Treatment Options for Low Anti-Müllerian Hormone (AMH) Levels
For individuals with low AMH levels, treatment options include hormone replacement therapy, fertility medications, assisted reproductive technologies, and fertility preservation, with the specific approach determined by age, fertility goals, and the presence of symptoms.
Understanding Low AMH and Its Implications
- AMH is considered the best endocrine marker to assess age-related decline in ovarian reserve in healthy women, with levels below 0.7 ng/ml indicating incipient ovarian insufficiency 1
- Low AMH levels are indicative of diminished ovarian reserve, which affects fertility potential and may be associated with increased risk of miscarriage 1
- The interpretation of AMH should be age-dependent, with more reliable indication of diminished ovarian reserve in women 25 years and older 1
Diagnostic Evaluation
- Comprehensive hormonal assessment should include FSH, LH, and estradiol levels to confirm diagnosis of diminished ovarian reserve 2
- Antral follicle count (AFC) by transvaginal ultrasound correlates well with AMH and should be included in the evaluation 2
- Bone mineral density testing should be considered for patients with confirmed hypogonadism to assess for potential bone loss 2
Treatment Options
Hormone Replacement Therapy (HRT)
- For patients with symptoms of estrogen deficiency or premature ovarian failure:
- Estrogen may be replaced with oral, micronized, or transdermal preparations 2
- Progesterone therapy should be added to avoid unopposed estrogen effect and maintain endometrial health in women with a uterus 2
- Timing and dosing of HRT should be managed by specialists, particularly in younger patients to ensure appropriate pubertal development and final height 2
Fertility Medications
- Clomiphene citrate may be used for ovulation induction:
- Starting dose of 50 mg daily for 5 days, typically beginning on day 5 of the cycle 3
- If ovulation does not occur, dose may be increased to 100 mg daily for 5 days in subsequent cycles 3
- Treatment should not exceed 100 mg/day for 5 days, and should be limited to approximately six cycles total 3
- Monitoring for ovulation is essential, with ovulation typically occurring 5-10 days after completing medication 3
Assisted Reproductive Technologies (ART)
- In vitro fertilization (IVF) or intrauterine insemination (IUI) may be considered:
- For women with extremely low AMH (≤0.4 ng/ml), IVF can still achieve reasonable clinical pregnancy rates of 17%, improving to 27% in women younger than 35 years 4
- In women with AMH ≤1.2 ng/ml, IUI may be as effective as IVF, with similar pregnancy rates (13.3% vs 13.0%) 5
- IVF with donor eggs may be recommended for women with extremely low AMH who have failed other treatments 2
Fertility Preservation
- Oocyte cryopreservation should be considered for patients who wish to preserve fertility options 2
- Gonadotropin-releasing hormone agonist treatment before gonadotoxic therapy (e.g., chemotherapy) may help protect against premature ovarian failure 2
Special Considerations
- Women with low AMH can still achieve spontaneous pregnancy, as demonstrated by case reports of successful pregnancies even with negligible AMH levels (0.072 ng/ml) 6
- Low AMH does not necessarily increase the risk of early pregnancy loss in IVF/ICSI treatment 7
- AMH levels may fluctuate and increase with gonadotropin stimulation, suggesting it reflects the growing follicular pool responsive to gonadotropins rather than the entire primordial pool 8
Referral Guidelines
- Endocrinology/gynecology referral is warranted for patients with:
- Reproductive endocrinology consultation is recommended for: