Low AMH and Natural Conception (Episode 464)

Full Transcript: Episode 464

Welcome to the Fertility Friday podcast, your source for information about the fertility awareness method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of The Fifth Vital Sign and the Fertility Awareness Mastery Charting Workbook. I’m a certified fertility awareness educator and holistic reproductive health practitioner with over 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormone health, and optimizing the menstrual cycle without hormones. I have been consistently outspoken about hormonal birth control over the past two decades and its impact on fertility and overall health because you have the right to know how your body works and how artificial hormones disrupt that natural process. I teach women’s health professionals how to utilize the menstrual cycle as a vital sign in their practices. And I host live coaching programs to help you achieve optimal fertility and health because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys and a brand new baby girl. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health. And I’m so excited that you’re here with me today.

I’m excited to share today’s episode with you. I think it’s going to be a great follow-up to last week’s episode with Amanda. I just wanted to take some time to go into a little bit more depth about AMH and so I have a great study to share with you today in today’s FAMM Research Series episode. So without further ado, let’s go ahead and jump right in.

Today I’m sharing all about a recent study that came out that was looking at measures of ovarian reserve. And the title of the study is “Markers of Ovarian Reserve as Predictors of Future Fertility.” And I’m excited to go through this study because it really sheds some light on this very, very common question I receive about AMH from clients and from listeners of the show. And I feel like it’s a great way to follow up from last week’s episode with Amanda. So if you chose this episode randomly and you haven’t listened to last week’s Pill Reality Series with Amanda, definitely go back and have a listen, because in that episode we really get into the impact of the pill on ovarian reserve parameters.

And what we focused on in the episode was AMH, anti-Müllerian hormone, and FSH, follicle-stimulating hormone. If you were using the pill, if you have questions about how that could relate to AMH levels, then that is an excellent place to start. Today’s episode is not focused on hormonal contraceptives and their influence, but more so on whether or not AMH levels are related to a woman’s future fertility.

All right, I’d like to start with a little bit of an overview about the study itself. And again, the study aimed to determine the association between ovarian reserve markers and future fertility in women of “late reproductive age.” So when they were saying ovarian reserve markers, they were specifically measuring AMH, anti-Müllerian hormone, FSH, follicle-stimulating hormone. They were also measuring inhibin B, but I won’t be going into detail about that. We’ll be focusing primarily on the AMH and FSH.

This was a time-to-conception study, and so they were measuring the length of time it took women who were between the ages of 30 and 44 without a history of infertility to conceive naturally. And that gives you an idea of the age range of the women in the study and what they were looking at. In just general terms, they were basically taking this group of women and looking at over a certain span of time — and in the study was about 12 months — and so they were looking at how long it would take these women to conceive, how many would conceive. And they were also doing blood draws to determine their AMH level, FSH level, and they were looking at do the women with low AMH, high FSH, do these women take longer to conceive compared to the women whose AMH or FSH is optimal.

And just a little bit of a recap about what these things even are for any of you who are listening who aren’t that familiar. AMH, anti-Müllerian hormone, is a hormone that is produced by the developing pool of follicles in the ovary at any given time. And during each menstrual cycle, essentially beginning of the cycle, once you’ve stopped having your period, once your period is over, there’s a little pool of follicles that starts to develop as they prepare for ovulation. And what the research has found over the years is that there is a connection between the size of that little pool of ovarian follicles that are developing each cycle and the total remaining reserve of eggs that you have left.

When they measure AMH, the hormones that are coming from this little pool of ovarian follicles, they’re getting an indirect measure of the total remaining pool of follicles in your ovaries. And that is essentially what the AMH is doing. They use it as a bit of a proxy, an estimate. And the reason that they have to do that is because in order to get the actual number, they would have to take out your ovaries, cut it open, count the eggs kind of thing. And there’s never a situation for women to get this accurate, specific, detailed number of exactly how many eggs that you have left.

With men, when they measure sperm counts, very different. A man can ejaculate into something and they can look at the count and calculate it and it’s very, very different. But since we can’t provide an egg sample, this is one of the ways that they can indirectly measure how many eggs you have left. And this essentially comes about because toward the beginning of a woman’s reproductive life, the AMH values are higher and there’s a steady and slow decline as we get older, and this is how they’ve discovered that there’s this relationship.

But the interesting piece of that is that it’s not 100%. It’s not to say that the AMH is only affected by the total reserve that’s left. And if you listened to last week’s episode where we talked about how AMH levels can be affected by the birth control pill, and a woman coming off the birth control pill could have lower levels until her ovaries go through that transition period that we all would go through after coming off of contraception. There’s also other factors that can affect AMH levels — different conditions like PCOS, like endometriosis. Even vitamin D levels can affect AMH. So although there is this indirect way to measure the remaining overall reserve of eggs using this test, it’s not to say that it’s 100% exact, and it’s also not to say that there aren’t other factors that can affect it.

So what AMH is most useful for clinically is that there is a really strong correlation between AMH values and how successful IVF treatments are going to be. If a woman’s AMH numbers are too high — so for example, women with PCOS, they tend to have a lot more of those follicles developing at any one time. That’s the name of the condition, polycystic ovary syndrome. It means they have a lot of little follicles developing, that’s part of the condition. And these women often have higher AMH values as a result. So they just have a higher pool of eggs putting out more of this anti-Müllerian hormone, and therefore their results tend to be higher.

When it comes to IVF treatments, when you have a lot more follicles, you’re more likely to overstimulate. So women with really high AMH values are likely to then produce too many eggs, which can cause a big problem when they’re doing IVF treatments. And similarly, women who have a really low AMH number, they tend not to stimulate well. So the research is pretty consistent and clear on the value of AMH numbers and how effective it is at predicting a woman’s IVF success.

But ironically, it’s often used in a different way. It’s often used to then tell women whether or not they’ll be able to conceive naturally. And that is what this study is getting into. It is asking the question of if a woman has low AMH values, so lower than what’s optimal for her age range, then is that going to mean that she’s going to have a harder time to conceive?

And similarly with follicle-stimulating hormone. And so if you’re not familiar with FSH, FSH is produced particularly toward the beginning of the cycle as you’re moving towards ovulation. FSH is what is stimulating the ovary to essentially develop the follicles and to prepare for ovulation. If a woman’s FSH is too high, it generally means that her ovaries are not necessarily responding effectively to that message. So if you were to think of FSH as a messenger, your pituitary is sending it out to tell the ovaries something. So the FSH is supposed to go to the ovaries and tell them, okay, it’s time, let’s start maturing the eggs, right, in layman’s terms here. And if the FSH is too high, it means the ovary isn’t really responding. It means that you’re trying to get a hold of, you’re trying to call, you’re trying to get hold of the ovary here, but the ovary is not receptive. And so high FSH can be a sign of an issue from that respect.

But again, these markers, the question in the study is, are they going to affect a woman’s chances of natural conception? Because what can happen is if you’re going to a fertility doctor, let’s say you’ve been trying to conceive, or for whatever reason you’re getting your ovarian reserve markers tested. And when those values come back, often women are being told that, okay, this is going to mean you’re going to go into menopause soon, or this is going to mean that you’re not going to be able to get pregnant.

And so that’s the preamble. So hopefully with that brief explanation, you at least have a better idea now of what is AMH, what is FSH, to some degree, and why are they even doing the study in the first place.

And what’s interesting about this study is that the researchers, their hypothesis was that they were going to see a connection between these what they call diminished ovarian reserve. Diminished ovarian reserve is the word for when your AMH numbers are too low, below optimal, and when the FSH is too high. Basically, the markers are indicating a low ovarian reserve. So based on everything that I mentioned to you, if the ovarian reserve markers are showing “diminished ovarian reserve,” they’re basically saying, well, it looks like that pool of follicles is depleting or has been depleted, and so it looks like you’re not really going to be that fertile. That’s basically how they’re using it.

And the researchers in the study were hypothesizing that, okay, so if a woman has low ovarian reserve markers, if she meets our definition of diminished ovarian reserve, we hypothesize that she’s going to have a harder time getting pregnant naturally. They defined, for anyone who’s interested, they defined diminished ovarian reserve as an AMH level below 0.7 and an FSH number that’s higher, greater than or equal to 10.

And what they found was that women with diminished ovarian reserve did not have a lower likelihood of future fertility — that’s in their words — compared with women with normal ovarian reserve. So what they’re saying is that they did the study, they studied all these women, over 300 of them, and when they got their result at the end of the study, they found that the women who had low ovarian reserve markers actually didn’t have a difference in terms of how likely they were to conceive compared to the women who had normal ovarian reserve markers.

So I mean, I took a while to kind of get to this point, but I’m just going to say it again. The researchers did not find that women who had low ovarian reserve markers had a harder time getting pregnant than the women who didn’t — the women whose ovarian reserve markers were normal. And again, if you remember what I shared with you, the research is quite clear on how useful the ovarian reserve markers are at predicting IVF success. It’s so interesting how they’re so often also used to tell women whether or not they’re going to be able to have a natural pregnancy.

So the researchers concluded, based on their results, the conclusion states: diminished ovarian reserve is not associated with reduced future reproductive capacity. And they actually go on to caution women. They believe women should be cautioned about using these common reproductive biomarkers as predictors of their future ability to reproduce.

And that’s basically the point. That’s the point of today’s episode. If you have had this issue, if you’ve been tested and you’ve been told that because of your low AMH or high FSH that that’s going to mean that you can’t get pregnant, the research doesn’t say that that’s what it is effective at predicting.

The AMH number doesn’t actually predict whether or not a woman will be able to get pregnant naturally. This is what they’re saying. They’re saying that even women with low ovarian markers, even women with low AMH, high FSH — so diminished ovarian reserve, meeting the definition that they laid out — even those women were able to conceive at similar rates as the women who had normal levels. And so we need to really start to understand that AMH levels, FSH levels are not in and of themselves some sort of sentence of infertility.

And we also have to remember that there’s research that has been done in terms of how long it takes for the current research — I mean, this study was published in 2022, like this is right now, this is like current stuff — and so on average it takes about 20 years for current research to be adopted into clinical practice. And this is the reality. So many of you selected this episode today because you have concerns about your AMH, because you’ve been told that your AMH is too low, because you’ve been told that that’s going to mean you’re not going to be able to get pregnant, or because you’ve been told that it’s going to mean that you’re going to go into early menopause.

And the irony, again, is that AMH can be affected by other factors. And even though there is a correlation between the AMH gradually decreasing alongside our natural depletion of our ovarian reserve, so it’s not to say there’s no relationship — even the studies that look at how effective AMH is at predicting when a woman will go into menopause, it’s not 100%. Even for women with very low levels, there’s still a limited ability of these markers to accurately predict exactly when you’re going to go into menopause. Even if the markers are low, it doesn’t mean that a doctor can use those data points to say you are going to go into menopause at this date. There’s still a limit to how much they can predict these things.

And what does this mean for you? Okay, so I’m going to go through a couple of interesting pieces of information from the study. I took a couple notes here that I think will be interesting. And then we can wrap up by going through what does this mean for you, right? Like what ultimately, what are our action steps, or like what ultimately should we be taking away from this information.

All right, so a couple of points from the study. The researchers noted that there was considerable variation in ovarian reserve between women of the same age. That’s interesting. With AMH values, even if you do get these tests done, if you’re, let’s say you’re 40 years old and you do an AMH test, your results would have to be looked at within the age range of someone about 40 years old. Or if you were 20 years old, your results would have to be looked at within an age range of someone of 20 years old. So there are different ways to look at it. We don’t just take the test and look at it independent of a person’s age. But even within the age itself, there’s a lot of variation, and that in of itself is interesting. It means that there is a lot of individual variation for women with regards to this.

If you have women of the same chronological age and they’re showing different markers, it also means that there’s likely — I’ve seen it in my work with women — there’s likely things we can do to improve it to some extent. But of course, if you’re 40 years old, you’re not going to get your AMH levels necessarily to what they would be if you were 19. But within your age cohort, there are things you can do to bring it up or down, which is often not what we’re told. I’ve had clients who are told that there’s nothing they can do, that it’s set in stone. It seems as though there are certain health professionals that are taught that it is very much fixed, a very fixed number. But the research does show otherwise.

And of course, they found that women with low AMH values did not have a significantly higher risk of future infertility compared to women with normal values. There was not really something there. And what I find interesting is that it did contradict their hypothesis. They did find that women who met their definition of diminished ovarian reserve did not have the reduced ability to conceive or carry a baby to term. They didn’t necessarily have a higher miscarriage rate according to this particular study. And they did have to note that it did contrast what they hypothesized because their result was different to what they thought that it would be.

They also said here: probability of achieving a live birth, probability of being diagnosed with infertility, and probability of conceiving in any given menstrual cycle did not differ based on the AMH or FSH value.

And again, so I just keep hammering the point home. And I want to say this specifically because women get so freaked out when they’re told that their FSH is too high or their AMH is too low. It doesn’t mean that we should just assume everything’s totally fine if your numbers are really off. But I guess the point that they’re making in this study is that although it does have an effect — for example, if you are looking to do artificial reproductive technology, if you are looking to do IVF, if your partner’s sperm parameters are way too low to result in a natural conception, right? If they’re really off the WHO limit and there’s an issue there, right? Or whatever the case is. If there’s a reason that you need to use artificial reproductive technology and you’re looking into IVF, then this is bad news if the ovarian parameters are too low because it does mean that you’re likely a poor candidate for IVF, may not stimulate very well. And so, again, that is what these values have been shown in the research over and over again consistently to be the best at predicting. They’re the best at predicting how well a woman will respond to IVF stimulation.

But again, in this particular section here, we’re not talking about that. We’re talking about how these are incorrectly then used also to predict whether a woman will be able to conceive naturally.

So I guess the question is, what do we take from this? We had to conclude to wrap up today. What do we take from this? What does this all mean? Well, obviously it means that we should be looking at these values for what they can actually tell us. They can tell us whether or not you’re a good candidate for IVF, if you’re going to stimulate well or if there’s a possibility that you may overstimulate. But ultimately, they should not be used to tell you whether or not you’re going to be able to have a natural conception. That is the thing that they’re not good at predicting. Because if a woman can have a diminished ovarian reserve, if she can meet those criteria, but she can still get pregnant naturally at about the same rate as a woman who has normal levels, then obviously we shouldn’t be using them to freak women out and to scare them and to give them this conclusion that they won’t be able to have the baby naturally.

To piggyback off of that, if you have been told then by your doctor that these numbers mean that you won’t be able to conceive naturally, then I would say that it also means that you would want to seek a second opinion, whether that’s from another doctor, another fertility specialist, or if you’re going to look at working with a functional practitioner or someone who can look at other parameters and other factors. Because although these results do have a strong predictive value at how you’ll likely respond to IVF treatment, they don’t have that ability to predict whether or not you’ll be able to have a natural conception.

And I feel like that’s good news because it means that you could then spend your time focusing on optimizing both you and your partner’s health and fertility and sperm parameters and everything for a conception to then increase the chances of conceiving naturally. What I think happens for a lot of women is when they’re given this result, they’re just so defeated. They can even go into depression. I’ve spoken to so many clients who’ve been told this and it’s just devastating because basically they’re told that this is essentially — like you’re essentially infertile. You won’t be able to get pregnant. This is how they’re told. This is how this information is used. And again, it’s just not the way that it should be used. Again, we don’t want to ignore this information, but we want to use it correctly and we want to apply it where it would actually make a difference.

So I’m going to stop here. I feel like that’s a good place to stop. Again, the study is called “Markers of Ovarian Reserve as Predictors of Future Fertility.” And if you do want to take a peek at the study, you can head over to fertilityfriday.com/464. That’s where I will be putting all the links from today’s episode and you can take a peek if you’re wanting to look into it a little bit more. I mean, it’s such interesting information. And what I find just to be completely upsetting about this AMH situation is that the research is so clear. You don’t have to look for an obscure study. There’s a ton of research out there on AMH. And it’s pretty consistent in terms of what it’s good for, what it’s useful for, what it’s best at predicting, and what it’s not. And what’s sad about it is just that so many practitioners seem to be still using it as a way to diagnose women with infertility or not, or tell a woman whether or not she’s going to be able to conceive and all that kind of stuff. And unfortunately, that’s just not what it should be used for. It should be used to inform practitioners about who is a good candidate for artificial reproductive technology treatment, because that has been what is consistently shown in the research time and time again at what this is best for.