AMH levels, IVF and egg freezing
Dear Professor Winston,

I wonder if you could advise on a situation I am currently in. Approximately two years ago my partner and I, both female, underwent two cycles of IVF.  At the time her AMH was 1.3 and mine was 3.8 respectively. This was ok as we intended to use my eggs as donors. At the time we were offered additional tests such as FSH and LH. We only intended to do this once, however, my partner had polyps which were removed, but on the day of insemination there was another 10mm polyp present. The clinic (as it was their Dr that did the removal) suggested that this had grown back since the operation two months earlier. Because of this, my eggs, which had been retrieved, were frozen and insemination took place place a month later. This was unsuccessful and because of this issue we decided to try one more cycle which was also unsuccessful. We have recently been thinking about IVF again and we have had initial tests carried out with the same clinic. However, my partner’s AMH has now gone from 1.3 to 3.8, (age 41) and mine has gone from 3.8 to 1.4 (age 41) and they messed up my report with one from two years ago. We have found it strange that these results are almost polar opposites. Also I think that 3.8 is a significant rise particularly as everything I have read suggests that eggs decline with age.

We have had a consultation and I have expressed my concern over the AMH results. However, they have pushed this aside and suggested that diet may have helped the increase and given us a price list for a further two cycles circa £8500 (on top of £15k previously spent). I don’t feel that they have done anything to address our concerns and we have lost confidence. I have tried to find answers via HFEA, and journal papers, but this is difficult. Should I be concerned that our AMH results are completely opposite, or that my partner’s has gone up threefold? Is this usual? We are looking at just my partner going through the whole IVF cycle this time and we just don’t know if this is worth it and don’t feel confident that the clinic are being impartial with their advice. My partner’s full results are as follows: (FSH 7.7, LH 3.0, OESTRADIOL 220).

We just need some independent advice from someone who speaks their language, we are happy to pay for this.

Best regards, N

Dear N,

I think that there is a possibility here that you place too much reliability on AMH results. You are not alone as many clinics run by professionals tend to do so, too. AMH is possibly the best current test we have of ovarian reserve but it is by no means infallible. Moreover, the variations in levels that you record are totally within the usual limits of the test and I am somewhat surprised you were not told this. It just is not that accurate. Moreover, AMH varies very considerably, for example depending on how the blood is stored and also how the actual assay is done. Very often the fluctuations are far greater than those you record. Moreover, very low or very high AMH levels are not a guarantee of sterility or indeed fertility. Actually your two ages are probably more important and the truth probably is that the great majority of IVF cycles in women over 40 do not succeed. And when they do, the risk of early pregnancy loss or miscarriage is well-nigh close to 50% and this incidence rises after the age of 42. In some ways, FSH is actually a better measure because in my experience, in women whose FSH is raised – even if it is only on one occasion out of several tests over a period of time – the chances of successful IVF are poor. So much so that women in a heterosexual relationship often seem to have a better chance of pregnancy without IVF but just with regular sexual intercourse.

One thing you don’t tell me is more about your response to the drugs given to make you ovulate. These are frequently the best pointer of all. So the number of eggs that you produced and the number of those that fertilised successfully with an embryo is a very good rule of thumb measurement. If you are only yielding two or three eggs after stimulation with FSH injections, you may have to face the fact that further cycles are not likely to succeed. Also a further measure of a good response from ovaries in older women is, to some extent, the levels of estradiol which are produced at regular intervals during a simulated cycle. These may be available in your case, but sadly many clinics no longer bother to measure this hormonal response which I think makes assessment of a failed cycle a bit more problematic afterwards. Furthermore, the size of your ovaries when unstimulated and the number of small follicles seen at the beginning of a menstrual cycle are useful ultrasound indicators of your overall likelihood to succeed.

By the way, it seems from your email that your eggs were frozen before attempts at fertilisation. The success rates of egg freezing are very, very much lower than people realise, even in far younger women than yourself. I think you will find that very few women in the UK have had successful pregnancies after egg freezing when they were over 40 years old. I think you may need to ask the clinic you are attending what precisely are their live birth rates after egg freezing and particularly in women in your age group. How many successful pregnancies have they recorded? In my view, egg freezing for older women is simply not justified by the results I have managed to obtained from the government’s Department of Health.

I hope this is helpful. I notice that you kindly offer to pay for this information; that is really not necessary at all, but I should say that answering these emails easily takes up as much time as a consultation – and we both know what is charged for consultations in the average IVF clinic. However what is always deeply appreciated is a donation to the Genesis Research Trust which tries very hard to give impartial advice, whilst funding only top-quality research into all aspects of reproductive problems, including of course, infertility and miscarriage.

With best wishes
Robert Winston

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