Ovarian Reserve Assessment (AMH)

AMH (Anti-Müllerian Hormone) is produced by granulosa cells of small (2–6 mm) antral follicles and preantral follicles. It reflects the current size of the pool of growing follicles, which in turn reflects the total remaining primordial follicle pool. Because granulosa cell mass is proportional to follicle number, AMH closely correlates with the available ovarian reserve. It is not significantly affected by the menstrual cycle phase, combined oral contraceptive pill use, or pregnancy.

No. AMH predicts ovarian response to stimulation drugs in IVF but does not directly predict the chance of natural conception. Women with low AMH still ovulate (unless POI is present) and can conceive naturally, though they may have a shorter reproductive window than women with higher AMH. The best predictor of natural fertility is age, followed by regular ovulation — not AMH level alone.

There is no proven intervention that increases ovarian reserve or reverses age-related AMH decline. Some studies suggest that DHEA supplementation, Coenzyme Q10, and certain antioxidants may modestly improve IVF outcomes in poor responders, but evidence is insufficient to make firm recommendations. Avoiding smoking (which accelerates follicle loss) and maintaining a healthy weight are the most evidence-based protective measures.

AMH guides individualised FSH dosing for ovarian stimulation. Low AMH (<1.2 ng/mL) predicts poor response and requires high FSH doses (300–450 IU/day). Normal AMH (1.2–3.5 ng/mL) supports standard dosing (150–225 IU/day). High AMH (>3.5 ng/mL) predicts high response and requires lower doses (75–150 IU/day) with careful monitoring to prevent OHSS. AFC is used alongside AMH for dose selection.

Ovarian Hyperstimulation Syndrome (OHSS) is a potentially life-threatening complication of ovarian stimulation in which the ovaries become massively enlarged and fluid leaks into the abdominal cavity and chest. It is most common in women with high AMH and high AFC (polycystic ovarian morphology). Severe OHSS (ASA grade 3) manifests as ascites, pleural effusion, electrolyte imbalance, and thromboembolic risk. Modern IVF uses GnRH antagonist protocols with GnRH agonist triggering (instead of hCG) to virtually eliminate severe OHSS.

The POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) classification categorises poor prognosis IVF patients into 4 groups: Group 1 (young, unexpected poor response — adequate reserve but poor response); Group 2 (older, unexpected poor response); Group 3 (young, low reserve — AMH <1.2, AFC <5); Group 4 (older, low reserve). Each group has specific stimulation and strategy recommendations to optimise the number of mature oocytes retrieved.

AMH is most informative in women with fertility concerns, irregular cycles, or planning future fertility (egg freezing). Routine AMH testing in asymptomatic women without fertility concerns is not recommended by most guidelines, as a low result causes anxiety without altering management (natural conception advice remains the same). Women considering egg freezing should have AMH and AFC assessed to estimate the likely yield per stimulation cycle.

No. FSH (follicle-stimulating hormone) is produced by the pituitary gland and rises when the ovaries have fewer follicles to feedback onto the hypothalamic-pituitary axis. Elevated basal FSH (above 10–12 IU/L) indicates reduced ovarian reserve, but FSH varies considerably between cycles and is less sensitive than AMH as an early marker. AMH starts declining years before FSH rises, making it a more sensitive early indicator of diminishing reserve.