When a woman is considering her family planning options—whether she’s actively trying to conceive or thinking of what her choices will be in few years—knowledge is power. Basic female infertility tests can provide valuable insight into a woman’s current fertility potential. Whether the infertility tests suggest reassuring results or paint a less than ideal picture, you will have information to make important decisions about your family planning.
Infertility Tests: AMH & FSH
For many women, the first step will be an appointment with their OB/GYN for blood tests to evaluate their hormone levels. One of the main goals when looking at a woman’s hormone levels is to predict the status of her ovarian reserve. Your ovarian reserve tells your physician roughly how many eggs you have remaining, which can give your physician an idea of how your fertility compares now relative to other similar aged women.
Physicians generally start with two hormone measurements to determine current ovarian reserve: follicle-stimulating hormone (FSH) and anti-Müllerian hormone (AMH). Together, FSH and AMH give your physician the greatest insight into your current ovarian reserve.
What is follicle-stimulating hormone (FSH)?
Follicle-stimulating hormone (FSH) is released by the pituitary gland and is responsible for recruiting and developing follicles in the ovary which usually contain an egg that’s released during ovulation. Traditionally, testing a woman’s FSH levels is one of the most common infertility tests performed.
As you age, the number of eggs you have remaining decrease, your pituitary gland needs to work harder to recruit a follicle. As a result, the pituitary gland produces a higher level of FSH, which is then seen in your day 3 bloodwork. This high level of FSH is correlated with infertility.
FSH levels fluctuate throughout your monthly cycle. To determine the most accurate FSH level, infertility tests are done on days 2, 3, or 4 of your menstrual cycle along with estradiol.
“While the FSH level is helpful for your physician, it certainly isn’t without limitations,” explains SGF reproductive endocrinologist, Jeanne O’Brien, M.D. (Rockville, MD). “For example, the level of FSH can vary from month to month. One month the level may be high where the next month it would fall into what we would consider to be a normal range for the patient’s age,” Dr. O’Brien adds. Your physician will obtain multiple assessments of your ovarian reserve as no single test is conclusive. A comprehensive picture is obtained by factoring your age, FSH, estradiol, AMH and antral follicle count on ultrasound.
What is anti-Müllerian hormone (AMH)?
In 2015, the American College of Obstetricians and Gynecologists (ACOG) issued new recommendations and criteria for ovarian reserve testing. While doctors only used FSH to determine ovarian reserve in years past, ACOG now recommends that doctors include AMH testing as well. Unlike FSH, which may vary day to day and month to month, AMH is more consistent and, when combined, AMH and FSH provide the best insights compared to FSH alone.
AMH is produced by the granulosa cells that line the tiny follicles within the ovaries. Your physician can test AMH at any time as the number of granulosa cells remains consistent throughout your menstrual cycle. As the number of available eggs in a woman’s ovarian reserve begins to decline so does the corresponding AMH level. AMH has been found to reflect the quantity of remaining eggs. A low level of AMH reflects a lower ovarian reserve where as a high level of AMH would indicate a higher ovarian reserve.
Beyond providing insights into a woman’s ovarian reserve, AMH also helps your physician determine the appropriate type of treatment and subsequent protocols. “Women with higher AMH values will likely respond more positively to ovarian stimulation and treatments such as egg freezing, intrauterine insemination (IUI), and in vitro fertilization (IVF),” explains Dr. O’Brien.
“We have found that women with lower AMH levels tend to require greater amounts of stimulation medication and produce smaller numbers of eggs. As a result, when AMH levels are lower than expected, your physician may recommend more advanced treatment options sooner such as IVF or IVF with donor egg,” explains Dr. O’Brien. For women interested in egg freezing this may indicate that additional cycles may be needed to achieve the desired number of mature eggs to freeze.
When should I transition from my OB/GYN to a fertility specialist?
Most recommendations for when to seek the help of a fertility specialist are based on the female partner’s age and how long the couple has been having unprotected intercourse. For example if you’re younger than 35 and have been having unprotected intercourse without conception for 1 year, it is appropriate to get a complete fertility evaluation, which includes a semen analysis for the male partner.
For women with decreased ovarian reserve, despite the female partner’s age and length of time trying to conceive, it is appropriate to complete infertility testing immediately since the window of opportunity may be smaller. In these situations we recommend seeking a complete fertility work-up from a fertility specialist. This saves patients time and gives them access to advanced fertility information and treatments that otherwise are not available at an OB/GYN’s office.
Women who are interested in egg freezing, should consult with a fertility specialist to assess their available options.
References:
American Society of Reproductive Medicine. (2015). Diagnostic testing for female infertility. Reproductive Fact Sheet.
Ovarian reserve testing. Committee Opinion No. 618. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:268–73.
Wilkes, S., Hall, N., Crosland, A., Murdoch, A., Rubin, G. (2009). Patient experience of infertility management in primary care: an in-depth interview study. Family Practice Advance Access. 26(4), 309-316.
