Low AMH – Causes and Treatment
AMH is Anti-Mullerian Hormone, it is a glycoprotein hormones secreted by pre antral follicles 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 other tests of ovarian reserve like FSH has to be done on a specific day of the period i.e., Day 1 or day 2 of the menstrual cycle.
The normal AMH levels are between 1-3.5 ng/ml. Any 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. AMH can also be expressed as picomol/ml, where the values are multiplied by a factor of 7.
Causes of Low AMH:-Age, endometriosis, genetic factor, auto-immune diseases 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 lupron 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. Relaxation techniques like yoga and pranayam must be followed. 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 natural method, IUI( intra-uterine insemination), IVF (In-vitrofertilization), Donor eggs, Surrogacy and 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-relayed with the AMH values. A realistic chance of the pregnancy is discussed. In older women it is usually not more than 5-10%. In younger women it can be 30%. All these discussions are important to avoid unnecessary anger and disappointment later.
The various protocol to stimulate the ovaries in women with low AMH are agonist, antagonist and duostim. Duostim is still experimental. We usually recommend multiple cycle stimulation and embryo pooling in many cases with low AMH.
It is very important to know the fertility pyramid. This means that the total no. of the embryos is not the same as total no. of follicles.
We must no ignore the male partner. He also needs to have a good diet and exercise regularly. He must stop smoking and alcohol. Zinc and L-carnitine supplementation may be useful.
There are some experimental ways to treat women with low AMH. They are intra ovarian platelet rich plasma infusion, stem cell treatment, mitochondrial transfer, and ovarian transplantation. These cannot be routinely tried on the patients as they are still experimental.
At Advanced Fertility and Gyne Centre we have had reasonable success with women with low AMH. One must know that having low AMH does not mean you cannot get pregnant. Older women with AMH fare much worse than younger women. Multiple cycles of stimulation may lead to better egg nos in subsequent cycles. Antagonists and long protocol work equally well. Embryo pooling is helpful. Early cleavage transfer is better than blastocyst and routine PGS is not recommended.
Finally it is important to know when to stop treatment or go ahead with other options like egg donation or adoption.