Drawray TIMES
No. D023005N004
AMH and Conventional Fertility
Hormones
By Kristina ZENG
P roduction of AMH in adult women was first reported in 1990. In the past two decades, its role
in female ovarian function and the clinical utilities of serum AMH level has been increasingly
studied. So how is AMH different from the conventional fertility hormones, such as follicle
stimulating hormone (FSH), luteinizing hormone (LH), estradiol, prolactin, progesterone,
testosterone and dehydroepiandrosterone (DHEA-S) ?
Biological Characteristics of AMH
AMH was predominantly known for its physiologic involution of the Mullerian ducts during sexual
differentiation in the male fetus, where AMH is synthesized by fetal Sertoli cells at the time of
testicular differentiation and induces regression of the Mullerian ducts that form the base for the
development of the oviducts, uterus and upper part of the vagina. Whereas, in a female fetus, the
Mullerian ducts develop into the oviducts, the uterus and the upper part of the vagina in the absence
of AMH.
In women, the AMH serves to
function as an autocrine and
paracrine regulator of follicular
maturation. It is secreted by the
granulosa cells of small growing
follicles with sizes between 2 to
8mm. The preantral and small
antral follicles secrete AMH as
soon as they leave the quiescence
Figure 1. Changes in AMH levels and the numbers of primordial
phase and stop when they reach
follicles with age.
the large antral stage. This
secretion profile suggests that the AMH level is strongly correlated with antral follicle count (AFC)
and can reflect ovarian reserve, as the initial follicular recruitment appears to be continuous over
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the course of a woman’s reproductive life and proportional to the number of primordial follicles
remaining in the ovaries. In addition, it has been established clearly that serum AMH levels are
strongly correlated with an ultrasound evaluation of the AFC, a procedure that is recognized as
another excellent method for evaluating ovarian reserve.
The serum AMH level in women follows a characteristic trajectory: the secretion of AMH starts
around the 36th week of gestation, then reaches a peak around 25 years of age, before declining
throughout the reproductive years and becoming undetectable soon after a precipitous drop at
menopause (Figure 1). As the size of the residual follicular pool depends on the quantity of small
antral follicles and declines with age.
Furthermore, AMH has an inhibitory effect on early follicular recruitment preventing the entry of
primordial follicles into the growing pool and thus premature exhaustion of follicles/oocytes. AMH
also has an inhibitory effect on cyclic follicular recruitment in vivo by reducing the follicle sensitivity
to FSH and LH. In vitro, AMH inhibits FSH induced preantral follicle growth. Thus, it is clear that
AMH is involved in the regulation of follicle growth initiation and in the threshold for follicle FSH
sensitivity.
The Clinical Values of Serum AMH Levels
The clinical applications of serum
AMH levels in women are numerous
(Figure 2). Firstly, AMH is clinically
useful as a screening tool for
diminished ovarian reserve (DOR).
Perturbations in serum AMH are
linked with a variety of pathological
conditions, for instance, polycystic
ovaries syndrome (PCOS), where the
excess follicles in this syndrome
produce increased amounts of AMH
or premature ovarian failure (POF),
where the insufficient follicles in this
syndrome fail to produce AMH.
Early diagnosis of reduction of
ovarian storage can prevent
expensive costs in the treatments of
infertile women and in women who
are susceptible to premature ovarian
Figure 2. Clinical applications of AMH.
failure, and oocytes freezing, ovarian
tissue freezing, and embryo freezing are recommended for those who are at risk of POF.
Evaluation of the AMH level has clinical value in predicting the successful rate of in-vitro
fertilization (IVF). Serum AMH assays are widely used to derive prognostic information such as the
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chance of successful ovarian stimulation, subsequent pregnancy rates and even birth rate. Studies
showed that women undergoing IVF treatment with higher AMH levels are associated with lower
miscarriage rates and unfavorable outcomes.
AMH levels can be used to determine the optimal dose of gonadotropin stimulation during IVF for
individual patients, which can improve the chances of success while minimizing the risk of ovarian
hyperstimulation syndrome (OHSS). As well as identifying patients who may be at risk for poor IVF
outcomes or OHSS, allowing for more personalized counseling and treatment planning. In IVF-
embryo transfer (ET), AMH levels can also be used to predict the likelihood of successful embryo
implantation and pregnancy. Studies have shown that women with higher AMH levels have higher
rates of embryo implantation and clinical pregnancy, as well as lower rates of miscarriage.
In addition, as women age, the numbers of ovarian follicles gradually decline, and this follicle loss
leads to lower AMH serum levels. Consequently, AMH level can be used as a good predictor of the
time of menopause, even in young women. A low AMH serum level as well helps to confirm the
diagnosis of menopause.
Lastly, studies have reported that serum AMH can be used as a biomarker in the clinical diagnosis
of granulosa cell tumor (GCT) with high accuracy, and measurements of AMH are also very
informative in monitoring cancer patients having received gonadotoxic chemotherapy or having
undergone mutilating ovarian surgeries. Chemotherapy often damages the follicles, thereby
impairing the future reproductive potential, especially the ovarian reserve of patients, and patients
whose AMH levels were higher before chemotherapy maintained better menstrual cycles after
treatment and had a higher probability to achieve pregnancy. Therefore, it is important to assess
their ovarian reserve function regularly for patients receiving chemotherapy. In conclusion, the
measurement of AMH is now a useful tool in the management and treatment of female infertility.
Understanding AMH and Conventional Fertility Hormones
Even though AMH levels are significantly associated with PCOS, POF, menopause and outcomes of
IVF, measuring AMH levels in combination with FSH, LH, testosterone, E2, progesterone, DHEA-S
and AFC could improve the diagnostic specificity and sensitivity for the detection of infertility and
fertility potential.
Fertility hormones play essential roles in the development and maintenance of the reproductive
system. They are responsible for the pregnancy, puberty, menstruation, menopause, sex drive and
egg production in females, and when these reproductive hormones do not work as they should,
fertility problems can occur. Hormones such as FSH, LH, E2 and progesterone involved in the
menstrual cycle are released at regular fluctuating patterns during the menstrual cycle. On the other
hand, the serum level of AMH is not significantly disturbed during the menstrual cycles, and the
following table tells about the mechanisms and functions of AMH and classic fertility hormones,
helping to explain the different purposes between AMH tests and classic fertility hormone tests
(Table 1).
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Table 1. Physiology of AMH and conventional fertility hormones in females.
Hormones Physiology in Female
AMH Low levels reflect DOR, POF, menopause or infertility
High levels reflect higher ovarian reserve, PCOS and GCT
FSH Levels rise in menopause
Low levels suggest amenorrhoea and pituitary disorder
High levels suggest low follicle counts in the ovaries
LH Levels rise in menopause
Low levels suggest pituitary disorder
High levels suggest PCOS
E2 Production ceases in menopause
Low levels result in menstrual irregularities, vaginal dryness, and
reduced bone strength
High levels result in bloating, breast tenderness, mood swings,
weight gain, sleep disturbance and increased risk of breast or
uterine cancer
Prolactin Elevate during pregnancy for preparation of breastfeeding
May be raised in non-pregnant women whose periods have
ceased or become very infrequent due to a small tumor in the
pituitary gland or the use of particular medications.
Progesterone Can be used to detect ovulation
Production ceases in menopause
Low levels suggest ovulation problems, headaches, hot flashes,
mood changes and reduced libido
High levels suggest vaginal dryness, mood changes, and fatigue
Testosterone Productions continue in menopause
Low levels result in thinning hair, dry skin, mood changes, sexual
dysfunction and bone loss
High levels result in acne, menstrual irregularities, diabetes,
obesity and infertility
DHEA-S Typically measured to screen for adrenal hyperfunction in
women with virilization
Production decline in menopause
Low levels result in chronic fatigue, low libido, and mood
changes.
High levels can be a sign of PCOS, adrenal glands disorder or
other problems such as acne, infertility, absence of menstrual
cycles or increased body and facial hair
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Advantages of AMH Tests Over Conventional Tests
Serum AMH measurement offers
many advantages over more
conventional hormonal markers of the
ovarian reserve, such as FSH or E2. In
particular, the serum level of AMH is
relatively constant over the menstrual
cycle, and it can be measured any day
of the menstrual cycle. Whereas, levels
of FSH and E2 fluctuate significantly
throughout the menstrual cycle and
are normally measured around day
three of the menstrual cycle to
determine the ovarian reserve. Hence,
measurements of serum AMH are
highly reproducible, it has little
variation within and between cycles Figure 3. The ROC curve of AFC, AMH, and other
unlike other hormones. markers in the prediction of ovarian reserve.
Transvaginal ultrasonography is the gold standard for diagnosing PCOS, and this method can also
be used to evaluate the AFC. The level of circulating AMH strongly correlates with AFC, visualized
by ultrasonography in the follicular phase of the cycle (Figure 3). However, some patients deny
doing transvaginal ultrasound examinations, for religious and cultural reasons. Thus, AMH has
been recognized for several years as the best hormonal assay to indicate ovarian reserve.
Assays From Drawray to Evaluate Female Fertility
Deficiency or imbalance of the fertility hormones is not the only factors of infertility, other factors
affecting reproductive health include i) Thyroid related diseases, ii) Tumor, iii) Anemia, iv)
Cardiovascular disease. Drawray’s panel supports the diagnosis and screening of all the health
conditions mentioned above.
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Copyright © 2023 Drawray. All Rights Reserved
