AMH level – can it be improved?
AMH (Anti-Mullerian Hormone) is a substance which is produced by the granulosa cells in ovarian follicles. Granulosa cells surround each egg on a woman’s ovary and perform many vital functions, including supplying the developing oocyte with nutrients as well as the production of some hormones. More eggs equal more granulosa cells, and more granulosa cells mean more AMH.
As women age and their pool of ovarian follicles begin to decrease, their AMH levels naturally begin to fall. High AMH levels can also be a sign of decreased fertility, however. Women with Polycystic Ovary Syndrome (PCOS) often exhibit elevated levels of AMH due to an increase in their number of antral follicles. Bearing in mind that AMH levels naturally decline as a woman matures, a level of 30 pmol/l may be totally normal in a 25 year old, but it could be a sign of PCOS in a 45 year old. Therefore for optimal fertility you do not wish your AMH level to be either too high or too low. Like Goldilocks, it’s best when it’s just right.
An individual’s AMH level may be confirmed by a simple blood test, and in the last couple of years this test has been gaining increasing popularity among clinics as a credible measure of ovarian function. AMH levels do not change during the menstrual cycle and are not affected by the contraceptive pill, so a woman can be tested at any time in her cycle, unlike the common “Day 3” tests.
AMH levels and Womens' ages
Image source: Fertility Associates Different laboratories may report AMH results in either pmol/l or ng/ml. Table above uses pmol/l 0.14 pmol/l = 1 ng/ml | 7.14 pmol/l = 1 ng/ml.
I was originally tested for my AMH level just before we began our first round of IVF, in September 2015. I was just after having my sixth miscarriage, and we were hoping that by going through IVF with Pre-Implantation Genetic Screening (PGS) to test all our embryos for chromosomal disorders, we would have a much better chance of a successful pregnancy. Our IVF clinic in our hometown wanted to know what my AHM level was, as it would help them decide what stimulation drugs to prescribe for me, and in what dosages. Women with low AMH generally need their ovaries stimulated much more than women with high AMH. For women with very high AMH, as well as being a possible sign of polycystic ovary syndrome, it can also be an indication that they may be at extra risk for Ovarian Hyperstimulation Syndrome (OHSS), a thankfully rare, but potentially fatal complication associated with IVF.
Up to this point, all the blood tests I had had over the preceding two years had come back either negative, or within normal ranges. I had no reason to expect that this one would be any different. I was healthy, a pescetarian since I was 15, active, and I was obviously fertile – I kept getting pregnant, right? Also, people often thought I looked younger than my partner (who is seven years younger than me). My body did not feel 40. Whatever that was supposed to feel like.
So when I got the result back it was a shock.
My AMH level was only 2.6 pmol/l (0.36 ng/ml).
First AMH result. Sample taken 21st September 2015
I checked my result against a number of scales I could find online. I was just scraping above the limit for the “Very Low / Undetectable” range.
Ovarian Fertility Potential pmol/L:
- Optimal Fertility 28.6 – 48.5
- Satisfactory Fertility 15.7 – 28.6
- Low Fertility 2.2 – 15.7
- Very Low / undetectable 0.0 – 2.2
- High Level > 48.5
Ovarian Fertility Potential ng/mL:
- Optimal Fertility 4.0 – 6.8
- Satisfactory Fertility 2.2 – 4.0
- Low Fertility 0.3 – 2.2
- Very Low / undetectable 0.0 – 0.3
- High Level > 6.8
I was stunned by this result. The IVF was soon to fail too (we did not know it yet) as we would create only aneuploid embryos so we would not even get as far as a transfer. Further defeat.
Statistically, it was approximately a 95% certainty that the our embryo chromosome problems were the result of faults with my eggs (as opposed to faults with David’s sperm). It was a crushing realisation but at least it gave me a focus. Was there any way I improve my egg quality?
AMH is not thought to be an indicator of egg quality, and more useful as a tool to measure the quantity of eggs left. However it stood to reason that if my number of eggs was waning due to age, egg quality (also linked to ageing) must be similarly in decline. We already knew from karyotype testing that bad egg quality was a factor in at least two of our miscarriages. Could it have been the reason behind them all?
Optimal AMH levels are correlated with optimal egg retrieval numbers, which in turn are correlated with higher IVF success rates. Women with the best AMH levels are also much more likely to conceive naturally, and most importantly of all of course, carry a healthy baby to term. As a predictor of fertility and ovarian health, my AMH level could be a useful instrument. Importantly, it was also something I could measure.
Maybe if I could get my AMH to improve, our chances for a happy ending would improve too.
However, almost everything I read told me that egg quality could not be improved upon. It was irrevocably linked to age, and eggs that were now depleted in some way could not be rehabilitated. Women were born with all the eggs they would ever have (this has long been the accepted wisdom, although this too is now being questioned by some researchers). Over time these eggs would simply begin to deteriorate. I was just too late.
But I did find a few articles and books which suggested that women could positively influence their ovarian health and improve their egg quality and quantity.
One book in particular stood out. It was written by a molecular biologist called Rebecca Fett who, while still in her twenties, was diagnosed with Diminished Ovarian Reserve (DOR). She decided to use her knowledge of molecular biology and biochemistry and her understanding of the mechanisms of DNA damage and repair, and delved into the latest research and scientific papers available. She made some small lifestyle changes, stopped using certain product ingredients, and introduced some supplements into her everyday regime. She went on to have a very successful first IFV cycle (22 eggs recovered, 19 fertilised and all of which made it to blastocyct (day 5) stage. A phenomenal result for any IVF cycle, but particularly so for a woman previously diagnosed with DOR.
As she explains herself:
Ms. Fett’s book is called It Starts with the Egg: How the Science of Egg Quality Can Help You Get Pregnant Naturally, Prevent Miscarriage, and Improve Your Odds in IVF (2014, Franklin Fox Publishing LLC). I would recommend it to any woman even thinking of getting pregnant, or indeed anyone (man or woman) curious about the effect that many everyday products and their ingredients may be having on our reproductive health. The book is clear, informative, objective, based on scientific research, and also very well-written. No mention of baby dust (which after months of researching online was a very welcome relief). I throw all my stars at it.
I read it, then re-read it. Not all the advice in the book applied to me. There were different recommendations for women trying to get pregnant naturally, or trying to get pregnant via IVF, or indeed women with PCOS. But most of the advice was directly relevant, and vitally, backed up by accredited scientific studies and research data.
Based on what I read, these are the changes I decided to make to my daily routine:
- I stopped using any products containing bisphenol A (BPA). This is an industrial chemical used to make certain plastics and resins, and found in a wealth of everyday objects including food packaging, paper receipts, water bottles, and babys’ bottles. It has already been banned for use in many european countries in the food industry, and in baby products and toys.
In practice, this meant throwing out all my plastic kitchenware and storage containers (replacing them with glass and wood), washing my hands after the handling of any receipts (avoiding them completely if possible), avoiding food packed in plastic where possible, and never microwaving anything in plastic.
- France now “prohibits the use of BPA in all packaging, containers and utensils intended to come into direct contact with food”, as reported by the Food Packaging Forum in 2015.
- A recent article published online by the Illinois News Bureau (2015) is also well worth reading: BPA exposure in pregnant mice affects fertility in three generations.
- I stopped using any products containing Phthalates. Phthalates (pron. tha-lates) are used as binding agents and preservatives. They are now banned across the EU in all toys and childcare articles, and in cosmetics and are officially recognised as a reproductive toxin in the European Union. They are commonly found in soft plastics and vinyl, household cleaning products, fragrances & perfumes, hairspray and nail polishes. For me this meant giving up perfume (which I loved!), hairspray and nail varnish. I replaced all shampoos, conditioners, body lotions, handcream, sunscreens (basically anything I put on my skin or in my hair) with ones labeled “phthalate-free”. My local healthfood shop was helpful here, and I particularly came to like products made JĀSÖN and Dr. Organic. I stopped using my regular household detergents and instead switched to Ecover for cleaning products, and even used lemon juice for mild cleaning jobs, like dissolving hard water marks on bathroom screens.
- For more information read The Guardian article, published February 2015 entitled Phthalates are everywhere, and the health risks are worrying. How bad are they really?
- I stopped using any products containing Parabens. These are a range of preservatives also widely used in the cosmetics and personal hygiene industry as anti-bacterial and fungicide agents. Again, my local healthfood shop was helpful here, and the two brands already mentioned above as being free from phthalates are also paraben-free.
- As well as being linked to fertility issues, parabens have now also been linked to certain forms of breast cancer. An article published on Web MD (October 2015) goes into detail.
- I raised my Vitamin D levels, originally by taking a good-quality supplement. Make sure to source Vitamin D3 (cholecalciferol) instead of vitamin D2 (ergocalciferol). When I moved to sunnier climate I exchanged the supplements for one hour daily sun exposure instead.
- I started taking a supplement called Coenzyme Q10 daily. When I discovered that there was a more natural, activated form of it also available called Ubiquinol, I switched to that instead.
- I started taking Alpha-Lipoic Acid (a water and fat soluble anti-oxidant).
- I began taking N-Acetyl Cysteine (an anti-oxidant linked in a number of studies to improved ovulation rates).
- I began taking DHEA (Dehydroepiandrosterone). This supplement had been shown to improve egg numbers in women with DOR, and increase live birth rates in women with multiple miscarriages, apparently by reducing chromosomal abnormalities.
- I reduced my Carbohydrate intake, especially refined carbs (white bread, rice, pasta, sugar). I only ate unrefined carbs (brown pasta, brown rice, wholemeal bread) and increased my protein intake. I tried to have protein with every meal and every snack (for example, if I ate a piece of fruit, I would also eat a piece of cheese or some nuts). The aim was to stabilise my blood sugar and prevent large insulin swings. It also had the added advantage of cutting down on the sugar cravings I had happily indulged in for years.
- I also made an effort to eat more healthily in general. We bought a blender and each morning David would make us both a veg & fruit blend which we would drink. It was easy and fast – chop up a carrot, apple, passion-fruit, some strawberries, spinach, whatever happened to be on hand (and organic where possible), and throw it all in the blender for a minute. Added some fresh ginger for an extra zing. I also added a spoonful of wheatgrass to mine (he hates the stuff) but I felt it was a good way to get extra nutrients in a wholesome way. I also upped my intake of nuts, seeds and (organic, free-range) eggs. If these were Mother Nature’s chosen germination media, who was I to argue?
- I tried to lower my stress levels.
Another change I made was that I threw away by folic acid supplements and replaced them with Folate (l-methylfolate).
L-methylfolate is a bio-active form of Vitamin B9 (unlike folic acid, which is the synthesised version).
Due to a history of spina bifida in my family (I had a sister and an aunt both affected) I had been prescribed a very high dose of folic acid by my GP from my very first pregnancy, 5mg per day. During my research subsequently however, I had come across a number of articles linking nural tube defects to an individuals inability to absorb folic acid adequately. This inability could be due to a simple and common mutation on gene, commonly known as MTHFR. Genetics Home Reference of the US National Library of Medicine offered the following:
“The MTHFR gene provides instructions for making an enzyme called methylenetetrahydrofolate reductase. This enzyme plays a role in processing amino acids, the building blocks of proteins. Methylenetetrahydrofolate reductase is important for a chemical reaction involving forms of the vitamin folate (also called vitamin B9). Specifically, this enzyme converts a molecule called 5,10-methylenetetrahydrofolate to a molecule called 5-methyltetrahydrofolate. This reaction is required for the multistep process that converts the amino acid homocysteine to another amino acid, methionine. The body uses methionine to make proteins and other important compounds.”
No-one had mentioned the possibility of a MTHFR mutation to me, neither GPs or fertility specialists I had spoken to. Given my family history of spina bifida I had to look into this further so I went to my local maternity hospital and requested a test. It was a simple blood test. And it came back heterozygously positive for the genetic mutation, MTHFR C665T (previously known as C677T). It proved that I was not able to adequately process folic acid, and additionally it was likely that I was also at risk for elevated homocysteine levels – another factor associated with neural tube defects… and recurrent pregnancy loss. MTHFR mutations are hereditary. Was this the reason my mother and grandmother both lost children to neural tube defects? Was this a contributing factor to all my pregnancy losses?
I cried when I got the result. All I could think about was my sister dying at three months old from complications due to spina bifida, and what my parents had suffered. And I thought about my grandmother losing her daughter at 6 years old, and who (as I read her death certificate only a couple of years previously) also died from complications due to spina bifida.
Mothers losing daughters – there were three generations of us now.
By early 2016 we decided to try IVF again, this time use an Egg Donor. We decided we couldn’t put ourselves through the agony of another likely miscarriage. My periods had been erratic and unpredictable since my own IVF cycle the previous year, we were still raw from all the failures, and our relationship was suffering. We desperately needed hope.
We picked a new clinic, this time in the Czech Republic. At their request we had to get some of our previous blood tests repeated. I would not be going through the ovarian stimulation and egg-collection this time, so I did not need my AMH levels re-checked. But I asked for the test anyway. I was curious whether my level would have changed at all in the 7 1/2 months since I had the first test, and since I had made all the lifestyle, dietary and supplementary changes.
In theory, as I was now older, my AMH level should have dropped even further.
But my new AMH level came back at 9 pmol/l (1.26 ng/ml). A 345% increase in less than 8 months.
Second AMH result. Sample taken 6th May 2016
I was still in a “Low Fertility” category but my AMH level was definitely moving in the right direction.
That wasn’t supposed to be possible.
Something I was doing was working.
Here are some links and articles related to this post:
- AMH and your fertility? Siobhán Boucher.
- Aneuploidy. Wikipedia.
- BPA exposure in pregnant mice affects fertility in three generations. Illinios News Bureau.
- Diminished Ovarian Reserve. What is DOR?, The Centre for Human Reproduction.
- Dirty Dozen Endocrine Disrupters – 12 Hormone-Altering Chemicals and How to Avoid Them. Environmental Working Group.
- Embryo Transfer. Wikipedia.
- FAQ: Parabens and Breast Cancer. WebMD, LLC.
- France bans BPA. Food Packaging Forum.
- Varga, E.A; Sturm, A.C; Misita, C.P; and Moll, S. (2005). Homocysteine and MTHFR Mutations. Circulation. May 17, 2005; Vol. 111, Issue 19, e289-e293.
- Hormonal Fertility Tests. Reproductive Care Center.
- Is Vitamin D the same as Vitamin D3? Drugs.com.
- JĀSÖN Natural.
- MTHFR methylenetetrahydrofolate reductase. Genetics Home Reference, US National Library of Medicine.
- Ovarian Hyperstimulation Syndrome. Wikipedia.
- Paraben. Wikipedia.
- Phthalate. Wikipedia.
- Phthalates are everywhere, and the health risks are worrying. How bad are they really? The Guardian.
- Pescetarianism. Wikipedia.
- Polycystic Ovary Syndrome (PCOS). Mayo Foundation for Medical Education and Research.
- It Starts with the Egg: How the Science of Egg Quality Can Help You Get Pregnant Naturally, Prevent Miscarriage, and Improve Your Odds in IVF. (2014) Franklin Fox Publishing LLC.
- What daily exposure levels to phthalates are considered safe? European Commission on Public Health.
- What is the difference between homozygous and heterozygous? MakGene.com.
- What is BPA, and what are the concerns about BPA?. Mayo Foundation for Medical Education and Research.