As a Fertility Nutritional Therapist, I encounter many women who have been told their AMH is low for age and sent into a spiral of despair about what this means for their fertility. AMH testing carries a heavy weight of confusion and concern. In the fertility and IVF world, this marker has been heralded as a key indicator of a woman's ovarian reserve. However, it's important to understand what this marker truly signifies and what it doesn't. Through this post, I’ll highlight the science behind AMH, clarifying its role and the common misconceptions that surround it. We'll discuss what low AMH levels mean and why it doesn’t paint a complete picture of a woman's fertility potential.
The journey to conception is much more about the quality of eggs rather than about their quantity. I’ll discuss why egg quality, rather than ovarian reserve alone, is a paramount factor in fertility. This distinction is essential, as it shifts the focus toward actionable steps that can be taken to support and potentially enhance egg quality through lifestyle and nutrition. Additionally, we'll explore the various factors that may contribute to low AMH levels, understanding that this is a complex interplay of genetics, environmental influences, and individual health status. My goal is to provide some clarity and hope for those women with low AMH levels navigating their fertility journey.
Understanding AMH
Anti-Müllerian Hormone (AMH) is a substance produced by the granulosa cells in ovarian follicles and has become a focal point of IVF clinics in the discussion of fertility and reproductive lifespan. AMH plays a critical biological role in the body, as it is involved in the regulation of follicle development and ovulation. AMH is often hailed as a key indicator of ovarian reserve—the pool of eggs present in the ovaries at any given time. It is often used by IVF clinics and fertility doctors to assess a woman’s remaining egg count and, therefore, her potential fertility. Unlike other fertility markers that fluctuate throughout the menstrual cycle, AMH levels remain relatively stable, making them a reliable measure of ovarian reserve. They are tested through a simple blood test and can be performed at any time during the menstrual cycle. The results of an AMH test can give insight into a woman's reproductive lifespan and her potential response to fertility treatments. For example, higher AMH levels generally suggest a greater pool of eggs and number of eggs collected in an IVF cycle, while lower levels may indicate a reduced reserve, where less eggs can be harvested, which can be a concern for those trying to conceive through the ART and IVF routes.
However, it's important to contextualise AMH levels properly. While they offer a snapshot of ovarian reserve, they do not necessarily predict a woman's current fertility status or her chance of conceiving naturally. Research highlights the importance of ensuring that AMH levels are not viewed in isolation but as part of a broader fertility assessment. We also know that AMH reflects quantity, not quality, of eggs. This key distinction is crucial as the quality of eggs is more determinant of fertility than quantity alone. What’s more, AMH should not be the sole predictor for the onset of menopause, given the complex interplay of factors that contribute to a woman's reproductive lifespan.
So, while AMH is a valuable tool in assessing ovarian reserve, it is not an all-encompassing measure of fertility. It should be interpreted with caution and in conjunction with other assessments. Understanding AMH within the bigger picture of reproductive health can empower women with a more accurate understanding of their fertility.
Debunking Some Common Myths
Anti-Müllerian Hormone (AMH) testing has become a popular tool for IVF clinics, in assessing women's ovarian reserve and suitability for IVF. However, there are a number of misconceptions around AMH, fertility and the success of fertility treatments. Here I'll debunk some of the common myths:
Does low AMH mean I cannot conceive naturally?
One common myth is that AMH levels can predict a woman’s ability to conceive naturally. Whilst AMH is a marker of ovarian reserve, which refers to the quantity of eggs remaining in the ovaries, it does not reflect the quality of those eggs or a woman’s overall fertility potential. Therefore, a low for age AMH status does not predict the likelihood of natural conception.
Can AMH predict my IVF success?
Another misconception is that AMH levels can predict the outcome of IVF. While it's true that AMH can give an indication of how the ovaries might respond to stimulation drugs in IVF, it is not a standalone predictor of IVF success. For example, women with higher AMH levels may not respond well to IVF either as it is simply not a marker of egg quality! It’s a combination of factors, including current health status, nutrition, genetics, age and specific ovarian response to stimulation, which are more accurate in predicting IVF outcomes.
Does my low AMH mean I need to start IVF right now?
IVF clinics will often scare women with lower AMH levels into starting IVF right away. However, waiting 3-6 months is unlikely to reduce your chance of IVF success. Since we know that low AMH does not determine egg quality, working on supporting the egg quality (alongside your partners sperm quality) will only be beneficial in relation to IVF outcomes.
Is low AMH the reason we cannot conceive?
Often, low AMH can become the central focus for a couple that are struggling to conceive. Yet, there could be other factors at play such as male factor (DNA fragmentation, poor semen parameters including low morphology), infections, vaginal dysbiosis, thyroid dysfunction and more. Working on optimising your health, nutrition and lifestyle for 3-6 months would allow the time to resolve and rule out other factors at play. Three months is the amount of time it takes to improve egg and semen quality (3 months accounts for egg maturation and spermatogenesis).
Does low AMH mean I am approaching menopause?
AMH is also sometimes wrongly assumed to be a predictor of the onset of menopause. Although lower levels of AMH are associated with a smaller ovarian reserve, which is expected as women age, the timing of menopause is influenced by a complex interplay of other factors and cannot be precisely determined by AMH alone.
Do AMH levels only ever decline?
AMH can fluctuate, albeit small fluctuations, but we have in some cases seen it increase over time. For example, lifestyle factors, such as diet and body mass index (BMI), can influence AMH levels. A higher BMI is associated with higher AMH levels, which could reflect a larger ovarian reserve.
Hopefully, this has helped your understanding of the limitations of AMH testing. While it is a useful marker for assessing ovarian reserve, it is not a definitive measure of a woman’s fertility. Age, ovarian function, and overall health play significant roles in fertility and the success of fertility treatments.
Egg Quality Over Quantity
While Anti-Müllerian Hormone (AMH) levels are an indicator of ovarian reserve, they do not provide information about egg quality, which is crucial for fertility. Egg quality refers to the ability of an egg to be fertilised and develop into a healthy embryo, and it is a critical factor in natural conception and assisted reproductive technologies (ART) such as IVF. As women age, the quality of our eggs tends to decrease due to a variety of factors including chromosomal abnormalities and mitochondrial dysfunction, even if our ovarian reserve, as indicated by AMH levels, remains adequate. This decline in egg quality (and sperm quality) is a major factor in the age-related decrease in fertility and the increased risk of miscarriage and genetic abnormalities.
The mitochondria are the powerhouses of each cell, and they play a key role in egg quality. They are responsible for producing the energy required for cell division and growth. Mitochondrial dysfunction can lead to poor egg quality by impairing this energy production, which is essential for the complex process of fertilisation and early embryo development. This is why whilst IVF can help to overcome some hurdles of subfertility, the success of these treatments is still influenced by the quality of the eggs. Techniques such as intracytoplasmic sperm injection (ICSI) and preimplantation genetic screening (PGS) can help select the best quality eggs and embryos, but they cannot improve the inherent quality of the eggs used in the treatments. So, while AMH and ovarian reserve are considerations in fertility treatments, the quality of eggs is a more decisive factor in successful conception, both naturally and through IVF. Mitochondrial health is a crucial aspect of egg quality, and supporting mitochondrial function can play a role in enhancing fertility. And this is where nutrition comes in, so keep reading for more on this!
Factors Contributing to Low AMH
There are several factors which can influence AMH levels from a health, medical and holistic viewpoint. Here, are the most common factors:
Age - this is the most well-known determinant of AMH levels. As we age, our ovarian reserve naturally declines, which is reflected in lower AMH levels. This biological process is inevitable; however, there are other contributory factors that can influence these levels.
Environmental factors – this includes exposure to toxins and endocrine-disrupting chemicals, which can impact ovarian function and AMH levels. Research shows us that certain environmental pollutants can adversely affect reproductive hormones, including AMH.
Genetics – our genes also play a role in ovarian aging and AMH levels. Some women may have a predisposition to a lower ovarian reserve, independent of external factors.
Diet and lifestyle – these have a significant impact on AMH levels and overall fertility. For instance, a low body mass index (BMI) and poor nutrient status are associated with lower AMH levels. Studies highlight the correlation between BMI and AMH, suggesting that extremely low body weight may be linked to reduced ovarian reserve. Nutritional deficiencies, particularly in fats which are essential for hormone production, can also influence AMH levels. Gut and vaginal dysbiosis have been recognised for their role in overall health, including reproductive health. The microbiome's influence on the body's hormonal balance, suggests that maintaining a healthy gut and vaginal microbiota is essential.
How can I support low AMH and egg quality?
To potentially improve AMH levels and support egg quality, focusing on a nutrient-rich diet that includes adequate healthy fats is crucial. Anti-inflammatory foods such as oily fish, nuts and seeds can support hormonal balance and reproductive health. Additionally, ensuring a diet high in antioxidants can help mitigate the effects of environmental toxins and support ovarian health. Gut support following gut and vaginal microbiome testing, alongside probiotics and prebiotics may also contribute to improved AMH levels by supporting gut and vaginal health, which in turn can help optimise hormonal balance and potentially improve fertility markers. A holistic approach to lifestyle, including stress reduction techniques and regular exercise, can further support this process.
What nutrients and foods support the mitochondria?
Mitochondrial health is key for optimal egg quality, given that mitochondria are the powerhouses of cells, including oocytes (egg cells).
Here are my top 5 nutrients/foods to support mitochondrial health and, consequently, egg quality:
Coenzyme Q10 (CoQ10)
CoQ10 is crucial for mitochondrial energy production. It is a component of the electron transport chain and is involved in ATP synthesis. Studies suggest that CoQ10 supplementation can improve ovarian response and mitochondrial function, which may positively influence egg quality. However, not all CoQ10 supplements are created equal so its best to use a form that’s readily absorbed by the body.
Spinach & Broccoli
These greens contain a substance known as alpha lipoic acid, which is a potent antioxidant that can help to protect mitochondria from oxidative damage and therefore decreased egg quality. Red meat, beetroot and potatoes also contain ALA.
Oily Fish
Oily fish is the richest source of omega-3 fatty acids, particularly EPA and DHA, which are known for their anti-inflammatory effects and have also been implicated in supporting mitochondrial function. Research links dietary omega-3 intake with improved mitochondrial function and reduced oxidative stress in oocytes. Omega 3 can also be found in chia, flaxseeds, hemp seeds and walnuts although this is in ALA form which then needs to be converted to EPA and DHA.
Purple Berries
Blueberries and grapes contain resveratrol which has been shown to activate a group of proteins that are important for mitochondrial function. They are also rich in anthocyanins and vitamin C, both powerful fertility antioxidants.
Magnesium
Magnesium is a cofactor for many enzymes, including those involved in energy (ATP) production within mitochondria. It helps maintain the structural integrity of mitochondria and regulates calcium transport, which is crucial for mitochondrial energy production. Food sources include leafy greens, nuts, and seeds.
Studies used:
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Liu, M., Yin, Y., Ye, X., Zeng, M., Zhao, Q., Keefe, D.L., and Liu, L., (2019). Resveratrol protects against age-associated infertility in mice. Human Reproduction, 28(3), pp. 707-717.
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van der Reest J, Nardini Cecchino G, Haigis MC, Kordowitzki P. (2021). Mitochondria: Their relevance during oocyte ageing. Ageing Res Rev. 70:101378