Is AMH the Only Test for Ovarian Reserve?
No, AMH is not the only test for ovarian reserve—antral follicle count (AFC) by transvaginal ultrasound is actually the most established method for assessing ovarian reserve in adult women, though AMH is considered the best endocrine marker and is increasingly preferred in clinical practice. 1
Primary Tests for Ovarian Reserve Assessment
Antral Follicle Count (AFC)
- AFC by transvaginal ultrasound remains the most established method for assessing ovarian reserve in adult women, despite not being part of current clinical criteria for premature ovarian insufficiency (POI). 1
- AFC shows a strong positive correlation with AMH levels (r=0.972), making it one of the best predictors of ovarian reserve. 2
- However, AFC is operator and equipment-dependent, limiting accuracy and reproducibility, and requires expensive equipment and trained personnel. 1
Anti-Müllerian Hormone (AMH)
- AMH represents the best endocrine marker to assess age-related decline in ovarian reserve in healthy women, particularly those ≥25 years of age. 1, 3
- AMH shows the strongest negative correlation with age (r=-0.931) compared to other biochemical markers, making it the most reliable indicator of reproductive aging. 2
- AMH is considered a first-line test by 60% of IVF clinics worldwide and is deemed the best test for evaluating ovarian reserve by 54% of providers. 4
Follicle-Stimulating Hormone (FSH)
- The monotropic rise in FSH is the hallmark of the menopausal transition and is important for diagnosing POI. 1
- Day 3 FSH shows a positive correlation with age (r=0.408) but is less reliable than AMH for predicting ovarian reserve. 2
Additional Markers
- Inhibin B shows a strong negative correlation with age (r=-0.878) and positive correlation with AFC (r=0.769), though less robust than AMH. 2
- Ovarian volume correlates negatively with age (r=-0.876) and positively with AFC (r=0.919). 2
- Estradiol and LH are measured but show weaker correlations with ovarian reserve compared to AMH. 2
Age-Specific Considerations
Women ≥25 Years
- AMH is inversely correlated with increasing age in women ≥25 years, making it a clinically useful marker of ovarian reserve in this population. 1, 3
- AMH interpretation is most reliable in this age group where validated normative data exist. 5
Women <25 Years
- AMH may fluctuate significantly throughout the menstrual cycle in young women, particularly those under 25 years. 1, 3
- Interpretation should be cautious in this age group due to potential fluctuations. 3
Clinical Context Matters
For Fertility Assessment
- At-risk postpubertal females without signs of POI who desire assessment of future fertility should be referred for specialist consultation rather than relying on a single test. 1
- While AMH is useful for ovarian reserve assessment, age remains the best predictor of live birth rate according to 81% of IVF providers. 4
For Cancer Survivors
- AMH is frequently used as a marker of ovarian reserve in survivors of childhood cancer treated with alkylating agents and/or radiotherapy. 1
- AMH may be useful to distinguish between different levels of ovarian reserve impairment in this population. 1
For PCOS Diagnosis
- AMH could serve as a valuable surrogate marker or alternative to ultrasound for detection of polycystic ovarian morphology (PCOM), though this is still being validated. 1
Important Caveats
Assay Limitations
- The lack of an international standard for AMH limits comparison between different AMH assays, and direct comparison of results remains problematic. 6
- Different AMH assays may yield varying results, requiring interpretation within specific laboratory reference ranges. 7
Clinical Application Gaps
- There are no studies describing the value of AMH in the diagnosis of POI in either cancer survivors or the general population, despite its use as a marker of ovarian reserve. 1
- Standard laboratory evaluation is not recommended as primary surveillance in at-risk females without symptoms of POI. 1