Latest / The Brilliant Fertility Podcast / Episode 047: Fertility Testing Part 3: What does AMH mean for Fertility?

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Episode 047: Fertility Testing Part 3: What does AMH mean for Fertility? · The Brilliant Fertility Podcast

• 0:05
  Speaker 1: Welcome to the Brilliant Fertility Podcast.
• 0:07
  Speaker 1: I'm your host, dr Katie Rose, and this podcast exists to help illuminate the path ahead of you.
• 0:13
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• 0:27
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• 0:47
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• 1:00
  Speaker 1: Welcome back to the Brilliant Fertility Podcast.
• 1:13
  Speaker 1: We couldn't have a conversation about fertility tests without talking about AMH.
• 1:17
  Speaker 1: Amh is one of those markers that I get a ton of questions about.
• 1:20
  Speaker 1: It creates a lot of panic for fertility patients if they find out their AMH is low.
• 1:26
  Speaker 1: So let's dive in to what this marker is, why it's creating such a fuss and what it actually means for fertility.
• 1:36
  Speaker 1: So AMH stands for anti-malarian hormone.
• 1:40
  Speaker 1: It's a hormone that is released by the granulosa cells, which are the little cells in the ovary that create the follicle line, the follicle and house the egg.
• 1:49
  Speaker 1: And when you have more follicles and healthier follicles you will tend to have higher AMH.
• 1:57
  Speaker 1: Fewer follicles we may tend to see lower AMH, and there is a question mark around whether the quality of the follicles or the quality of the eggs also impacts AMH as well, but I have not found clear research on that.
• 2:18
  Speaker 1: That's a much harder factor to study in and of itself.
• 2:22
  Speaker 1: Harder factor to study in and of itself.
• 2:28
  Speaker 1: Amh is causing some panic because if someone is diagnosed with diminished ovarian reserve, it is in part because they have found that their AMH is low, and usually this diagnosis is given with a combination of markers high FSH, low AMH and a low antral follicle count.
• 2:47
  Speaker 1: So we really don't want to use AMH alone to give a diagnosis or give any predictions about whether or not someone can get pregnant or stay pregnant.
• 2:59
  Speaker 1: We have to look at it in context of the greater picture and what else is going on, and AMH is also tied to some other factors that are less often tested.
• 3:12
  Speaker 1: So if you go back to the first two parts of our lab series, you'll understand a little bit more about how I test differently.
• 3:20
  Speaker 1: But in particular, vitamin D deficiency and iron deficiency anemia can contribute to a lower follicle count and therefore lower AMH.
• 3:32
  Speaker 1: So if someone has a low AMH, some of the first things I'm looking at are their nutrient status.
• 3:39
  Speaker 1: Do they have low vitamin D?
• 3:41
  Speaker 1: Do they have low iron?
• 3:42
  Speaker 1: Do they have high inflammation?
• 3:45
  Speaker 1: And do they have high inflammation and do they have chronic stress?
• 3:47
  Speaker 1: These are the four factors that I have viewed in my practice to have the greatest impact on the follicle count, follicle function.
• 3:57
  Speaker 1: But we still can't use AMH alone to tell us if someone can get pregnant or stay pregnant.
• 4:02
  Speaker 1: Really, this marker is going to be most valuable for someone who's thinking about going through IVF and wants to understand how they might expect to respond to those IVF stimulation meds.
• 4:17
  Speaker 1: That's the best way to use AMH.
• 4:21
  Speaker 1: So we cannot use it to tell us if someone can get pregnant or stay pregnant, and this may be controversial, but I'm actually pulling back on how often I test AMH.
• 4:34
  Speaker 1: So the way I use AMH in my practice well, if I think that there's a possibility.
• 4:40
  Speaker 1: Someone has PCOS and AMH is actually now used as part of the diagnostic criteria to diagnose PCOS.
• 4:45
  Speaker 1: That's a situation in which I will test AMH because if their AMH is high then that more likely points towards PCOS.
• 4:54
  Speaker 1: But if someone comes to me and their cycles are regular, there's no evidence of PCOS and they say I'm never going to be interested in IVF, that's not something I ever want to pursue, then I'm not likely going to test their AMH because I don't want to create unnecessary panic when there are so many other things that we can look at that we do have influence over, like vitamin D and iron levels and inflammation and chronic stress.
• 5:24
  Speaker 1: So I caution people not to look at AMH in a vacuum and allow it to create more stress, more unnecessary panic, and to look at the greater picture so that we can understand what factors we do have influence over.
• 5:44
  Speaker 1: So that we can understand what factors we do have influence over.
• 5:45
  Speaker 1: Because with any test, I am mindful of asking will the result of this test change anything about our treatment plan?
• 5:52
  Speaker 1: And if it's not going to change anything, then why are we testing it?
• 5:57
  Speaker 1: What does that give us?
• 5:58
  Speaker 1: To have that information?
• 6:00
  Speaker 1: So if we know that someone is not going to be pursuing IVF.
• 6:10
  Speaker 1: There's no evidence of PCOS.
• 6:10
  Speaker 1: I'm probably not testing AMH anymore.
• 6:13
  Speaker 1: I've seen too many times over 12 years how much stress it has created for someone to get their AMH back and is lower than they expected.
• 6:23
  Speaker 1: And then they start going down the thought spiral of oh my God, this means I'm running out of eggs and I'm never going to be able to get pregnant and I waited too long and I'm too old and you know insert, whatever your worry has been, I promise you're not alone.
• 6:41
  Speaker 1: I've heard them all and we have to be really careful about how we utilize that number right.
• 6:49
  Speaker 1: So I have a few stories for you about people who've had low AMH and gone on to get pregnant unassisted and go on to have very healthy babies.
• 7:00
  Speaker 1: Now I'll start with Amanda.
• 7:03
  Speaker 1: So Amanda came to me at 38 years old.
• 7:06
  Speaker 1: She'd had recurrent pregnancy losses and um, her AMH was, you know, in in that category technically where someone could receive the diagnosis of diminished ovarian reserve.
• 7:19
  Speaker 1: When we first tested it it was a 0.5 and she had no interest in ever pursuing IVF.
• 7:27
  Speaker 1: She said you know, if it's in God's plan for me to conceive, then I'm going to need to conceive unassisted.
• 7:34
  Speaker 1: So we really worked on her nutrient status, her stress resilience skills and she started acupuncture and red light therapy with us and she actually had, you know, been right around the one year trying to conceive.
• 7:53
  Speaker 1: Mark, after starting these protocols, when we retested her FSH and her LH on her cycle day three and her FSH had actually gone up a little bit, her AMH had dropped nearly in half.
• 8:07
  Speaker 1: So she was just on the cusp of turning 40 when we had retested that and I I called to let her know that I'd gotten the results back and I've learned over the years to check in with people, ask if there's anything I need to know before I drop their lab results on them.
• 8:26
  Speaker 1: And she said, well, yeah, I actually just got a positive pregnancy test.
• 8:31
  Speaker 1: It was her 40th birthday and she had just gotten a positive pregnancy test.
• 8:35
  Speaker 1: And I was like, oh well, how amazing, because here I was calling to let you know that your numbers had actually not improved and I was, as the practitioner, feeling kind of down about that.
• 8:50
  Speaker 1: And here she was just elated because she'd gotten her first positive pregnancy test in over a year and and her baby was born very healthy and then six months postpartum she actually conceived again, unintentionally thinking, oh, if I want another one, it's going to be that much harder.
• 9:12
  Speaker 1: So I can only imagine that her AMH had probably not improved at that point.
• 9:18
  Speaker 1: You know, because through her pregnancy and six months postpartum, it would have been about 16 months since we had tested it.
• 9:28
  Speaker 1: At that, you know, almost 40 timeframe.
• 9:31
  Speaker 1: And she was just such a wonderful example of how little control we truly have over this and how possible it is to get pregnant and stay pregnant even with a low AMH.
• 9:47
  Speaker 1: So in her scenario we did identify that she had nutrient deficiencies and really she worked diligently and was committed to changing how she responded to stress, changing her relationship to a healthy lifestyle, and I believe that made a significant difference for her, despite her AMH dropping.
• 10:15
  Speaker 1: Her AMH at the time that she conceived was 0.035.
• 10:19
  Speaker 1: So for any of you out there who have had a low AMH reading maybe you'll think of Amanda's story and feel some hope and inspiration for what's possible.
• 10:36
  Speaker 1: Now the next story hopefully you'll actually be hearing from her on the podcast within the next couple of months.
• 10:42
  Speaker 1: We've got her scheduled to record and this is Erica.
• 10:46
  Speaker 1: So when Erica came to me, I believe she was 43, almost 44.
• 10:50
  Speaker 1: And she had been trying for over a year.
• 10:56
  Speaker 1: At that point She'd actually also had recurrent pregnancy losses and her REI was, you know, pretty open-minded said hey, listen, like, if you want to try IUI or IVF, like I'm with you, I will support you every step of the way.
• 11:13
  Speaker 1: But given your age, given your AMH, I just I don't know what the likelihood is, know what the likelihood is.
• 11:29
  Speaker 1: Her AMH, she was being told, was almost undetectable, so measuring at the 0.003 mark.
• 11:32
  Speaker 1: When we first started working together and at the very first visit, she was pretty hung up on that particular number.
• 11:39
  Speaker 1: I'm just like, what do I do with that?
• 11:41
  Speaker 1: Like, am I crazy for even trying?
• 11:44
  Speaker 1: Like am I irresponsible for trying this old?
• 11:49
  Speaker 1: There were a lot of fears that she had, some of them valid and in her case, because there were elements that we could work on, like her nutrition and her antioxidant status.
• 12:05
  Speaker 1: That's where we had to put the focus on the physical, but we also put a strong emphasis on the mental, emotional, clearing the fears and giving her a pathway to connect her intuition and connect to the spirit of this baby that she was calling in and ultimately also connecting with the spirits of the babies who had come through her so that she could continue to learn from them.
• 12:32
  Speaker 1: So I know we went full woo today, you've got.
• 12:36
  Speaker 1: We were just talking about AMH.
• 12:38
  Speaker 1: But she really questioned whether that was possible and we had to have a few conversations at different points about how the AMH alone could not tell us if she could get pregnant or stay pregnant.
• 12:59
  Speaker 1: And she was thinking about pursuing IUI.
• 13:03
  Speaker 1: She thought, well, maybe if I just do, she'd done a couple rounds with Clomid.
• 13:09
  Speaker 1: She thought, maybe if I just do like another cycle with that, maybe that'll be it.
• 13:14
  Speaker 1: And as she connected more and more to her intuition, she's like, actually, like I don't know why.
• 13:22
  Speaker 1: It may sound crazy, it may sound delusional, but like I just feel like I can do this.
• 13:26
  Speaker 1: And when she was 45 she did conceive unassisted with an undetectable AMH and now has a very healthy one-year-old baby who was born when Erica was 46.
• 13:40
  Speaker 1: So again that AMH couldn't tell us whether she could get pregnant or stay pregnant and she'd had a history with recurrent pregnancy losses as well Both of the patients, in this case dead.
• 13:55
  Speaker 1: So we knew that there was something in their body that told them like all right, we can get pregnant.
• 14:00
  Speaker 1: What else do we need in order to stay pregnant?
• 14:03
  Speaker 1: What does this body need to feel safe?
• 14:05
  Speaker 1: What resources do we need to support the body in maintaining pregnancy?
• 14:08
  Speaker 1: Those were much larger questions in my mind than this AMH, and I've got some questions that I had pulled from Instagram stories because I figured the audience may have some questions as well, so I'm going to pull these up here.
• 14:40
  Speaker 1: Okay, this question is why does this happen?
• 14:43
  Speaker 1: Secondary infertility diagnosed with severely low AMH.
• 14:49
  Speaker 1: So the questions I would have in this scenario low AMH.
• 14:52
  Speaker 1: So the questions I would have in this scenario well, there's a lot of them.
• 15:02
  Speaker 1: We really need, again, a full workup.
• 15:03
  Speaker 1: We can't look at that AMH alone in a vacuum and really know or understand why someone isn't getting pregnant.
• 15:09
  Speaker 1: It's possible that that ovarian reserve was declining the entire time, but we got lucky with that first pregnancy and then, as time continues and through pregnancy, through delivery and postpartum, that the decline will continue and we can't use the AMH alone to tell us why that person hasn't gotten pregnant again yet.
• 15:37
  Speaker 1: Pregnancy itself is also such a high nutrient need time.
• 15:42
  Speaker 1: It's a very depleting time.
• 15:44
  Speaker 1: It can take a long time to replete those nutrients.
• 15:47
  Speaker 1: So that's likely where I would be putting some emphasis of understanding what might be going on in someone's body is have they had adequate repletion of nutrients postpartum?
• 16:00
  Speaker 1: To get a better understanding of that?
• 16:03
  Speaker 1: Okay, next question, trying for number two no period, six months.
• 16:11
  Speaker 1: Amh is lower than when I got pregnant.
• 16:13
  Speaker 1: Is it too late?
• 16:14
  Speaker 1: Oh, my heart is with this one because I know some of the background of this, of the first pregnancy when AMH was low even then.
• 16:26
  Speaker 1: But again conceived with low AMH, and what I would be concerned about, of course, is the no period in six months, and I would want a better understanding of what is the FSH.
• 16:38
  Speaker 1: Are there any antral follicles showing up on an ultrasound?
• 16:43
  Speaker 1: Is there any ovarian response happening?
• 16:46
  Speaker 1: And if someone has maybe tried to use ovulation induction, does that seem to get the ball rolling?
• 16:57
  Speaker 1: If someone ovulates, will they then get a period?
• 16:59
  Speaker 1: So again, maybe completely different situation from the other question about secondary infertility and severely low AMH, but with this one with not having a period in six months, we really need to understand what's happening between the communication between the brain and the ovaries, and are the ovaries responding to anything?
• 17:18
  Speaker 1: And if not, what does the body need to feel safe?
• 17:23
  Speaker 1: Is this truly a situation of premature ovarian failure or is this a situation where there's a lot of inflammation, there's an infection, there's nutrient deficiencies?
• 17:36
  Speaker 1: That can be addressed differently?
• 17:38
  Speaker 1: And you know, maybe the elephant in the room with a lot of situations of low AMH and unexplained infertility is the possibility of endometriosis.
• 17:49
  Speaker 1: And if there's a lot of inflammation locally, a lot of adhesions or scar tissue locally, then that can also suppress the ovarian function.
• 17:59
  Speaker 1: It's a totally different podcast episode, but that is something that I'm thinking about when someone has that low AMH.
• 18:13
  Speaker 1: The next question this is the last one that I'll have time for is what could be the chances of conceiving with an AMH of 0.19?
• 18:22
  Speaker 1: So again, amh alone really can't tell us the chances.
• 18:26
  Speaker 1: We do know that, just statistically, with age there's a decreased chance of pregnancy within each cycle.
• 18:36
  Speaker 1: So at about 30 years old your chances of getting pregnant with each cycle about 20%, and that does start to go down as you go up in the age brackets.
• 18:47
  Speaker 1: But we can't use that alone to tell us whether someone can get pregnant.
• 18:52
  Speaker 1: So what we really want is a better assessment of well, is someone ovulating?
• 18:56
  Speaker 1: Is there viable sperm, are there tubes open and are they actually having intercourse during the fertile window?
• 19:04
  Speaker 1: Are they able to identify the fertile window and time things so that pregnancy is possible, time things so that pregnancy is possible.
• 19:16
  Speaker 1: So those are the four factors that I'll try to consistently ask questions about is do we know that the tubes are opened?
• 19:21
  Speaker 1: We know that you are ovulating.
• 19:23
  Speaker 1: Do we know that the sperm looks good and are we definitely hitting it in that fertile window?
• 19:29
  Speaker 1: Not to be crass, but you know, just is what it is.
• 19:33
  Speaker 1: We ought to make sure things are happening during the window when someone is actually fertile, and that's only about five days out of the entire month.
• 19:42
  Speaker 1: So I would love to be able to answer these questions much more thoroughly.
• 19:49
  Speaker 1: And it really does require individualized assessment to understand what might be going on on a deeper level and how those numbers relate to AMH.
• 20:00
  Speaker 1: We can't look at that AMH alone.
• 20:02
  Speaker 1: So for all of you who have had the experience of being told they have low AMH and a low chance of conceiving on their own, just know that that number alone cannot tell you if you can get pregnant or stay pregnant and we need more information about your nutrient status, about inflammation, about stress levels, and we can't use that number alone.
• 20:26
  Speaker 1: And I have had dozens of patients with low AMH got pregnant, stay pregnant and have healthy babies.
• 20:32
  Speaker 1: Please don't hesitate to reach out to me with questions about AMH.
• 20:37
  Speaker 1: If you're ready for an individualized workup and you think okay, now is the time, reach out to my team at info at brilliantfertilitycom, or send me a message on Instagram.
• 20:50
  Speaker 1: You can DM me at Dr Katie Rose or send me a message on Instagram.
• 20:53
  Speaker 1: You can DM me at Dr Katie Rose.
• 20:54
  Speaker 1: I would love to have these conversations with you and help get you some better answers.