AMH and Ovarian Reserve: Debunking Myths and Clarifying Facts | Ep. 595

Episode 595

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This is the Fertility Friday podcast, episode number 595.
In today’s episode, I am diving into AMH, anti -malarian hormone.
This is an important topic for women who are trying to conceive, women who are
struggling with fertility challenges, and for practitioners alike. And of course,
the reason why it’s such an important topic is because there are still many
misconceptions about how this information, how this number should be used in practice,
and it leaves many women feeling hopeless, feeling like they’re not going to be able
to conceive all based on this number, this result. So we should really talk about
what it really is, what it really measures, what the research tells us that it is
best used and most useful for so that we can be providing the best and most
accurate information to our clients. And if you yourself are listening for
understanding a gaining a better understanding of how this could apply to your
fertility, then I think you’ll find today’s episode very helpful. So As always, I
will link the paper that I’m referring to to the show notes page, which you’ll find
at fertilityfriday .com /595.
So the paper is called Evaluation of Female Fertility, AMH, and Ovarian Reserve
Testing. So this is a review paper and it’s going through some of the latest
research. It provides a really good summary. It’s intended for practitioners and
clinicians to clarify some of the most common misconceptions about AMH. And to start
this episode, I think it’s useful to share a little bit of background in terms of
how common fertility challenges are. So it’s estimated that anywhere from one in six
to one in eight couples are struggling with fertility issues. And as we’ve talked
about many times on the podcast, Although we tend to think of fertility issues as a
woman’s issue, up to 30 % of the time, infertility is related solely to male factor
and about 50 % of the time. So half male factor is involved and that it might not
be the sole factor, but it is involved in statistically speaking. When we’re looking
at couples who’ve been trying to conceive for a year or more, if we were to test
his sperm parameters Again, statistically speaking, they’re likely not hitting those
optimal levels. One thing I’ll mention is that these topics are covered a lot more
in depth in real food for fertility. The sperm chapter is chapter 11, over 200
citations in that chapter, going through what’s normal, the normal sperm parameter. So
I won’t be going through that in today’s episode. And in the egg quality chapter,
you’ll find a detailed discussion of AMH and other and reserve parameters and
essentially what the research says is going on there. So there’s a couple other
things. I mean, being a research paper, I think it’s really helpful that they kind
of go through some of the bigger picture challenges that could be contributing to
the rise of infertility across the world. And I think it is worth mentioning that
we know that there’s a trend across the world for women to be delaying their first
pregnancy. And it’s interesting because the way the researchers frame it is that
there is a lack of knowledge about fertility, and there are a lot of studies out
there about fertility awareness, but not in the sense that we talk about it, which
is the fertility awareness method, but generally awareness about fertility, how it
works, and how it changes with age. So certainly one of the challenges of our
modern era is that our bodies are primed and most receptive to pregnancy,
our natural fertility is the highest when we’re in our 20s. And then of course,
even into our early 30s, but as we get into our mid to late 30s, there is this
natural decline in fertility. And this is something that we should talk about. It’s
something that we should be aware of. It’s something as women that we should be
taught to understand. And of course, that’s one of the topics I talk about a lot
in my books and in my work, which is But when we are not taught about our
fertility, but we’re kind of taught we can get pregnant anytime, we’re not taught
that it changes as we get older. So a lot of women are essentially afraid of
pregnancy for most of their life. And then when they’re finally ready to start
trying for a family in their 30s, they haven’t been provided this information. And
if we’ve been using hormonal contraceptives and suppressing fertility, we’re also not
taught about the fact that there is a temporary period of subfertility while our
body adjusts, especially if you’ve used birth control long term. So if you’ve used
birth control in the studies, they define long term as two years. And that is for
anyone who’s hearing that for the first time, it’s often kind of shocking, like,
wait a minute, they define long term as two years when many women are using birth
control hormonal contraceptives for five years, 10 years, 15 years, 20 years, it’s
not in common for women to be using it for that long. But if we don’t know about
that transition phase, then we don’t necessarily know to come off birth control while
we’re still avoiding for ideally, I would say a year or two before you’re ready to
start trying to conceive, just to let your body sort itself out so that you can
actually see what your cycles look like and so that you can have a good sense of
the lay of the land. If you come off of birth control when you’re still avoiding
and then you and your partner are using non -hormonal methods that are not affecting
your cycles, then if there was an issue with your cycle, you would have some time
built in to sort it out. If you need to go for testing, if you need to work with
somebody, you would actually have the time to do that when you’re not also actively
trying to get pregnant at the same time. And this is especially important for women
that did have a history of irregular cycles or cycloabnormalities or hormonal
disturbances, or if you had really severe PMS, if you had really severe pain with
your periods, you would be in a category that would certainly benefit from coming
off contraceptives early. And what I always say is that doesn’t mean that you can’t
get pregnant right away. There are, of course, women who get pregnant while they’re
still taking hormonal contraceptives, but we want to be able to have a buffer
period, kind of like how we have car insurance for when we drive. We don’t want to
assume the worst, but we always want to plan, and we want to have a strategy in
place. So Getting back to this paper, that is one of the things that the
researchers are identifying. Women are having children later in life, and a lot of
women aren’t really aware of fertility and how it changes with age. And interestingly
enough, although AMH is being used often today in the clinical setting to try to
predict a woman’s chances of conceiving naturally or to predict when she’s going to
be going into menopause, the researchers are clear that that is not actually what
the research tells us. That’s not how we should be using this information. And they
still maintain that a woman’s age is the most significant factor in determining
whether or not she will conceive over AMH numbers.
So let’s get to what is really going on here in terms of AMH, antimalarian hormone
is a hormone that is produced by our ovarian follicles as they are maturing.
And what happens is we are born with all the eggs that we’re ever going to have.
And as we go into puberty and as we kind of move through our reproductive life,
every time we are gearing to ovulation, so we have our periods, we’re at the
beginning of the cycle, there’s a small pool of primordial follicles that are
developing. And the size of that pool is actually related to the total amount of
eggs that we have left. So over the years, what the researchers have identified is
that there is this link between how many eggs that we have in that pool of
follicles that are developing at the beginning of our cycle to the total number that
we have left, and they’ve made that connection by looking at the changes over time.
So when we look at a woman’s antropholical count from when she’s younger all the
way through to her forties, we can see this gradual decline. And in the same way,
the AMH is actually produced by this pool of follicles. And so when they’re looking
at that number, they are kind of able to see the size of this pool.
Now how it’s used is actually as a proxy for your ovarian reserve. And so because
if they look at AMH values from younger women all the way into their 40s, there’s
a gradual decline. We have this correlation between the AMH and the number of
estimated eggs that we have left. But keep in mind that it’s always an estimate and
it’s always indirect because unlike sperm testing, we can’t just go in and like cut
out the ovary and count how many eggs that we have left, right? Like with sperm
testing, they can actually have the man ejaculate into something and count the sperm.
And so we get a pretty clear idea of how many sperm are in there. But we can’t
do that with women, obviously. And so AMH is never a direct, like this is how many
eggs you have left. It’s always an estimate. So some of the misconceptions out there
then about AMH are that it’s going to predict if you’re going to be able to
conceive. And it’s going to predict how long you have until menopause. And one of
the misconceptions about it as well is that it’s this static number that never
changes, so it can’t go up or down. And even that it’s genetically inherited by
your parents. And so based on this study, the researchers identify and estimate that
about 50 % of our capacity in terms of when we’re going to hit menopause is related
to genetic factors because of studies that have been done that show a similarity
between mother and daughter in terms of when they actually reach menopause, but 50 %
is certainly not 100. There are other studies that show that AMH is affected by
other factors. AMH is affected by obesity. AMH is affected by conditions like PCOS.
Women with PCOS are known to have higher AMH levels because they
one of the characteristics of PCOS that you have polycystic ovaries. So you have
multiple little follicles that are growing in the egg, and so therefore you have a
higher antrofolical count and a higher AMH level. Because again, AMH is essentially
related to how many follicles are in that little pool and they’re all kind of
kicking out AMH. So that’s how they’re looking at this number. AMH levels are also
impacted by other conditions such as endometriosis. Women with endometriosis are more
likely to have lower AMH levels due to all of the inflammation and complexities of
the condition itself, but that doesn’t necessarily correlate to her ovarian reserve
directly. So what we can see and one other study that I’ll just point out is that
there are also studies that have shown there was an interesting study that Lily and
I shared in Real Food for Fertility where the women were given vitamin D at a
certain time of their cycle towards the beginning of their cycle, and it actually
increased the AMH levels over a period of time. So the reason I’m pointing that out
is because one of the common misconceptions about AMH is that it’s static, and it
doesn’t change. So the misconception is that it’s set in stone. But as we can see,
we have all these examples of how it can actually change or respond to different
conditions. So while we do have a correlation between AMH levels and the ovarian
reserve, it is not this direct, this means that we can predict exactly when you’re
going to go into menopause. And then the other piece of it that’s really important
is that this number is estimating your reserve. So it’s estimating how many eggs
that you have left. Again, “estimate” is an important word in that sentence. But
it’s also a quantity thing. So that means that even if you have a low number,
that doesn’t automatically mean that the quality of those eggs is also low. And so
interestingly, then, when these authors and researchers in this paper, when they are
reviewing the data and they’re outlining how the AMH number should be used, they are
crystal clear on a few points. They’re crystal clear on the point that it is not
actually predictive of your reproductive capacity, how likely you are to get pregnant.
And it also can’t be directly used to predict when you’re going to be going into
menopause. And so I’m sure that at least some of you listening to this episode have
been told the exact opposite thing. And so, I mean, the good news is that, like I
said, you can go to the show notes page and you can have a look at the paper.
And there’s a lot of research on this. This is not difficult to find. For those of
you who are really into the research literature, it’s really easy to find because
this is not a hidden thing. There’s a lot of research on AMH and the conclusion is
crystal clear. And that is what makes it really interesting for me when I hear so
many of my clients being told that, “Well, my doctor told me that I’m going to go
into menopause. My doctor told me that I won’t be able to have kids. My doctor
told me blah, blah, blah.” And it’s just like, unfortunately, as we know, it takes
up to two decades for the latest research to get into clinical practice and to
standard clinical practice. So we do have to keep that in mind as we go through
these studies that are pretty coming out. This study that I’m going through today
was published in 2022. So like I said, this is not new information. This is pretty
standard.
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ahead and jump back into today’s episode.
So I guess this brings us to the question. So then what is AMH used for? What are
the clinical applications and what are the best uses of this number? And so I think
what’s really important to understand is that the research shows that the best use
of AMH, like what it is best used for, is for clients who are undergoing ART,
assisted reproductive technology. So, for example, if you’re going through IVF or
you’re planning to and they test your AMH, whether it’s low or high, it’s going to
be an excellent predictor of how many eggs they’re likely to retrieve. There’s a
really, really strong correlation between that AMH number and how successful that
retrieval is going to be, how receptive your ovary is going to be to the
stimulation and how many eggs that they’re going to be able to retrieve. And again,
the reason for that is because when the AMH number is low, it’s saying that the
follicle, the little follicle pool, so the pool of antroph follicles towards the
beginning of your cycle is low. So if there’s a pool of eggs and the pool is
very, very small, well, the amount of eggs that they’ll be able to stimulate through
the IVF process is going to be directly related to how many eggs are actually in
that pool. It makes perfect sense that that number correlates really well with how
many eggs that they’re able to successfully stimulate and retrieve. If the AMH levels
are normal, if they’re in that optimal range, then you’re a good candidate for that
stimulation process. Conversely, if your AMH levels are too high, which is commonly
seen in PCOS, because again, that is related to this polycystic ovary situation where
we have a lot of little follicles developing but aren’t necessarily reaching maturity,
which is characteristic of the condition. What you have then is the situation where
you have too many and that can lead to a greater chance of hypostimulation,
which is it can be a very serious condition. It can even be fatal in very severe
cases where they’re stimulating the ovary and there’s so many eggs in that pool that
it can kind of cause a lot of pain and a lot of discomfort and that kind of
thing. So in the paper, what the authors talk about is how then one of the best
applications for the AMH is specifically related to IVF procedures and to let the
clinicians, if they see certain numbers, they’re able to gauge the dosing, they’re
able to be more specific and precise with how they’re going to approach that
stimulation and potentially if a woman has a higher number, they may change how
they’re going to dose so that she’s less likely to overstimulate and they’re so
crystal clear. Let me read a few things. Let me read a couple of quotes here. So
they say serum AMH estimates ovarian reserve helps determine dosing in ovarian
stimulation and predicts stimulation response. And they say as such, AMH is a good
marker of oocyte quantity. Again, the amount, how many, but does not reflect oocyte
health or chances for pregnancy. So could we be more clear that it has this utility
for these procedures and predicting not, and this is one thing that’s really
important. It doesn’t have the utility to predict if that pregnancy is going to go
to term, but it can predict whether or not the woman will be receptive to the
stimulation and how many eggs likely will result from that. I mean, these are really
important factors. So for example, if you are not planning to do IVF,
or if your client is not planning to do IVF, or that’s not their preferred, at
least at this time, that’s not their primary goal, then that AMH number is not as
helpful because it doesn’t actually tell her if she’s likely to get pregnant
naturally. It actually doesn’t tell them that. And interestingly, there are research
studies that have been done where they compare the pregnancy rates of women with
higher and lower AMH levels. And typically they’re not, it’s not that one is related
to another. So if I take a moment to read a brief section from Real Food for
Fertility, outside of IVF and IXE procedures, AMH is similarly a poor predictor of a
woman’s ability to conceive naturally. In an observational study of 87 women planning
to conceive, 88 % conceived within one year, and the researchers found no relationship
between AMH levels and time to pregnancy. So I think this is the point, right? This
is always the point that I want to share when it comes to AMH and how we should
be looking at it and how we should be talking about it, how we should be
understanding it, interpreting the results. The authors of this paper goes so far as
to say that women who are not seeking IVF treatments, I mean, their language was
kind of like women who are not in the infertile population, so very like researchy.
But what they’re saying is like, if you’re dealing with a normal healthy woman who’s
trying to conceive naturally, and there aren’t specific signs potentially of
infertility, that it shouldn’t necessarily even be used because there’s no research to
show that it’s going to help in any way to predict if she’s going to conceive or
not. And they go on to really stress that age is still the biggest factor.
So one of the things that they talk about is that as we get older, we are more
likely than to have chromosomal abnormalities, all these things that a lot of us are
aware of. And ultimately, if you are trying to conceive naturally, that’s the route
that you’re trying to take, then it would make a lot more sense to focus on
strategies to support egg quality. Whether that’s strategies to support mitochondrial
health, to reduce oxidative stress, which is damaged due to oxygen exposure,
and the example I always give is if you take out a banana and you leave it on
the canner, it turns brown, but if you dip it in lemon water or lemon juice or
something like that, it doesn’t. That’s because vitamin C is a potent antioxidant,
and so therefore it’s protective. And so if we have an understanding that these
numbers are not telling us about the quality and instead they’re just telling us
about the quantity, then we can focus on the thing that is likely going to make
the biggest difference, which is supporting nutrient reserves, working on improving a
quality and of course really focusing on improving sperm quality as well. So I’ll
just share a couple other direct quotes from the study because again, just to kind
of like put the nail in the coffin here. So one of the things the researcher said,
“AMH is a good marker of oocyte quantity but does not reflect oocyte health or
chances for pregnancy.” And another quote from the paper, “There was no AMH level
below which pregnancy did not occur.” There are recorded in the literature in the
research pregnancies that occur, even when women’s AMH levels are undetectable. And so
Well, that isn’t necessarily the best situation. I think that if the AMH levels are
low, there is room, certainly, to be supporting egg quality, really looking at
nutrition. A lot of the things that we talk about in the egg quality chapter of
Roe Food for Fertility and the nutritional strategies that we talk about throughout
can be helpful, of course, and looking at sperm quality as well. But ultimately, the
research is not showing this direct link, this causative effect that if the AMH is
low, that natural pregnancy can’t occur, or that if AMH is low,
if pregnancy does occur, that it has any predictive value on how likely that
pregnancy is to go to term. And so again, the most useful way to use this
information would be to determine the approach that your practitioner would be taking
to IVF procedures. So in many ways, this is good news. It’s good news for women
who are trying to conceive. It allows them to kind of step out of the fear around
this number and these results that is often perpetuated to them, at them, and allows
them to refocus on what’s most important. As practitioners, it’s helpful for us to
have a clear understanding so that when our clients are coming to us with these
types of issues, we know how to support them. And it’s a good reminder that we
really should be looking at the research and the literature and understanding the
true implications of it. I think when they first discovered it, there was all of
this excitement, “We’re going to be able to predict when women are going into
menopause.” It was kind of like this, like the promise, I suppose, was that, and
that may have been how it was presented decades ago, but now we have a lot more
data on it and it really changes how this conversation should be had. For many of
This is not, it hasn’t, just because it’s changed and updated in the literature,
doesn’t mean that it’s changing their experience. And this is a common, common
challenge for practitioners who are working with fertility clients. So again, if
you’re wanting to dive into the study that we talked about today, you’ll find that
in the show notes, fertilityfriday .com /595. If this episode was,
if you can think of someone, if there’s someone who comes to mind when you hear
this episode, then I would encourage you to share it. And like I said, if you’re
wanting to do a deep dive and to go, you know, way more into quality and sperm
quality and all those things, I would certainly direct you to real food for
fertility. If you haven’t grabbed your copy yet, you can head over to
realfoodforfertility .com and get the first chapter for free. Otherwise, you can find
it on Amazon and we also have the audio book version. So it’s there for you when
you are ready to take a deeper dive into it. So with that said, I hope you have
a wonderful week weekend whenever you tune into the show. And until next time, be
well and happy charting. If you’re loving the podcast and you’re ready to apply
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