What if your AMH is wrong?

In 2014, I started something called the Egg Freezing Party. I traveled not only all over the San Francisco Bay Area, but all over the country to build awareness about egg freezing and educate attendees about how to get their levels checked and make the best decisions for their own fertility.

At my first party, I said to all the women there that they need to get their levels checked and talk to their OBGYNs about it. They all told me, “I go to my OBGYN and they’d say you have to be trying for one year before you can get your levels checked.” 

That was incredibly frustrating and disheartening for me to hear. That’s why I started EggWhisperer.com, a website where you can get your levels checked, talk to me, and we’ll look at everything, (including your TUSHY, which we cover in more detail in this episode!)

One of the biggest realizations I’ve had in doing these Egg Freezing Parties is that sometimes people put too much stock into their AMH levels. And because this is a test that can be repeated, you might get it checked and see differing results and wonder “how do I know which one is accurate?” And the real question is: what do you do if your AMH is wrong?

I think this is a really important show for anyone who is tracking their levels over time. I’m going to help you understand what the AMH level means for you and what you can do to make it the best it can be for your unique body. Let’s dive in!

Dr. Aimee:  The title of tonight’s show is “What If Your AMH Is Wrong?”

First of all, what is AMH? It’s a hormone secreted by cells that surround the eggs. We can’t give a woman a cup and say, “Go watch some movie and put your eggs in that cup,” the same way we can tell a man when we’re looking at his sperm count. Basically, this is similar, kinda sorta. It’s the best we have. It is a gauge for how many eggs a woman has left.

What does it stand for? We know it stands for anti-müllerian hormone, but I jokingly say it also stands for “always meandering hormone” and, depending on your age when you get it checked, “always mean hormone.”

When I look at levels, I consider them diagnostic tools. They’re not something that we can treat. We just use them to give us an idea about what’s going on. But it’s normal to a level that’s low when you’re over 40. It’s also normal to have a level that’s really high when you’re young.

Oftentimes, when people get levels that are either high or low, they sometimes internalize those levels, it’s almost like those levels are tattooed on their forehead and now those levels define them. The thing is your AMH level does not define you. It does not define your fertility. You’ll often hear me say that “low does not mean no.” Also, on the other side of things, high does not mean yes.

What does it tell you? We know that AMH can tell you when you’re going to go into menopause. It can tell you, in a way, how many eggs you have left. That’s what studies tell us, we know that. I’ve published some of those studies related to AMH and the prediction of your age at menopause.

Can it tell us if you’re fertile or not? What does it not tell you? It actually doesn’t tell you if you have good eggs. It doesn’t tell you if you’re fertile. Remember, low does not mean no, and high does not mean yes. When I say yes, I mean if you’re going to have an easy time for pregnancy or an easy time to get pregnant.

What I don’t want women to do is get their levels checked, let’s say at 30, and say my level is great, I don’t have to worry about a thing, and everything is going to be fine. What if your level is wrong?

One snapshot at one point of time in your life may not tell the whole story. There’s a lot more to your fertility than just the AMH test. You heard me earlier in the show, the TUSHY method. How do you check it? It’s actually quite easy to check. It’s one tube of blood, it’s a blood test. You can pretty much check it anytime in the menstrual cycle. However, it may vary during the menstrual cycle in some people.

I don’t just look at the AMH. If I can, I look at FSH and estradiol levels on cycle day three with your AMH level. A lot of young women who are getting this level checked may be on birth control pills, and we know that birth control pills can suppress your AMH level. If you’re taking birth control pills, let’s say for a year or for months, and you get your AMH level checked, you might get a level that might be low and cause you unnecessary concern.

What I do sometimes is have a woman stop her birth control pills for two months and then get her level checked, or I just have her check it in the placebo week on the seventh day, right before she starts a new pack. If it’s, let’s say, a normal level – again, I use the word “normal” cautiously because the level that you get is just normal for you and I don’t want you to think there is anything wrong with you if your level is considered low, because low does not mean no. I should come up with some sort of song or jingle, or something like that, or a bumper sticker because I’m really good at coming up with those.

What makes the AMH higher? It’s higher in young women, but again, it is not unusual for a woman to have a level that’s over 3 if you’re 20 years old. You Google, you go online, and you see that over 3 means you have PCOS. The answer is it doesn’t mean that. Just because you have a high level doesn’t mean there is anything wrong with you. It just means that you’re a young woman who has a lot of eggs. Alternatively, it can also be low if you have a low number of eggs.

It’s higher if you have a lot of follicles. What kind of conditions give us a lot of follicles? Just like I said, polycystic ovary syndrome or even hypothalamic amenorrhea. Women with both of these hormonal imbalances can potentially have high AMH levels. If you have a high AMH level, don’t freak out, don’t think that there is something wrong with you. If you have symptoms of PCOS or symptoms of hypothalamic amenorrhea, there might be some really good reasons to get a full thorough workup.

For me, I consider PCOS a lifelong condition. Again, who wants to be told they have a condition? But it’s something that you don’t just take seriously around the time when you want to get pregnant. Because it’s a hormonal imbalance, I really believe in close monitoring and management of PCOS so that the symptoms don’t get out of control because by the time you’re ready to have a baby, it might take you a while to get the symptoms under control. For example, the high testosterone and the low Vitamin D. Those are the kinds of things that I like to fix first before my patients get pregnant, so they can have the healthiest pregnancy ever.

What makes the AMH lower? Again, what if your AMH is wrong? I don’t want you to think that somehow you’ve done something to cause it to be wrong. It could be from medications. Some women take Depot Lupron, for example, if they have a condition called endometriosis. That can make your AMH lower. Same with birth control pills and low Vitamin D. Also, as you get older, your AMH goes down. Remember, it’s like an egg count test or a sperm count test. You can’t give a guy a blood test to see how many sperm cells he has, and I can’t reliably do that for a woman to see how many eggs she has left. This AMH test is the best thing we have.

What can make it wrong? I’ll tell you some stories.

I’ve had patients, for example, who had a level that was 0.2, and then five years later their level is 2.5, and they say, “Dr. Aimee, I knew it, I knew all that acupuncture I did, all the supplements I’ve been taking, and all the herbs I’ve been taking were going to help me grow more eggs.” At the end of the day, we just don’t grow more eggs.

The best predictor of your fertility is three letters, A-G-E, age. It’s not your AMH level. Of course, your AMH is part of it, but your age is the most important thing, especially for women over 40. It’s our age that matters. If, let’s say, you’re over 40, you had a level two years ago that was 0.2 and you had another level that was 2.5, chances are there was some sort of handling or lab error. If you see a level that seems a little bit off, I tell people to get it rechecked. See someone, and get an ultrasound. I’ll tell you about how you would know if it was wrong in just a second.

Birth control pills can suppress it, low Vitamin D, you’ve heard me say that a few times. It’s just so important to know that even if it’s low on birth control pills, if you stop the pills, that level should go right up. Same with the low Vitamin D.

How often should you get it checked? The answer is it really depends on your goals. I think everyone should have it checked by the time they’re 25. If, let’s say, you have a family member who has gone through early menopause, maybe even earlier, 20, 21. We’re advising women to have their first pap smear at 21 years of age. Why not get your AMH done at the same time?

For women who are taking birth control pills continuously, or even cyclically, I think it’s a really important thing to get your AMH level checked at least once a year. Believe it or not, a lot of people think that when they’re having regular menstrual cycles on the birth control pills, they actually think that it has to do with their fertility, but those regular periods are just hormonally induced and the birth control pills could be tricking you or masking infertility or egg related issues. The last thing I would want is for someone to start the pill at 16, stop it at 32, find out that they ran out of eggs, and regret not doing an AMH test. Maybe they would have started their family sooner or done an egg freezing cycle.

Not just women on birth control pills should be checking their AMH level, but also people who have an IUD. You get the IUD in and you forget about it. Then, five years later you go and have it changed out for a new one. It might not be a bad idea to also get your AMH level checked. Depending on the type of IUD, whether it’s a copper or a progesterone secreting IUD, you may or may not be having periods, so it’s not as reliable as a sign, meaning your periods, as far as what is going on with your hormones coming from your ovaries.

Get your level checked, you’ll find out what’s going on, and you can take that information and make an actionable plan. It’s not necessarily something that you want to check every month, and the reason is that we don’t expect to see big changes. It goes down slowly over time. Remember, it’s always meandering, so it’s going up and down, and then the trend is where it goes down to zero, and that’s where we’ve run out of eggs. It happens to everybody.

It is normal to have a low level at 40. That’s just normal. What’s hard is as a society we’ve shifted everything. We’ve shifted when we get married, we’ve shifted when we try to have kids. Since society has shifted, you would think that science has changed and we’d have new tools and new ways to improve a woman’s egg count, to help her grow more eggs, if men ran out of sperm, there would be a cure for them. Because it’s women, there’s no me too in the infertility movement. I wish there was because, believe me, if there’s one thing I could do, I would cure ovarian aging.

Right now, we try different things. You’ve heard of all sorts of therapies out there, but what I think can help women are supplements. For example, CoQ10. I recommend if you’re considering egg freezing in your 20s or you’re thinking about delaying childbearing, consider taking CoQ10 from an early age. As soon as you’re thinking, “I might want to have kids,” taking CoQ10 for a long period of time can potentially decrease the rate of egg loss. It’s true. We’ve seen it in mouse studies. More recently, at The American Society of Reproductive Medicine, this week they presented data on how CoQ10 can help with egg quality. So, it’s something that might help with your egg decline and slowing down of that rate.

Now, the big clue. How do you know if it’s wrong? Ultrasound. We have a diagnostic tool called an ultrasound. I call it my magic wand. I wish it was a magic wand, honestly. I sometimes wish that my ultrasound was a karaoke machine because I sit in front of it so often during the day. It’s a very helpful tool for me because I can look at someone’s ovaries, and by looking at their ovaries, I can see how many eggs I would potentially get if I were to do an egg retrieval cycle. I can look at the follicle count and give a pretty good guess as far as what a patient’s AMH level would be.

If someone’s AMH is 3.5 and they come in and their follicle count is 6, I might say there’s just something that doesn’t seem right, it seems your AMH level might be wrong, given what’s going on with your clinically. Sure enough, I repeat the AMH level and it comes back at 0.6. That can happen. You don’t want to get your level checked and just assume that’s the whole story. Certainly, get your level checked, maybe have it repeated, and then get everything checked. Not just your hormone levels, but also have an ultrasound to look at your uterus, see if you have fibroids, and also take a look at your ovaries and count the follicles so that you get a good idea as far as what your follicle count is.

You’re not just an age, you’re not just an AMH, your ovaries matter, too, and how many follicles you have really gives us a good picture about your fertility. Don’t have a fertility freak out. No one stands at an egg cliff. This is not a fertility time bomb that you’re facing. These things happen slowly over time. I don’t want anyone to call me at 39 saying, “I’m almost running out of eggs. I need your help tomorrow. Please get me in.” Nothing happens that quickly. If you wait, get the information, you have time for that.

Talking about the TUSHY method, if you haven’t heard me talk about it, it involves five simple fertility screening tests.

Check your fallopian tubes, especially women who have a history of chlamydia, gonorrhea, or some sort of pelvic infection. Get a pelvic ultrasound. Sometimes women have fibroids and they don’t even know it, and they’re sitting and occupying their entire uterus, and then they find out after a year of trying. That’s really frustrating. If you have heavy periods, if your mom had fibroids, there are so many reasons why getting an ultrasound before you start having a family is a good thing to do.

Then we have the sperm. I’m going to be doing a show very soon about whether sperm really matters. I think you know the answer to that question if you know me.

The H are the hormones. It’s not just the AMH, but we also look at FHS and estradiol, as well as other hormones like TSH, which is your thyroid, prolactin, and a number of other things to prepare people for future pregnancy. I always talk about trimester zero and doing everything you can to be in the best shape ever for the rest of pregnancy, and obviously, the rest of your life. Not many people get second chances at life, so we have to do it right the first time.

Then the last thing is your genetic profile. I have people say, “I did 23&Me, I’m totally fine.” That’s really not the full picture. We like to look at genes that you and your partner might share and that might result in a baby with a disease. We like to do that pre-pregnancy. There are reproductive genes and cancer genes that I check, depending on your family history.

There is a very simple way of thinking about fertility screening, and that’s this way, the TUSHY method. Overall, I hope you learned a lot about AMH levels, what they mean, and how AMH can be used to help you plan your future pregnancy.

I’m not going into the specifics about the exact number because everyone is so different. A number of 0.6 for someone who is 25, for me, means that person has a really good chance of getting pregnant because she is 25. Let’s say a number of 0.6 at 43, that’s a different story because a 25-year-old has a 95% chance of having viable eggs at that age and a 43-year-old has a 95% chance of not having viable eggs at that age.

Certainly, there are women who are able to achieve a healthy pregnancy over 40. You wouldn’t know until you tried. Your AMH won’t say don’t try. Your AMH will just give you an idea as far as your chance for pregnancy.

Potentially, it will tell you if you have a higher chance of miscarriage. That’s what some studies suggest. At the end of the day, it won’t tell you if you’ll be able to get pregnant or not. It will just give you a good sense as far as the number of eggs you have left and when you might go through menopause.

Thank you for joining tonight’s show. I can’t wait to talk more about fertility and eggs and all the things that I can do to just spread my message of positivity about fertility. Be sure to take a look at my website at DrAimee.org. You can also listen to the show on iTunes, The Egg Whisperer Podcast, as well as my Medium account where you can read all of the articles that we post.

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