Anti-Müllerian hormone (AMH) is a crucial marker for ovarian reserve, reflecting the number of remaining eggs in a woman's ovaries. This comprehensive review reveals that AMH levels help predict reproductive lifespan, IVF treatment responses (including poor response and ovarian hyperstimulation syndrome), and conditions like PCOS. Key findings show AMH is more stable than other hormones for assessing fertility potential, with specific cut-off values predicting IVF outcomes: ≤4 oocytes (sensitivity 72-97%, specificity 41-93%), pregnancy (sensitivity 50-86%), and hyper-response (sensitivity 69-93%). While highly predictive, AMH alone shouldn't determine treatment exclusion due to limitations in assessing egg quality.

The Role of Anti-Müllerian Hormone in Female Fertility: A Patient's Guide

Table of Contents

• Background: Why AMH Matters for Fertility
• Study Methods: How Researchers Analyzed AMH
• AMH in Ovarian Function
• How AMH is Measured
• AMH as an Ovarian Reserve Marker
• AMH's Role in IVF Treatment
• AMH and Polycystic Ovary Syndrome (PCOS)
• What This Means for Patients
• Study Limitations
• Patient Recommendations
• Source Information

Background: Why AMH Matters for Fertility

In Western societies, women are having their first child later in life due to education and career priorities. Female fertility naturally declines starting in the early twenties because of decreasing ovarian reserve – the quantity and quality of remaining eggs. This decline varies significantly between women, making it challenging to predict individual reproductive lifespans. Anti-Müllerian hormone (AMH) has emerged as a promising biomarker to help assess ovarian reserve.

AMH is a protein produced by small developing follicles in the ovaries. Unlike other hormones, its levels show minimal monthly fluctuation and reflect the continuous growth of small follicles. This makes AMH particularly valuable for fertility assessment because it provides a stable indicator of ovarian reserve throughout the menstrual cycle.

Study Methods: How Researchers Analyzed AMH

Researchers conducted a comprehensive analysis of scientific literature up to November 2011. They systematically searched medical databases using specific terms related to AMH, focusing on human studies in English. From 235 initial publications, they excluded 96 that were irrelevant, leaving 139 studies for detailed evaluation.

The analysis prioritized original clinical studies over reviews, with special attention to:

• AMH's role in female infertility and ovarian physiology
• Ovarian reserve assessment
• IVF treatment outcomes
• Polycystic ovary syndrome (PCOS)

For IVF prediction tables, researchers included only studies that defined poor response as ≤4 oocytes retrieved. They ultimately analyzed 80 high-quality publications: 12 prospective cohort studies, 7 retrospective cohort studies, and 1 case-control study.

AMH in Ovarian Function

Your ovaries contain primordial follicles (immature egg sacs) that gradually develop through stages:

1. Initial recruitment: Primordial follicles begin growing independently of hormones
2. Cyclic recruitment: After puberty, follicle-stimulating hormone (FSH) rescues developing follicles monthly

AMH is produced by granulosa cells in preantral and small antral follicles (up to 4mm). It plays two critical roles:

• Slows initial recruitment from the primordial follicle pool
• Reduces sensitivity to FSH during cyclic recruitment

This dual action prevents premature egg depletion. AMH levels peak in puberty and steadily decline until becoming undetectable at menopause.

How AMH is Measured

AMH is measured through blood tests using enzyme-linked immunosorbent assays (ELISAs). Two main commercial tests existed when this research was conducted:

• Immunotech-Beckman-Coulter (IBC) assay
• Diagnostic System Laboratories (DSL) assay

Important notes about testing:

• DSL results are typically 4x lower than IBC values
• No international standard existed, making direct comparison between tests difficult
• AMH is relatively stable – not significantly affected by pregnancy, birth control pills, or most medications
• Levels aren't influenced by body mass index or smoking

Results can be reported in ng/mL or pmol/L (1 ng/mL = 7.14 pmol/L). A new generation AMH Gen II assay was being developed to replace earlier versions.

AMH as an Ovarian Reserve Marker

Ovarian reserve describes both egg quantity and quality. AMH levels strongly correlate with the number of remaining primordial follicles – your "egg reserve." Key advantages over other tests:

• More stable: Minimal monthly fluctuation vs. FSH or estradiol
• Earlier detection: Declines before menstrual irregularities appear
• Long-term prediction: Can forecast menopause timing with reasonable accuracy

In healthy women, AMH is the best endocrine marker for predicting age-related fertility decline. However, it doesn't directly measure egg quality – a crucial factor for pregnancy success.

AMH's Role in IVF Treatment

AMH testing before IVF helps predict treatment responses:

Predicting Poor Response (≤4 eggs retrieved)

Studies show consistent predictive value:

• Sensitivity: 72-97% (correctly identifies poor responders)
• Specificity: 41-93% (correctly identifies normal responders)
• Positive predictive value (PPV): 30-79%
• Negative predictive value (NPV): 90-98%

Example cut-off values: 1.43-14.0 pmol/L (IBC assay), 3.57-9.71 pmol/L (DSL assay)

Predicting Pregnancy Success

AMH is less predictive of pregnancy than ovarian response:

• Sensitivity: 50-86%
• Specificity: 28-82%
• PPV: 31-84%
• NPV: 75-98%

Notably, pregnancy is possible even with very low AMH, especially in younger women. For women aged 34-41, AMH correlates with pregnancy rates – but not for women under 34 or over 42.

Predicting Hyper-Response and OHSS Risk

High AMH predicts excessive response to fertility drugs and ovarian hyperstimulation syndrome (OHSS):

• Sensitivity: 69-93%
• Specificity: 67-81%
• PPV: 22-65%
• NPV: 94-99%

Cut-off values: 15.0-34.5 pmol/L. This helps doctors adjust medication doses to prevent dangerous OHSS complications.

AMH and Polycystic Ovary Syndrome (PCOS)

Women with PCOS (affecting 5-10% of females) typically have 2-4x higher AMH levels due to:

• Excessive small follicles in ovaries
• Increased AMH production per follicle

Elevated AMH contributes to PCOS symptoms by:

1. Suppressing follicle development
2. Interfering with ovulation

AMH testing helps diagnose PCOS, especially in adolescents where traditional criteria are less reliable. Levels decrease with effective PCOS treatments like oral contraceptives or ovarian surgery.

What This Means for Patients

AMH testing provides valuable insights for fertility planning and treatment:

• Reproductive lifespan estimation: Helps gauge remaining fertility window
• IVF preparation: Predicts poor/hyper-response, allowing personalized medication protocols
• OHSS prevention: Identifies high-risk women for dose adjustments
• PCOS diagnosis: Supports identification, especially in complex cases

AMH is superior to FSH for ovarian reserve testing because it doesn't require specific cycle timing and has less variability.

Study Limitations

While compelling, this research has important caveats:

• No international AMH standard existed, complicating value comparisons
• Most data come from observational studies – not randomized trials
• AMH predicts egg quantity better than quality
• Cut-off values vary significantly between studies and populations
• Limited data on AMH's role in predicting natural conception
• Doesn't account for all causes of diminished ovarian reserve

False positives remain a concern – 21-70% of women with low AMH values in studies still produced >4 eggs during IVF.

Patient Recommendations

Based on this research, consider these steps if exploring fertility testing:

1. Discuss AMH testing with your doctor if:
   • You're over 30 and considering future family planning
   • You have irregular periods or PCOS symptoms
   • You're preparing for IVF treatment
2. Interpret results cautiously: Low AMH doesn't mean pregnancy is impossible, especially if you're under 35
3. Request assay details: Ask which test was used (IBC vs. DSL) as values aren't directly comparable
4. Combine with other tests: Use AMH with antral follicle count for best reserve assessment
5. PCOS management: If diagnosed, track AMH to monitor treatment effectiveness
6. IVF counseling: Use AMH values to discuss realistic expectations about egg retrieval numbers and OHSS risk

Remember that age remains the strongest predictor of egg quality – a critical factor AMH doesn't measure.

Source Information

Original Research Article: "The role of anti-Müllerian hormone in female fertility and infertility – an overview"
Authors: Anna Gracia-Alix Grynnerup, Anette Lindhard, Steen Sørensen
Journal: Acta Obstetricia et Gynecologica Scandinavica
Publication Date: 2012
DOI: 10.1111/j.1600-0412.2012.01471.x

This patient-friendly article is based on peer-reviewed research. For full methodology and statistical analysis, refer to the original publication.