Poor Ovarian Reserve And IVF – Low Anti Mullerian Hormone (AMH)

By Dr. Surveen Ghumman Sindhu: Poor ovarian reserve can be measured by Antimullerian hormone, Antral Follicle Count and FSH on day 2 of the period. In recent years, much dependence has developed on AMH as a marker as it has many advantages.


Advantages of AMH as an ovarian reserve marker:

Advantages of AMH as an ovarian reserve marker like antral follicle count and day 2 FSH
1. It is the earliest marker to change with age
2. It has the least variability from cycle to cycle
3. It has the least variability when measured on different days of the same cycle
4. It can predict hyperstimulation
5. Minimally invasive changes with oral contraceptives

However, AMH must be analysed taking into other factors when making decisions in IVF treatment. AFC and AMH perform with similar power in the prediction of the number of retrieved oocytes. The objectivity and potential standardization of AMH level and the convenience of testing any time throughout the menstrual cycle lean towards AMH level becoming the gold-standard biomarker to evaluate ovarian reserve.

Anti mullerian Hormone (AMH) is a glycoprotein hormone which specifies the number of eggs in a woman’s ovaries. All women are born with a fixed number of eggs. Anti Mullerian Hormone is produced by the granulosa cells. They are produced by the primordial follicles and antral and preantral follicles, less than 4 mm. As follicles grow they stop producing AMH. Hence, AMH production is not dependent on the time of cycle as they are not produced from growing follicles but from the quiescent pool of follicles.

It depicts the pool of primordial follicles which can predict a number of growing follicles in each cycle. As the women with PCOS have a large number of follicles their AMH is very high. In women nearing menopause the pool decreases, hence they have a low value of AMH

Impact of AMH on Ovarian Response:

Those women with high AMH have a good response and a larger number of eggs can be retrieved from them. Ones with very high AMH are more prone to ovarian hyperstimulation. If AMH is low there are a lesser number of oocytes one can recover and it is termed as a poor ovarian response indicating a low ovarian reserve. So high AMH levels will give more number of eggs, more chances of freezing eggs and a better pregnancy rate. However, results do not differ much in women under 35 years.

Dr Surveen has done research on AMH. She found that those with AMH above 2 ng/ml had higher success rates with IVF than those less than 2ng/ml.

Higher levels of AMH need caution as stimulation may lead to the Ovarian hyperstimulation syndrome. Hence these patients require low dose protocols and intensive monitoring.

Measurement of AMH:

It is a blood test. The patient does not need to be fasting. Different laboratories may have different methods and reference range which will need to be checked. The values are as given in the table

Accuracy of AMH in prediction of IVF success:

AMH may predict ovarian response but in some cases like women under 35 or in cases where other ovarian reserve parameters are normal like antral follicle count or day 2 FSH. In these cases, the eggs retrieved are fair in number and quality. IVF has good success rates. Hence, AMH values should not be the basis for excluding couples from attempting IVF.

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