Anti Mullerian Hormone (AMH)- The Ultimate Ovarian Reserve Test?

What you should know about AMH


When you seek medical advice for infertility issues, one of the hormone tests that you be advice to take is the Anti-Mullerian Hormone or AMH test. This test measures the AMH levels in your blood, which helps doctors determine your ovarian or egg reserve.


In this post, I’ll explain what egg reserves and AMH tests are, as well as what you can do if your AMH levels are low:


About egg reserves

Humans are born with a limited amount of eggs. To be precise, a girl is born with between one to two million immature eggs or follicles in her ovaries. But not all these follicles will survive into adulthood. In fact, throughout a woman’s life, the majority of her immature eggs will die in a natural process called atresia.


Did you know that by the time a girl has her first period, only about 400,000 follicles are left? And with each subsequent period, she loses about a thousand follicles, while just one matures into an ovum or egg. This means, throughout her reproductive life, a woman will develop only about 400 ovum. The number of developing follicles a woman has left, is called her “ovarian or egg reserve.”


Egg reserves and the quality of those eggs vary from one woman to another, due to factors such as age and infertility. Over time, both the quantity and quality of a woman’s eggs gradually decreases. Therefore, when seeking treatment for infertility, it is important for a woman to gain insight into the remaining quantity of her egg reserve and fertile years.

What is AMH?

When follicles develop in a woman’s egg reserve, her body release the Anti-Müllerian Hormone (AMH). AMH levels, therefore, can give us a good idea of the state of a woman’s ovarian reserve. Since AMH levels are determined by the number of developing follicles in a woman’s ovaries, low AMH levels are an indication that the ovarian reserve is depleted.


Fewer developing follicles mean slimmer chances for a mature and healthy egg to be released and fertilised. As such, when a woman knows the state of her egg reserve, she can determine how urgently she requires treatment.


AMH testing
While egg reserves generally decline in the mid to late 30s, leading to low AMH, age is not the only factor. Environmental factors can also cause low AMH, such as cancer treatment and inherited genetic causes. AMH levels can be easily assessed with a blood test, but like most diagnostic tests, it has its limitations. For example, it cannot indicate the quality of the eggs that are left, which requires a separate test. However, as AMH levels remain fairly constant in a woman’s cycle, she can have the test at any time.


What Can’t AMH tells you


As much as we would like to believe that AMH is ‘the ultimate test’ for ovarian reserves, however, it only tells us some aspect of your fertility performances but not all. AMH does not tell you the quality of your eggs. Therefore, some women who have plenty of eggs and high AMH level may not perform well in an IVF treatment cycle because of poor egg quality.


For women who take oral contraceptive pills, AMH level may not be a true reflection of their ovarian reserves. Those who were taking the pill had 19 percent lower levels of AMH and 16 percent fewer early-stage follicles.


Recently, there has been clinical studies which reported that there is a significant variation in serum AMH levels across the menstrual cycle regardless of ovulatory status. This variability, although statistically significant, is not large enough to warrant a change in current clinical practice to time AMH measurements to cycle day/phase.

What you can do

If you should take an AMH test and find that your level is low, do not lose heart! Your AMH level is just one piece in a complex jigsaw puzzle. Your best course of action is to discuss matters with your infertility specialist. Ask your doctor how you can protect your egg count and health, as well as discuss the best possible solution to your problem. For example, DHEA supplementation and well-managed IVF protocols have been shown to be effective in improving IVF pregnancy rates in women with low AMH. Maintain a positive outlook and don’t give up on your dreams of having a baby!





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Unexplained Subfertility


Woman in tears

Like most Fertility Specialist, we faced patients with all kinds of fertility problems everyday. One of the most unique group of patients would be those who are categorised as unexplained subfertility.


It is the most frustrating & awful diagnosis for the patients. These patients are generally well but frustrated. The label of unexplained subfertility is a diagnosis of exclusion, which means that these patients had gone through most of the tests for subfertility and all the tests came back with normal results, but yet they are not able to get pregnant naturally.


In general, up to 10-25% of couples will not find any causes for their subfertility after going through fertility testing. This diagnosis can be frustrating as many of them would wonder: why is it they have not achieved a pregnancy given that all the test results had been normal?


The important thing to note is that even though all the tests are normal, it does not mean that there are no factors that prohibit them from having a baby naturally.


It is important to note that most of the fertility tests are mainly simple fertility tests. These tests do not necessarily assess function.


For example, despite showing both of your Fallopian tubes are patent through a dye test (hysterosalpingography, HSG) or a diagnostic laparoscopy, it does not necessary translate that the Fallopian tubes function are good and it does not necessarily ensure normal transport of eggs and sperm in the Fallopian tubes as there has not been a valid test for this. We know that Fallopian tubes were lined with multiple fine hairs (cilia) within the tubes, and the function of these fine hairs is to transport the eggs and sperms to meet at the most suitable place to encourage fertilisation. The cells in the Fallopian tubes also produce secretions to encourage the process of fertilization. Although the Fallopian tubes were patent, if these functions of the Fallopian tubes were poor, fertilization fails to occur. Unfortunately, there are still no tests for these conditions.


There are also conditions whereby there are poor quality of eggs or poor functionality of the sperms which attributes to this diagnosis. As Fertility Specialists, we can visualized the number of eggs you have and measure the hormones which governs egg productions. However, there is no valid test to check the quality of the eggs until the day one goes through an IVF (in-vitro Fertilization) where the doctors and the embryologists would be able to examine the eggs under microscope. Therefore, apart from being a treatment, IVF can be a diagnostic tool in its own right.


The same principle applies to the functionality of the sperms. During semen analysis, we can see the number, the activity, speed and shapes of the sperms. However, there is no test to check whether the sperms can fertilize eggs until the day we perform an IVF using these sperms. Again, IVF becomes a diagnostic test in this scenario.


If you had been diagnosed with unexplained subfertility, my advice to you would be not to leave it for ‘nature to take its course’. There maybe other underlying conditions whereby the current fertility tests available are unable to address the issues or to diagnosed the condition. It is important to put things into perspective and move on with Fertility Treatment.