Combating the infertility monster : Low AMH or Poor ovarian reserve!

AMH is Anti-Mullerian Hormone, it is a glycoprotein hormone secreted by pre antral and small antral follicles of the ovary, which helps in their growth and differentiation. By the time of puberty a woman has about 100,000 oocytes. When she reaches around 40 years of age there are less than 10000 eggs remaining. By the time she reaches her menopause there are no eggs in her body.

AMH is used to test the egg reserve of a woman. It defines the potential of a woman to get pregnant. It can be tested on any day of the menstrual cycle. The normal AMH levels are between 1-3.5 ng/ml. AMH level above 2ng/ml is considered a good value, and level <1ng/ml is low. Levels less than 0.3ng/ml are considered very low. Women with Polycystic ovaries have AMH level > 3.5ng/ml. AMH level reduces with age, younger women usually have AMH > 3.5 ng/l and more than 40years have < 1 ng/ml.

Causes of Low AMH:- Age, Endometriosis, genetic factor, auto-immune diseases ,previous ovarian surgery and cancer treatment contribute to low AMH levels. Excessive smoking, environmental causes like pollution, obesity can also lead to low AMH levels. Women taking birth control pills and who have received lupride injections may show falsely low AMH levels.

Treatment of Low AMH:- Usually there is no specific treatment for low AMH, however with life lifestyle management, vitamins and supplements pregnancy outcome may be improved.

Lifestyle: The person must have proper nutritious diet, low in calories and high in protein. Diet should contain fresh fruits and vegetables. There should be adequate exercise atleast 40 min daily. Smoking and alcohol must be completely avoided.

Vitamin-D, Co-enzyme Q10, folic acid and fish oil supplementation has been associated with better outcomes in women with low AMH. DHEA (Dehydroepiandrosterone)and testosterone supplementation also is associated with better response.

The decision regarding which treatment modality is best for these women should be extensively discussed. All options like natural method, IUI( intra-uterine insemination), IVF (In-vitrofertilization), Donor eggs, Surrogacy or adoption must be discussed.

In most cases when a woman has low AMH and is desirous of pregnancy IVF option is best suited. The doctor evaluation will also include ultrasound of the ovaries to count her follicles and co-related with the AMH values.

The various protocols to stimulate the ovaries in women with low AMH are agonist, antagonist and duostim. We usually recommend multiple cycle stimulation and embryo pooling in many cases with low AMH.There are some experimental methods like intra ovarian Platelet rich plasma infusion, Stem cell treatment, Mitochondrial transfer, and Ovarian transplantation.

At Sunshine Fertility & IVF centre we have had many success stories with women with low AMH. One must know that having low AMH does not mean you cannot get pregnant or that you will neccasarily need donor eggs to have your child. Older women with AMH fare much worse than younger women. Antagonists and long protocol work equally well. Early cleavage transfer is better than blastocyst and routine PGT(Preimplantation genetic testing)  is not recommended for all patients.

We also recommend early testing of AMH in young women and consider Oocyte freezing for women who plan to marry late or postpone pregnancy.As soon as a women understands that she has poor ovarian reserve or AMH she must visit a fertility expert and seek quick treatment to attain the eternal bliss of motherhood through the magic of IVF technology.

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