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Ovarian reserve refers to the quantity and quality of a woman's remaining pool of primordial follicles — the fundamental currency of her reproductive potential. Women are born with approximately 1–2 million oocytes; by puberty this has reduced to approximately 400,000 through atresia; and by the menopause fewer than 1,000 remain. Ovarian reserve testing provides a window into where a woman sits on this trajectory. The two most widely used quantitative markers are Anti-Müllerian Hormone (AMH) — a glycoprotein secreted exclusively by granulosa cells of small antral follicles — and Antral Follicle Count (AFC), the number of small (2–10 mm) follicles visible on transvaginal ultrasound at the start of the menstrual cycle. AMH values decline progressively with age and are the most age-calibrated marker available. Published population medians: age 25 approximately 3.5 ng/mL; age 30 approximately 2.5 ng/mL; age 35 approximately 1.5 ng/mL; age 40 approximately 0.7 ng/mL. Low AMH is defined as below 1.0 ng/mL (or below 7.1 pmol/L in SI units), and very low (poor prognosis) as below 0.5 ng/mL. AFC values: normal range 10–20 follicles bilaterally (total); poor prognosis if AFC below 5–7. These markers do not directly predict the chance of natural conception, but they are powerful predictors of ovarian response to controlled ovarian stimulation (COS) in assisted reproduction, predicting poor responders (who are at risk of cycle cancellation) and hyper-responders (at risk of ovarian hyperstimulation syndrome, OHSS). The POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) classification uses AMH and AFC alongside age and prior ovarian response to categorise poor prognosis patients in IVF.
AMH interpretation: >3.5 ng/mL = high reserve; 1.0-3.5 ng/mL = normal; 0.5-1.0 ng/mL = low; <0.5 ng/mL = very low (poor prognosis). AFC: normal 10-20 total follicles; poor response predicted if AFC <5-7
- 1Arrange a fasting early morning blood draw for serum AMH; AMH is relatively cycle-independent and can be measured at any point in the menstrual cycle.
- 2If AMH is unavailable, alternative serum markers include day 2–5 FSH and oestradiol — elevated basal FSH (>10–12 IU/L) and/or elevated oestradiol (>80 pmol/L) indicate reduced reserve, though these are less reproducible than AMH.
- 3Perform a transvaginal ultrasound on day 2–5 of the menstrual cycle to count antral follicles (AFC): sum the number of follicles measuring 2–10 mm in both ovaries.
- 4Cross-reference AMH and AFC values against age-specific normative data to classify reserve as normal, low, or very low.
- 5Combine AMH, AFC, and age to estimate expected ovarian response in IVF: expected poor response if AMH <1.2 ng/mL and AFC <5; expected normal response if AMH 1.2–3.5 ng/mL and AFC 5–15; expected high response if AMH >3.5 ng/mL and AFC >15.
- 6Counsel the woman on the significance of her result: low reserve does not preclude natural conception but indicates a shorter reproductive window and typically predicts poor IVF response; high reserve with AMH >5.0 ng/mL and polycystic morphology warrants OHSS risk counselling.
- 7Reassess AMH periodically if clinical decisions are pending: AMH declines by approximately 5–6% per year in reproductive-age women, faster in some.
AMH of 2.8 ng/mL is above the median for age 32 (approximately 2.2 ng/mL); AFC 14 is within the normal range
Both markers indicate adequate ovarian reserve. No urgent need to escalate to IVF. Continue attempting natural conception for up to 12 months total in a woman under 35.
POSEIDON Group 3 (older age, low reserve) — discuss donor egg IVF as a realistic option if own-egg IVF fails
AMH 0.6 ng/mL and AFC 4 are both below the poor prognosis thresholds. At age 38, the combination of age-related egg quality decline and low quantity significantly reduces IVF success rates with own eggs. Realistic counselling about outcomes and donor options is essential.
10% chance of spontaneous ovulation persists; embryo or egg donation is the most effective fertility option
AMH below 0.1 ng/mL with elevated FSH and amenorrhoea confirms POI. The priority is HRT for health protection. Fertility options include donor oocyte IVF, which achieves similar success rates to the donor's age, or embryo donation.
GnRH antagonist protocol with GnRH agonist trigger recommended for IVF to minimise OHSS risk
Very high AMH and AFC indicate polycystic ovarian morphology. The fertility problem here is anovulation, not quantity or quality of eggs. In IVF, these women are at very high risk of OHSS and require careful stimulation protocol selection.
Pre-IVF assessment to guide gonadotrophin dosing and predict ovarian response before stimulation., where accurate ovarian reserve analysis through the Ovarian Reserve supports evidence-based decision-making and quantitative rigor in professional workflows
Fertility preservation counselling before chemotherapy, pelvic radiotherapy, or risk-reducing oophorectomy., where accurate ovarian reserve analysis through the Ovarian Reserve supports evidence-based decision-making and quantitative rigor in professional workflows across diverse organizational contexts and analytical requirements
Egg freezing candidacy assessment to estimate likely oocyte yield per cycle., where accurate ovarian reserve analysis through the Ovarian Reserve supports evidence-based decision-making and quantitative rigor in professional workflows across diverse organizational contexts and analytical requirements
Evaluating reproductive potential in women with amenorrhoea or suspected premature ovarian insufficiency., where accurate ovarian reserve analysis through the Ovarian Reserve supports evidence-based decision-making and quantitative rigor in professional workflows
Counselling women with endometriosis about ovarian reserve before or after surgical management of endometriomata.
PCOS and falsely elevated AMH
Women with polycystic ovary syndrome (PCOS) have elevated AMH (typically 2–3 times age-matched controls) due to the large number of small antral follicles in polycystic ovaries. AMH cannot be used to assess ovarian reserve in the same way in PCOS as high AMH reflects polycystic morphology rather than superior egg quality. AFC with measurement of follicle size distribution is more informative in PCOS.
Iatrogenic ovarian damage
Chemotherapy, pelvic radiotherapy, and ovarian surgery (particularly for endometrioma) can cause rapid and irreversible AMH decline and follicle pool destruction. Women requiring these treatments should be offered fertility preservation (oocyte or embryo cryopreservation) urgently before treatment begins. AMH should be measured before and after gonadotoxic therapy.
Combined oral contraceptive pill (COCP) use
Some studies report that COCP use is associated with lower measured AMH (by 15–30%), which normalises after stopping the pill. This is likely due to follicular quiescence suppressing AMH secretion rather than true reduction in follicular pool. AMH testing in women currently using COCP should be interpreted with caution; testing 2–3 months after stopping is more reliable.
BRCA mutation carriers
Women with BRCA1 or BRCA2 mutations who are considering risk-reducing bilateral salpingo-oophorectomy (RRSO) — typically recommended at 35–40 years for BRCA1 carriers — should have fertility preservation discussions and, if desired, oocyte cryopreservation performed before surgery. AMH testing guides the likely yield of any fertility preservation attempt.
| Age | Expected AMH (ng/mL) | Clinical Interpretation |
|---|---|---|
| 25 | 3.5–4.5 | Good reserve; no urgency for fertility interventions |
| 30 | 2.2–3.5 | Normal reserve for age |
| 35 | 1.2–2.5 | Slightly declining; consider fertility timeline |
| 38 | 0.7–1.5 | Declining; IVF within 1–2 years if desired |
| 40 | 0.5–1.0 | Low reserve; expedite IVF or consider donor eggs |
| 43+ | <0.5 | Very low; success with own eggs limited; donor eggs recommended |
What does AMH actually measure?
AMH (Anti-Müllerian Hormone) is produced by granulosa cells of small (2–6 mm) antral follicles and preantral follicles. It reflects the current size of the pool of growing follicles, which in turn reflects the total remaining primordial follicle pool. Because granulosa cell mass is proportional to follicle number, AMH closely correlates with the available ovarian reserve. It is not significantly affected by the menstrual cycle phase, combined oral contraceptive pill use, or pregnancy.
Does low AMH mean I cannot conceive naturally?
No. AMH predicts ovarian response to stimulation drugs in IVF but does not directly predict the chance of natural conception. Women with low AMH still ovulate (unless POI is present) and can conceive naturally, though they may have a shorter reproductive window than women with higher AMH. The best predictor of natural fertility is age, followed by regular ovulation — not AMH level alone.
Can AMH be improved?
There is no proven intervention that increases ovarian reserve or reverses age-related AMH decline. Some studies suggest that DHEA supplementation, Coenzyme Q10, and certain antioxidants may modestly improve IVF outcomes in poor responders, but evidence is insufficient to make firm recommendations. Avoiding smoking (which accelerates follicle loss) and maintaining a healthy weight are the most evidence-based protective measures.
How is AMH used in IVF?
AMH guides individualised FSH dosing for ovarian stimulation. Low AMH (<1.2 ng/mL) predicts poor response and requires high FSH doses (300–450 IU/day). Normal AMH (1.2–3.5 ng/mL) supports standard dosing (150–225 IU/day). High AMH (>3.5 ng/mL) predicts high response and requires lower doses (75–150 IU/day) with careful monitoring to prevent OHSS. AFC is used alongside AMH for dose selection.
What is OHSS and when does it occur?
Ovarian Hyperstimulation Syndrome (OHSS) is a potentially life-threatening complication of ovarian stimulation in which the ovaries become massively enlarged and fluid leaks into the abdominal cavity and chest. It is most common in women with high AMH and high AFC (polycystic ovarian morphology). Severe OHSS (ASA grade 3) manifests as ascites, pleural effusion, electrolyte imbalance, and thromboembolic risk. Modern IVF uses GnRH antagonist protocols with GnRH agonist triggering (instead of hCG) to virtually eliminate severe OHSS.
What is the POSEIDON classification?
The POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) classification categorises poor prognosis IVF patients into 4 groups: Group 1 (young, unexpected poor response — adequate reserve but poor response); Group 2 (older, unexpected poor response); Group 3 (young, low reserve — AMH <1.2, AFC <5); Group 4 (older, low reserve). Each group has specific stimulation and strategy recommendations to optimise the number of mature oocytes retrieved.
Should all women have AMH tested?
AMH is most informative in women with fertility concerns, irregular cycles, or planning future fertility (egg freezing). Routine AMH testing in asymptomatic women without fertility concerns is not recommended by most guidelines, as a low result causes anxiety without altering management (natural conception advice remains the same). Women considering egg freezing should have AMH and AFC assessed to estimate the likely yield per stimulation cycle.
Is AMH the same as FSH?
No. FSH (follicle-stimulating hormone) is produced by the pituitary gland and rises when the ovaries have fewer follicles to feedback onto the hypothalamic-pituitary axis. Elevated basal FSH (above 10–12 IU/L) indicates reduced ovarian reserve, but FSH varies considerably between cycles and is less sensitive than AMH as an early marker. AMH starts declining years before FSH rises, making it a more sensitive early indicator of diminishing reserve.
Pro Tip
AMH expressed in pmol/L can be converted to ng/mL by dividing by 7.14 (e.g., 14.3 pmol/L = 2.0 ng/mL). Always confirm the unit reported by the laboratory before interpreting results, as confusion between units is a common clinical error.
Did you know?
Anti-Müllerian Hormone was originally discovered as the signal produced by the fetal testis that causes regression of the Müllerian ducts (which would otherwise develop into the uterus, fallopian tubes, and upper vagina) in male embryos. It was not until the 1990s that researchers discovered that granulosa cells in the ovary also produce AMH, and that its level could serve as a marker of ovarian reserve — transforming it from a developmental biology curiosity into one of the most clinically useful reproductive endocrinology tests available.
References
- ›La Marca A et al — Anti-Mullerian hormone (AMH) as a predictive marker in ART — Human Reproduction Update 2010
- ›Poseidon Group — A poor ovarian response to gonadotropin stimulation — Fertility and Sterility 2016
- ›NICE — Fertility Problems: Assessment and Treatment (CG156)
- ›ESHRE — Guideline: Ovarian Stimulation for IVF/ICSI (2020)
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