Practically Fertile

Episode 11 - The Shocking Truth About the AMH and Ovarian Reserve

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No single marker for fertility causes as much anxiety and stress as the AMH.  If your AMH is low, you've likely thought that you're "running out of eggs" and that you won't be able to get pregnant naturally.

In this episode, I talk about why that is incorrect.  Here is what to expect:

  • What AMH actually is 
  • What AMH actually do
  • What does it mean if AMH is low
  • Can AMH be increased?
  • Factors that influence AMH

Please let me know what you think.  I would love to hear from you!

Follow me on instagram @dradriennewei

Website: www.adriennewei.com

Speaker 1:

Welcome to the Practically Fertile Podcast. I'm Adrienne Wee, doctor of acupuncture and Chinese medicine, functional medicine practitioner and functional nutritionist. I specialize in using an evidence-based method, blending principles of East Asian medicine and modern functional medicine to help women optimize fertility and get pregnant. I believe in a world where every woman who wants to be a mother becomes one. If you're tired of being told that you're infertile and you want to take the right steps to get pregnant naturally and quickly, this podcast is for you.

Speaker 1:

One of my patients, bridget her AMH was 0.29 and she was able to conceive naturally at the age of 43. Another patient, darcy her AMH was 0.7 and she conceived naturally at the age of 42 and then again naturally two years later at the age of 44. Gabriela I worked with her virtually. She was 36 years old and her AMH was 0.08, and she was able to conceive naturally after two months. So I know that AMH is probably one of these markers that causes you a lot of anxiety about your chances of getting pregnant. If you've been told that your AMH is low, you might think that it means you're running out of eggs and that you can't get pregnant naturally. And I'm telling you these stories because number one having low AMH does not mean you can't get pregnant, naturally. Number two AMH numbers can increase. And number three AMH is actually not a measure of your true ovarian reserve.

Speaker 1:

In this episode, I'm going to expose the shocking truth about the AMH and tell you what your doctors don't tell you. So let's get started. What exactly is AMH? It stands for anti-mullerian hormone, and what's really interesting about it is that this hormone is involved in the fetal development process. Both male and female fetuses are born with the mullerian duct, which eventually turns into the female reproductive duct, including cervix, uterus, fallopian tubes. Cervix, uterus, fallopian tubes Around eight weeks of gestation, amh production for the male fetus help to produce a protein that triggers a self-destructive process that then dissipates the mullerian duct, and this protein is only produced by the male fetus and not the female fetus. So then the mullerian duct turns into the structure that contains the cervix, uterus, fallopian tubes. So how does the AMH become a marker for ovarian reserve? The AMH production is very low for women at birth, but it increases gradually as the woman gets closer to puberty.

Speaker 1:

We focus a lot on the ovulation process, but in reality, the follicle that matures then releases the egg. It has been growing for the last five to six months, maybe even longer. So let's start from the beginning of the follicle development process. It all starts when you were in your mother's womb.

Speaker 1:

Around six months of gestation, primordial follicles, or very small follicles, start to form. All of the primordial follicles are formed between six to nine months of gestation and this, my friend, is your true ovarian reserve. And these follicles, they remain dormant until puberty, when they're activated. But naturally a lot of them will be lost from the time you were born to the time when you get your first period. So on average, you might be born with 1 to 2 million primordial follicles, but you might only have 400,000 left at puberty. There's no way to measure the exact number of these primordial follicles.

Speaker 1:

When a primordial follicle is activated or awakened, it becomes a primary follicle. Then the primary follicle becomes a pre-antral follicle, 120 to 90 days before ovulation, 120 to 90 days before ovulation, and then it becomes the antral follicle. These antral follicles are what cycle day three ultrasounds measure For IVF cycles. The higher the number of antral follicles, the better the outcome. So these antral follicles then grow and the rest of the process you're familiar with. There's a dominant follicle. Ovulation then, during the luteal phase is when the implantation happens or doesn't happen. If there's no implantation, you'll start your period and then the whole cycle starts over again. In the background, there's actually a lot happening. There's a constant supply of pre-antral follicles that are waiting to become antral follicles, and it's on these pre-antral follicles that the AMH is being produced. Amh is only produced by these follicles and nowhere else, and that is why AMH is so popular and is used as a marker for ovarian reserve. It shows how big the follicle selection pool is. It is directly correlated to the number of follicles that are growing. The idea is, the more pre-antral follicles you have, there's more to choose from for ovulation, and then that increases the odds of getting pregnant. So it's all a numbers game, but here's the real function of AMH and how our body uses it.

Speaker 1:

The AMH is used to regulate the follicle development process that we just talked about. It's meant to suppress the FSH so that not too many follicles are recruited all at once, and this will help to prolong the reproductive lifespan of the female, because if too many follicles are recruited at once, then you'll deplete the ovarian reserve very, very quickly, and this actually has been proven with experiments with mice, compared to mice living in the wild, the mice with no AMH that's artificially induced. The primordial follicles deplete and reach exhaustion at a much younger age. No one knows the exact number of primordial follicles you have. There's just no way to measure that, and that's why AMH is the best marker to date, but it still can't tell us how many more follicles you have left. So if you have low AMH, the challenge is that your follicle selection pool might be smaller. So AMH is used to measure the functional ovarian reserve rather than the ovarian reserve.

Speaker 1:

And, like we talked about before, amh and the antral follicle count are useful tools for doctors during an IVF cycle to predict how many eggs can be expected to be retrieved. A question you might be asking right now might be well, you just said that if the AMH is low, then more follicles are recruited. Then how come my antral follicle count isn't higher, according to the same logic? Well, that's a really good question. Lower AMH a lot of times can mean a higher FSH level. A higher FSH level means that the follicles are not going to respond to this hormone and most of them will stop growing and die off.

Speaker 1:

But the FSH doesn't just act on the follicles at the beginning of the cycle. It actually acts on the follicles all the way back to the pre-antral stage, 120 to 90 days prior to ovulation. So back to the example that I used before, the mice with no AMH. The number of follicles that made it to the early enteral stage is higher than the mice with AMH. But once the follicles enter the early enteral stage they also stopped growing and they just die off. And this process where the follicles naturally die off, is called atresia. It can happen from activation time of a primordial follicle all the way up until the antral follicle stage. We know that influences from the external environment. So things like diet, lifestyle, stress can influence how many and how quickly the follicles naturally die off. So more on that later.

Speaker 1:

But just because you have a low AMH it doesn't always mean that you have a high FSH. You can have a low AMH but normal FSH. If your FSH is normal, even though your AMH is lower, that's actually not a bad situation to be in because that means that your growing follicles will respond to the FSH is normal, even though your AMH is lower. That's actually not a bad situation to be in because that means that your growing follicles will respond to the FSH and grow appropriately, even if the number of them is smaller. I want to touch on briefly about the other end of the spectrum, which is when the AMH is too high.

Speaker 1:

The AMH is now becoming a popular marker to diagnose PCOS. Not every single PCOS patient will have high AMH, but it's very common, especially in the type of PCOS that causes ovulation to stop. One of the symptoms of PCOS is having many small follicles that get stuck in the pre-antral phase and never grow to maturity, and these are the follicles that produce AMH right. So if the AMH is way higher than the upper limit of normal, it's usually suspected that it's caused by PCOS due to the follicles failing to grow past a pre-antral stage. The AMH will often return to normal once the cycle is regulated and the ovaries can ovulate again, so this is definitely not a permanent situation. Amh is not the only marker that should be used to test PCOS, but it is a very useful one.

Speaker 1:

All right, the important question is does having low AMH mean that you can't get pregnant? Absolutely not. I hope you get that thought out of your head. Remember the three stories that I told you in the beginning. Even the ASRM, american Society of Reproductive Medicine, says that AMH is not a predictor of the ability to get pregnant. There are so many factors that can influence your AMH level and your AMH level can increase Because if you can optimize your reserve and increase the number of quality follicles in the selection pool prior to ovulation, more of them will survive and more of them will produce AMH and more of them will make it to the antral follicle stage. And yeah, of course your AMH won't suddenly increase from 0.5 to 5, but it could make a big difference depending on what your goals are Like. If it increases from 0.5 to 1.5 and you're doing IVF, that can be the difference between 5 follicles and 10 follicles.

Speaker 1:

My patient, konstantina she had an AMH of 0.08, and her most recent blood work showed that the AMH went up to 0.32. And that's great because she was told before that she would have to do IVF with donor eggs, but now she's a candidate for doing IVF with her own eggs. So that is a huge, huge accomplishment. And I've also had patients whose AMH has gone from 0.3 to 1.4, 1.5. So it's not uncommon for us to see this type of results.

Speaker 1:

So if you have low AMH, how can you increase the AMH and what should you do to get yourself the best chances of getting pregnant. Let's talk about that. Instead of focusing on increasing the AMH number, you should focus on optimizing the quality and the quantity of the follicles that grow. So let's go over some of the well-known factors that will affect AMH. Age is a factor. It's true that as you get older, the follicle depletion rate increases, but that's not a direct cause of low AMH. Young women can also have very low AMH. I have several patients right now who are in this situation, and remember Gabriela. She was only 36, but her AMH was 0.08. I have a 46-year-old patient right now. Her AMH is 1.5, which is higher than normal for her age.

Speaker 1:

Genetics is a factor as well. You could be born with a low reserve. Remember all the primordial follicles are formed between six to nine months gestational age, while you were in utero. Epigenetics is a huge factor. One of my favorite topics this is the environment that you're living in, everything from diet to toxin exposure, to sleep patterns, exercise and stress. There's evidence that genes that regulate follicle development in women with low reserve are often dysregulated, meaning their actions become irregular, unpredictable and inconsistent.

Speaker 1:

Major illnesses, chemo surgeries can trigger your body to start burning through the ovarian reserve. The human body will always prioritize survival over anything else and unfortunately, reproduction is not one of the necessities to survive. If you've had surgery on the ovaries, that would affect AMH, because the primordial follicles are stored in the ovaries, or your AMH could be temporarily suppressed Right after a woman gives birth. The AMH levels can be very low Immediately after an IVF retrieval cycle. The AMH can be low if the antral follicles are not replenished quickly enough. And here's one that recently came out about AMH being temporarily suppressed. It's now confirmed that if you're taking hormonal birth control, with the exception of IUDs, your AMH could be suppressed. This has huge implications because a very popular home testing kit company has made a business model out of this testing young women's AMH and encouraging them to freeze their eggs based on the results. But your AMH while on birth control could be lower than what it should be. So if you've done one of these tests and your AMH is low, don't panic. Just get it retested a few months after getting off the birth control.

Speaker 1:

I want to share an interesting case right now, actually my patient Maria. She took Clomid for a few cycles and her AMH dropped to 0.2 and her FSH shot up to 70. They told her that there's no hope and donor eggs is the only option, and turned out, after two months of stopping the medication and getting acupuncture, her FSH is now under 10, which is very, very normal, and she has had normal periods, and we're just waiting to see what her AMH levels are. So, as you can see, amh levels are not set in stone. They can go up and they can go down. The important thing here is to find out why the AMH levels are low or has decreased Some of the influencing factors that we just mentioned.

Speaker 1:

There isn't anything to be done, for example, age right, we can't stop the aging process. We also can't do anything about genetics, but we can control all these external factors like diet, lifestyle, toxin exposure, stress. Let's just talk about stress for a second, because women who experience higher levels of perceived stress are found to have lower antral follicle count and lower AMH. But it's never talked about much, because who doesn't have stress right? Isn't it normal to have stress? Of course it's very normal to have stress, but how are you handling the stress is the question. Stress is very broad and it can be emotional and physical stress and everyday life stress, work stress, but the truth is. It doesn't matter which form of stress it is and where it comes from. The effect on our body is the same, because our brains can't tell the difference between the type of stress.

Speaker 1:

When it feels like your survival is threatened, it will go into self-preservation mode and start shutting down whatever functions are not necessary, and reproduction is usually the one that gets shut down first. And you might not see the immediate impact of streks, because as human we can tolerate a lot of crap, right. But look at it this way it's like a pot of boiling water At some point it's going to boil over if the burner stays on. So when your body reaches that point, several things can happen. It can affect the menstrual cycle at the highest level, which is the hypothalamus, and that's where the signal to have a menstrual cycle comes from. So the hypothalamus is affected. Then there's no FSH, no ovulation, no menstrual cycle and no baby. And when your brain decides that you're in survival mode, then it will start to trigger processes to burn through the ovarian reserve much more quickly, more follicles will be activated and they will also die off very quickly.

Speaker 1:

Many of my patients tell me that they're not stressed, and then we dive deeper and find out that they're not sleeping well. There's tossing and turning, there's a lot of anxiety attacks throughout the day, there are headaches, daily, feeling of tightness in the chest. These are all warning signs that our body is sending us. And, yes, you can take a pill to sleep or relieve anxiety. You can take Advil for the headaches. But if you don't fix the issue at the root and understand where your stress is coming from, you're going to get stuck on this merry go-round of forever taking medication that have a lot of side effects. All right, so enough about stress.

Speaker 1:

From a TCM perspective, it doesn't matter that you have low AMH. What matters is what is the pattern of imbalance that's causing low AMH? Is it because your qi is not flowing? Is it because it's deficient? Is your blood deficient? Is your yin deficient? So once you discover the root cause, which is the patterns of imbalance, then it's simple to treat it with targeted nutrition, lifestyle changes and things like that. So that's why you shouldn't worry that you're never going to get pregnant. The problem is that you probably haven't found the root cause.

Speaker 1:

One more thing that I want to mention here is vitamin D. Vitamin D is pretty important for hormone balance and fertility. Majority of vitamin D is made on our skin from the sun, and wearing sunscreen and staying indoors more can definitely deplete the reserve. There's a lot of evidence that vitamin D deficiency is linked to certain symptoms of PCOS, like insulin resistance, high testosterone, ovulation dysfunction. It has been associated with an increased pregnancy rate, live birth rate from IVF, decreased risk of miscarriage and also decreased risk of various pregnancy complications. But there has not been a clear relationship established between AMH and vitamin D because a lot of data out there are conflicting. Some studies show that in the summer, the AMH is higher for certain women. Some studies show no difference between vitamin D supplementation and the AMH is higher for certain women. Some studies show no difference between vitamin D supplementation and the AMH. So it appears that vitamin D does help with the production and balance of sex hormones like progesterone, estrogen, testosterone, but might not necessarily help with FSH, amh or the antral follicle count. It is, however, an important vitamin regardless, and I haven't run into many women with low vitamin D status lately because I think more people are becoming more aware of the impact that low vitamin D has on health and fertility and they're actively supplementing.

Speaker 1:

Finally, you might be wondering if there's an optimal time to test for AMH. Unlike hormones like FSH, lh and estrogen that need to be tested on day three to get the most accurate baseline reading, amh stays relatively stable throughout the cycle because it's produced by a pool of follicles that are waiting to be selected in the months to come, and there's always a pool of follicles waiting. There is some variability, but very, very minor, not enough to matter, so you can get your AMH tested at any time. Now, as we wrap up here, I want to remind you that the AMH is just one data point. It doesn't represent your ability to get pregnant. It's not the end-all be-all.

Speaker 1:

If your AMH has been found to be low, just know that there are many reasons, and some of which can be reversed. You can't change the actual reserve, but what's important is that you do everything you can to nurture what you have, to nurture the pool of follicles that have been recruited, so that more of them make it to the enteral follicle stage and more of them are available for selection to become the dominant follicle. If you don't know where to start, start by identifying the triggers of stress in your life and how you're managing them. There will always be stress. That's not going to change as long as you're alive, but your reaction to them is what helps your body determine whether to prioritize survival or reproduction.

Speaker 1:

All right, fertile friend, hope you found this episode valuable and I hope that I have decreased some anxiety about having low AMH. If you like what you're hearing, please subscribe so that you don't miss an episode, and you can also follow me on Instagram at Dr Adrienne Wee. Thank you so much for tuning in. Take care of your amazing self and remember you're one fertile cycle away from getting pregnant.