Fertility specialists and fertility patients have many things in common – the desire for babies being the most obvious – but my favourite is their obsessive tendency to abbreviate everything.
EWCM, anyone? That’s “egg white cervical mucus”. Yeuch.
Someone telling you to POAS? You need to “pee on a stick”.
Is everyone on Mumsnet fretting over the 2ww/tww? That’s the beloved “two week wait” between embryo transfer and the moment at which you can POAS (to find out if you have a BFP – “big fat positive” result).
All these abbreviations can seem a bit overkill sometimes, but “AMH” is a legit useful one. It stands for “anti-Müllerian hormone”, and that umlaut makes it a right bugger to type on an English-language keyboard. So thank you, person who shortened it to AMH.
What is AMH?
AMH is a protein produced by cells in your ovarian follicles, so high levels of AMH indicate you have plenty of egg-containing follicles – which is useful if you want to become pregnant.
High AMH levels are particularly useful when you’re doing IVF:
- It’s beneficial to produce as many follicles as possible per IVF cycle. (See the article on the IVF process for more on this.)
- High AMH levels are also associated with a better response to IVF medication.
How do AMH levels differ from “ovarian reserve”?
Ovarian reserve measures both quantity and quality, whereas AMH is simply an indicator of quantity.
Having said that, The Endocrine Society recently stated that high AMH levels “may partially comprise information about egg quality”, but the wording suggests they’re not yet completely certain that’s the case.
What AMH levels are considered good (and bad)?
Bear in mind that you’re born with all the follicles you’ll ever have. That means your AMH levels aren’t going to increase over time. Also bear in mind that (super annoyingly) different clinics/hospitals have rather different ranges. Here are the two most frequently referenced ranges:
Optimal AMH levels (associated with increased fertility and better response rates to IVF and other fertility treatments):
- Range 1: 40.03–67.90 pmol/l
- Range 2: 28.60–48.50 pmol/l
Satisfactory AMH levels (basically: you’ll be fine)
- Range 1: 21.97–40.03 pmol/l
- Range 2: 15.70–28.60 pmol/l
Low AMH levels (associated with a decreased number of follicles, but you still have a good chance of getting pregnant – either naturally or through fertility treatment – especially if you have good-quality follicles)
- Range 1: 3.08–21.97 pmol/l
- Range 2: 2.20–15.70 pmol/l
Very low AMH levels (not great news, but all isn’t lost – as we’ll soon see)
- Range 1: 0.00–3.08 pmol/l
- Range 2: 0.00–2.20 pmol/l
Note: the National Institute for Health and Care Excellence (NICE) specifies that less than 5.4 pmol/l will lead to a “low response”, and greater than or equal to 25.0 pmol/l will lead to a “high response”.
There’s also a chance you have “high AMH levels” (range 1: over 67.90 pmol/l, range 2: over 48.50 pmol/l). While this seems like good news, it usually indicates that you have polycystic ovary syndrome (PCOS) – which means you have plenty of follicles, but many of those follicles are actually cysts that don’t contain any eggs. It’s perfectly possible that, in addition to all the cysts, you also have tons of follicles containing eggs; just be aware that high AMH levels put you at a greater risk for OHSS if you undergo fertility treatment.
Keep reading… there's more below.
What affects low AMH levels?
Age is a big deal: the number of follicles depletes with age, which is why AMH levels decrease with age too. (Things really start to fall off a cliff after the age of 35.) Women who are going through the menopause will typically have extremely low AMH levels (and high FSH levels).
It’s also possible for your ovaries to “get old” while you’re still young. Just as politicians seem to look ten years older within six months of becoming prime minister, early ovarian aging can happen as a result of stress, poor diet and lifestyle factors such as heavy smoking (as well as hormonal imbalances, illness, injury and genetics).
My AMH levels are through the floor! Should I get fertility treatment?
If you’re under the age of 35 and your only issue seems to be a low egg count (as shown by low AMH levels and probably also high FSH and low antral follicle count) and you appear to have absolutely no other issues when it comes to fertility, your egg supply doesn’t actually matter so much for conceiving – so you’d do well to just ignore the test results and carry on bonking until you get a BFP.
Why doesn’t a low egg supply matter so much for you? Well, with a natural cycle, you only release one egg a month anyway: it’s not as if you somehow have to magic up 30 eggs to keep the IVF doctors happy. What’s more, the quality of your eggs is likely to be good.
Having said that… you’re here, reading this article. What’s more, you already seem to know your AMH levels. That suggests you’ve already tried and struggled to conceive naturally, and you’ve decided that fertility treatment is the way forward. The next section goes into more detail about why you have a good chance of success.
If you’re over the age of 35, AMH levels matter a lot more – whether you’re undergoing fertility treatment or not. That’s because the quality of your eggs is also likely to be compromised, which means it’s less likely that natural conception or fertility treatment will work as well for you. While you shouldn’t give up and start scouring puppy adoption websites right away, it’s worth bearing in mind that it will be harder to get pregnant.
My AMH levels are low AND I definitely can’t conceive naturally! Am I a lost cause for IVF?
If you’re young, you have low AMH levels and you can’t get pregnant, it’s definitely worth trying IVF – even though you may struggle to produce as many follicles as your “high AMH level” friends.
You may not have as many eggs as you’d like, but you probably do have fabulous-quality eggs – and successful fertilisation and implantation also rely on good-quality eggs.
It’s for this reason that the vast majority of clinics and hospitals will still treat you if you have low AMH levels (unless, of course, it’s clear that you’ve gone through early menopause). They may well put you on a more aggressive IVF protocol (to make sure you respond well and produce as many follicles as you possibly can), but that’s about the only difference.
(If it turns out you have low-quality eggs too, despite being relatively young, there are a few things you can do to try improving them. Read more about how egg quality can be measured – and how you can improve it if necessary.)
If you’re over the age of 35, things get trickier – as this research article makes clear. Basically, being “of advanced age” and having low AMH levels is a rather shitty combination – and IVF is far less likely to be successful. BUT plenty of people in your situation have undergone successful IVF treatment, and it could happen to you too. Bear in mind that many clinics and hospitals have age cutoffs for treatment, though. If you’re no longer eligible for IVF treatment using your own eggs, you could consider donor eggs or embryos.
It’s also important to remember that while you can’t increase your egg count, you can improve the quality of your eggs. This article explores some of the ways in which you can do it.
How do I find out my AMH levels if I'm not doing fertility treatment (yet)?
If you're having IVF treatment, you'll be given an AMH test right at the start – whether you're on the NHS or paying privately. (Find out more about “day 3″/baseline scans here.)
But what if you've been trying for a baby for a while but think it's too soon to start considering IVF? Or you have a history of early menopause in your family and want to see if it's likely to affect you too? Or you don't want to have a baby yet, but would like to know if time is on your side?
If you want to check your AMH levels in those scenarios, you'll need to go private.
Most fertility clinics offer “ovarian reserve” testing for about £450/£500. It usually involves a blood test for AMH levels plus an antral follicle count scan.
If you're in London, you can make use of the Fertility Assessment Clinic at CRGH – which offers ovarian reserve testing for £350. Here's what's included in the price:
- Initial consultation with a nurse manager (including a holistic lifestyle assessment)
- AMH blood test
- Ultrasound scan (for antral follicle count plus endometrial assessment)
- Follow-up consultation with doctor
- Outcome letter and copies of results
Alternatively, it's possible to buy at-home AMH tests – which are cheaper (they cost about £100) and believed to be as accurate as the clinic tests for AMH. AMH tests won't give you the whole picture because they can't tell you about egg quality (see above for more on this), but then the ovarian reserve tests offered by clinics can't tell you about that either.
The one thing at-home tests can't do is tell you about your antral follicle count. The antral follicle count is one of the best ways to measure egg quantity, so that's definitely one way in which clinic tests (like those offered by CRGH) are superior to at-home tests.
As long as you're aware of the drawback(s) of at-home AMH tests, I don't see any harm in using them – especially if you're older than 35 and have been trying for a few months without success. An at-home test could give you the information you need to approach your GP and ask for further investigations.
There are a few companies out there providing at-home AMH tests, but the one I recommend is called LetsGetChecked. They have a team of doctors who'll review your results before sending them out, and nurses are available 24/7 in case you want to discuss your results after receiving them. The tests are super easy to use, and thoroughly non-fiddly!
If you enter the code “theduff” at checkout, you'll get 15% off your AMH test (and any other test you order).
AMH: A Motherf**king Hassle (my more accurate abbreviation)
Unless you have “optimal” or “satisfactory” levels of the stuff, your AMH results are likely to cause a fair amount of stress and annoyance. Just remember that a) it’s only one measurement, and b) plenty of women have become pregnant (both naturally and through fertility treatment) despite having low or super-high levels of it.