Should I have a fertility assessment?

As a general OBGYN for years, and who has a strong interest in fertility, I often ask about family-building at your annual wellness visit. I get common questions such as "Can I get pregnant?" or "How will I know everything is okay for me to conceive?" or "When should I start trying?" It is well-known that egg quality and quantity decline with age, naturally.

When I was a resident in OBGYN, the AMH test (anti-mullerian hormone) started to become mainstream and used in normal practice settings outside of research, for infertility evaluation.  Back then (I sound old LOL), we learned that we should reassure couples who were trying within the first 12 months, as long as cycles were regular, with adequate frequency of sex.  No testing was offered until month 13, generally.  During the past 10 years, this has evolved, and more is now known about the test, but it still has primarily been recommended to be used in the setting of infertility, and mostly studied & used in the setting of IVF (in-vitro fertilization) or egg freezing cycle patients.  

Infertility and when an evaluation should start by traditional definition is categorized by age.  Infertility is not conceiving with unprotected sex between a biologically female and male couple over 12 months if the female partner is less than 35, after 6  months of trying if you are age 35 or over, and over 3 months if over age 40.  

Okay, so more on AMH.  It is a test of ovarian reserve.  For simplicity sake, let’s call it an egg count test.  Traditionally, cycle day 3 FSH (Follicle-stimulating hormone) and Estradiol are used as indirect egg count markers of how your ovaries are functioning.  AMH is a hormone that is produced by the granulosa cells of the ovarian pre-antral follicles, or the immature eggs, that are sitting in the ovary waiting to be stimulated by your brain hormones to mature and ovulate each month.  It is more of a direct count (but still not exactly), than FSH and estradiol is.

The American College of Obstetrics & Gynecology (ACOG) issued a committee opinion in March 2019 that stated that this test not be used in the general female population as a screening test to gauge fertility potential.  It was titled “The Use of Antimullerian Hormone in Women Not Seeking Fertility Care.”  Well, just as I always felt there was something a little wrong with having absolutely nothing to offer my patients who were about to try to conceive, trying to determine timing of pregnancy, I also don’t totally agree with the absolution ACOG offered that stated AMH can’t be done outside of infertility.  

However, I always stand by the statement when asked “when should I get pregnant?” with “when you are with the right partner”  If you aren’t with the right partner, let’s look at the options for you.  It is important to understand that time and age are the biggest natural predictors of fertility decline.  And that should never be taken lightly.  None of this is meant to cause anxiety, but it is meant to empower you with choices.  Whether that is to naturally try to conceive now, never, or by egg freezing - you’ve got to know the options exist.  Far too many of my patients, have ever learned this information.

While I do think one must tread super lightly when ordering and interpreting an AMH result outside of infertility, I also think studies and research will one day prove this ACOG statement antiquated.  I also have concern regarding the increasing average age of the female partner in today’s modern world.  There is more delay of childbearing than ever, with all the fabulous things women are doing education and career-wise, but to see a 40 year old who was never made aware of her options, and now has a critically low egg count, is heartbreaking in my office.  Where the average female does not have the knowledge that she is born with all the eggs she will ever have, and that with time, their quantity and quality goes down.  

The point is this – the AMH test is a measure of ovarian reserve, or the number of eggs you have left.  It is used and correlated with number of eggs retrieved in IVF and egg freezing cycles.  It does not predict future fertility and pregnancy, as there are too many factors.  Plenty of women get pregnant with a low AMH naturally.  It is not a reliable predictor of menopause.  It is not a diagnostic criterion, of PCOS (even though PCOS patients usually have high levels).  However, to say it should never be used outside of the infertile population is not giving options to some of our patients.  To freeze their eggs, or the option to become more aggressive with trying to conceive at a younger age of 28, versus 35 when she has just learned her ovarian reserve is low, after trying for a year.  The option to refer you to a fertility subspecialist earlier.  

With proper counseling, I believe this test, in combination with an antral follicle count, an ultrasound test that is directly counting the number of ovarian follicles, could be used to prepare some women, in some circumstances, outside of the setting of infertility.  It is not absolute.  My two cents.  I believe there are times where this testing can be done as a “fertility assessment” outside of infertility.  Only you with your OBGYN, or fertility doctor can decide.  With understanding that the AMH test is purely a test of quantity of eggs in the ovarian vault, and it is not a test of quality, nor is it a predictor of future fertility or ability to get pregnant.  It is however, one very important piece of the fertility puzzle.  There is certainly more at play, and proper education can bring informed decision on obtaining this test, or not, and how to interpret it.

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