It is widely known that anti-Müllerian hormone (AMH) is an important ovarian reserve marker in fertility treatments. But what does it really stand for? What does it mean to have low or high AMH levels?
In this webinar, we have invited Dr. Valeria Sotelo Kahane from UR Vistahermosa
Clinic, Spain to talk about IVF prognosis and pregnancy chances in case of low AMH levels. The doctor also talked factors that cause AMH to drop significantly.
AMH and its functions
Dr. Valeria Sotelo Kahane starts with precisely defining what anti-Müllerian hormone (AMH) stands for. It is a protein produced exclusively in the granulose cells of the ovarian follicles. When secreted by the ovary into the circulations, its levels can be determined in serum by a blood test. Its blood levels reflect the pool of ovarian follicles (follicular reserve) and therefore, AMH is a marker of the quantity of the eggs. It helps us measure the ovarian reserve – that is, the eggs that are stored in the ovary.
AMH has also other, less known characteristics. It is found in both men and women – but with different functions. Its main action consists of the sexual differentiation in the embryo state. In male embryos, it is expressed early and inhibits the Müllerian duct – the embryo structure that forms the uterus and the tube. In female embryos, it is expressed later on, when the uterus and tubes are already formed. In adult women, ovarian follicles are expressed. Anti-Mullerian Hormone is produced in a woman’s ovaries by the primary follicles (small clusters of cells that surround immature eggs).
AMH – the analysis
Serum AMH levels seem to be the best ovarian reserve hormone marker since they correlate directly with the proportion of primordial follicles with a sensitivity of 80% and a specificity of 93%. The analysis of anti-Müllerian hormone (AMH) can be done any day of the menstrual cycle – unlike other hormones (e.g. FSH) which levels are practically constant throughout the cycle. Dr. Valeria Sotelo Kahane says that the measurement of AMH level is done through a simple blood test that doesn’t require fasting. It is good to remember that the AMH test tells us how many eggs remain in the ovary. It does not tell us anything about the quality of those eggs. The quality of woman’s eggs cannot be evaluated unless the eggs are collected and used for fertilisation attempts.
Resulting laboratory figures of the AMH test can be divided as follows: less than 1 ng/ml (low ovarian reserve and worse results for ovarian stimulation in fertility treatments), 1-3 ng/ml (levels considered normal) and above 3 ng/ml ( good reserve but special attention required in case of the ovarian stimulation). Basing on this data, we can classify patients according to their response to the ovarian stimulation during IVF treatment. The patients with AMH between 1 and 3 ng/ml are normal responders obtaining 10-15 eggs during the ovarian stimulation. The ones with AMH below 1 ng/ml are poor responders (with less than 3 eggs per stimulation) and those with AMH over 3 ng/ml are characterised by a high response to the treatment (even over 15 eggs).
However, it is worth considering that the AMH test results should not be understood as the only information determining a woman’s chance to conceive. The latter usually depends on many other factors, such as e.g. the quality of the partner’s sperm, the condition of the fallopian tubes, and the occurrence of ovulation. What is more, having a “normal” AMH value right now does not predict that it will stay the same in the future. All women will have a decline in fertility as they age – only the pace at which the decline occurs is difficult to predict.
Indications for the AMH test
According to dr. Valeria Sotelo Kahane, the AMH analysis an important fertility test to tell us about a woman’s ovarian reserve and should be suggested for all women who simply need advice about their future reproductive life. It is especially important for women who consider the so-called ‘late motherhood’ ( from 30/35 years of age) and those who experience infertility problems. The latter means being over 35 and trying for a pregnancy for over 6 months with no results. It is also advised for women who are thinking about cryopreservation of ovules or those having present risk factors of premature ovarian failure (family history of early menopause, smoking or health problems). Additionally, the AMH test is always obligatory prior to the ovarian stimulation in order to determine the indicated treatment.
The importance of AMH test
Dr. Valeria Sotelo Kahane stresses that the explanation of the information provided by AMH blood test (together with the count of central follicles made in ultrasound and the maternal age) is essential in reproductive counselling. If it is determined that the ovarian reserve is good and the pregnancy is still not achieved, some tests may be necessary in order to try to find out the reason of infertility. If the ovarian reserve is compromised, IVF can be the best option to achieve a pregnancy. In the worst-case scenario (meaning the lowest AMH level), egg donation might be necessary.
Poor ovarian reserve
Even before being born, women already possess the eggs that they will have throughout their whole life. Over the years, there is a decrease in the ovarian reserve – it refers to both the quality and the quantity of the eggs and it seriously affects the chances of a pregnancy. According to the Spanish Fertility Society (SEF), when women are born, they have about 2, 000, 000 eggs and when they are in the puberty, this number is reduced to 400, 000. Dr. Valeria Sotelo Kahane reminds us that this is exactly at the puberty stage when a woman starts ovulating. It is calculated that, in the reproductive life, a woman will ovulate between 400 and 500 times.
When, on the other hand, a woman in a menopause, her ovarian reserve is completely diminished. Therefore, we have to remember that a woman’s biological clock runs against her fertility. With every passing year, the chances of getting pregnant decrease – it is especially true for women over 35 years old. And although the age of a woman is the most common reason for the diminished ovarian reserve, there are other factors as well. These include mainly the presence of other diseases, such as endometriomas (ovarian cysts), teratomas or autoimmune disorders (rheumatoid arthritis, celiac disease, Crohn’s disease) as well as oncological or radiation therapies. The ovarian reserve may also be seriously affected by surgical interventions in the ovaries or lifestyle risk factors, such as obesity, tobacco smoking, increased alcohol consumption and stress.
Dr. Valeria Sotelo Kahane admits that the decreasing rhythm of every woman’s ovarian reserve is different. In some cases, ovarian reserves are over even before the menopause arrives. But whatever the reason for the decrease, we must realise that this situation is completely irreversible and there is no treatment to re-establish the amount of lost eggs.
According to dr. Valeria Sotelo Kahane, anti-Müllerian hormone (AMH) is one of the most significant prognostic determinants of the treatment outcome and pregnancy. It is considered a hormonal marker of ovarian ageing as its levels are directly proportional to the number of antral follicles and ovarian reserve. The advanced age of a woman is the most important factor for the diminished ovarian reserve and – as a result – a poor response to ovarian stimulation for IVF.