AMH: The Fertility Test That Isn’t a Fertility Test

AMH is one of the most misunderstood fertility blood tests. Many patients hear that their AMH is low and immediately worry that they cannot get pregnant, that their eggs are bad, or that menopause is right around the corner. But AMH does not tell the whole fertility story.

In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols explains what AMH really measures and what it does not. AMH is a marker of ovarian reserve and helps predict how many eggs someone may make during fertility treatment, especially IVF stimulation. But it does not directly predict whether someone can get pregnant naturally, whether their eggs are genetically normal, or whether the next egg they ovulate can become a baby.

Using simple analogies like a basketball player’s vertical jump, egg contests, and ovarian reserve as a “toolbox test,” this episode breaks down the difference between egg quantity and egg quality, why low AMH does not mean infertility, why high AMH does not guarantee pregnancy, and how AMH may give some clues about ovarian aging and menopause timing.

If you or someone you know has been told they have a low AMH, this episode will help explain why AMH is important information — but not a fertility verdict.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

>> Dr. Mark Amos: 0:00

Today we talk about amh M anti mullerian hormone, the fertility blood test that tells us something important, but not always what patients think it tells us. I'm, Dr. Marc Amals, and this is Taco about Fertility Tuesday. Maybe you or a friend had an anti mullerin hormone tested, and maybe it came back good, maybe it came back bad. But the thing is, it may be one of the most misunderstood tests in fertility, and unfortunately, it causes a lot of stress. If you get a high MH and you think, well, wow, I must be the most fertile person on earth. You get a low MH and you think, this means I can't get pregnant. Or even worse, your eggs are bad. Or that you're going into menopause and people panic and people run to the doctor and they run into ivf. And in today's episode, what we're going to talk about is what does it really mean? By the end of today's episode, you're going to understand that AMH is not a pregnancy test. It doesn't give you a fertility score and doesn't tell your egg quality. It's really just a marker of ovarian reserve and how well the ovaries will respond. So the big picture today is going to be AMH predicts a quantity much better than it predicts pregnancy. So let's start with why AMH causes so much fear. See, AMH is often presented to patients as a fertility test. And, that's where the confusion starts in, because when patients hear fertility tests, they think, oh, my God, this means I can or can't get pregnant. But that is not what AMH tells us. As I mentioned before, AMH is a marker of ovarian reserve. An ovarian reserve refers to a quantity, not really a quality. The problem with the word ovarian reserve is it's a grabback term. I've said in prior podcasts that it's like, say, an automobile. Automobile can be a van, it could be a truck, it could be a car. That's what ovarian reserve means. If you have fewer follicles in your ovary, we call it low ovarian reserve. Yet you may be able to get pregnant with no problems. And AMH stat is low. May also mean you may not respond very well to medications, but doesn't mean you can't get pregnant. I joke around a lot and I say ovarian reserve is really a measure of how many eggs you can make compared to your peers. So if you take two women and let's say they have the same age, same body build and everything. And one has an AMH that's higher than the other, and you give them both the exact same amount of medications. The one with a higher AMH is usually going to make more eggs. So if we're having an egg contest, so who can make the most eggs, the one with the higher AMH is going to usually win. But you don't need that many eggs to get pregnant. You only need one egg per month. And so ovarian reserve is really something that we use in fertility, not so much in real life, because you only need one egg per month to get pregnant. And this distinction matters because there is a huge difference between asking, how many eggs might I make during ivf? Or when you give me medicines, which is not very normal because naturally I only make one, or can I get pregnant? Those are not the same question. Now, AMH is great in answering the first question. It's probably better than most tests. The only test close to it is an antral follicle count, which is where we look at the number of follicles on the ovary at the beginning of the month. But AMH is not good in answering that second question about if you can get pregnant or not. And the problem is when patients hear that they have a low mh, they get scared and think you're infertile. And that's not what they're saying. Sure, you're not going to win the egg contest, but that's not what you care about. What you care about is getting pregnant. So it's important to understand. Low AMH does not mean zero eggs. Low AMH does not mean bad eggs. Low AMH does not mean you cannot ovulate and get pregnant. And that means pregnancy is possible. So then what is amh? Well, AMH stands for anti mullerian hormone. It's a hormone made by the cells surrounding the small developing follicles in the ovary. These follicles are not necessarily the eggs you're going to ovulate this month. And they're not all the eggs you have left in storage forever. They're part of the group of small follicles that you have starting every month that may end up leading to ovulation. So AMH becomes this marker of what's available to be recruited. Think of it like a small sample of the ovarian activity, and then we use that to estimate the larger picture of how many eggs you'll be able to make. Now, it's really good, and as I mentioned, only an antiflocal Count is probably as good as it, but it's not perfect. So if it's not perfect, why we use it? Well, because it's a relative easy test to do. You can do it almost anytime in your cycle, not only on day three, like FSH and estrogen, and tends to be a little bit more stable through the menstrual cycle. And that makes it a very convenient test. Unfortunately, that convenience doesn't answer every question, and that's why many doctors will use that test with other tests. Think of it like a tool in the toolbox. Hammers are great for pounding things, but when you need a screw in the screw, you need a screwdriver. And that's how we use amh. Sometimes it's a test to help us validate other tests. Sometimes it's a test we're using to determine if you're at higher risk for ovarian hyperstimulation in an IVF cycle. No one should ever take a low MH and run with it. It should always be tested against other tests such as antral follicle count and cycle day three labs, because it's just one part of a bigger picture. There are essentially three different questions patients mix together when it comes to amh. One, how many eggs might I make in ivf? Well, AMH is very good here. And when you use AMH in the antifollocal count, they are very good predictors of how many oocytes you will yield during ovarian hyperstimulation. The next question then is, will AMH help me know if I can get pregnant? This is where AMH is very weak. Ovarian reserve testing is a poor predictor of reproductive potential, meaning m. It can't predict whether you're going to get pregnant or not. The other question is, can AMH predict if my eggs are going to be genetically abnormal or normal? And again, AMH does not answer this. Age is going to be the bigger driver of egg quality, and that's important to separate ovarian reserve versus egg quality. Quantity is different than quality. Think of AMH like the vertical jump in basketball. If you can jump high, well, that's going to help you. You may get more rebounds, you may block more shots, you may be able even the dunk. But jumping high does not mean you're going to get in the NBA and become a great basketball player. You still need to be able to shoot and pass and dribble and do other things to become an NBA player or a great basketball player. Well, a high AMH is similar. It may Give you more eggs to work with, especially in ivf, but it doesn't guarantee you egg quality or pregnancy. So just like a high vertical doesn't make you an NBA player, a high amateur doesn't guarantee a baby. And just because someone cannot jump high doesn't mean they cannot be in the NBA or cannot play basketball at a high level. They may still be a great shooter, a smart passer, or the best player on the court. Low AMH is very similar. It may mean fewer eggs, but it doesn't mean every egg is bad. It does not mean pregnancy is impossible. So a, low AMH may mean fewer shots, but that doesn't mean you can't score. AMH is just one skill in the game. It's not the final score. As I mentioned before, as long as you're ovulating, there is a chance of getting pregnant. And low AMH does not mean you cannot ovulate. And if you can ovulate, that means pregnancy is possible. And this is where AMH is overused. Whether your AMH is high or your AMH is low, you still ovulate one egg per month. That means if you have a high mh, you don't have a better chance of getting pregnant compared to someone with a low mh. If both of you don't have infertility. I see all the time where someone who doesn't even have infertility will get an MH checked and think, oh, my God, now I can't get pregnant. But that is far from the truth. As long as you're ovulating, there is no issue because you only need to make one egg per month. Just like you don't need to jump 40 inches to be able to play basketball. Now, this is important. I'm not talking about people with infertility. We're talking about natural conception. If you have no infertility or you're just checking your AMH and you don't have a history of infertility, you cannot take that number and think, I have a lower chance of getting pregnant than someone else because everybody just releases one egg. Well, everybody meaning women. And so the higher AMH or low AMH doesn't make a difference at that point because. Because everybody's playing by the same rules, one egg at a time. It's only when you go into something like IVF or IUI where you're making more eggs, does that AMH benefit you. And this is why a low AMH does not automatically mean you cannot get pregnant naturally. And if that egg releases and that tube is open and the sperm is present and the egg is good. Pregnancy can happen. And don't take my word for it. Studies have backed this up, showing that women trying to conceive naturally have shown that AMH is not a strong predictor of who will get pregnant, especially in women without a prior diagnosis of infertility. And this is extremely important because a low amh, can scare patients into thinking they are going to have issues. And that is not accurate. Now, that doesn't mean low AMH doesn't mean time matters. Sure, if you have a lower amh, we're going to get into why that may matter. Maybe a low AMH may say, hey, I may need to start my family sooner now, and even if you're not infertile, but maybe you want to do things like family balancing. A low AMH might tell you it may be a little harder for you because you won't make as many eggs. But what it doesn't say is it doesn't say whether those eggs are going to be good or not. It just tells us how many eggs are likely there. So think of natural conception like a basic pickup basketball game. You don't need to jump 40 inches in a basic pickup game because most of the people there can't do that. And so that would be similar to natural conception, releasing one egg per month. And so having a high MH is not going to help there. But when you get to the NBA now, everyone there can jump pretty high. And so a higher amh, meaning a higher vertical jump, is going to benefit you. And that's why in IVF, a higher MH usually benefits you, because that is a numbers game. In ivf, we're not trying to get one egg like natural conception. We're trying to recruit multiple follicles so we can retrieve multiple eggs and develop multiple embryos. If you're someone who does have a low egg quality, making more eggs is going to help because now you have more chances. It doesn't mean someone can't get pregnant with a low mh. It just means you're not going to make as many eggs. We usually break this into low responders, normal responders, and high responders. Low responders are going to be people with an AMH under 1. Doesn't mean everyone will make fewer eggs. It's just saying you'll make fewer eggs compared to people who have an AMH above 1, especially people who have an AMH above 1.5. The normal responders are going to be in that 1 to 2 the high responders are going to be people above 3 and anyone above 4. We're thinking like polycystic ovarian syndrome or polycystic ovaries. Where this benefits us as doctors is, is now we can pick the protocol that's best for you. I don't want to use a strong stimulation protocol if you're a high responder or I'm, going to put you into ovarian hyperstimulation. On the same token, if I think you have lower ovarian reserve, I also don't want to put you on a weak protocol because I won't get as many eggs as you can make. The goal isn't for everyone to make the same amount of eggs. The goal is to get the best out of you. Now you're probably thinking, well, great, a high MH is going to put you in a better chance. So let's say if you're 42 and you have an AMH of 4, well, then you must do better than someone who is 20 with an AMH of 1.5. Well, not even close. That younger patient with an AMH of 1. 5 has a much higher chance of having success. And the reason is because age is going to be the predictor of egg quality. Sure, the 42 year old is going to win the contest of who makes the most eggs. Absolutely. But an AMH doesn't always mean better. In that situation, age is going to be the better predictor of success because most of the eggs that the person with a high MH is going to make is going to be poor quality. Approximately 85% of the eggs are going to be genetically, abnormal. Whereas with a young 20 year old, most of their eggs are going to be normal. So even if they make less eggs, they will actually end up with more euploid embryos, which will give them a higher chance. But what's really interesting is a very high MH when the AMH is above 4 and we get worried about things like PCOS. Sometimes these patients may make a lot of eggs, but the quality can be poor. Now, it's a little bit different this time. It's not due to age, but it's more about the response of the high stimulation and how it affects things like inflammation and insulin levels in their body. And that can create an environment that lowers the quality of those embryos. So they're not genetically abnormal, but the environment caused them to reduce in quality, leading to lower chances of implantation. And you've probably seen this, you probably saw on Facebook where Someone said, oh, I got 42 eggs but only two embryos. And that scares people because they think, wow, I only got 15 eggs. Am I going to end up with no embryos? Well, it's different because although they made a lot of eggs, those eggs didn't have the same quality. When I have patients like that, I usually use a PCO protocol that helps reduce that inflammation so we can get more high quality embryos. But we'll save that for a future podcast. So we've probably beaten the horse dead when it comes to that concept of a low AMH means your eggs are bad. That is not true. We talked about it, just means you make less of them. But what about the question of menopause? If you have a low AMH and you're young, does that mean you have a higher risk of early menopause? Well, the simple answer is, yes, it does. The problem is we don't have a timeline. So compared to your peers, yes, you probably will go into menopause earlier, but compared to a person with the same amh, they may go into menopause faster than you. You may go into menopause faster than them. So unfortunately, there isn't some countdown that we can figure out from the amh. And this is what research shows, that AMH predicts time to menopause by estimating the risk of early menopause, but individual predictions remain imprecise. And going back to our basketball analogy, someone who comes into the league with a ton of skills that can jump very high and move very fast, even as they get older, they're probably still going to be better than most people because they came in with such higher tool sets. But if someone already comes in a little bit slower, can't jump as high, well, their career may not be as long. So it's important to understand the distinctions here. Low AMH is not the same as menopause. Low AMH is not the same as premature ovarian failure. Low AMH may say you may go into menopause early, but it cannot predict when. So if you're someone who ends up finding out they have a low amh, what I'll tell you is do not panic. But also do not ignore it. There are many things to consider, such as your age, when you're going to be trying what your antral follicle count is, or your cycle day three labs. If you have a normal AMH but you're 42, you should be worried, because being 42 is the bigger prediction of whether you're going to get Pregnant or not. But if you're also 22 and you have, a very low inmates, let's say 0.5, then you don't need to panic. But now you might need to either preserve your fertility with egg freezing or think about having children sooner because you don't know how much that's going to affect you in the future. Because we just talked about it, doesn't mean you won't be able to get pregnant. But the thing is, everybody has about a 15% chance of infertility. And if you are one of those patients that has infertility and your AMH is low, then it just makes everything harder. So what a low AMH means when you're younger is that you have to start thinking about things sooner. Whether that's egg freezing, whether that's having your kids sooner. You just need to think about these things. It also matters how many kids you want. If you're just wanting one kid, maybe don't panic much. If you're wanting nine kids and your AMH is low, well, then you need to start thinking about preservation. Because to have nine kids is over a span of 12 to 15 years. And that low AMH may say it's going to get harder for you near the end. And this is why probably the most important thing to do is when you have an AMH that is low, make sure you talk to a fertility doctor. Not an obgyn, not a naturopathic doctor, but a fertility doctor. They're great doctors, but for this you want to talk to a fertility doctor. And if they tell you the sky is falling, then you might want a second opinion. In the end, a low MH is important information, but do not freak out about it. Talk to someone first. Look at the other test and then with a fertility doctor, figure out what your best course of action is. Because in the end, AMH is not a fertility score, it's not an egg quality test, it's not even a pregnancy predictor. AMH is the best tool when used to estimate ovarian reserve and, predict how the ovaries may respond due to stimulation. It may give us information about ovarian aging and menopausal timing. But what it can do is, is it can't tell you whether the next egg you ovulate can become a baby. In the end, Amaze tells us how many eggs we may have to work with. It does not tell us whether one of those eggs is the one that's going to lead to our miracle baby. If you, or maybe a friend or family member have been told they have a low mh, let them know about this podcast. This may help them with some of the stress that comes with being told that you have a low mh. If you go on the Google, it may create a lot of stress. So this podcast may let them have a little bit more relief knowing that it doesn't mean that they can't get pregnant. As always, if you like this podcast, please give us a five star review on your favorite medium. Tell your friends about it, but most of all keep coming back. I look forward to talking again next week on Taco Belt Fertility Tuesday.