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Can AMH levels be increased?

AMH, or Anti Mullerian Hormone, is a hormone made by the ovaries in females and the testicles in males which helps to develop the male and female reproductive organs. When assessing fertility, the amount of AMH in a woman can be measured to get an idea of her ovarian reserve – how many eggs are left in the ovaries.






Introduction

Unlike men, who are always producing new sperm to replenish their supply, women will have produced all the eggs that they will ever make by week 20 of gestation. At this time, roughly  halfway through the pregnancy, a female fetus will have reached her peak with an egg count between 6 to 8 million eggs. Due to a degenerating process known as atresia where egg cells are constantly dying, by the time the baby girl is born her egg count has dropped to 1 to 2 million. By the time a girl reaches puberty, according to a paper written by Human Reproduction Update, her egg count is between 300,000 to 400,000. By the time she is 30 years old, her count is between 100,000 to 150,000.

 


Where do all the eggs go?

It is estimated that a woman in the peak of her fertility loses about 1,000 eggs every month and only ovulates one. This is mainly due to the recruitment process where an average of 30 eggs are recruited every day from the primordial pool -the pool of dormant follicles that a baby girl is born with. Once recruited, it takes between 85 to 90 days for those eggs to be fully developed and be ready to be ovulated. By day 70, those eggs become sensitive to FSH and begin to grow and have a chance to participate in the menstrual cycle. Since FSH increases at the beginning and at the end of a menstrual cycle, a large number of the recruited eggs don’t make it to the menstrual cycle – they are either too old or too young to be affected by FSH. For example, those eggs that got recruited much more than 70 days earlier would have died by now, or be too old to respond to FSH. Those that got recruited a few days before the menstrual cycle are too young to respond to FSH, but they have a chance for the next cycle. It is interesting to note that only eggs that leave the primordial pool approximately 70 days before the start of any given menstrual cycle have a chance of being chosen as the egg that will be ovulated.



Background

Primordial follicles, which are created during fetal development, are the starting point of follicular development. They go through a series of changes; first, changing into primary follicles where only a single layer of cuboidal granulosa cells can be detected. They later develop into secondary follicles (sometimes referred to as preantral) where two layers of granulosa cells can be detected. The follicles then transition to tertiary, or antral follicles, where a fluid-filled vesicles appear in the granulosa cell layer. At this stage the follicles, now between 2 to 8mm in diameter can be seen and counted via a vaginal ultrasound on cycle day 3. This count, known as the antral follicle count (AFC), can be used by fertility experts to “predict” how many eggs are left – also known as the ovarian reserve.




AMH

The granulosa cells found in the follicles at the different stages of follicular development are the ones that produce anti-mullerian hormone (AMH). AMH production is at its highest in the preantral and small antral stages (less than 4mm diameter) of development. As the follicle grows, the amount of AMH being produced begins to decrease and by the time the follicle reaches more than 8mm in diameter there’s almost no AMH being produced. Since AMH is produced only in small follicles, the levels are fairly constant and a blood test can be done at any time during a woman’s menstrual cycle to measure the level of this hormone. The result of this blood test is used by fertility experts to attempt to measure the size of the pool of growing follicles in women. Research showing that the size of the pool of growing follicles is heavily influenced by the size of the pool of remaining primordial follicles (microscopic follicles in “deep sleep”) has made the results of an AMH blood test a standard to reflect the size of the remaining egg supply – or “ovarian reserve”. While ovarian reserve says very little about egg quality, there’s plenty of research showing that embryo quality depends on age, AFC and AMH. A study published in 2017 by the Journal of American Medical Association (JAMA) looked at the correlation between low AMH and fertility in women aged 30 to 44 and concluded that:


Among women attempting to conceive naturally, diminished ovarian reserve was not associated with infertility; women should be cautioned against using AMH levels to assess their current fertility


Can AMH be increased?

While several studies, including this one, have concluded that there is no correlation between primordial follicle counts and blood levels of AMH, they have also shown a strong correlation between AMH levels and antral follicle counts. In other words, AMH levels primarily reflect the number of antral follicles in the ovary.


As explained earlier, antral follicles - follicles that have advanced to a tertiary stage by having a fluid-filled vesicles appearing in their granulosa cell layer and have reached a size between 2 to 8mm in diameter, are the ones producing detectable amounts of AMH. Then, in order to increase the level of AMH one needs to increase the number of antral follicle.


To recruit follicles from the primordial pool of resting follicles requires a lifestyle where exercise is a daily routine to help regulate hormones, control stress, and help maintain a healthy weight. A diet that is rich in amino acids to help improve egg quality, rich in antioxidants to protect the eggs from future damage, and high in omega-3 fatty acids for overall reproductive health. Leafy greens such as spinach, kale, collard and bok choy are high in folate - an important nutrient for fertility. Berries are rich in antioxidants, nuts and seeds are high in vitamin E, and Brazil nuts, chia seeds and sunflower seeds are high in selenium.


A triple-blind study published in 2021 by Complementary Therapies in Medicine looked at the effects of vitamin E and selenium supplementation on AMH and antral follicle count. The study concluded that:

Supplementation with selenium and vitamin E can increase AMH and AFC in women with premature ovarian insufficiency


Acupuncture, AMH and AFC

The diagnosis of poor ovarian reserve (POR) or diminished ovarian reserve (DOR) is given when a woman has low AMH and/or low AFC. A study that was conducted to evaluate the effects of acupuncture in women diagnosed with POR who were going through the retrieval process of an IVF cycle, was published in 2021 by the Journal of Clinical Medicine. The study concluded that:

Acupuncture before IVF treatment has beneficial effects; it increases the number of retrieved mature oocytes or fertilized oocytes in patients with POR and aged > 37 years or undergoing more than one IVF cycle. These findings suggest that physicians can consider acupuncture for the treatment of women with POR and aged > 37 years or undergoing multiple IVF cycles

In a more recent study (August, 2023), a meta-analysis of randomized controlled trials evaluated the clinical efficacy of acupuncture for the treatment of diminished ovarian reserve (DOR). The study, which included a total of 13 randomized controlled trials involving 787 patients, concluded that:

Acupuncture may have significant clinical potential for patients with DOR in terms of improving sex hormones level and increasing AFC

A Chinese study conducted to evaluate the clinical effect of acupuncture on diminished ovarian reserve (DOR) and its influence on ovarian reserve function was published in June of 2020 by the Chinese Journal of Acupuncture and Moxibustion Science. The study used a protocol consisting of 13 acupuncture points where acupuncture was done 3 times per week for 3 months. The study concluded that:

Acupuncture at thirteen acupoints for regulating menstruation and promoting pregnancy can effectively improve the ovarian reserve function of DOR patients


Conclusion

AMH is produced by antral follicles and not by primordial follicles, therefore AMH is a reflection of follicles in their third stage of development with a size between 2 to 8mm and not a reflection of the total amount of “resting” follicles in the primordial pool. It has been demonstrated by several studies that AMH can be increased by using acupuncture to increase the number of antral follicles.



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