How low is too low when it comes to AMH?

Written by Dr Raelia Lew
08 Sep

The Anti-Mullerian Hormone (or AMH) is a hormone produced by the primary follicles (small clusters of cells that surround immature eggs) in a woman’s ovaries. An AMH test can give you an indication of your ovarian reserve compared to other women of a similar age. Unlike men who continually produce sperm, women are born with their lifetime supply of eggs. It can be important to know what your ovarian reserve is when considering having a baby.

What is the AMH test?

An AMH test is the best biochemical marker of a woman’s ovarian reserve.  The test itself is a hormonal blood test that estimates the number of eggs at rest in a woman’s ovaries. As a fertility specialist it gives me a very good idea of what the ovary is capable of in the context of fertility treatments. This can determine how strong a candidate a woman is to undergo certain fertility treatments (like IVF and egg freezing) and how successful those treatments are likely to be. However, it is also important to remember that an AMH level does NOT predict your chances of a natural conception in the near future.

Who should have an AMH test?

An AMH test may be requested for women contemplating their fertility options and wanting to investigate their ovarian reserve.  Women planning IVF or fertility treatment will usually have an AMH assessment, alongside other markers of ovarian reserve such as an ultrasound antral follicle assessment. The AMH test is the most modern way to understand a woman’s ovarian reserve. It also creates the opportunity to personalise a strategy to achieve the best possible individualised treatment outcomes.

What factors contribute to a low AMH?

Age affects every woman’s AMH level. From birth, women have already produced all the eggs that they will release in their lifetime. This starting number is genetically determined and can vary greatly between women. However, whatever a woman’s starting point, her ovarian reserve will dramatically reduce over time. Eggs are steadily lost until the age of 30 years. After this time, the rate of loss increases rapidly, especially after 35 years and this can be one factor that contributes to a lower chance of live birth in older women. There are some circumstances where a low AMH level is inaccurate, such as when AMH is measured in women using the pill or who have hypothalamic dysfunction.  

How are the results of the AMH test measured?

An AMH test is not a measure of egg quality – and our best estimation of quality and potential of eggs to become a baby is a woman’s age. AMH is a measure of quantity – and can infer how many eggs can be expected to develop in a fertility treatment cycle. It is important to interpret the AMH result in context of other factors that influence fertility. 

What is a healthy range for an AMH test?

AMH levels can vary widely, even amongst fertile women. Interpretation of the AMH level should be considered in the context of a woman’s holistic situation and her plans for future fertility.  A low AMH should not necessarily be considered as a stand-alone concern, and is not associated with a reduced monthly chance of getting pregnant. 

However, if a woman has complex or multifactorial infertility, a low AMH can reduce her chance of having a baby. A low AMH can also influence whether or not a woman is a strong candidate for preventative strategies like elective egg freezing. The table below depicts the normal range for AMH at different ages.

What can a woman do if she has a low AMH?

There is no known therapy that can increase the number of eggs in the ovary. What we can do is take proactive action. If I see a patient and she has a low AMH and has presented a history of infertility, I would be more inclined to consider recommending more advanced treatment sooner. I would also discuss proactive family planning strategies if she wishes to have more than one child in the future, such as frozen embryo banking.

How can I determine the quality of my eggs?

Age is the best indicator of egg quality. Other lifestyle factors such as being overweight, smoking and exposure to environmental toxins might affect a woman’s egg quality. Over time, eggs can become metabolically fatigued which makes them more prone to genetic changes. In older eggs, chromosomal abnormalities can occur before fertilisation and during early cell divisions reducing the chances of forming a healthy embryo and therefore a healthy baby.

How do I get an AMH test?

Any woman who wants to know more about her fertility should see a general practitioner and request a referral to see a fertility specialist. Your GP can order an AMH test (and other tests relevant to fertility like routine antenatal screening investigations) so that your result is available to discuss at your fertility consultation. This might include checking things like infection status, rubella and chickenpox immunity and your blood group. 

The most important message about AMH is that it is not a standalone measure of a woman’s current or future fertility. The result should be interpreted in the context of an individual and her plans for future fertility, as a part of a comprehensive assessment with a fertility specialist.

 

If you are planning for pregnancy or already trying and would like to have an AMH test please contact your local fertility specialists: 

AMH testing in QLD

AMH testing in NSW

AMH testing in VIC

AMH testing in TAS

AMH testing in Singapore 

 

Contact

Make an enquiry

Share this article


We hope this article was informative and useful to you. If you have any questions or feedback, feel free to get in touch at info@blogivf.com.au.



Related Articles

Conceiving in your 40s, what are the chances?

I was recently asked to comment in a Sun Herald article on 26th August (also published online here: Sydney Morning Herald) on Collette Dinnigan, who pregnant at the age of 46, has called on women not to leave it too long to try for a baby.

It is always news when a high profile personality such as Ms Dinnigan, has a child, particularly when the personality in question is a bit older.  The difficulty is that these occasions, while very happy for the people involved, give a misleading picture of the actual likelihood of conception in these circumstances.  Remember that high profile personalities such as Ms Dinnigan, are human beings who quite rightly value their privacy and so very rarely (quite understandably) talk to the press when things aren’t going so well.  It was therefore, a particularly courageous action of Ms Dinnigan, while celebrating her own happiness, to so publicly, point out the difficulties that may face other women, seeking the same fulfilment.

What then, are the issues for women in their forties who are planning to have a child?

The main difficulty is that conceiving is simply harder at that age and, even once a woman does conceive, the risk of miscarriage is higher.  Surprisingly, although we have very good data about the effects of age on IVF conception (more shortly), we don’t have very good statistics about the effects of age on conceiving naturally. The limited available data about natural conception comes from old population studies or studies of unique populations, such as the Hutterites of North America, who do not use contraception.  Interestingly these data, such as they are, seem to be entirely consistent with the more modern and abundant IVF data.  Generally, in one year of trying, 75% of women under 30 years and 66% of 35-year-old women but only 44% of 40-year-old women will achieve a live baby naturally.

The main explanation for this, is that women are born with a finite number of eggs, and from that moment onwards, the number of eggs is declining all the time, until women go through their menopause at around 50-51.  Nonetheless, women in their 40s do still ovulate each month.  What is it about their eggs that cause all these problems?

A common misunderstanding with some women is that the fact she looks and feels young, and leads a healthy lifestyle, means that her eggs will be healthier. I regularly see women who have taken enormous care with their fitness and their health.  The rest of their body is in great shape, completely fit and ready to carry that longed-for pregnancy.  Sadly, despite this, the eggs still can’t do it.  The effects of time are remorseless and, sadly, there is no wonder drug to fix it.

Scientists have shown that eggs from older women are more likely to have an abnormal makeup making pregnancy less likely, miscarriage more common and increasing the risk of Down Syndrome, a condition where a child is born with an extra chromosome number 21.

Nor is IVF a cure for this problem. For women, in their early 40s, IVF is still a good thing to try and gives significantly higher success rates than trying naturally.    However, IVF success rates fall sharply after the age of 40 and by the time a woman is 45 are close to zero.

So, what’s the good news?  Well despite all of the above, many women do conceive in their forties, either by IVF, or naturally, and have very happy healthy families.  It is obviously better to have your family earlier, if you can, but all hope is not lost, just because you’re past 40.  Conception and early miscarriage are the big problems but, if you do conceive and get past the first few weeks, by far the most likely outcome will be a healthy child.  While the risk of Down Syndrome is increased, most of the other problems that affect young children are not increased by being conceived a later maternal age.

Finally, many women worry that by having their children later, their long term health and emotional development may be affected.  On the contrary, we now know that the children of older mums grow up to be as healthy and bright as any other child.

Snapshot of Fertility in Australia

There have been a number of happy and high profile stories in the press recently about older celebrities giving birth to healthy children. Stories like this used to be extraordinary, but they certainly seem to be on the increase. While this trend is supported by data that shows the fertility rate and numbers of births are increasing for women over 30 and especially for women in their early 40s, women and couples should understand the risks associated with having children later in life.  IVF Australia, Melbourne IVF and Queensland Fertility Group, have teamed up to create their latest infographic - “Fertility and Age in Australia” which explores some of these issues.
 Fertility in Australia infographic

Paternity, Maternity, Equality

Conceiving a baby in a same sex relationship

IVFAustralia, and its partner clinics Melbourne IVF, Queensland Fertility Group and TasIVF, are proud supporters of ‘rainbow families’. IVFAustralia were an Official Supporter of Sydney’s Gay and Lesbian Mardi Gras this year, and we’ve seen the number of same sex couples accessing our donor program double in the last year.
 
In 2011, a survey of 3,835 LGBT people found 33% of women and 11% of men had children1 - but close to 40% reported wanting to have children or have more children. This so-called ‘gayby’ boom is thanks to changes in community attitudes and laws, including better access to Assisted Reproductive Treatments for lesbian and single women.
 
So, if you’re hoping to experience the joy of starting a family within a gay or lesbian relationship, what do you need to consider?

How long will it take to conceive?

Generally speaking, we’d expect a healthy woman with no fertility issues to fall pregnant through IVF or Artificial Insemination within six months. You can prepare for pregnancy by improving your diet, doing regular exercise and other lifestyle factors.
 
When you access the donor program there are a few extra decisions you need to make.
 
Do you choose a known donor, or an anonymous donor? In a lesbian relationship, do you want to implant an embryo with eggs from one mother into the other? Should you store some sperm from the same donor for later, in case you’d like a related sibling? For two dads, the process of finding a surrogate can also be complex.

How do we choose a donor?

Our fertility clinics offer access to both Australian and US* donor sperm. The access fee for US donor sperm is higher, but the waiting list is also shorter as there is a shortage of local donors (gay men, we’d love to hear from you!)
 
When you’re using donor sperm or eggs, there are a few legal, emotional and ethical factors to consider and a counsellor will help you work through these concerns so you can make the best decisions for your family’s future.

Are there any legal issues?

Each state has different laws about parental recognition and access, so it’s worth seeking specialist advice before you start.
 
For example, in Victoria, the Victorian Assisted Reproductive Treatment Act (2008) removed discrimination against lesbian and single women with regard to fertility treatment, recognised parenting status for non-birth mothers and also effectively legalised ‘altruistic’ surrogacy. It also recognises lesbian couples as equal parents of their child or children as long as they were in a de facto relationship.

What else should we be prepared for?

30 years of research2 has shown that the children of same-sex parented families do just as well as the children of heterosexual parents socially, educationally, physically and emotionally.

The issues your children will face as they get older are just the same as the issues facing any children conceived using donor sperm or eggs: Where did I come from? Should I contact my donor? You need to be prepared for these questions at some point.
 
In the meantime, we hope we can help you fulfil your dream of having a baby, and that you will experience the joys of pregnancy, birth and parenthood.

What should be my next steps?

If you would like to learn more about the fertility treatments available for same-sex couples in your regions, visit one of our websites. 


 * IVFAustralia and Queensland Fertility Group patients only.

1 Leonard et al. (2012) Private Lives 2: The Second National Survey of the Health and Wellbeing of GLBT Australians, The Australian Research Centre in Sex, Health and Society, Melbourne
2Rainbow Families Council of Victoria (2010) Rainbow Families and the Law, RFC, Melbourne, http://www.rainbowfamilies.org 

Receive our quarterly e-news with free advice from the fertility experts.