There are so many fertility terms in the glossary of IVF, and one you’ve undoubtedly heard of before is AMH, or Anti-Müllerian Hormone. A simple blood test can reveal your AMH level, which is key in understanding your overall fertility because it indicates your ovarian reserve, or how many eggs you have left in the ovaries. But an abnormal AMH result alone doesn’t necessarily mean you’ll struggle with infertility.

Below and in our latest installment of DandiTV, David E. Reichman, MD, chief medical advisor at Dandi Fertility and reproductive endocrinologist at Weill Cornell in New York City, explains how AMH affects fertility, normal AMH levels by age and what a low or high AMH means for your IVF cycle. Plus, he clears up some myths, like does high AMH mean twins? Read on…

What is AMH and how is it related to fertility?

AMH, or Anti-Müllerian Hormone, is a protein secreted by the follicles in the ovary. Follicles are small fluid-filled sacs that house each egg and mature over a menstrual cycle before ovulation. We don’t have a great handle on the physiologic role AMH plays in the female body, but what we do know is it’s an excellent quantitative marker of egg reserve, meaning it tells us how many eggs are left in the ovaries.

What AMH does not reveal is the quality of those eggs.

How can I test AMH?

You can test AMH with a blood test; just request it from your primary care physician or your OB/GYN. However, only specialists like reproductive endocrinologists truly understand the nuances of AMH and can help you understand what a high AMH or low AMH means for your fertility (more on this below).

AMH is a relatively new measure. For many years, all we had in the field of reproductive medicine to indicate a woman’s ovarian reserve was testing her FSH, or follicle-stimulating hormone. If her FSH was elevated, that indicated there was low ovarian reserve and that the brain had to work harder to get the body to ovulate. But now, by testing AMH in conjunction with antral follicle count (AFC), which is how many follicles are visible via transvaginal ultrasound, we have a better understanding of where you fall on the scale for your age-related egg reserve.

Average AMH

There’s a broad range of normal AMH. You can have undetectable AMH and get pregnant right away, or you can have a 9.0 AMH (this is exceptionally high) and still need fertility treatment. It’s important to know that low AMH does not necessarily mean you have infertility.

What AMH can tell us though is how long your fertility journey may be — how much time do we have before your egg reserve runs low? This is why it’s key to understand your AMH before you begin trying to conceive.

Normal AMH for my age

AMH levels naturally decrease with age, which is why there’s such a broad range of normal. But as a general rule of thumb, if your AMH is higher than 3 ng/dL (the unit of measure used in the United States), you have good ovarian reserve.

Here are the average AMH levels broken down by age:

• Under the age of 30, AMH of at least 2.5
• Between the ages of 30-35, AMH of at least 2
• Older than 35, AMH of at least 1.5 or 1

AMH and IVF success

AMH is not directly correlated to in-vitro fertilization (IVF) success, but it predicts the number of eggs we can expect to retrieve in a given IVF cycle. Even if you have low reserve, you can still have high quality, genetically normal embryos. However, low AMH means fewer eggs will be retrieved during a cycle.

The most common indication of egg quality is age, but beyond that, lifestyle factors can affect the quality of eggs, such as smoking cigarettes, drinking a lot of alcohol and certain endocrine disruptors, hormones that can affect the body’s natural reproduction process.

What AMH is too low for IVF?

No AMH level is too low to move forward with IVF. But if sperm counts are normal and we expect that we’ll only be able to retrieve one or two eggs, then we may opt for other less invasive and less expensive treatment options such as ovulation induction (OI) and/or intrauterine insemination (IUI). I like to look at the advantage of IVF as it relates to the efficiency of how many eggs you can get. If IVF won’t be efficient, it might not be the best way forward.

Essentially, we as doctors look at individual patient factors and family building goals. You can still be a candidate for IVF with a low AMH, even if some clinics might tell you otherwise.

How does AMH determine IVF protocol?

AMH can help your practitioner determine your IVF protocol, as well as dosing for IVF medications such as Gonal-F or Follistim and Menopur:

• IVF dosing is based on AMH and body mass index (BMI)
• If you have high AMH, IVF dosing is more nuanced because the goal is to get enough eggs for success but not too many that it could lead to ovarian hyperstimulation syndrome (OHSS), ovulating too many eggs that could cause fluid leaking into the abdominal cavity.

Studies have found that for patients with low AMH, lower doses of stimulation medication have equal success rates as high dose protocols, but maybe less side effects and definitely more cost savings.

Again, there’s no one-size-fits-all answer on IVF protocol and AMH. Each patient has very specific response rates to stimulation medications, and you won’t know how you respond until you try.

Does high AMH cause twins?

The short answer is no, AMH is not related to a singleton or twin pregnancy, and high AMH does not mean twins.

If you have high AMH, you’re only at an increased risk of twins if you’re being treated with fertility meds that could result in more than one follicle growing and ovulating, like Clomid or Letrozole. This is why during treatment cycles your reproductive endocrinologist (RE) will monitor you frequently with blood tests and ultrasounds, in this case to make sure only one follicle is growing.

Does high AMH mean you have PCOS?

No, high AMH doesn’t mean you have polycystic ovarian syndrome (PCOS). PCOS is a hormonal imbalance disorder that causes you to ovulate infrequently or not at all. PCOS patients may require oral medication like Clomid or Letrozole to induce ovulation, which can lead to more than one follicle growing and therefore can result in multiples if more than one egg fertilizes.

A PCOS diagnosis can only be made if you have clinical evidence of PCOS, which includes:

• elevated androgens (male hormones like testosterone) via a blood test
• polycystic ovaries via ultrasound
• or symptoms such as unwanted body hair, acne or obesity

Polycystic ovaries should really more accurately be called polyfollicular ovaries, because the ovaries contain more-than-usual immature follicles (not cysts). The high AMH is a result of so many follicles, since follicles produce AMH.

Some individuals with high AMH don’t have PCOS and are just normal fertile women with good egg reserve. Yes, those people do exist!

To put it simply, PCOS patients can have high AMH, but AMH level doesn’t define this condition.

Does birth control affect AMH testing?

Yes and no. If you have your AMH tested while on birth control, the AMH value will be about 50 percent lower than it would’ve been if you had tested it a few weeks before beginning oral contraceptive (OCP).

The birth control pill does not lower the egg reserve; it simply lowers the accuracy of the test.

That’s because the pill makes the ovaries “sleepy.” If you start an IVF stim cycle after 6-12 months on birth control, that will affect how much AMH your body produces, as well as the number of eggs retrieved. You may be prescribed birth control during your IVF cycle, but that’s only for a short period of time and to keep your hormone levels at baseline to make sure they’re ready for stimulation meds.

If you get your AMH tested while you’re on the pill, get it checked again about 2-3 months after getting off of it to get a more accurate understanding of your AMH value.

Medications that can affect egg reserve

Some medications can affect egg reserve and AMH such as:

• Depo-Provera, an injectable progesterone-related contraceptive that suppresses the ovaries even more than the pill
• Implanon or Nexplanon, contraceptives implanted in the arm

Key takeaways about AMH and fertility

• Anti-Müllerian Hormone, or AMH, which can be determined through a simple blood test, indicates the quantity of eggs, known as ovarian reserve, but it reveals nothing about the quality of those eggs
• Average AMH is dependent on a woman’s age. Generally speaking, an AMH of 3 ng/dL or higher indicates reassuring ovarian reserve
• AMH alone is not a good predictor of IVF success, though low AMH means fewer eggs will be retrieved in one given cycle
• High AMH doesn’t determine a singleton or multiples pregnancy
• High AMH also doesn’t mean you have PCOS, though many patients with PCOS do have higher AMH levels since they have more follicles, which produce the AMH
• Birth control pills and other oral contraceptives don’t affect egg reserve, but your AMH value will be lower while on birth control and for the few months thereafter

AMH is just one piece of the puzzle when it comes to your fertility. It’s important that you see a qualified reproductive endocrinologist who can run these tests and address concerns about your fertility as you start to think about family planning.

 Book a personalized fertility planning consult with one of Dandi’s qualified nurses as you get started on your fertility journey.