Anti-Mullerian Hormone Why You Should be Asking for This Test

By: Susanna J Park, MD

Women are delaying pregnancy for a variety of reasons. Perhaps she is focusing on her career; perhaps she is enjoying the freedoms of an unattached life; perhaps she has not found the right person yet.  The ability to defer motherhood is a wonderful privilege. However, when should a woman start to be concerned about her ability to conceive? One test that may help women track their reproductive potential is the Ant-Mullerian Hormone.  This hormone is believed by many to be the best blood test currently available to assess a woman’s supply of follicles in her ovary.

A woman stores all of her eggs in small fluid-filled structures called follicles in her ovaries. A single follicle contains a single egg. Each woman has the greatest number of follicles when she is a 5 month old fetus in her mother’s womb.  At this time, she has 6-7 million follicles.  Subsequently, while still in the mother’s uterus, she will start to experience loss of follicles (and therefore eggs) via a process called atresia, defined as programmed cell death. By the time she is born, a baby girl will have only 1-2 million combined total follicles remaining in her ovaries. Through childhood, follicles continue to undergo atresia such that by puberty, the total number of follicles is approximately 400,000.  Puberty marks the start of ovulation. During ovulation, one follicle per month is released from the ovary into the fallopian tube. This process allows women to conceive via fertilization. It is a common misconception that only one follicle is lost per month. However while one follicle is being released through ovulation, many other follicles simultaneously are dying through atresia. Thus, every month, both ovaries lose a significant number of follicles. This continues throughout adulthood such that by the age of 52 (the average age of menopause), there are only approximately 1,000 follicles remaining in both ovaries combined.

The loss of follicles is permanent and irreversible. Unlike men who continue to produce new sperm, scientists believe that women do not produce new follicles.  Instead, women are born with a finite number of follicles. Fertility medications do not increase the follicle supply in an ovary.  Rather, fertility medications increase the number of follicles which ovulate from the ovary in a given cycle.

It used to be believed that the rate of loss of follicles due to atresia decreased at a gradual rate, until the age of 37, at which time the rate of loss of follicles accelerated.  Recent studies have demonstrated this is not the case, and that instead, the loss of follicles is continuous.  Thus, we used to reassure women in their early 30’s that they did not need to worry about their fertility until they were in their mid 30’s.  Now we know that it is possible for women in their early 30’s to have fertility issues due to a low supply of follicles in their ovaries.

Many physicians and researchers believe that the best blood test to assess the supply of follicles in a woman’s ovaries is Anti-Mullerian Hormone (AMH), also known as Mullerian Inhibiting Substance (MIS). In females, this hormone is secreted by a particular group of cells in the follicles called granulosa cells. Thus, the more follicles there are in the ovaries, the greater the amount of AMH in the blood. Conversely, the fewer follicles there are in the ovaries, the lower the amount of AMH in the blood.  Therefore, AMH is a reflection of the number of follicles in both ovaries. With time, as women become older, the level of AMH will naturally decrease.

Other tests are currently used to assess the supply of follicles in ovaries. The most common of these tests is Follicle Stimulating Hormone (FSH) and Estradiol, which are measured on the third day of the menstrual cycle (Day 3 FSH & Estradiol).  There are several disadvantages to this test.  First, the test is time sensitive – that is, it must be performed on either the second, third, or fourth day of the menstrual cycle.On the other hand, AMH can be measured any time of the menstrual cycle. Second, Day 3 FSH & Estradiol results become abnormal once the supply of follicles in the ovaries has diminished substantially. Therefore, it is possible to have a borderline low reserve of follicles but a normal Day 3 FSH & Estradiol result. This provides a woman with a false reassurance that she has an ample supply of follicles and thus, ample time to become pregnant. In contrast, AMH decreases with the gradual decline in the supply of follicles over time. Studies have shown that AMH is the earliest indicator that the supply of follicles is diminishing. Finally, Day 3 FSH & Estradiol levels from one menstrual cycle may be different from the levels repeated at a subsequent menstrual cycle. There is a lot of cycle-to-cycle variability. And while studies suggest that the highest FSH value is most predictive of egg quantity, a woman may be falsely reassured if she sees a subsequent lower FSH value. The value of AMH, however, remains rather constant cycle-to-cycle.

Another common test used to assess the reserve of follicles is measuring the number of antral follicles visible on transvaginal ultrasound. This test is called antral follicle count (AFC). The antral follicles are those which have the ability to grow into mature follicles each month. The greater the number of follicles in the ovary, the greater the number of antral follicles seen on ultrasound; therefore, AFC is a reflection of the reserve of follicles.  AFC is a rather good test of a woman’s ovarian supply of follicles. AFC measurement can be performed any time of the menstrual cycle.  However, there are some disadvantages to antral follicle count. First, acquiring the information requires a vaginal ultrasound, whereas AMH requires only a blood test. Second, because it is natural for the number of follicles that grow into antral follicles each month to vary monthly, the AFC number will accordingly change each month. In contrast, AMH levels show little monthly change. Third, AFC measurement is subjective because it is a count of the number of antral follicles seen. Therefore, different people measuring the same ovary at the same time may count slightly different numbers of antral follicles. AMH, however, is an objective measurement performed by measuring the level of the AMH hormone in the blood so the result is not subjectively determined.

Which women should be requesting an AMH test to assess their ovarian follicle reserve? Answer: Any woman who wants to know her follicle reserve may benefit from an AMH test. However, there are known factors which affect the reserve of follicles in the ovary: age, environment, and genetics. Therefore, women with the following conditions which may lower ovarian follicle supply, should consider asking their physicians for the AMH test:

(1)  any woman over 30 years of age;

(2)  any woman with a history of surgery on the ovary (removal of an ovarian cyst, removal of an ovary);

(3)  any woman with a history of any toxins which may have a negative impact on the ovary (smoking, chemotherapy, radiation);

(4)  any woman with a family history of menopause earlier than 50 years old;

(5) any woman whose family history includes female relatives who experienced a loss of ovarian function at less than 40 years old.

Regardless of AMH results, the greatest predictor of the ability to conceive is a woman’s age.  Women who are young have higher quantity and better quality eggs (also known as oocytes).  With increasing age, both the quantity and quality of eggs decrease. No test exists, not even AMH, which can measure the quality of an egg.  The AMH is only a measurement of the quantity, not quality, of eggs/follicles.  It is for this reason that the likelihood of conception decreases with age.  And while lifestyle choices such as maintaining a healthy weight and exercising regularly are essential in achieving optimal conditions for pregnancy, these factors do not slow down the rate of decrease of egg quantity or quality with time.

As more and more women make the decision to delay their child-bearing, it is critical that they be aware of the age-related decline in fertility. While all of us know a family member or a friend who became pregnant at an “older” age, not all women will be able to do so.  Therefore, it is important that women empower themselves with knowledge of their fertility so that they can make informed reproductive decisions. AMH is an important factor in determining a woman’s reproductive potential.

References:

[1] Faddy Hum Reprod 1996;11:1484
[2] Seifer and MacLaughlin F&S 2007;88:539

Let’s get started! June 2012

By: Danielle E. Lane, MD

July 2011 marked the launch of Lane Fertility Magazine.  In addition to providing the best reproductive care for women and men, a long-time personal goal has been to increase awareness of fertility issues and provide for women all over the world access to reproductive information. Publishing Lane Fertility Magazine provides a platform upon which to do this.

In our pilot issue, we introduced the basics of fertility.  This issue will address the prevention of age-related fertility challenges.  In 2011, 20% of the women that I saw in consultation were interested in pursuing care to preserve their fertility while they delay their child-bearing. At least 40% of the women I see are over the age of 40, and many are trying to conceive their first child. Most of the women in this latter group will say that they were unaware of options to preserve their fertility when they were younger. But, times and technology are changing! While we have not had the ability to freeze unfertilized eggs successfully until recently, embryo freezing is readily available. We simply need to spread the word!

The reasons to increase awareness are many.  First, we simply cannot reverse biology and find healthy eggs once they have passed their peak. Second, as a direct result of this reality, the cost effectiveness of preserving fertility as compared with treating infertility is staggering. And third, societal pressures are not reversing; women continue to delay their child-bearing.

In this issue, we discuss the technology of vitrification in Young, Hip and Not Ready for Kids.  In Selecting Your Sperm Donor, we provide some insight into selecting donor sperm for women and couples in need, who are ready to begin their family. The Road Less Traveled presents some compelling information about consideration of starting your family as a single woman. Our article on Anti-mullerian hormone discusses a new and easy test to look at your reproductive potential. 

In every issue you will find a sumptuous fertility friendly recipe and a personal journey with fertility.

So jump in for a good read and enjoy!

ABOUT THE AUTHOR

DanielleDanielle E Lane, MD, Reproductive Endorcinology and Infertility Specialist. Dr. Lane attended McGill University before completing her medical training at the University of Pittsburgh School of Medicine, her residency at Yale-New Haven Hospital and her fellowship at the University of California, San Francisco. She opened the Center for Reproductive Health at Kaiser Permanente in Napa-Sola-no in 2005. In 2009 she founded Lane Fertility Institute. The Institute has grown to a three physician practice with a state of the art embryology laboratory. She is committed to providing education for women about preservation of their fertility and developing lower cost models to improve access to care.

Anna & Glenn

By: Anna Lindo

From the time we began dating, my husband and I had discussed the number of kids we wanted.  At one time, my number was a dozen, but we settled on four. After being married for two years, we started to try and thought that it would happen within a few months. After all, I was 31 and my husband was 30. But, after about a year of trying, I decided to get some testing done. My follicle stimulating horomone (FSH) and estradiol levels were checked and they were normal. My husband’s semen analysis came back normal too. We had what the doctors call “unexplained infertility”.

It felt as though for some mysterious reason, God didn’t want us to have a baby. We watched friends who married after we did have their first child, and then their second. This discrepancy created a very painful time in our lives. My husband and I met in church, and our relationship with God is very important to us and is the glue that holds us together. We cried out to God with our feelings and asked for guidance.

I became very proactive. I bought multiple books on “infertility” in search of answers. One that really encouraged me was  6 steps to increased fertility by Robert Barbieri and Alice Domar.  This book gave me a framework with which to move forward. And finally, I sought the help of a fertility doctor.

From the first appointment that my husband and I had with our fertility specialist, we knew that we had found a great fit. This isn’t always the case, but for us it was.  I showed her the book that I was reading, and she pointed to her shelf  and said, “You mean that one?” There was a whole shelf of the same books that she gave out to patients to provide them with resources and encouragement.  I knew that God had led us to her.

We discussed our history and went through treatment options. My husband and I went through two unsuccessful intrauterine inseminations before I decided to get a hysterosalpingogram (HSG) performed. This test evaluated my fallopian tubes to see if the eggs and sperm could actually meet.  And finally, we had an answer to why we were not conceiving.  My right fallopian tube was blocked. And to make matters worse, most of the mature eggs that I was making were on my right side…we would need to consider In Vitro Fertilization (IVF).

We were devastated. We knew how much IVF would cost, and we knew that it would exceed our finances. Again we turned to our church. We asked family members and friends, and within two weeks, our amazing family and friends had helped us with almost all of the money we would need. 

Now it was time to get through the actual IVF process. At first it seemed overwhelming, but the fertility team worked to make every step of the way easier. In the end, holding our baby in our arms made it all seem so easy.  Our healthy baby girl was born in March 2009.

But our journey is not over. We want to expand our family, and it only gets more difficult as each month passes. The challenges are emotional, physical and in other ways as well.  But in my heart, I still believe that my husband and I can have four children!

Hebrews, chapter 11, verse 1 reads: “Faith is being sure of what we hope for and certain of what we don’t see.” I don’t see how it’s going to happen yet, but I have to be certain that God has a plan for what we hope for, and for our ‘yet unseen’ babies.

10 Things You Should Know before picking a sperm donor

By: Aimee Eyvazzadeh, MD MPH

1. Not all donor sperm banks are the same.

Ask your fertility doctor for a recommended list of sperm banks that she or he considers reputable. You will not know who has consistently high quality specimens without this information. Ask your physician if she or he will review your prospective donor’s information before you purchase the vial(s). Having a medical doctor review your donor’s history may help you make the wisest donor choice.

2. Pregnancy rates with frozen sperm may not be as good as with fresh sperm.

The amount of motile sperm after being thawed can be lowered by as much as 50%.  Additionally, frozen sperm when thawed doesn’t live as long as fresh sperm, and pregnancy rates are lower using frozen sperm when compared to fresh sperm. And while the data supporting the use of more than one insemination in a given cycle is controversial, do ask your physician whether two inseminations or combining multiple vials of sperm is appropriate for you. 

3.   Medicated vs. Unmedicated: I generally recommend medicated cycles for patients over 30, but this is not a requirement.

If you’d rather try natural cycle inseminations, let your physician know.  The use of a fertility pill like Clomid or Femara will potentially increase your chances of getting pregnant sooner in any given cycle. Fertility medications do come with side effects. The biggest risk is the increased rate of twins (25-30% versus background rate of 1%)  Additional side effects can range from hot flashes and vaginal dryness, to mood swings, to others. While not everybody has side effects, you should talk to your physician about whether you would be a good candidate for fertility drugs.

4.   Make sure your fallopian tubes are open.

Intrauterine insemination (artificial insemination) depends on your fallopian tubes for sperm and egg to meet. If your fallopian tubes are blocked, then the only fertility treatment that is likely to be successful is In Vitro Fertilization (IVF).  Given the potential expense (financially, emotionally and otherwise) of fertility treatments, confirming open fallopian tubes is an important part of any fertility evaluation. Even if you don’t have any risk factors for blocked tubes (Chlamydia, Endometriosis, a history of appendicitis to name a few), it doesn’t mean your tubes aren’t blocked. It’s worth checking and certainly won’t hurt your chances of conceiving if you try right after your tube test. Your doctor may recommend a hysterosalpingogram or a saline infusion sonogram to check your tubes.

5.   Know your body.

If you are not doing a medicated cycle, then your insemination will occur near the time of your natural ovulation. Track your ovulation as you are getting close to your first insemination cycle. This way, you will know when you’re ovulating and how to plan your life around your treatment. If you are under 30 and your ovulation is not regular, you may want to add a fertility pill. If you are over 30 and are hesitant about using fertility pills, the fact that your ovulation is regular may give you reassurance that you can try a couple of natural cycles before adding medication (if necessary).

6.   See your doctor for a preconception counseling appointment.

Even if you are using donor sperm, you should still sit down with your doctor for a preconception counseling appointment. Review your medical and family history with your doctor.  Consider genetic testing for cystic fibrosis and other diseases that you could possibly be at risk for based on your ethnicity and family history. You can visit www.counsyl.com for more information about testing, but this test has to be done through your doctor. Don’t forget to start folic acid.

7.   Known vs. Anonymous donor.

If you’re planning to use a known donor, be sure to have a legal contract in place, and discuss your situation with a psychologist with expertise in this area. If you are using an anonymous donor, I still recommend talking to a psychologist, but a legal contract is obviously not necessary unless you are in a same sex relationship. I recommend a legal contract to protect both partners when starting a family.

8.   Required lab work.

Talk to your fertility physician about the required lab work. States have different rules and clinics also set their own different rules.  For example, some clinics will require both partners to have infectious disease testing even though donor sperm is being used. If you know the requirements up front, there won’t be any surprises.

9.   Do your research about which type of sample you should buy.

There are different types of vials that you can buy. Ask your doctor which type of sample would be the best for the type of treatment you are doing.

10. Know your insurance benefits.

Just because you are using donor sperm, doesn’t mean that your insurance won’t pay for your treatment. Being a same sex couple does not prevent you from using insurance to pay for your treatments. Get all the information first, then start treatment. Being well-informed about costs upfront will allow you to just focus on treatment as you’re hopefully going through a successful treatment cycle.

Dinner For Two

Poached Tarragon Chicken

By: Jabir Ponce

Tools Needed

• 2qty. 9×8 roasting pans
• Cutting board
• 8 or 10 inch chef knife
• Medium pot with lid
• Measuring cup
• Tablespoon

Shopping List

• Double breast of chicken (or two single breasts)
• Bunch of fresh Tarragon
• Salt
• Pepper
• Chicken broth
• Brown rice
•  White balsamic vinegar
• Carrots

Get Started

  1. Preheat oven to 450° on broil.
    1 9×8 roasting pan
    1 Double breast of chicken or two single breasts
    2 tbsp. chopped fresh Tarragon
    Pinch of salt
    Pinch of pepper
    Chicken broth
  2. Sprinkle fresh chopped Tarragon in the roasting dish, on an area the size of the breasts.
  3. On the underside of the breasts you will find the tenderloins; flip them outward so that they are away from their resting place, and place the breast on top of the Tarragon.
  4. Pour in chicken broth gently into the pan, until the breast is covered ¾ of the way up the breast.
  5. Sprinkle salt, pepper and dried Tarragon over the breast.
  6. Place in oven on second rack from the top (between 8 and 10 inches from the top) for 30 minutes.

Braised Carrots

in Balsamic Vinegar

Brown Rice

Cooked in Chicken Broth

Preheat oven to 450° on broil.

 

1 medium pot with

 

1 9×8 roasting pan

 

1 Cup Brown rice

 

4 tbsp. White Balsamic Vinegar

 

2 ¾ C Chicken Broth

 

2 Cups Water

 

Place rice and chicken broth in pot and bring to a boil.

 

6 Carrots

 

Turn heat down to low and cover.

 

Wash carrots and remove tops.

 

Cook for about 40 to 45 minutes.

 

Place carrots in pan, pour in water and add 4 tbsp. vinegar.

 

Let sit for a minute before serving.

 

 

ABOUT THE AUTHOR

Jabir Ponce, Private Chef. Jabir Ponce’s first passion is food and its preparation. While working in the pastry line and bake shop at the Ritz Carlton Manalapan, Mr. Ponce received his culinary degree in 1993 from the Florida Culinary Institute. After returning to San Francisco Mr. Ponce helped to open several small restaurants while running his own catering company. He served as the Lead Concierge for the Archbishop’s Mansion until its closing. Since July 2009, he has worked in San Francisco as a private chef. His email is jabirponce@sbcglobal.net