AMH {Information and TTCAL user experiences}

Anti-Mullerian Hormone (AMH) is a substance produced by granulosa cells in ovarian follicles. It is produced by primary follicles and is highest in follicles that are in the preantral and small antral stage (less than 4mm in diameter). Because AMH is produced only in small follicles, it is believed to be a measure of the remaining egg supply.
Finding out your AMH level is low (0.5 – 1.0 ng/ml) is devastating for most women. It is believed that you can do nothing to improve your AMH levels. It is used, along with other hormone levels, to determine if you are an IVF candidate. Finding out that your AMH level is low or very low (less than .5 ng/ml) is hope crushing. You feel like the window on your fertility is closing or that it may have already closed.

I have been on TTCAL long enough to see many of our ladies who have low and very low AMH go on to PgAL and PAL. Some of these ladies conceived via IVF, some with donor eggs, some with their own, and some naturally. I asked our grads to share their stories to help remind our ladies with low AMH that it is just one test and it does not mean that you cannot get pregnant with a healthy pregnancy. Thank you to all of our graduates who replied with their stories and agreed to share them with you.

I would like to give special thanks to MsAmandaPants who provided me with a copy of her well thought out and researched reply that she gives to ladies who post about receiving low AMH results. I have included it in its entirety.

A special note on supplements: many of our grads used supplements while they were still TTC and credit those with helping them conceive. If you would like to take any of these supplements, please talk with your doctor first.
buggirl72, AMH .17

From MsAmandaPants – AMH is an indicator of ovarian reserve–how many eggs you have left. Low AMH itself won’t cause a miscarriage, but it might (but not necessarily) point to egg issues that could have contributed to it. Most research suggests that AMH has more to do with the quantity of your remaining eggs. There are different opinions on whether it is also an indicator of quality. While it does not necessarily indicate poor quality eggs, there are some that think that the eggs that remain at the end of your reserve may not be the highest quality, that higher quality eggs are selectively ovulated first, but there are differing opinions. AMH is also used as a predictor of how well you might respond to fertility drugs; low AMH is often correlated to poor response (but not necessarily so– I have shitty AMH and had a decent response).

It is important to keep in mind that AMH is only one marker of ovarian reserve and should always be considered in the context of your entire medical history, appropriate CD 3 blood work (estradiol, LH, FSH), and an antral follicle count. These are all critical parts of a whole that make up your entire fertility outlook.
Age naturally plays a role in decreasing AMH since egg reserves decrease with age; older women would be expected to have a naturally lower AMH range. While a lower normal range would be expected in AMA women, there is a threshold at which your AMH might be deemed irregularly low for your age. AMA + abnormally low AMH is a bit more worrisome because you are naturally dealing with older eggs and the quality issues that come with that, as well as a decreased reserve of quantity. There are some studies that show that low AMH in younger women is less of an issue because they typically have younger, higher quality eggs, in which case it is likely merely an issue of quantity/remaining eggs.

Other factors can artificially influence AMH readings and, again, it is important to understand it in context of our your entire fertility picture. This also means understanding factors that can influence and skew CD 3 blood work. For example, high estradiol can falsely suppress FSH. High FSH, particularly when combined with a low AMH could be indicative of diminished ovarian reserve. Low vitamin D can also artificially suppress AMH. Anyone that gets a low AMH reading, particularly if not AMA, should have their vitamin D checked to determine if it could be falsely lowering your score. Finally, from what I have read, the AMH test itself is fairly difficult to run/process and can be prone to errors. If you get a low initial AMH reading and don’t show any risk factors or corroborating blood work/antral follicle count, etc., I would encourage a recheck before resigning yourself to a dx of low or diminished ovarian reserve.

There are a lot of conflicting reports about whether you can improve your AMH through supplementation. DHEA, CoQ10 (or, even better, ubiquinol the more readily available for absorption version of CoQ10) to support your egg health, have been linked to possibly improved AMH readings. This is fairly controversial and without significant acceptance in the larger medical community. Talk to your doctor about whether supplementations might be helpful in your specific case. Do not start any supplements without consulting with your RE. There are significant drug interactions and supplementation can also do more harm than good. DHEA, in particular, is a hormone that can have negative consequences if taken without appropriate need and monitoring.

Take heart, whether AMA or not, a low AMH does not necessarily mean that you are going to run out of eggs next month. It may, however, mean that your window to conceive is shorter than the average person and that you may need to consider more aggressive treatment under the direction of your RE. Low AMH does NOT, repeat NOT, mean that you can not get pregnant and stay pregnant.

  • MsAmandaPants – February 2012: 1st pregnancy: natural BFP after one month of trying. Ended in MMC and D&C.
    • April-October 2012: trying on our own with no success, despite temping, OPKs confirming ovulation, good timing, etc.
    • November 2012: 2nd pregnancy: natural BFP after 6 or 7 cycles of trying with no luck, ultimately determined to be complete molar pregnancy
    • December 2012: RPL/AMA testing, including AMH. AMH comes back at .53. Crushing. Diagnosed with low AMH, DOR, and complete molar pregnancy. Benched until August for molar pregnancy.
    • August 2013: Recheck of AMH to determine how much it had decreased during mandatory bench time. It came back at .29. Devastating.
    • August-October 2013: Started fertility treatments in August because of worsening AMH. 3 IUIs using Femara and injects (Menopur) and Ovidrel trigger. All failed, although I had a decent response to fertility drugs, 3, 4, 6 mature follicles, respectively).
    • December 2013: We were told we would have to move to IVF. Recheck of AMH to see if ubiquinol was helping and to determine how much worse it had gotten before moving to IVF. It came back at .54, showing some improvement.
    • A few days later in December 2013: Learned I was pregnant. I had been told that I had to move to IVF and was letting my body and brain rest from treatments for a couple of months before jumping into that. I got pregnant on my own, on a treatment break.

During my molar pregnancy mandatory bench time, I was exercising very heavily (training for half marathons) and I was also regularly taking between 200 and 300 of ubiquinol (the more bio-available version of coQ10) daily. I can’t say for certain that it was the result of my efforts, but my AMH did show improvement during this time. I also took high quality prenatals throughout the period I was TTC.

Grateful&Thankful AMH was .23 & my first RE told me there was no way to increase it. I took 2tsp daily of Royal Jelly & 300 mg of CoQ10 2x a day for 3 months. After retesting my AMH was .77

I don’t have any tubes so IVF was my only option any way. I got pregnant via IVF after taking those supplements for about 2.5 months. I miscarried due to a SCH. I’m currently pregnant again after IVF 5.5

I wanted to add that I’ve heard RJ can make fibroids grow so if you have trouble with fibroids, you may want to tone down your dosage.
2MomsinCA – Hi! Low AMH was devastating. I did a full work up with the RE before even attempting to ttc so I found out I had an AMH of .8 early on. My paperwork at every RE appt from then on said my diagnosis was “diminished ovarian reserve.” Ouch.

I took ubiquinol coq10, L-arginine, and pure royal jelly daily for about 4 months during the ttc process. I also practiced yoga and abdominal massage through the whole process. We did a total of 6 IUI’s and 2 ICI’s over the course of 10 months. The 2nd through 5th IUI were medicated with clomid, trigger shot, and progesterone suppositories. My 6th, final and sticky IUI was medicated with injectable menopur, trigger, and progesterone suppositories. My 2nd, 4th, and 6th IUIs resulted in BFPs. I lost the first two by 6 weeks. I was very good about taking my supplements for the 2 months prior to starting the injectable cycle and once I started menopur I stopped all supplements, did not do any vigorous exercise, and ate plenty of protein.
Emma2370 – In June ’13 my AMH came back at .39 July ’13 BFP naturally mmc at 8 weeks, November ’13 BFP ended in chemical pregnancy. December.’13 natural BFP healthy baby girl. I took my prenatal and royal jelly supplements. We had no issues getting pregnant staying pregnant with a healthy viable pregnancy was the issue. My DH has an chromosomal inversion which could have contributed to our losses. We did make an appointment with a RE just before our BFP.

2RedTulips – My OB ordered my bloodwork in July 2013, and that’s when my AMH came back at 0.2. I was devastated. We had already suffered one miscarriage and had been trying again for eight months at that point.

With those results, OB sent me to an RE, and we did a full work-up. In addition to my low AMH (tested at 0.8 at the RE’s), DH had poor morph, and we were given a less than 2 percent chance of conceiving naturally. Devastation #2. The one piece of good news I received during that time was that I had 12 resting follicles, which was a big shock.

We both started a slew of supplements per the RE. I also started a low-gluten diet, acupuncture and baby aspirin.

We were gearing up for a first round of IUI (certain we’d have to do IVF after a cycle or two) when I got a BFP. So, I call this baby our “2 percent baby,” because he ducked in under the wire.

So, from the time we received the low AMH results to conception was four months.

ETA: I am 39, by the way. I also took all the supplements with the RE’s blessing (L-Arginine, DHEA (prescription compound only), DHA, Inositol, Vitamin C, Vitamin E, CoQ-10 and Melatonin)

Eliz77 – My AMH was tested twice under two different REs and came back at 0.27 both times-tested in August 2013 and January 2014. Both REs recommended we try naturally for two cycles and if no success, move on to letrozole and IUI. We did get pregnant both times one 2nd cycle, 1st time ended in natural MC at 7 weeks. This one is far from a success story, but doing better than previous.

However, neither RE felt the low AMH was reason for losses or cause of concern. It was explained to me as having a lower egg reserve due to AMA, not necessary an indicator of quality since all other results came back normal.

Due to 2nd RE’s discovery of two copies of the MTHFR c77t gene, I was put on low dose aspirin, folate and started lovenox and calcium once an intrauterine pregnancy was determined. I know opinion vary on whether this is reason alone for losses, but since it was the only thing found amiss, RE decided to be proactive in his treatment plan just in case.

If we lose this pregnancy, my RE has already said he would like to move to IVF with PGD.

Daisy19782011 – Age 35, AMH .16
Did a back to back IUI with injections (gonal F) and a trigger. Got pregnant on 1st cycle. I lost that baby at 19 weeks, unrelated to IF, and did the same protocol 3 months later and got pregannat again. All of my other numbers are OK though, and we have not MFI.
BootsOrHearts –
I am trying to remember my AMH number from way back, I think it was 0.25 I’ll have to ask my doctor as the online records don’t go back that far.
Jan 2012: AMH 0.25 (?) @ 38 years old, diagnosed with DOR, told we are unlikely to get pregnant except via IVF or donor eggs.
Later that month. . . . natural BFP! Loss at 18 weeks, unrelated to DOR diagnosis
Started taking DHEA, one pill/day
2012/early 2013 Lots o’ failed fertility treatments, but good response to IVF, estrogen priming protocol: 7 retrieved, 7 mature, 5 fertilized (with ICSI) and 4 available for transfer, 2 implanted (resulted in C/P) and 2 frozen
April 2013. . . natural BFP @39 years old. Isaac, a.k.a. Baby Boots born 11/23/13.

egsquared –
I had 4 early losses between September 2011-August 2012. In October of 2012, my AMH was .18 at 36 years old. All my other results were normal, and two different RE’s recommended IVF. We had to wait until January 2013 to do an IVF cycle (switched to DH’s insurance). I had 9 eggs retrieved (which I thought was a low number), 5 fertilized with ICSI and two available for a 3 day transfer. we implanted both and got pregnant that cycle. DS was born 4 weeks early in September 2013.

In the months leading up to our IVF cycle, I took DHEA, CoQ10 and myoinositol.

The RE explained that with low AMH, you have a higher percentage of abnormal eggs left, so I was probably having bad luck and getting BFP’s on the cycles where my body released a bad egg. He said we could just keep trying naturally and we could get lucky and get a ‘good’ egg and a BFP, whereas with IVF we would be picking the best looking embryo(s) out of the group. We chose to go the IVF route to hopefully avoid any additional losses and because age/time was not on my side.

rslh10 – 28 years old, DX of .58 AMH in March 2014. Started Clomid CD 3-7 with trigger on CD 15, BFP the first try, but ended up ectopic @ 5w6d.
I was taking prenate minis, vitamin D, and biotin. Also my FSH was 7.5, and all the other blood work that had been drawn has been normal. HTH

Recurrent Pregnancy Loss (RPL) Testing

       Pregnancy loss alone is devastating. Not knowing why it occurs even once is heartbreaking. To continue to experience loss after loss causes anxiety, depression and fear. Recurrent pregnancy loss is typically defined as 3+ consecutive losses, while some practitioners may Dx RPL as 2 consecutive losses.
       One thing I ran into personally, was I had two early miscarriages and then an ectopic- some doctors may not consider this RPL because ectopics are either flukes or caused by tubal factors, not necessarily in the same department as another type of loss. My old OB did not feel as though I need RPL testing, whereas my current OB and RE did.  Depending on the types of losses you’ve had, your doctor may order a couple, a handful or all of the testing listed below.
       Bottom line is you need to advocate for what you feel is right. RPL testing can be very expensive (I’ve listed prices my insurance was billed FYI, but obviously prices and benefits will vary), emotionally exhausting and may still not provide you with answers. Below are some tests you may request or discuss with your medical practitioner. I decided not to include normal lab values because one lab’s ‘normal’ may be another lab’s ‘abnormal’.

  • Hormonal Factors Tests (prices may vary from $50-300 per test): This includes prolactin, thyroid and progesterone. Other hormones that may be checked (as part of an IF work-up, some tests may be cycle day sensitive) are estradiol, testosterone, LH and FSH. 
    •  An imbalance with one or more hormone may warrant treatment depending on the Dx. Depending on hormonal imbalance an ultrasound may also be ordered to make a firm Dx (PCOS, DOR)  
  • Blood Clotting Disorders- typically treated with some type of blood thinner (baby aspirin, heparin, lovenox)
    • homocysteine/MTHFR
    • Prothrombin gene
    • Protein C&S
    • Antithrombin III
    • Factor V Leiden
    • Fibrinogen
    • PT/PTT (INR)
  • Structural Factors Tests: These tests are conducted to determine the size and shape of your uterus as well as checking the uterine wall in hopes it is free of scarring, polyps, fibroids or a septum- all of which can affect implantation. Tests to check the integrity of your tubes may also be ordered if one or more of your losses were ectopic, or if you are at higher risk for one. 
    • SHG (sonohysterogram) ($300-ish): This test is conducted by inserting a catheter through your cervix to push saline into the uterine cavity. Simultaneously, your doctor will also be performing a transvaginal ultrasound to get a visual of your uterus. This test can identify if there’s abnormalities in your uterus (listed above). If there are concerns about the uterus, a hysteroscopy or laparoscopy may be performed to fix and further Dx the issue.
    • HSG (hysterosalpingogram) ($500-ish): This test is typically performed in your local hospital’s X-ray lab by an X-ray tech, and sometimes your doctor depending on how their practice handles this procedure. Similar to an SHG, a catheter is inserted through your cervix, except this test requires dye to get an adequate picture of your tubes. Sometimes, simply performing this test may unblock tubes if there’s a blockage while other situations may require surgery. 
  •  Uterine Lining Test/ Endometrial Biopsy: While this test is considered obsolete by some in the medical community (results may vary from tech to tech reading doing the biopsy, which may not give accurate results), it can still be an important piece of the puzzle, especially if you’re dealing with possible luteal phase defect (LPD) or spotting for more than a couple days during your LP. 
    •  This test is typically performed in the office after CD 21 (be SURE you have ovulated, as this test is checking your uterine lining for implantation). To get an accurate and reliable reading, it is typically recommended for this test to be performed two cycles for comparison to make a firm Dx. 
    •  If the uterine lining is ‘out of phase’ (2+ days… meaning you’re 7dpo and your biopsy is showing 9dpo, your body may not be adequately using hormones to build your uterine lining) treatments of clomid/femara, hCG trigger and/or booster and progesterone supplementation may be used for Tx. 
    •  I do want to mention that if the endo biopsy does leave you with a LPD Dx, to ask your doctor about what type of defect it is. Click HERE to read more about the different types and causes.  LPD is a controversial Dx in the medical community, about 50/50- if you are concerned about your LP and your doctor does not believe it’s an issue, seek a second opinion.
  •  Tests for Chromosomal Causes
    • Pathology from D&C/D&E ($480- pathology only): this will show if the cause of your loss was from a chromosomal abnormality or not. Most chromosomal abnormalities found are not typical to repeat in the future. 
    • Genetic testing (saliva testing $960 for MH and I) on one or both partners- This may consist of blood or saliva tests. Some cultural groups may be at higher risk/genetic carriers for certain chromosomal defects. 
    • Karyotyping ($2300 for MH and I): Blood test to be performed on you and your partner to check for translocations (normal number of genes, but are joined together abnormally) Tests for 
  • Immunologic Causes: This is one area that seems to not have as much research on all areas of testing, some are controversial and some are routine- and that I admittedly do not know much about. If you have more information I can add to this section, please feel free to leave a comment, message me on the bump or page me on TTCAL
    •  Anti cardiolipin antibodies (ACA) 
    • Anti-nuclear antibodies (ANA) 
    • Anti-thyroid antibodies (ATA) 
    • Anti-Ovarian Antibodies (AOA) 
    • Anti-Sperm Antibodies (ASA) 
    • Anti-phospholipid antibodies (APA) 
    • Leukocyte Antibody Detection (LAD) 
    • Lupus anticoagulant (LAC) 
    • Embryo Toxic Factor (ETF) 
    • NK activation assay (NKa) 
    • reproductive immuno-phenotype (RIP)

Infertility- Testing, questions and information

There’s a wide range that will “qualify” someone to be considered infertile. For a man, it could be low sperm count, no sperm release, or sperm that are physically incapable of going into the egg on their own. For a women, the list seems to be greater. The range is generally seen as:

You are in your mid-30s or older, have not used birth control for 6 months, and have not been able to become pregnant.
You are in your 20s or early 30s, have not used birth control for a year or more, and have not been able to become pregnant.

How will we be tested?
As a general start-out, both partners are given a general overview. This includes:
Medical History
Physical Exam
Blood and Urine Tests- (LH, prolactin, Progesterone, thyroid, testosterone, and STD’s)

There are certain tests specific to each partner that maybe done. Women may be asked to do a postcoital test (checking cervical mucous) and a home LH test. Men may be asked for a semen analysis to check the amount and “capabilities” of his sperm.

Should all the tests not give definite answers a second level of tests could be performed. A general antibody test and karyotyping will be done for both partners. For women a pelvic ultrasound, Hysterosalpingography (HSG), Sonohysterography (SHG), endometrial biopsy and laparoscopy may be performed. For men and ultrasound and/or testicular biopsy may be performed.

It’s been studied that for 80% of couples, the cause is either a sperm problem, irregular or no ovulation, or blockage in fallopian tubes. For about 15% of the diagnosed ‘infertile’ couples, there may be no answers resulting in a diagnosis of unexplained infertility.

The most common causes of infertility have been found to be
Men:
Impaired function of sperm
Impaired delivery of sperm
General health and lifestyle
Environmental exposure

Women:
Fallopian tube damage or blockage
Endometriosis
Ovulation Disorders
Elevated Prolactin
Polycystic Ovary Syndrome (PCOS)
Early Menopause
Uterine Fibroids
Pelvic Adhesions

There are a variety of treatments can be done to help with any diagnosed explanation of infertility.

For men, the solution may be as simple as medication, increased frequency of intercourse or aid in unblocking tubes allowing adequate semen release.

For women, there is a large list of aids:
Clomiphene (Clomid, Serophene)
Human Menopausal Gondrotriphin or hMG (Repronex)
Follicle Stimulating Hormone or FSH (Gonal-F, Bravelle)
Human Chorionic Gonadotripin (Ovidrel, Pregnyl)
Gonadotropin Releasing Hormone
Aromatse Inhibitors
Metformin (Glucophage)
Bromoctrptine (Parlodel)
Assisted Reproductive Technology (IUI, IVF, ICSI)

As with any medical treatment, there can be complications. With fertility medications, the result may be multiple pregnancy, overstimulated ovaries, bleeding or infection, low birth weight, or birth defects.

As with any medical advice, you should only listen to your doctor. They will know the best test, treatment and level of risk for each procedure or aid you may be prescribed.

Additional links and information:

(overview of tests)http://www.webmd.com/infertility-and-reproduction/tc/infertility-tests-overview

(breakdown of tests)http://www.webmd.com/infertility-and-reproduction/guide/infertility-reproduction-diagnosis-tests

(Understanding Infertility) http://www.webmd.com/infertility-and-reproduction/guide/understanding-infertility-treatment

(infertility ‘causes’) http://www.mayoclinic.com/health/infertility/DS00310/DSECTION=causes

(Discussing infertility with a dr) http://www.mayoclinic.com/health/infertility/DS00310/DSECTION=preparing-for-your-appointment

(Treatments and drugs) http://www.mayoclinic.com/health/infertility/DS00310/DSECTION=treatments-and-drugs

(Recent news and updates about infertility) http://www.webmd.com/infertility-and-reproduction/news-features

Feel free to join the discussion on The Board if you have any questions or input or put a comment down below!