If you and your partner have been experiencing struggles when trying to conceive, or you have PCOS, or just curious about your reproductive health, you might have come across the term Anti-Mullerian Hormone. Keep reading to learn more about this hormone and its health effects.

AMH is a very important marker to monitor, especially if you haven’t been leading the best lifestyle or you have chronic health issues. 

What Is Anti-Mullerian Hormone?

Anti-Mullerian Hormone (AMH), or Mullerian inhibiting substance, is a protein. The preantral and small antral follicles (maturing eggs and their surrounding cells) produce AMH. The name comes from the discovery of Mullerian ducts, structures that continuously divide and replicate to form the female reproductive system [1].

Anti-Mullerian Hormone Function in Women

In women, granulosa cells (in eggs) produce anti-mullerian hormone (AMH) [2].

The primary purpose of AMH in women is to inhibit FSH and follicular growth [2].

Throughout a woman’s life, eggs leave the primordial follicular pool (first stage of a follicle) into a growing pool where they fully mature. The majority of the eggs in the growing pool eventually get lost [3].

amh Image credit: https://www.ncbi.nlm.nih.gov/pubmed/19589949

At birth, there are around 1-2 million primordial follicles in the body. At menarche (first menstruation), about 300,000 to 400,000 remain. Afterward, the numbers continue to decline and there are only less than 1000 left during menopause [4].

However, the FSH hormone rescues one of these follicles to become the dominant follicle. This process is continuous throughout life until menopause hits. AMH helps inhibit the recruitment of follicles in the growing pool, consequently preventing their permanent loss [3].

A decreased AMH has shown a faster rate of depletion for primordial follicles. This has been associated with earlier menopause [3].

The follicles also require specific thresholds of FSH to ensure growth to the preovulatory stage. Low AMH increases sensitivity to FSH, which makes the follicles susceptible to continued growth and ovulation [3].

As a woman ages, she releases more and more primordial follicles, accordingly reducing AMH levels. In clinical settings, AMH levels are measured to determine the period of fertility of a woman [2].

Anti-Mullerian Hormone Function in Men

In men, AMH is produced by Sertoli cells in the testes. During the fetal stages of a male, AMH inhibits the development of female reproductive organs and is also responsible for testicular development [5].

In the first few days after birth, AMH levels are low but gradually increase after the first week. The rate rapidly increases during the first month reaching an apex at 6 months of age, immediately followed by a slow decrease throughout childhood [5].

Anti-Mullerian Hormone Testing

All AMH tests evaluate blood samples to determine the AMH concentration. The ranges defining normal AMH levels vary between tests [6].

While AMH is the most accurate existing reflection of the quantity of a woman’s eggs and follicles (ovarian reserve), to achieve the most accurate depiction of a woman’s ovarian reserve, antral follicle count must also be measured [2].

You can request that your doctor test your AMH levels. Conventional doctors will look at high or low AMH levels and not mention anything. Sometimes, a lab result may be in the reference range, but not actually be in the optimal range. Reference ranges are not the same as optimal ranges. This is why AMH even in the ‘normal’ range can be unhealthy and indicate that certain processes in the body aren’t optimal. 

FSH and estradiol are also part of the routine check, but since they fluctuate with every cycle, they are not accurate markers of ovarian reserve [2].

AMH-Related Disorders in Females

Diseases Associated with Low AMH Levels And Infertility

1) Premature Ovarian Failure

Premature ovarian failure (POF) is the loss of reproductive or hormonal function in the ovaries. It is the same as a premature menopause and chromosomal defects usually cause POF. An individual with POF has very low AMH levels, maybe even undetectable [2].

2) Endometriosis

Endometriosis happens when the uterine lining grows outside of the uterus. This disorder is a potential cause of premature menopause; over 50% of patients have it. Patients with endometriosis exhibit AMH depletion at a rate much faster than healthy women [7].

3) Gonad Failure

Cancer patients who have gone through extensive exposure to chemotherapy and radiotherapy, are much more prone to losing eggs faster than normal, which is reflected by low AMH levels [2].

AMH testing can be especially useful in this situation if measured before the treatment. It has immense clinical implications because can help assess risk for infertility and predict chemotherapy-related risk in regard to future fertility [2].

4) Autoimmune Disorders

Low AMH levels are also associated with various autoimmune disorders [8]:

  • Lupus
  • Crohn’s disease
  • Autoimmune thyroid disease

Diseases Associated with High AMH Levels

1) Polycystic Ovary Syndrome (PCOS)

This syndrome is a hormonal disorder that is common among women of reproductive age. These women have an above-average concentration of male hormones (androgens) and an increased number antral follicles [9].

Antral follicle count is one of the diagnostic criteria for PCOS. AMH has a positive association with the number of early antral follicles in both healthy women and women with PCOS. Although the exact cause for high AMH production in PCOS is unknown, androgen production can cause AMH levels to rise [10].

AMH is also correlated with other PCOS symptoms, including oligomenorrhea (infrequent periods), amenorrhea (absence of periods), and insulin resistance. Thus, AMH may also contribute to PCOS [11].

A review of various studies showed that PCOS treatments improved AMH levels alongside PCOS symptoms. For example, six months of metformin therapy in PCOS significantly decreased AMH levels. Therefore, future studies of AMH inhibition may help improve PCOS therapies [11].

2) AMH and Cancer

Only the granulosa cells produce AMH and contribute to its function. Because of how location specific the hormone is, it is a good indicator of potential tumors in these cells. Abnormally high levels of AMH are associated with granulosa cell tumors [3].

AMH levels may also be used in the diagnosis of a potential return of an ovarian granulosa cell tumor [12].

AMH-Related Disorders in Men

Diseases Associated with Low AMH Levels

1) Persistent Mullerian Duct Syndrome

Mutations in the AMH gene can result in irregular AMH production and defects in the AMH receptors. These factors result in genetically male individuals having female reproductive organs. Patients with Persistent Mullerian Duct Syndrome have undetectable levels of AMH [5].

2) Congenital Hypogonadotropic Hypogonadism

Congenital Hypogonadotropic Hypogonadism is a condition in which the male testes produce little to none sex hormones. It leads to a decreased number of Sertoli cells and consequently low levels of AMH [5].

3) Cryptorchidism

Measurable levels of AMH in young boys with cryptorchidism indicate undescended testicles, while undetectable levels indicate the presence of ovaries or a sexual ambiguity, a condition in which the infant’s external genitals don’t appear to be clearly either male or female [13].

Health conditions associated with cryptorchidism include [14]:

  • Reduced fertility
  • Potential testicular tumor

4) Klinefelter Syndrome

Klinefelter syndrome is a chromosomal ailment that results from 2 or more X chromosomes in a male. In males with this condition, Sertoli cells function steadily decays resulting in undetectable levels of AMH [15].

5) Monorchidism

Monorchidism is a condition in which the affected patient has only one descending testicle. This results in less functioning Sertoli cells and lower AMH levels [15].

The reason AMH is popularly used as a testing mechanism for sex function disorders in young males is that it is much more sensitive and location-specific than other hormones [5].

Diseases Associated with High AMH Levels

1) Androgen Insensitivity Syndrome (AIS)

High AMH levels possibly affect Androgen Insensitivity Syndrome (AIS). Males with AIS have androgen (male hormones) deficiency or defects in androgen signaling (transmission), which results in female or ambiguous genitalia. High levels of AMH are considered when a patient is diagnosed with AIS [5].

2) Varicocele

Varicocele is a disorder in which the veins in the scrotum get bigger and causes blood to drain from the testicles. Prepubertal boys with this syndrome have high AMH levels. This can cause abnormal testes function and infertility [5].

AMH Tests

1) Determines the Quantity of Egg Supply

Ovarian reserve involves the quality and quantity of the follicles and eggs that a woman has. Both characteristics are crucial for a woman’s reproductive potential [16].

The specificity and sensitivity of AMH make it a go-to for determining the number of functioning egg cells left in a female.

Women with the following clinical conditions may be at risk for an abnormally reduced supply of eggs [17, 18]:

  • Being born small
  • Type 1 diabetes mellitus
  • Lupus erythematosus
  • Ovarian surgery
  • Uterine artery embolization (harmless tumor found between the abdomen and thighs)

Ovarian reserve testing allows for tailored fertility treatment plans.

Predicting the age of menopause at a young age is also useful to preserve fertility in those who are higher at risk for certain conditions [17].

Traditionally, hormones such as FSH, estradiol, and inhibin B are measured during the early stages of the follicular phase to determine a woman’s egg supply; their concentrations are affected by different phases of the menstrual cycle. AMH is much more constant between puberty and menopause and can be used as an accurate measure any time of the year [19].

AMH testing in women with cancer can also help determine their ovarian reserve [17].

2) Optimizes In Vitro Fertilization (IVF)

IVF is an assisted reproductive technology in which the egg and sperm meet outside of the body in a petri dish [20].

In IVF, because the premature follicles secrete AMH, higher levels of AMH are predictive of a higher number of ovarian follicles (egg cells) [21].

Prevents Excessive Response to IVF

In IVF, FSH stimulants are administered to a patient as part of the procedure. These stimulants pose the risk of an excessive response from the patient.

Ovarian hyperstimulation can cause [22]:

Mild Symptoms

  • Stomach pain
  • Nausea
  • Diarrhea
  • Bloating

Moderate Symptoms

  • Vomiting
  • Excessive weight gain
  • Excessive thirst
  • Darker urine
  • Low blood pressure

Severe Symptoms

  • Decreased blood levels (hypovolemia)
  • Stomach inflammation
  • Difficult breathing
  • Blood clots (thrombosis)
  • Kidney failure

A meta-analysis indicated that AMH can be used to predict excessive response to an IVF treatment [17].

3) Can Determine Various Diseases and Conditions

Testing AMH levels can also help determine whether someone has reproductive conditions.

AMH levels can be used to determine and recognize various conditions including [23]:

  • Ambiguous genitalia or undescended testicles (in infants)
  • Persistent Müllerian Duct Syndrome
  • Premature ovarian insufficiency
  • Low/undetectable sex hormone levels
  • Granulosa cell tumors
  • PCOS

Testing Limitations

Relative to other markers used for ovarian reserve testing, AMH has few limitations. However, normal fluctuations, medication and contraceptives, and surgeries can all contribute to differences in AMH levels [8].

There is also no international standardization among different procedures that test for AMH (assays). Different ranges define normal, high, and low AMH concentrations from test to test. In clinical practices, it is imperative to use the same test as the one used in a reference population study to have accurate results [24].

Additionally, once pregnancy begins, AMH is not useful in determining the ability of the embryo to survive successfully [25].

There are also controversies regarding the usefulness of AMH testing and reproduction. In a study of 49 women over the age of 40, AMH levels did not affect potential pregnancy. Both women with normal AMH and extremely low AMH (<0.4 ng/ml) were able to become pregnant [26].

Factors That Influence AMH Levels

Increasing AMH

In a study of 81 women, overweight women with PCOS had an increase in AMH levels when supplementing Orlistat (weight loss drug) along with diet and physical exercise [27].

DHEA and Vitamin D supplementation can also help increase AMH levels [28, 29].

Decreasing AMH

Metformin therapy for PCOS can decrease AMH levels. In a study of 36 women, metformin administration decreased AMH levels in PCOS patients [30].

Lifestyle choices can change AMH levels in females. Daily smoking has a negative association with AMH levels in a cross-sectional study of 2,320 women. However, these changes are reversible. Quitting smoking soon diminishes these effects and AMH levels resume back to normal [31].

Other factors that can decrease AMH levels [32]:

  • Regular coffee consumption (for at least 6 months)
  • Alcohol consumption
  • Exposure to pyrethroid pesticides

Irregular AMH Levels?

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