality are good.
Why are IVF clinics so interested in AMH?
Studies have shown that the level of AMH correlates well with how successful IVF treatment and egg maturation will be (La Marca et al, 2007). Very low AMH (lower than 1.4 pmol/l) has been associated with lower egg yield and poorer egg quality. This is not set in stone however; other studies suggest that AMH is not reliable enough to be used as a predictor for IVF success (Broekmans et al, 2007) and some suggest that women with low AMH still have a moderate chance of conceiving.
From the perspective of standard IVF, a very low AMH indicates that for any given month there may be very few follicles ready and waiting to be matured in that cycle. As a consequence of the small number of follicles available, the chance of having a successful IVF with a sufficient number of mature eggs to harvest is smaller so some clinics are more reluctant to take on such cases.
There are clinics which specialise in working with women with low AMH levels – they may choose a less intensive approach to ovarian stimulation such as ‘egg banking’ or pre-load the cycle by stimulating in the later stages of the preceding cycle to try to encourage more follicles to be ready for the beginning of the cycle and to create a longer, more gentle stimulation phase. Egg banking is a process whereby ovaries are stimulated very gently to make the most of the few follicles available, possibly harvesting as few as one or two eggs per cycle; this is usually repeated for 2-3 cycles in order to achieve sufficient eggs prior to continuing with fertilisation and transfer.
IVF clinics are not just looking for low AMH, they are also checking to see if you have a very high level of AMH because that tends to be more difficult to manage through IVF. If you have very high AMH you will have many, many more small follicles available for stimulation, as this mass of follicles grows they each start to generate additional oestrogen. If not carefully managed, this can result in a mass of small eggs being harvested which are not fully matured and which may fail to fertilise or fail to develop. An additional risk in this situation is that if your oestrogen level gets too high you are likely to slip into Ovarian Hyperstimulation Syndrome (OHSS) which is a potentially life-threatening condition if left unmonitored.
How To Increase Low AMH
There is some interesting evidence that suggests Vitamin D can help raise AMH levels, particularly Vitamin D3 (Dennis et al, 2012). Vitamin D deficiency has also been associated with decreased fertility and an increase risk of early pregnancy loss, so it is definitely worth checking your Vitamin D level and supplementing if necessary.
There is some research that suggests DHEA is a supplement that could help to improve AMH but this needs to be viewed with some caution as it is not going to be appropriate for everyone. DHEA can be measured in the blood, so if you are considering DHEA supplementation it would be a good idea to check your DHEA level before starting to supplement, keep an eye out for symptoms of testosterone excess and recheck DHEA level every month. An excess of DHEA is likely to result in an excess of testosterone which would have a negative effect on your fertility.
How to Decrease High AMH
There seems to be quite a strong correlation between insulin resistance and the high AMH levels seen in PCOS. It would be prudent to recommend dietary changes to try to reduce PCOS-related high AMH levels, a healthy diet such as the Mediterranean Blood Sugar diet would be a good place to start (Pellatt et al, 2010). To see my article on how to tackle PCOS through diet, Click Here.
Melatonin seems to have a regulating effect on AMH as it has been shown to increase low AMH and to decrease high AMH.
- Low AMH - There is some research suggesting that supplementing with 3mg/d melatonin can help to increase AMH, improve egg quality and the likelihood of developing top quality embryos (Jahromi et al, 2017).
- High AMH (PCOS) - There is some research suggesting that melatonin supplementation can help decrease high AMH in normal weight women with PCOS (Tagliaferri, 2018)
Specialist Fertility Acupuncture
In clinic I regularly see hormonal levels improve and the overall hormone balance shift into a better state. As your cycle improves, various hormone markers will improve and can be used to confirm the benefits of fertility acupuncture on a case by case basis. When you choose to work with a Fertility Acupuncture Specialist you are likely to be asked to check some of your basic hormone levels at the beginning of your treatment and to monitor them as you go along so that we can see the improvements. This integration of ancient acupuncture knowledge and modern scientific knowledge is a very important aspect of how we work.
If you are starting to wonder whether you need to be worrying about your AMH, find a Fertility Support Trained Acupuncturist to work with - let them help you to work out what you need to be concerned about, let them help you to improve your natural fertility or prepare for IVF.
Read more about Alex and Essex Fertility here.