Thursday, November 3, 2011

Low AMH: Diminished ovarian reserve or a Vit D deficiency?

I received this email a few days ago. This post is to address this question and as well as the many people  who have come across my blog doing Google searches for "low AMH" or "AMH and Vitamin D."

"I came upon your blog while googling for information about low AMH levels, which I'm sure you know, is very difficult to find.  I'm curious whether you've found any other information about increasing AMH levels other than Vitamin D.  I was diagnosed with low AMH (all else normal) and my RE told me there is no way for it to increase and that it would only decrease.  He was pretty doom and gloom about everything.  I'm currently using royal jelly, acupuncture, Chinese herbs, sprirullina, and a general prenatal multi-vitamin.  I haven't had my Vitamin D level checked yet but am considering doing that and asking about DHEA next time I go to the doctor as I'm hesitant to add anything else to the mix right now.  Thanks for sharing your story online."

In addressing the question asked of me, I have to point out one important fact that I think falls between the cracks with most people.

AMH is a surrogate marker. Why it is considered a good indicator of your ovarian reserve is because it tells you how many antral follicles are present in your ovaries each cycle. The antral follicles actually make your AMH. So more the antral follicles you have, the more your AMH, or at least, that is the logical stream of thought. Women with a failing or low ovarian reserve have very few follicles left, so their AMH is low. In other words, the problem is not that their AMH is low, but it is that they have few follicles left.

The question is, can your AMH be falsely low? To find this out, you must have an antral follicle count done. AMH alone, or AMH + FSH/E2 cannot give you the full picture.

If you have a low AMH and very few follicles left, then the probability, sadly, is indeed that you do have a case of diminished ovarian reserve.However, if your antral follicle count is normal/good/high and your AMH is too low, then something may be wrong.

One of two possibilities may account for this:

1) The lab messed the test up
2) The tantalizing Vitamin D theory: Now----I came up with the theory only based on the finding that the AMH gene is turned on by Vitamin D. This is solid, irrefutable science here.  What is still unclear is whether a vitamin D deficiency leads to suboptimal AMH production in the antral follicles. My findings imply that it did, but we cannot rule out that the first lab really messed up my AMH test. It needs to be studied clinically.
Updated 2 years later: Yes, this has been studied, and it is now fairly certain that your vitamin D level affects your AMH level. If your AMH level is too low when compared with your AFC, Vitamin D may be the culprit.

Overall, if you have a low AMH, then your plan of action must be to test for both vitamin D and your antral follicle count.

If your vitamin D is normal and your antral follicle count is low, then that just means you do have few eggs left.  DHEA seems to have some little success at improving the success rate in cases of diminished ovarian reserve, but its horribly unclear as to what is happening. Is it increasing recruitment of antral follicles from the diminished supply left? Is it improving egg quality as well? There was a study which actually showed that DHEA decreases the rate of aneuploidy. I don't know how solid the data is, but that is tantalizing if it is indeed so.

When you truly have DOR, then it is what it is. There is no way to fix it. You can, however, improve your chances with supplements (look for the CCRM cocktail).

I'll end on this note, and this is purely an informed opinion on my part: If  you want to have a baby, it is folly not to investigate your vitamin D3 levels. Its not just to treat infertility, but it is also proving to be very relevant in preventing pregnancy-related complications stemming from infection, autoimmunity, or pre-eclampsia. Just taking supplements is not the best way to go, because you don't know how much to take: you could end up taking too little, or in rare cases, too much.  

21 comments:

  1. You know, I just have to say that you. are. awesome.
    Plain and simple.
    Thank you for this post. There is nothing to be done with my ovaries, but I appreciate learning more about all issues surrounding infertility. AND, you are prompting me to ask my doctor to get my D3 checked next time I visit her.
     

    ReplyDelete
  2. Fascinating stuff. thank you for sharing. was just found to be vitamin d insufficient and am now supplementing.

    ReplyDelete
  3. A couple of other things about Vitamin D that I'll mention in case you haven't already come across them in your research...People who have hypothyroidism have a higher rate of low vitamin D levels than people who have normal thyroid function.

    Also, it used to be thought that people who live in locations that are mostly sunny are less likely to have a vitamin D deficiency because of the role that sunlight's exposure to the skin plays in the body processing vitamin D. However, with all of the publicity around avoiding the sun and/or wearing sunscreen to prevent skin cancer, that's not necessarily true any more. I live in the Southwest, and my PCP (who has been practicing for 30 years) said it used to be rare that her patients had a vitamin D deficiency, but now the majority of them do.

    ReplyDelete
  4. Good post. I was talking about the Vitamin D/AMH stuff with my SIL the other day, as she has a friend with super low AMH but a great AFC. Unfortunately, her friend isn't really that into actually learning about any of this stuff.

    Just because you might find this clinically interesting, I took shitloads of CoQ10 the cycle I got pregnant with this (successful, so far at 22.5w anyway) pregnancy. And for the first time, I had *true* EWCM. Not just "Meh, that's the closest thing to egg whitey, so I'll count it" but rather no shit, raw egg stuff going on. And lots of it. Coincidence? Maybe. But it's the ONLY cycle since I've been paying attention (3 years of regular cycles) that I've had the textbook EWCM.

    ReplyDelete
  5. It's surprising that more research hasn't been done into this, and that women aren't routinely tested for their D3 level. I'm also fascinated by what the poster below said - that there is a Vit D deficiency-hypothyroidism link. I have both (and had no idea).

    ReplyDelete
  6. You are one freaky smart addition to our little community.  Seriously, thank you for your posts and sharing your thoughts. 

    ReplyDelete
  7. Hi,

    We have been TTC for over a year off and on and 9 months rigorously. I was just diagnosed with low AMH and thanks to your site, I got my vitamin D tested since getting an AFC is a big expensive process. It turned out that I was severely deficient and now have had treatment for it. After I finish this course of vitamin D, I will get another AMH test done. I know 2 is not 'data', but hopefully - one day. 

    ReplyDelete
  8. Adele, yeah, there is most definitely a link. I think the most straightforward route is that hypothyroidism is most often autoimmune and a vitamin D deficiency really messes with immune cell homeostasis and is a promoting factor for autoimmunity.

    There could be a direct effect on the pituitary/thyroid glands themselves, this I have not ever investigated the literature.

    A post will one day come up on the role of vitamin D in various disease states, I find that stuff fascinating, but it requires significant research to write.

    ReplyDelete
  9. Very interesting. Kinda hard to say coincidence as its the first time you saw it in years!

    ReplyDelete
  10. wow, that is really interesting. Even if it turns out your ovarian reserve was really on the lowish side, based on everything I've read, your chances will be significantly better with the vitamin D repletion.

    Please keep me posted on what happens!

    ReplyDelete
  11. This is by no means scientific proof, but...

    I did three IVFs. Before the last one I had my D3 tested and treated back up to normal levels. While the last IVF was not successful, donor sperm medicated IUI did the trick (we were mostly male factor, along with my advanced maternal age of 41). Before the IUI I took DHEA, stopping just before I stimmed.

    I never had my AMH tested and my FSH was normal. But I am convinced that getting my Vit D level up helped.

    ReplyDelete
  12. Jay, thanks for commenting. I had been taking Vitamin D 2000-4000iu a day during my pregnancy. I was adding it in to be cautious since I knew my levels were slightly low. Your comment about my pcos and the immune issue does make sense, but I shouldn't have been deficient with the amount I was taking. Who knows what caused all this...
    MissConception

    ReplyDelete
  13. Hi Jay, 
    I was very happy when I got my vitamin D levels tested and found that it had jumped from 12 to 64. After a fortnight, when my curiosity got the better of me, I decided to go in for a repeat AMH test. I got the first one done in Australia and it was 6.4 pmol/l. The second one done in india turned out to be 3.01 ng/ml, which I am given to believe is close to 21 pmol/ml for AMH - I was overjoyed since this puts me in the satisfactory fertility range, and I am still in the middle of my course of vitamin D. I owe a lot to you and your blog and hope you find the resources you need to conduct research on this matter. 
    My sincerest thanks,
    T.

    ReplyDelete
  14. Wow, that is pretty darned amazing. It definitely not a slam dunk theory yet, one could always argue that the first lab messed the test up, but its starting to look more and more likely.

    Best of luck with your next attempt!

    ReplyDelete
  15. I should also add, now is the time to dial back on your Vitamin D3- about 4000 IU a day should be good for maintenance.

    ReplyDelete
  16. Do you think 10000I ii of vitamin D daily is enough to improve amh?? Mine was 1?6.

    ReplyDelete
  17. Well, if the theory above applies to you, then the goal really is to raise vitamin D and see what happens to AMH. 

    You first need to see what your VitaminD level is before taking large quantities, 10000 IU /day (for about 2 weeks) is what I'd recommend only if you ARE deficient. Afterwards, a good maintenance dose is between 2000-5000 IU, IMO.

    If you are already have normal levels of vitamin D, 10000 IU/day could put you in the toxicity dose.

    ReplyDelete
  18. Thank you for the connection you make between Vitamin D and low AMH. Unfortunately when I mentioned to my fertility specialist, this might be the culprit for my low AMH level (6.5 pmol/l) as my Vitamin came out severely deficient (I live in Canada), she shrugged it off and said it was impossible for AMH to change. I am now taken a high dosage of vitamin D. I have a question about the AFC, my AFC count was 13 during the cycle that I also tested for low AMH. Does this sound like it confirms the AMH level? Is 13 a small amount of follicles? Also I have ZERO other fertility issues that they can find and am 31, with one miscarriage in one year of trying. I really appreciate your time, what a lonely journey!

    ReplyDelete
    Replies
    1. Sorry about the late response, I never know when anybody comments here. How low was your AMH?

      Whether an AFC count is high or low in itself also depends on age. For example, an AFC of 13 would be low in a 20-year-old, but would be maybe okay for a 35-year-old (there are studies establishing ranges).

      Delete
  19. This comment has been removed by the author.

    ReplyDelete
  20. This comment has been removed by a blog administrator.

    ReplyDelete