How Much Does AMH Vary In Normal Female?

What is AMH?

Anti-Mullerian Hormone (AMH) is produced by follicles in ovaries and reflects ovarian reserve. AMH in normal women is taken as 1-4ng/ml. It progressively increases in girls, from first day of life &reaches maximum at 25years of age. After puberty AMH is expressed by granulosa cells of smallest antral follicles in ovaries, until they have reached the size at which they may be selected for dominance, so it strongly corelates with early follicular count.

It decreases gradually in adult females & becomes undetectable by the time of menopause. In comparison to other hormonal biomarkers such as serum FSH& LH, low intra cycle & inter cycle variability has been seen in serum AMH.

Variability in AMH values in a female can be inter-individual or intra-individual. It has occasionally been seen that when AMH is tested in the second half of the men-strual cycle lower values than AMH in first half of cycle are noted. However most studies have demonstrated no change in AMH values all through the cycle.

Q. What can make AMH vary?

1. AGE →YES
It has been proved a number of times that as age increases, number of eggs decreases. Thus, AMH becomes low by the time menopause approaches. AMH acts as a good predictor for fertility period, as its level is very low, or even below detectable limits approximately 5 years before menopause. Therefore, AMH is considered as marker for ovarian ageing.

2. RACE →YES
Hispanics and black women have 25% lower AMH in comparison to Cauca-sians of same age.

3. BMI- Body Mass Index → YES
Due to altered metabolism of hormones in obese patients, BMI has negative impact on AMH.BMI has inverse relation with AMH.

4. SMOKING →YES
It is seen that women who smoke have low AMH, poor egg quality & de-creased follicular count. It partly depends on the number of cigarettes smoked per day. Heavy smokers have an increased likelihood of attaining menopause much earlier as compared to women who are non-smokers.

5. CAFFEINE→ NO
No significant difference in AMH has been seen in women who consume caffeine as compared to those who do not consume caffeine.

6. MENSTRUAL CYCLE DAYS→ NO
AMH in normal female is considered as a stable hormone with respect to menstrual cycle days. It can be measured anytime during the cycle which is one of its advantages. Random fluctuations are small, indicating that AMH in normal women is a cycle independent marker of fertility.

7. OVARIAN SURGERY→ YES
Any ovarian surgery which includes the removal of small or large part of ovary as in cases of ovarian cysts like dermoid cyst, chocolate cyst or any procedure which may affect blood supplyof the ovary causes depletion of AMH in normal women.

8. ORAL CONTRACEPTIVE PILLS→YES
It decreases the ovarian reserve due to prolonged use, probably due to FSH- Follicle Stimulating Hormone suppression. The actual AFC (antral follicular count) & AMH in normal women who are OCP users are comparatively lower than non-users. The suppression effects have been known to recover after 3-6 months of dis-continuation of the drug.

9. PREGNANCY→YES
AMH levels decrease during pregnancy. The decline in AMH levels during pregnancy indicates ovarian suppression. AMH levels recover quickly after delivery. AMH levels assessed in pregnant women are not an accurate indicator of ovarian reserve, since AMH levels during pregnancy seem not to be independent of gestational age.

10.STRESS→ YES
Higher level of psychological stress makes AMH in normal female low, lead-ing to reproductive failure. Attention should be given on relieving stress to promote reproductive health of women.

CAN AMH LEVEL BE IMPROVED?

AMH in a normal female is influenced by the number of antral follicles in the ovary. As a lady ages, her AMH levels decrease due to loss of antral follicles which is a natural process in every menstrual cycle. And as Anti-Mullerian hormone levels naturally decreases with age, many women wishing to get pregnant at 40 may wish to increase their AMH level.

Many researchers have suggested that alteration in diet may affect reproductive func-tion in normal women, yet the association between dietary factors and markers of ovarian reserve like AMH has not been proved.
Supplements like DHEA, Vitamin D3 have been suggested to be helpful in increasing the level of AMH. However, no conclusive evidence is available which can make its widespread use an effective therapy to improve AMH levels .