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For older infertile women, AMH ( anti-Mullerian hormone, also known as MIS ( Mullerian inhibiting substance) has become the new FSH . AMH is a very good marker for egg quality - and provides us with a quantitative measure for egg quality and quality.

In the past, we had to depend upon FSH levels. A high FSH level suggests poor ovarian reserve, but FSH levels are not very reliable, because they vary according to which day of the cycle the test is done; and can also be artificially suppressed by a high estradiol level

AMH is a much better marker for ovarian reserve. It does not vary from cycle to cycle; and remains the same throughout the cycle. A low AMH suggests you have poor ovarian reserve - but even if your level is low, this does not mean you should panic !

Remember that it's just a test - and good doctors do not treat tests - we treat patients !

Step number one is to repeat it again - preferably from another lab.
Step number two is to run additional tests to check your ovarian reserve.

You have 2 options: an ultrasound test called the antral follicle count ?
and a blood test called a clomid challenge test.

Even if these are poor, this does not mean you cannot improve it ! While Western medicine does not have much to offer, there are alternative medicine options you can try to improve your ovarian reserve

These include the following:

1. Yoga
2. Acupuncture
3. DHEA, 25mg thrice a day.
4. Wheat germ daily
5. CoQ 10, 100 mg daily
6. Vit D3 ( Calcirol), 60000 IU, once a week for 10 weeks

Read the book, Inconceivable.

Re-test your AMH level after 12 weeks to see if it improves.

Even if it does not improve this does not mean you cannot get pregnant ! Patients with low AMH levels do also get pregnant on their own ( though their chances are reduced). After all, levels provide information about groups of women , and there can be a lot of individual variability !

If you have poor ovarian reserve, IVF is often your best option as it maximises the chances of a pregnancy. IVF allows you to make the best use of the few eggs which are left, by telescoping time.

Plan B would be to use donor eggs, if you are willing to consider this option. This has a much higher success rate

Many older infertile women are very unsure as to whether they need to do IVF; and if they do need IVF, if they should use their own eggs or to use donor eggs. While they understand with their heads that using donor eggs would maximise their chances of getting pregnant, it's hard for their heart to accept this decision, because most of us want a genetic link with our child !

This is especially true for older women who have regular cycles; grow follicles on ultrasound scans ; or have had a miscarriage in the last 2-3 years. If my cycles are regular and I can get pregnant in my own bedroom, doesn't this prove my eggs are fine ?

Gynecologists ( who do not specialise in infertility treatment) will often add to this confusion. Because they see 42 year old women who get pregnant in their own bedroom, they fail to understand there is a big difference in the biology of a fertile 42 year old and an infertile 42 year old. They will often "treat" these older women with clomiphene and follicular monitoring - causing them to waste valuable time !

The more sophisticated doctors will get their patient's FSH levels tested - and if these are normal, this will lull them into a false sense of security ! Not only are FSH levels very poor markers of ovarian reserve, they also vary from month to month; and if they are checked without also testing the estradiol ( E2) level at the same time, you may get an apparently normal FSH level, even if the ovarian reserve is very poor. ( A high E2 level can suppress a high FSH level into the normal range, and fool both doctor and patient !)

Unfortunately, most older women do not want to hear bad news. They are often in a state of denial and are not happy to listen to an IVF specialist who tells them that their "eggs are bad" ! They confuse calendar age with ovarian age - and are even more perplexed when they go online and read success stories of older women with high FSH levels who have got pregnant in their own bedroom !

Who should they trust ? Is the IVF doctor pushing IVF because he wants to make more money ?
Or is he providing medically sound advise ? Will you regret not doing IVF ? Or do you have an equally good chance of making a baby in your own bedroom ? And what if the IVF cycle fails ? Then what ?

While it's true that we do have better tests today for checking ovarian reserve, such as the AMH level and the antral follicle count , it's hard to make such an emotionally charged decision based purely on the results of medical tests. How reliable are these tests ? Can the results improve with alternative medicine ? herbal supplements ? acupuncture ?

If you are unsure what to do , and are emotionally detached enough to make a decision based purely on medical testing, then please ask your doctor to do a clomiphene citrate challenge test ( CCT) for you. This is a simple , inexpensive test, which provides very valuable information; and has stood the test of time. When it's hard to make a decision and you are confused, sometimes basing your decision on an objective test result can help you overcome your paralysis and move on with your life !

How does one do this test ?

Day 1 = day the bleeding of the period starts

On Day 3 , you need to do a blood test to measure your levels of FSH,LH,PRL and TSH; and AMH ( anti-mullerian hormone). Do this from a reliable lab please !

Take 100 mg clomiphene citrate from Day 5 - Day 9.

Repeat the blood test for FSH again on Day 10.

If the Day 3 plus Day 10 FSH levels are less than 25, then we can try to do IVF with your own eggs.

If the Day 3 plus Day 10 FSH levels are more than 25, this suggests you have ovarian failure,
and that donor egg IVF would be your best treatment option, if you are willing to consider this. A low AMH level will help to confirm this diagnosis.

If you are not sure how to interpret your results , you can ask me for a free second opinion !

For the older woman, time is now at a premium for you - please don't waste it ! When you are 60 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. Treatment can be expensive, but a baby is priceless !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

I saw a 30 year old woman today who wanted a second opinion. She had failed multiple IVF cycles in other clinics and had been advised surrogacy. When I reviewed her medical records, I found out that her ovarian reserve had never been properly tested. I checked her AMH levels, and found to my dismay that they were very low. She had very poor ovarian reserve and would need donor eggs if she wanted a baby. I was afraid she would be upset when I broke this news to her, and did so as gently as I could .

I answered all her queries :

Why didn't the other doctors do this test for me ?
How come I am still growing eggs if my AMH is so low ?
Can't we treat the AMH level ?

and then asked her - Are you angry with me for giving you this bad news ?

She looked at my crestfallen face , and then gave me an answer which proved she was wise beyond her years ! She reassured me - Please don't worry doc, actually, this is good news. At least we know now what our problem is, and rather than continuing to grope in the dark, we can explore options which will maximise our chances of success !

Truly I am blessed that I have the opportunity to learn so much wisdom from my patients daily !

Many women these days are postponing having a baby in order to pursue a career. The good news is that while usually fertility does not decline too much until the age of 32, for some women the decision to postpone childbearing can prove to be one they bitterly regret later on. Fertility does decline as a woman grows older, and the problem is that it is not possible to predict the rate of decline for an individual woman. Most women are lulled into a false sense of security if they have regular period, because they assume that if their periods are regular, this automatically means that their egg quality if enough for them to make babies !

Unfortunately, this is not always true - and for some women, while their egg quality is enough for them to produce enough hormones to get regular periods, it may not be enough to make a baby ! Also, many women have very unrealistic expectations of IVF technology, thanks to all the stories of the over-40 celebs who have babies all the time ( often by using donor eggs, a fact which is very jealously guarded secret) !

How is an individual woman going to find out which category she falls into ?

Suppose you are 32 and want to postpone childbearing for another year because you have a very good chance of getting a promotion ? Is it safe to do so ? Or will this be something you will kick yourself for later on when your IVF doctor says - I wish you had come to me earlier ?

The bad news was that until now, there really was no very good test to check ovarian reserve. This often meant that most women had to just leave things upto destiny, which can be notoriously fickle.

The good news is that there is now a very good test to check your ovarian reserve !

The bad news is that most women are unaware of this test !

The good news is that this is a very simple blood test, which most labs now offer !

The bad news is that most family physicians and gynecologists are still unaware of this test and what it means !

So what's this test ?

This is a blood test for checking your AMH ( anti Mullerian hormone) levels. It can be done on any day of your cycle. The level correlates well with your ovarian reserve - the quantity and quality of eggs you have in your ovaries. Women with normal levels have good ovarian reserve; while those with low levels have poor ovarian reserve.

If you are more than 32 and want to postpone childbearing, I'd suggest you get this test done. If it's low, you might want to re-think your priorities. If it's normal, then it's fine to postpone childbearing, but do get the test repeated every year. If it starts dropping, this is a sign you might want to pay attention to your biological clock before it is too late !