Sunday, April 27, 2014

AMH Is it all that?

New studies published in the Journal Nature in 2004 led by Jonathan Tilly at the Vincent Centre
of Reproductive Technology in Boston indicate that women may actually regenerate their eggs each month and we may in fact be born with the ability to produce newbie eggs on demand! This is contrary to what we are led to believe and are told when past 30.

As a woman on a quest for a baby I'm sure you are no stranger to that good old chestnut ' You are born with millions of eggs that are literally withering and dying every year past 25’ and my personal favourite ' Why did you leave it so long to try'. Which is always the first thing on a 25 year old womans mind with a mature man at her side and in a career that is paying the mortgage nicely! Sarcasm aside women are amazing and with all that is going on outside and inside the cave its a huge relief we make it through the day sometimes! If you need some inspiration on this watch Dr Libby Weaver on TED Australia

https://www.youtube.com/watch?v=tJ0SME6Z9rw  

Anyway back to AMH...
When you look inside an ovary you will only see follicles not an egg. They are far too small at the early stages and haven't grown sufficiently to predict overall fertility. It is only by following a woman's ability to produce an egg through careful consideration over a couple of months that will we know if she really is fertile or in fact heading to menopause. However this would be a costly affair involving multiple blood tests, scanning and invasive procedures and unless you are the owner of a clinic this is probably not the cheapest of routes!

In 2002-2004 a new tool in town to help assess fertility came about in the form of Anti- Mullerian Hormone (AMH). This was a simple test and it promised to hold the answers and indicate if our egg reserve was low or high.  Ovarian reserve its a term used to indicate the amount and number of oocytes ( eggs) and also their quality.

As I mentioned above, when women are born they have over a million primordial follicles, which are largely dormant until they are triggered into action by puberty. As a woman gets older these primordial follicles are then pulled into the growing follicle pool, to be used as part of the woman's cycle and given the right chemical markers over the month are grown to maturation.  

As she grows older, less of the primordial follicles are pulled into the growing follicle pool. AMH is the substance given off by the growing follicle pool and is thought to also predict the primordial follicle pool also.


According to the Journal of the Society for Reproduction and Fertility in the Netherlands: ‘…Direct measurement of egg from the primordial follicle pool is impossible.’ 
http://soft-infertility.ca/blog/anti-mullerian-hormone-ovarian-reserve/

When I looked into this further, I wasn't convinced about the science behind it!
According to another study I found low AMH is not an overall measurement of reproductive function. In this study in question overweight and obese women with PCOS and reproductive dysfunction were studied as part of a 20-week weight loss intervention. This resulted in improvements in reproductive function but no change in AMH levels.In this case when reproductive function improves AMH being tied to this should improve also, however this is not the case. 

I think AMH may be a good indicator together with detailed blood analysis that something isn't right hormonally, but should not be used as the only indication of whether a woman can conceive or not. I also feel we have a lot to learn when it comes to analysing AMH hormone which will unfold in years to come and maybe use it in a much less cruder fashion. Using it to predict egg reserve and quality can be tricky. As a measure of fertility it never seems to stack up in my clinic. This is especially when women are frightened into not going for fertility treatment by a low AMH level, only to find that when they began to relax, eat well and look after themselves their stress levels reduce and all their key fertility hormones, such as FSH reduced and they produced viable eggs that survive implantation.


Scientists are basically making assumptions based on the number of growing follicles that they can see on the ovaries based on a substance released by these follicles, AMH and using this to 'predict' primordial egg reserve isn't in my view the cleverest way to pinpoint fertility. This method really is like counting the chicks by looking at the chicken!

There are no long term studies to see if AMH levels are an indicator of overall egg count. I have researched through many journals and have not found any studies or peer reviewed studies that have looked at women and AMH levels in their 20's or 30's and then followed these women until menopause to determine who had children.  This would be a little difficult I hasten to add as the test only started to be used as another stick to beat  'Infertile' women in clinics from 2002.

Until we have proof that it really is a useful test then, in my view, it should be used with caution and along side a thorough hormone panel over a period of 4 months to look at patterns to diagnose fertility.

FSH  (Follicle Stimulating Hormone) is another test that clinics and surgeries use to indicate possibly infertility. A crude assessment is given again and high levels of this hormones are enough evidence in some consultations that a women is not producing eggs any more. However the human body and particularly female reproduction is incredibly complicated and the precarious waltz it dances in order to produce an egg, is more than the sum of one hormone! 

In regards to FSH; I have seen many clients with varying FSH levels and personally think if this is high in one month I need to consistently see a high level over a 4 month period to indicate that the ovaries have ‘shut up shop’ so to speak. As part of this assessment I look at all the key hormones and how they are also presenting.  I have supported women with FSH as high as 30, and I  have helped them to bring these levels down. I don't look at FSH in isolation I have also put programmes together that look at all fertility hormones in order to bring them into a more natural state. Many have gone on to become pregnant 'defying the odds' with both a high FSH and Low AMH level.