First, before we talk about what AMH is, I think it is important for women to understand the basics of female fertility.
Women are born with all of the eggs they will ever have in their life (approximately 1-2 million at birth). Throughout their lifespan, starting at the first menstrual cycle, the body recruits a group of follicles (each with a small immature egg inside) that have the potential to respond to hormones, grow and ovulate.
Usually, a woman will ovulate one egg per month, the eggs that do not get selected to ovulate will dissolve and the process repeats itself if a woman is not pregnant that month.
The average age of a woman having children in the US is on the rise over the past few decades as more women choose to advance their education, career or simply live their life prior to starting a family. The result is that more women in their 30s and 40s are having children than in the past.
However, we know fertility declines as we age so it’s important that women understand their fertility and what the current tests and treatments can and can’t do for them.
Only when women are armed with all of the knowledge will they be able to make informed decisions about their health!
What exactly are AMH levels?
AMH or anti-mullerian hormone is a laboratory test that OBGYN and fertility doctors may use to assess a woman’s ovarian reserve or egg count. AMH is a hormone produced by cells from the small follicles in a woman’s ovaries and is used as a marker of oocyte quantity.
The nitty-gritty details about AMH
- AMH, or anti-mullerian hormone is a substance produced by granulosa cells in ovarian follicles.
- It is first made in primary follicles that advance from the primordial follicle stage. At these stages, follicles are microscopic and cannot be seen by ultrasound.
- AMH production is highest in preantral and small antral stages (less than 4mm diameter) of development.
- Production decreases and then stops as follicles grow. Almost no AMH made in follicles over 8mm.
- Therefore, the levels are fairly constant and AMH testing can be done on any day of the woman’s cycle.
What does AMH mean in regards to your fertility?
AMH is an important fertility test to tell us about a woman’s ovarian reserve as it stands today. Higher AMH values (greater than 1 ng/mL) usually signify that a woman has a normal ovarian reserve and lower numbers (less than 1 ng/mL) may indicate a woman with a low or diminished ovarian reserve (DOR).
We know that a woman’s fertility declines as she ages so typically we see AMH values also start to decline as women age. The value of this test is that a woman with a low AMH can choose to do something about her fertility now if she desires a family for the future.
How can an AMH blood test help diagnose infertility?
Since AMH is produced only in small ovarian follicles, blood levels of this substance have been used to attempt to measure the size of the pool of growing follicles in women.
- Research shows that the size of the pool of growing follicles is heavily influenced by the size of the pool of remaining primordial follicles (microscopic follicles in “deep sleep”).
- Therefore, by reading the levels of an AMH blood test a fertility doctor can determine the size of the remaining egg supply – or “ovarian reserve.”
With increasing female age, the size of their pool of remaining microscopic follicles decreases. Likewise, their blood AMH levels and the number of ovarian antral follicles visible on ultrasound also decrease.
Women with many small follicles, such as those with polycystic ovaries (PCOS) have high AMH hormone values. Women that have few remaining follicles and those that are close to menopause have low anti-mullerian hormone levels.
What can AMH measure? What can AMH not measure?
What AMH is:
A great tool to assess a woman’s current ovarian reserve. It gives an overall picture of what you look like today.
Additionally, it can help with setting realistic expectations on the number of eggs that may be retrieved or how you will respond to medication should you decide to proceed with IVF either for infertility or for egg freezing.
What AMH is not:
A predictor of whether a woman can get pregnant spontaneously in the future.
The only true test of whether a woman is able to conceive, regardless of her AMH values, is for her to get pregnant on her own. A large cohort study demonstrated that there was NO difference in pregnancy rates in women with normal AMH values trying to conceive versus women with low AMH levels (less than 1 ng/mL) trying to conceive.
If you check your AMH today and get a low number that does not mean you can’t get pregnant tomorrow or in 3 months if you were to try on your own.
Additionally, just because you have a “normal” AMH value right now does not predict that it will stay normal for the future. All women will have a decline in fertility as they age and how rapidly that decline occurs is different for every woman and can’t be predicted.
Should I get an AMH test?
I am a big proponent of women being educated about their fertility so they feel empowered to make decisions regarding their health. One piece of that education is knowing what your ovarian reserve looks like at a given point in time and once you have that information, what, if anything you want to do about it.
AMH values can help you determine if you want to do something NOW for your fertility. Remember AMH tells you what your ovarian reserve is now. They can’t predict how quickly your ovarian reserve will decline in the future and they can’t predict if you will be able to get pregnant spontaneously on your own.
Is an AMH test covered by insurance?
Some insurance companies will cover the testing of AMH as a basic diagnostic test.
The best way to find out is to speak to your insurance provider or your physician. Otherwise, you can pay cash and that price will vary based on the clinic or lab you use.
Testing can range from $20 to slightly higher for a single AMH test.
What are normal results from an AMH blood test?
Interpretation of anti-mullerian hormone levels
There are some inconsistencies to consider when interpreting the results from an AMH blood test. Since the AMH test has not been in routine use for many years, the levels considered to be “normal” are not yet clarified and agreed on by the experts. Also, not all current commercial assays give equivalent results.
The table below has AMH interpretation guidelines from fertility literature. Please review your AMH result with your fertility doctors. The graph below should only act as a guide.
For example, the difference between 0.6 and a 0.7 ng/ml test result puts a woman in a “different box” in this table. In reality, there is very little real difference in fertility potential. In reality, it is a continuum – and not something that categorizes well.
AMH Blood Level
|High (often an indicator of PCOS)||Over 3.0 ng/ml|
|Normal||Over 1.0 ng/ml|
|Low Normal Range||0.7 -- 0.9 ng/ml|
|Low||0.3 -- 0.6 ng/ml|
|Very Low||Less than 0.3 ng/ml|
The below graph shows the average AMH level for women not experiencing trouble conceiving, according to age.
PLEASE NOTE: The above table, AMH Blood Levels (by ng/ml) should not be compared to the graph below (measured by pmol/l) as they are measured in different increments.
More will be learned regarding anti-mullerian hormone levels and outcomes. As we continue to use the AMH fertility test and study the relationship between AMH hormone values, fertility, and ovarian responsiveness.
What questions should women ask their doctors about AMH levels?
Women should talk to their doctors about ordering an AMH if they are interested in learning about their fertility and where it stands now.
If you find out you have a lower than expected AMH you should consider a consult with a fertility doctor to discuss the options of egg freezing if you are not ready to start a family now.
AMH levels and pregnancy chances with in vitro fertilization
Women with higher AMH values will tend to have a better response to ovarian stimulation for IVF (in vitro fertilization), with more eggs retrieved. Women with lower AMH have lower antral follicular counts and produce a lower number of oocytes (eggs).
AMH levels probably do not reflect egg quality. Having more eggs at the IVF egg retrieval provides an opportunity for a greater number of eggs to fertilize and develop into embryos. More eggs do not always mean more embryos. Egg quality plays a role in the fertilization and development of embryos. The ultimate goal is to have at least one healthy embryo to transfer back into the uterus.
How to Increase AMH Levels
Having a low AMH level means that a woman has a low ovarian reserve (egg supply).
Low AMH means that you have a low ovarian reserve, but it doesn’t mean that you are not able to conceive naturally. Unfortunately, there are no proven ways to increase your AMH levels, but some research has shown that vitamin D and DHEA may help increase AMH levels.
Ovarian reserve testing methods
The anti-mullerian hormone is just one potential test of ovarian reserve. Fertility specialists often use a combination of fertility tests to best assess a woman’s ovarian reserve, including a transvaginal ultrasound to count the number of antral follicles and other hormone levels.
How Do FSH and AMH Levels Affect Pregnancy?
Dr. Marcy Maguire, the lead physician at RMANJ’s West Orange office, recently explained FSH and AMH in detail on an episode of This is Infertility, a new podcast examining what it’s like to be infertile in the U.S.
You can listen to the entire episode in the audio player below or read Dr. Maguire’s discussion below.
What is premature ovarian aging, premature ovarian insufficiency or diminished ovarian reserve?
Dr. Maguire: All of the above mean essentially the same thing: the ovaries have fewer eggs in them than they should, given the woman’s age. Diminished ovarian reserve is not synonymous with whole-body aging – it doesn’t mean that the woman herself is somehow aging prematurely, it just means her egg count overall is lower than it should be given her age.
What are the symptoms of premature ovarian aging?
Dr. Maguire: The two most common symptoms are infertility and irregular or skipped menstrual cycles.
How can a fertility specialist diagnose premature ovarian aging?
Dr. Maguire: The best diagnosis will come from FSH and AMH levels, and then an ultrasound – all three can be markers of a lower egg count.
What is FSH?
Dr. Maguire: FSH, or follicle-stimulating hormone, is a hormone produced by the pituitary, an organ in the brain that encourages follicles and eggs to grow and mature each month. If the FSH level starts to go up, typically above the number often, that means that the brain is trying hard to stimulate the ovaries to produce eggs but having a hard time getting the ovaries to listen. So the FSH goes up and up, getting louder and louder and louder, trying to get the ovaries to listen – but there just aren’t many eggs left, so the ovaries are having a harder time producing.
What is AMH?
Dr. Maguire: AMH, or Anti-Mullerian hormone, is a hormone that is made by granulosa cells that take care of the eggs, so the more eggs a woman has, the more granulosa cells she has, and the higher her AMH. We like to use AMH as a marker of a woman’s overall egg count. If the AMH is above 1.2, we feel relatively reassured. If the AMH level is less than 1.2, that is more concerning. Of course, this will also correlate with a woman’s age, so a woman in her early 30s with a low AMH less than 1.2 is very worrisome, whereas it’s more common for women in their early 40s to have a low AMH.
How do you test for FSH and AMH?
Dr. Maguire: A blood test will identify a woman’s FSH and AMH levels.
What are fertility options for women with high FSH and low AMH?
Dr. Maguire: If a woman has diminished ovarian reserve, meaning an overall lower egg count, she still may have the opportunity to have children using her own eggs – it just depends on her relative level of eggs. If there are some there that we can access, typically we would do in vitro fertilization (IVF) to retrieve them. A woman could also potentially bank some of the eggs retrieved. Banked eggs are cryopreserved or “frozen”. Frozen eggs can be used in future IVF cycles.
What if a woman cannot use her own eggs at all?
Dr. Maguire: When a woman’s egg reserve is so low that she is in the early stages of menopause, fertility treatments typically can’t help a woman use her own eggs – but donor eggs (from both known and anonymous donors) are available and the woman can carry the pregnancy herself.