Anti Mullerian Hormone (AMH) in Indian Patients Presenting With Infertility

In the present scenario of advanced infertility treatment, there is lot of expectations and great disappointments when negative results are obtained. Hence good markers are needed to counsel patients about the probabilities of success and detect the poor prognostic patients so they can be counselled in greater detail. Most cases of success depend on the number and quality of ova produced. This in turn depends on the ovarian reserve. Ovarian reserve in the quantification of the number of follicle that are still present that can develop and release the ovum. As the age increases the reserve reduces. In age more than 40 the reserve is very poor. A number of tests are available to quantify the reserve. One of them is anti mullerian hormone.  

Anti Mullerian Hormone (AMH) is considered as an important marker of the ovarian reserve.  It is secreted by the granulose cells (the cells surrounding the ovum) of the ovarian follicle. More the ova, more is the granulose cells and so the AMH is high. Very low values indicate exhaustion of the ova or low ovarian reserve. This is a poorer prognostic indicator for in-vitro fertilization (IVF) success, as a low AMH levels indicate that only few follicles will be formed and they may be of poor quality.  Conversely, high AMH levels are also clinically significant. High AMH levels may be seen in polycystic ovarian disease (PCOD) and it may be a predictor for ovarian hyper stimulation (OHSS) in IVF cycles. This means excess eggs are formed leading to water retention and rarely heart failure or even death during IVF cycles. Reliable data on AMH levels in Indian patients are limited. This study was done to compare the AMH levels in infertility patients presenting at our Infertility Centres in New Delhi. The AMH levels were correlated with age and western standard (normal) range available.

Materials and Methods:
All Indian consecutive patients who presented for evaluation of infertility in a one year period (2012) at our centre were enrolled for this study. Patients not consenting for the study were excluded. The age of the patients and demographic features were noted. Five ml of blood was collected from the patients, and the AMH levels were estimated. The AMH levels were compared with the western standard cut offs.

A total of 123 infertile patients in the age group of 20 to 51 years were tested for AMH levels. The average age is 32.40 years. The average AMH is 14.635 pmol/L.  

There were 18 patients in the age group less than 25 years, 23 patients between 25 to 29 years, 33 patients between 30 to 34 years, 36 patients in age group 35 to 39 and 14 patients more than/ equal to 40 years of age. The youngest patient was 20 years old and the eldest was 51 years. They belonged to middle and upper socio economic status.
There was a significant inverse correlation between AMH levels and age. With increasing age, the mean value of AMH declined.

Two tables are given:
Table 1. Standard cut off for serum AMH LEVELS
1.       Optimal Fertility        -              28.6 - 48.5 pmol/L
2.       Satisfactory Fertility                -             15.7 - 28.6 pmol/L
3.       Low Fertility               -                 2.2 - 15.7 pmol/L
4.       Very Low                     -                 0.0 -   2.2 pmol/L
Table 2. Age-wise categorization of AMH levels
Age groups
Number of patients
Very low
<25 years
25 – 29 years
30 – 34 years
35 – 39 years
> 40 years

It can be seen that only one third of patients in all age groups have either satisfactory or optimal AMH levels. Even in < 25 years age group 8 of the 18 patients have either low or very low AMH levels.  85 out of 123 patients (69.1%) had levels of AMH below 14 pmol/L. This value is considered as the critical level of ovarian reserve for good pregnancy outcomes.  

AMH levels are useful in predicting the likely response during the IVF cycles, so it is useful to decide the type and dosage of medicines. AMH estimation may also be useful predicting ovarian ageing and act as a guide in how long a woman can delay childbearing. AMH levels may also be useful in predicting the age of menopause. AMH levels may also serve as a useful marker of PCOS. AMH levels are also worthwhile in estimating the reserve prior to or following chemotherapy and ovarian surgery.

Studies from India have shown that AMH levels and antral follicle count (AFC) correlate with each other.  Large databases from the Western population have clearly established the values and age specific cut-offs of AMH. Such data are limited among Indian fertile and infertile patients. We found surprisingly lower levels of AMH among Indian infertile patients undergoing IVF. 85 out of 123 patients (69.1%) had levels of AMH less than 14 pmol/L, which is the critical level for good pregnancy outcomes. Larger studies with more number of patients are required to establish whether Indians really have lower levels of AMH than published in the western literature.

To conclude, we found lower levels of AMH among Indian infertile patients undergoing assisted productive techniques. The AMH levels were lower across the age categories. Majority of patients did not have optimal or satisfactory levels of AMH.