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Prakash Chandran (Host):  There’s a specific hormone with a long name that can tell us much about a woman’s fertility, menopause and even certain conditions. It’s called the Anti-Mullerian hormone or AMH for short and today, we’re going to talk about it with Dr. Deborah Wachs, a reproductive endocrinologist at the Reproductive Science Center of the San Francisco Bay Area.

This is Fertile Edge, the podcast by the Reproductive Science Center of San Francisco Bay Area. I’m Prakash Chandran. So, Dr. Wachs, this is the first time I’m hearing all about this. so, why don’t you tell us what exactly is the Anti-Mullerian hormone?

Deborah Wachs, MD, REI (Guest):  First, goof job in pronouncing it perfectly and secondly, we can call it AMH going forward. That way it will be easier for everybody. So, AMH is a hormone that we can draw at any point in a woman’s cycle and it tells us more about the overall pool of eggs that a woman has remaining. One thing we know that’s different between men and women is that woman are born with all of their eggs whereas men continue to make new sperm throughout their lives.

So, we have this hormone that we can measure, and it gives us a little bit more information about where a woman is in her overall pool of eggs. The AMH is produced by cells that surround eggs so when a woman has lots and lots of eggs, she’ll have a very high AMH level. And as the pool of eggs gets smaller; that AMH level goes lower. So, if it measure it in a postmenopausal woman; it’s going to come back undetectable and if I measure it in a young teen or a woman in her early 20s; I’m going to have a nice high normal result.

So, when we have an AMH level drawn in our patients who are usually in their 30s and 40s; it give us more information about where they are in their overall pool of eggs.

Host:  Okay and before I get into the AMH levels, that I’m interested in; I want to learn a little bit more about when exactly an AMH test might be ordered. For example if a woman comes in and they are trying to get pregnant, is that when they would get this done?

Dr. Wachs:  Yes. It can be done in that scenario and it can also be done to help a woman do a little future planning. So, sometimes, we have patients who aren’t ready to have children yet and they might be thinking of freezing their eggs or they just want to get an overall snapshot of where they are. So, an AMH is a great way for a woman to have either confidence to know that she’s got a nice high AMH and she’s got a large pool of eggs remaining or is that level borderline or low and therefore does she need to make some different decisions than she might have realized.

Host:  Okay, so you mentioned that if a woman has a high level of AMH, that there are a lot of eggs around, but what if she has a low level of AMH. Does that mean that she has a lower chance of getting pregnant?

Dr. Wachs:  Good question and one that most of our patients come in the door asking especially if their OB-GYN has ordered the AMH and they come in having that result already. So, while a low AMH does mean that there’s a smaller pool of eggs remaining; it does not necessarily correlate with a woman’s chances for getting pregnant. But what it does correlate with is what fertility treatment we may be recommending or what is her overall trajectory. If she has a low AMH and she thought, she was going to have four kids; this is really important information for her to have.

So, each month, a woman has a group of eggs that all start off charging together when she gets her period. And in a month where a woman does not take any fertility medication; she will ovulate one of those eggs and the rest of the eggs will die. And that happens every month for a woman as she marches through her reproductive years. So, when the AMH level is low; it tells us that pool of eggs is smaller. It doesn’t say those are bad eggs. It doesn’t say that those can’t be fertile eggs. It just means that pool of eggs that was likely larger at one point is now getting smaller. So, when a woman is young and she has a low AMH; she likely still has very good fertility because in a young woman, most of her eggs are still good quality. So, even if the pool of eggs is small, she has a higher chance that within that smaller pool, she’s still going to have good eggs.

But when a woman is older and her AMH is lower; that can be more significant because if the pool of eggs is smaller and the likelihood of having normal eggs within that smaller pool gets lower, it can be harder on a monthly basis for there to be a good fertile egg that can get fertilized.

Host:  Okay, I’m really glad that you made that clarification. So, what I’m hearing is that there isn’t a necessary correlation between AMH levels and fertility. Is that correct?

Dr. Wachs:  Correct. It can be correlated with fertility treatment, but I have patients all the time who walk in the door with a low AMH and get pregnant very quickly and easily.

Host:  Okay so speaking of treatment, how exactly would a doctor use the AMH result to guide a woman’s treatment?

Dr. Wachs:  Okay so one way is what I was referring to before. So if a patient comes in and she has a AMH result and I say to her, in your perfect world, how many kids did you think you want to have. If she says oh, one or two kids and her AMH is in a pretty good range; then we don’t have to necessarily shift from where our conversation might have been going. But if she says I’ve always thought of having a big family, ideally, I want three to four kids; then that AMH result being low will likely be a big driver of fertility treatment. And one of the main reasons is there’s one treatment that’s available that can actually preserve a woman’s fertility as her years go forward and that is IVF where we can have additional embryos frozen for future use.

So, if I have a patient who is 35, whose AMH is borderline and she really thought she wanted three kids; IVF would become a higher treatment for me to recommend because we are going to transfer an embryo now, but we will very likely have extra embryos frozen. So, let’s say she comes back when she’s 37 and wants a second baby, now she still has embryos frozen from when she was 35. So she keeps that pregnancy rate from 35 rather than 37.

And then what if she comes back two years later and now, she’s 39; same thing. If we still have embryos frozen from when she was 35, even at 39 she has that excellent pregnancy rate from 35. So, one of the main ways that it’s used, is it helps us decide how aggressive with fertility treatment do we need to be. Can we start off slowly or might we go to something like IVF sooner? Not because we need the aggressive treatment but because it can preserve her future chances of having kids down the road.

Host:  Okay and just based on my layman understanding from what you’re saying, it feels like the AMH levels would just decrease over time. So maybe talk a little bit about how that changes for a woman.

Dr. Wachs:  You are right. It does decline. We know that as a woman ages, she doesn’t get a higher AMH but the rate at which an AMH declines can be very individualizes. So, I may have a patient whose AMH is borderline when she’s 36 or 37 but when I check it again when she’s 39 or 40, it may not have declined tremendously versus another woman whose level was completely normal when she was 36 and then she came back at 38 or 39 and it has taken a big decline.

So, because we know fertility doesn’t get better with age, we certainly know that from an ovarian standpoint, our fertility declines with age. We can use an AMH level at any timepoint to make decisions going with the assumption that as time marches on, that AMH level will decline. And from an IVF standpoint; which is one of the main ways that we use AMH; we know that as that pool gets smaller with age; the chance that an IVF cycle will be successful can become lower because if the pool of eggs is smaller then we know that even IVF which can collect several eggs, not just have a woman ovulating one egg, but if the pool of eggs is smaller, and the quality of those eggs is lower; then even a treatment like IVF in a woman who is over 40 can have lower success rates.

Host:  Earlier in the conversation, we talked about when you could get your AMH levels measured but is there an ideal time that a woman should do it? Like I imagine for example if a woman wants to start a family for the first time, she’s thinking about trying in a couple of months; is that the right time to get the levels measured?

Dr. Wachs:  Yes, that would be a great time. I would have an AMH level drawn early on in your process of starting a family, especially if you are in your 30s and then as we discussed earlier; if you’re not ready to have a family, and you are in your 20s or even your early 30s and you are wanting to know should you start thinking of something like freezing your eggs or freezing embryos; an AMH can be drawn at that point too to really give you some good guidance on what’s going to put you in the best position for having the family that you want when you are ready to have it.

Host:  All right Dr. Wachs, I really appreciate your time today. That’s Dr. Deborah Wachs, a Reproductive Endocrinologist at the Reproductive Science Center of the San Francisco Bay Area. Thanks for checking out this episode of Fertile Edge. For more information please visit www.rscbayarea.com. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks, and we’ll see you next time.