2013
Low AMH and Natural Conception
Author affiliations
- NeoFertility Clinic, Suite 7, 1st Floor, Beacon Mall, Sandyford, Dublin 18, Ireland. Phil.Boyle@NeoFertility.ie. ROR
RRM Academy Synopsis
Low AMH Does Not Predict Whether a Couple Can Conceive Naturally
Three couples with low AMH, all advised donor-egg IVF, conceived naturally with their own eggs after cause-based treatment.
Key Findings
- All three couples had been told donor-egg IVF was their best or only option. Natural conception, they were advised, was not worth attempting. After cause-based ovulation induction with letrozole or clomiphene and cycle charting, all three conceived naturally with their own eggs.
- Couple 1 carried an AMH of 0.07 pmol/l. The testing lab classified that as very low or undetectable ovarian fertility potential, and her FSH had run as high as 45. Both partners were 36, with six years of infertility, and had been judged unsuitable even for IVF. They conceived on the first ovulation-induction cycle and delivered a 9lb (4.08kg) boy at term with no complications.
- Couple 2 had an AMH of 3.2 pmol/l after four failed IVF cycles, one a donor-egg cycle. Charting and bloods found the real obstacles: brown premenstrual bleeding, a day-7 progesterone of 36.7 nmol/l, poor cervical mucus, and incomplete follicle rupture. Once those were corrected, they conceived.
- Couple 3 had an AMH of 2.8 pmol/l and a label of unexplained infertility after two failed IVF cycles. Boyle found treatable causes the label had hidden: mild endometriosis, a fimbrial cyst, low luteal hormones, and recurrent unruptured follicles. They conceived on the third modified cycle.
- Boyle set the recommended alternative beside his cases. An Irish clinic logged 104 donor-egg IVF pregnancies from 2007 to 2012. Among them, 46% had major antenatal complications, the cesarean rate was 77%, and there were two fetal deaths.
Clinical Implications
A low AMH tells you how a woman might respond to IVF stimulation. It does not tell you whether she can conceive. It is not a reason to skip treatment and route a couple straight to donor eggs. In each of these cases the AMH number was treated as a verdict, and the verdict was wrong. What changed the outcome was looking for the actual obstacles: anovulation, incomplete follicle rupture, low progesterone, poor cervical mucus, endometriosis. The working parts are ordinary restorative tools. Cause-based ovulation induction with letrozole or clomiphene, follicle tracking to confirm rupture, day-7 progesterone and oestradiol, and Creighton chart review. Natural conception needs one good egg, not the ten to twenty an IVF retrieval is built around. A thin reserve is a far smaller obstacle than the number implies. A very low AMH is a reason to look harder, not a reason to stop.
Study Notes
A three-couple case series from Boyle's Galway clinic, presented at the 2013 IIRRM meeting. Each case is documented end to end: serial hormone levels, Creighton charts, ultrasound follicle tracking, the exact treatment protocols, and outcomes through delivery. Each of these women had been told her own eggs were finished. Each is shown, cycle by cycle, conceiving with them.
RRM Context
Boyle's clinical claim has since been backed by the strongest evidence available. Steiner's 2017 JAMA cohort followed 981 women. Low AMH did not lower the chance of conceiving naturally. By twelve cycles, 84% of the low-AMH women had conceived, against 75% of those with normal AMH. The EAGeR trial (Zarek 2015) found AMH was not associated with fecundability, with conception rates near 65% across low, normal, and high AMH. Galati's 2024 study compared 252 women with unexplained infertility to 252 with male-factor infertility. Ovarian reserve markers were identical between the groups. The authors concluded ovarian reserve is unremarkable to natural conception. AMH predicts response to stimulation, an IVF parameter. It does not predict natural conception, the question these couples were actually asking. Boyle's later record carries the thread forward, including healthy singleton pregnancies after failed IVF.
Abstract
AMH levels are commonly measured in fertility clinics to assess ovarian reserve and give an indication of female fertility potential. AMH levels are useful in deciding on stimulation protocols for IVF cycles. High AMH levels are useful to confirm a diagnosis of polycystic ovaries. Currently AMH levels cannot be used to predict a couple's ability to conceive naturally.
Cite this article
Boyle, P. C. (2013). Low AMH and Natural Conception.
Boyle PC. Low AMH and Natural Conception. 2013.