Dear ACOG, No.
My thoughts on AMH screening to evaluate your fertility…
Dear ACOG,
We are in a fight.
I don’t agree with you.
ACOG released a committee opinion in March 2019 titled “The Use of Antimullerian Hormone in Women Not Seeking Fertility Care.”
In this document, ACOG goes on to try and present the case that AMH should not be used as a screening test for women to gauge their fertility potential.
What is AMH?
AMH is a marker of ovarian reserve.
I like to use the analogy that there is a vault inside the ovary which contains of all the eggs a woman is ever born with. Each month, a group of these eggs are released as follicles and these follicles are surrounded with granulosa cells. These granulosa cells make AMH. To put it simply, the more eggs released from the vault, the higher the AMH value will be. As we age, we have fewer eggs. This is called our “ovarian reserve” – or the number of eggs we have left. As we have a decrease in ovarian reserve – we also see a decrease in the average number of eggs released from the vault each month (measurable on vaginal ultrasound as the “antral follicle count” and also a lower AMH value (fewer eggs, so fewer follicles, so fewer granulosa cells making AMH). Importantly, the ovary is not perfect and this is not linear. Meaning, we can see up to a 30% difference in AMH values in any given month as a different number of eggs are released. Women have good months and bad months. I like to tell women that a single AMH is only useful to categorize them as “above average, average, below average, critically low.” AMH helps us guide fertility treatments – how aggressive should we be, how much medication we may need to get the ovary to respond, what type of protocol may be best, and how many eggs we may get with IVF or egg freezing.
In this opinion, ACOG points out many important facts:
AMH is not correlated with fecundability (ability to get pregnant) in a fertile population. Meaning, many women with a low AMH get pregnant naturally.
AMH is not a reliable predictor of when a woman will go through menopause.
AMH is not a diagnostic criteria for PCOS.
AMH is a measure of “ovarian reserve” or the number of eggs you have left.
AMH is correlated with the number of eggs retrieved in an IVF or egg freezing cycle.
But the article concludes by saying “at this time, however, serum antimullerian hormone level assessment generally should not be ordered or used to counsel women who are not infertile about their reproductive status and future fertility potential.”
Friends at ACOG,
I love what you do for our field. But I am a fertility doctor. I see these women. Young women who are delaying childbearing. Yes, their currently low AMH does not correlate with not being able to get pregnant RIGHT NOW - but what if they want to wait? What if they don’t want to be pregnant right now? Or what if they could start I they needed to? What if they might consider freezing their eggs? What if they want more than one child? Could they freeze embryos now and then still get pregnant naturally? Would this information change their entire reproductive plan or family potential?
ACOG’s argument is that commercial testing of AMH (at home fertility tests), or AMH screenings to the young population at large may cause undue stress or anxiety and may cause women to seek alternative treatments than what they need to conceive. ACOG is rightfully trying to protect reproductive care from become an “industry” where women go to get AMH testing and then feel pressured into egg freezing for financial profit. I understand and respect this protection of a field that I love. In fact, I hate when fertility medicine is referred to as an industry.
And I completely agree that AMH testing is only one piece of the puzzle. Meaning, a normal or reassuring AMH test does not in any way predict future fertility or the ability to get pregnant. I do see women who had a “normal screening” but then had other fertility issues which prevented pregnancy.
That said, AMH screening gives women the opportunity to evaluate their reproductive life and weigh the options that may be best for them.
AMH screening allows women to consider my favorite question: “What is your goal?”
What is your goal when it comes to having kids or a family?
Do you want kids?
Single or married? Does that matter?
Does your job play a role in this decision?
When are you ready for kids?
How many kids do you want?
What does your ideal future family life look like?
We, as women, are planners. We look to look ahead and evaluate our options. There are no guarantees. Egg freezing, embryo banking, delaying pregnancy may not result in your future family. The only “guarantee” is to get pregnant and have a baby now. But for many women, and I was one of them, this option is not right for the time.
I personally believe that fertility should be discussed at annual visits by OBGYNs. I believe that just as we ask “How are you preventing pregnancy?” in women who want children later, we should also be asking “Do you want to have kids sometime?”
What does an AMH test do in this scenario?
It will trigger an earlier evaluation by a Reproductive Endocrinologist.
It will give a patient more data.
It will allow me to counsel patients on their options.
Give them an understanding of what their reproductive future may hold.
The 36 year old who ran out of eggs early and is using donor eggs, she is my patient. She may have chosen to attempt pregnancy earlier or freeze eggs if she had this information that she had a “low” value at age 29. She would have at least had the opportunity to make her own choice for her future, instead of having her choice taken from her by time.
We need to stand up for women and understand that true empowerment comes from education.
Dear ACOG, no. Your recommendation to exclude AMH from a potential evaluation of reproductive timeline hurts women by taking away their opportunity for reproductive choice. And, as an organization, aren’t we all about supporting women in their reproductive goals?