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Low AMH, now what?

It’s arrived. Your Grip report, ready and waiting in your inbox. It’s finally time to see your results and (hopefully) gain some clarity. But once you open it, you read that you have low levels of AMH. To panic or not to panic? What does that mean? What can you do?


At Grip, we think that learning more about what might be happening on the inside is a great step to take, but it can also be pretty scary if you don’t understand the why.



Here’s the 411:


If you’ve got ovaries, then you were born with all the eggs you’ll ever have. At birth, you probably had around 1 million eggs. But by the time you’re 30, you have an average of 13% left. And by the time you’re 40, that’s 3%.


Sounds scary, but 3% of 1 million is still 30.000 eggs, and most people are perfectly capable of having a baby at 40. When your supply runs out, that’s menopause.


If you’ve got a low AMH, that means you may have a smaller egg supply than the majority of people your age. Again - a ‘low’ amount of eggs is still a lot of eggs, and that doesn’t have to mean anything bad.



Eggs and hormones: huh?!


Every month, your body releases loads of eggs. Those premature eggs, called follicles, are stored in your ovaries. We love a metaphor, so here’s one:


Think of your ovaries as a big freezer where your eggs are held. Every month, in preparation for ovulation, you take a big chunk of frozen eggs out of the freezer to defrost. Think of these defrosting eggs as being put on a kitchen counter. Your body then gets out what we can only describe as a big hairdryer (consisting of the hormones LH and FSH), points the hairdryer at a single one of those defrosting eggs, and helps that egg develop into your one golden egg that jumps that cycle. And voila! You are now ovulating. The eggs that didn’t become the ‘golden egg’ are lost, and the cycle repeats itself.


Still following? There’s more!


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For your natural fertility, it really doesn’t matter how many eggs you had on the counter, and it doesn’t matter how many of them are lost. Because here’s the thing: All it takes is one golden egg to get pregnant!


Now, back to AMH:


While it is not a predictor of the chances of you getting pregnant right now, nor how long it will take you to conceive, AMH is currently the most accurate predictor of your ovarian reserve (1) i.e. how big the pool of eggs, or the freezer, is that you have left. We’ve written more about AMH in a post here and here.


From this, we are able to estimate:



1. Your risk of entering menopause early (2).


Your body is clever in that it becomes more sparse with the amount of eggs it takes out of the freezer as you get older, as your freezer starts to empty. Given that it doesn’t actually matter whether one egg jumps from 10.000 eggs on the counter, or 1.000 eggs on the counter, that is a smart move. We use the amount of eggs on the counter as an estimation for how close you are to menopause. If you have a low amount of eggs on the counter for someone your age, then that means you have an increased risk of entering menopause early. However - it doesn’t mean you will.


A low AMH *can* mean that you might be closer to menopause than other people your age, but it can also just mean that your body is being more clever and saving up the amount of eggs required to let 1 jump.



2. How well you may respond to ovarian stimulation if you were to go through

IVF or freeze your eggs (3, 4).


AMH is used routinely by fertility specialists to identify how many eggs are available for extraction. Women with a very low AMH have been shown to have fewer successful outcomes with IVF (16), and this is because the number of eggs that can be taken from the freezer is dependent on what is in storage in the first place. While this means that a higher AMH means more eggs available to retrieve for IVF (17), it’s key to note that AMH is not related to egg quality. In fact, not all of the eggs we produce will be suitable for IVF. In summary: you are more likely to have a higher number of eggs that are viable for IVF at a younger age. The chances of this decrease gradually with age.


Knowing whether you have a high or low AMH can also be a useful aid for deciding whether to freeze your eggs now, later or at all. You can read more about egg-freezing in our blog here.


Okay, got it. But does having a low AMH mean i’m infertile?!


No. Having a low AMH does not mean that you’re infertile! It just means that you might have a smaller window for deciding whether you would like to have children or not. If you plan to delay your fertility, egg freezing may be an option to consider now rather than later. However, the best way forward is to discuss your options with a fertility specialist. Many factors, including genetics, age and existing medical conditions, can influence what those may be. Fertility specialists may recommend genetic testing or further blood tests to check your Oestradiol and Follicle Stimulating Hormone (FSH) levels at a specific point in your cycle. It is also important to pay attention to how regular your cycles are. If you have low AMH levels and irregular cycles, this could indicate premature ovarian failure (early menopause), particularly if you have other symptoms such as vaginal dryness and hot flashes. In these cases, IVF or egg donation may be more suitable.


So what can I do if my AMH is low?


Truth is, this will depend on what your life goals are. Perhaps you’ve completed your family, or you’re certain you don’t want children. In which case, you might not be as worried about this. But if you do want to start a family, it’s important to seek advice on the best options for you sooner than later.



AMH & Lifestyle


While the number of eggs you have and how fast you lose them is mostly determined by how old you are and by your genes, that doesn't mean there's nothing you can do to influence this. Lifestyle factors, including hormonal contraceptives, smoking, diet and obesity, may also influence your AMH levels.


Sounds pretty wild, right? Well now let’s take a look at how these factors affect AMH:


Hormonal contraception


Hormonal contraceptives (including Depo-Provera, the Mirena coil - also known as a hormonal intra-uterine device - and the pill), have been shown to lower your AMH through pituitary suppression (18), causing you to produce less follicle stimulating hormone (FSH) which in turn affects ovarian follicle growth. Fewer follicles = less AMH.


The average reduction of your AMH levels on birth control is 19% (5) but the good news is that within 3-6 months after stopping your birth control this suppressive effect will typically wear off and your levels should go back to your normal (5, 6). That said, if you have low levels on birth control, it might be a good idea to stop this and retest to know your baseline.


Your BMI


The evidence about a link between AMH and BMI is inconclusive. There are plenty of studies out there that report no link with obesity (7) and also studies that report a lower AMH in women considered obese (8-10). Higher AMH levels have also been found in women that have had gastric sleeve surgery to remove part of their stomach (11) but it is important to note this is only relevant to a relatively small proportion of women.


So really, there appears to be no consistent evidence (yet) that losing a few kilograms will improve your ovarian reserve or influence your age of menopause. However, a balanced diet and regular exercise as part of a healthy lifestyle will always be of benefit.


Your diet


It's currently impossible to say anything conclusive about how your diet impacts your ovarian reserve. Most of the studies that are published so far have used FSH as the proxy for ovarian reserve, but FSH fluctuates during your cycle. Additionally, as there is so much inconsistency in study design and dietary factors measured, it is almost impossible to draw any conclusions from these studies. More research into this area is needed. Stay tuned, while we wait for more evidence to come out…


Smoking


What might not come as a surprise, is that smoking is detrimental for fertility. A meta-analysis (that is a study that statistically summarises all the published data on one topic) has shown that, on average, women who smoke will enter menopause 1-2 years earlier than non-smokers (12). Because the menopause is defined as the point from which your egg stores are depleted, this suggests that smoking empties your freezer quicker. Studies using AMH as a marker of ovarian reserves have confirmed that women who smoke:

  • have a more rapid decline in their AMH levels than non-smokers (13).

and

  • tend to have lower levels of AMH.

That said, these effects are less conclusive in instances of passive smoking and in ex-smokers (14,15). So the sooner you quit smoking, the better for your AMH levels (6)!

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Ethnicity


Lastly, although not a lifestyle factor, it is good to know that AMH can be influenced by ethnicity as well. As women of different races have different times that they enter menopause, it is not surprising that there are differences found in AMH levels and AMH reduction (10). One study investigated AMH levels and trajectories of AMH decline in African American, Caucasian, Chinese and Latino women aged 25-45 and found that:

  • African American women may have lower AMH levels at a younger age, but also have less of a reduction when they get older.

  • Latino and Chinese women typically have lower AMH levels at a younger age, but decline at similar rates as white women, possibly explaining why these two groups enter menopause earlier.

Interesting, right? But it’s equally important to understand that this is only one study with limited applicability. It included only around 200 women per ethnicity and it was cross sectional – meaning they investigated these women at one moment in time, so there was no follow up of these women to verify their personal trajectories.


In summary, if you get an unexpected low AMH result from your Grip test there are a few things you can do to improve your levels. Of note:

If you’re on hormonal contraceptives, consider stopping them for a while and then retest.
The biggest lifestyle change that will do good for your ovaries is to quit smoking, and if you’re successful we think your ovarian reserve will go back to your baseline.
Although there is not enough existing and conclusive evidence on the links between diet, weight and fertility, maintaining a healthy and varied diet is always an important part of a balanced lifestyle .

Finally, remember that AMH is not the holy grail – it’s a mere a reflection of your egg pool, not the quality of your eggs nor a guarantee of pregnancy!




References


1. Broer SL, Broekmans FJ, Laven JS, Fauser BC. Anti-Müllerian hormone: ovarian reserve testing and its potential clinical implications. Human reproduction update. 2014;20(5):688-701.

2. Depmann M, Eijkemans MJ, Broer SL, Tehrani FR, Solaymani-Dodaran M, Azizi F, et al. Does AMH relate to timing of menopause? Results of an individual patient data meta-analysis. The Journal of Clinical Endocrinology & Metabolism. 2018;103(10):3593-600.

3. Broer S, Dolleman M, Opmeer B, Fauser B, Mol B, Broekmans F. AMH and AFC as predictors of excessive response in controlled ovarian hyperstimulation: a meta-analysis. Human reproduction update. 2011;17(1):46-54.

4. Elgindy EA, El-Haieg DO, El-Sebaey A. Anti-Müllerian hormone: correlation of early follicular, ovulatory and midluteal levels with ovarian response and cycle outcome in intracytoplasmic sperm injection patients. Fertility and sterility. 2008;89(6):1670-6.

5. Birch Petersen K, Hvidman H, Forman J, Pinborg A, Larsen E, Macklon K, et al. Ovarian reserve assessment in users of oral contraception seeking fertility advice on their reproductive lifespan. Human Reproduction. 2015;30(10):2364-75.

6. Dolleman M, Verschuren W, Eijkemans M, Dollé M, Jansen E, Broekmans F, et al. Reproductive and lifestyle determinants of anti-Müllerian hormone in a large population-based study. The Journal of Clinical Endocrinology & Metabolism. 2013;98(5):2106-15.

7. Hardy R, Mishra GD, Kuh D. Body mass index trajectories and age at menopause in a British birth cohort. Maturitas. 2008;59(4):304-14.

8. Freeman EW, Gracia CR, Sammel MD, Lin H, Lim LC-L, Strauss III JF. Association of anti-mullerian hormone levels with obesity in late reproductive-age women. Fertility and sterility. 2007;87(1):101-6.

9. Steiner AZ, Stanczyk FZ, Patel S, Edelman A. Antimullerian hormone and obesity: insights in oral contraceptive users. Contraception. 2010;81(3):245-8.

10. Bleil ME, Gregorich SE, Adler NE, Sternfeld B, Rosen MP, Cedars MI. Race/ethnic disparities in reproductive age: an examination of ovarian reserve estimates across four race/ethnic groups of healthy, regularly cycling women. Fertility and sterility. 2014;101(1):199-207.

11. Pilone V, Tramontano S, Renzulli M, Monda A, Cutolo C, Romano M, et al. Evaluation of anti-Müller hormone AMH levels in obese women after sleeve gastrectomy. Gynecological Endocrinology. 2019;35(6):548-51.

12. Sun L, Tan L, Yang F, Luo Y, Li X, Deng H-W, et al. Meta-analysis suggests that smoking is associated with an increased risk of early natural menopause. Menopause. 2012;19(2):126-32.

13. Sowers MR, McConnell D, Yosef M, Jannausch ML, Harlow SD, Randolph Jr JF. Relating smoking, obesity, insulin resistance and ovarian biomarker changes to the final menstrual period (FMP). Annals of the New York Academy of Sciences. 2010;1204:95.

14. Plante BJ, Cooper GS, Baird DD, Steiner AZ. The impact of smoking on antimüllerian hormone levels in women aged 38 to 50 years. Menopause (New York, NY). 2010;17(3):571.

15. Freour T, Masson D, Mirallie S, Jean M, Bach K, Dejoie T, et al. Active smoking compromises IVF outcome and affects ovarian reserve. Reproductive biomedicine online. 2008;16(1):96-102.

16. Nelson SM, Yates RW, Fleming R. Serum anti-Mullerian hormone and FSH: prediction of live birth and extremes of response in stimulated cycles implications for individualization of therapy, Hum Reprod, 2007, vol. 22 (pg. 2414-2421)

17. HFEA, A Long Term Analysis of the HFEA Register Data (1991–2006), 2007LondonHFEA

18. Kallio, Sanna et al (2012). Antimüllerian hormone levels decrease in women using combined contraception independently of administration route. Fertility and Sterility, Volume 99, Issue 5, 1305 - 1310