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Tan Xiaojun
·Senior reproductive medicine expert
·Postdoctoral fellow at Peking University
·PhD candidate at Xiangya School of Medicine, Central South
University
·Master’s tutor at Central South University
· Master's degree candidate in reproductive
medicine at the University of South China
· Professional training at Huazhong University
of Science and Technology and Tongji
Hospital Reproductive Center
Expertise:
diagnosis and treatment of infertility, first/second/third generation IVF (including
egg/sperm donation), microsperm retrieval, embryo freezing and resuscitation, artificial
insemination (including husband's sperm and sperm donation), paternity testing, chromosomal
disease
diagnosis, high-throughput gene sequencing, endometrial receptivity gene testing and other
clinical
technology applications. Many of these technologies are at the leading level both domestically
and
internationally.
What additional tests are usually needed for low AMH? Beijing AMH low test, Shanghai ovarian reserve assessment, AFC sinus follicle count, FSH estradiol test, pregnancy preparation process assessment, what else to check for normal menstruation with low AMH, and pre-test tube examination for low AMH.
What six types of tests are usually made up after AMH is low? From ovarian reserve to fallopian tube, make the pregnancy assessment clear at once.
Let's start with the conclusion: low AMH does not mean that only one hormone test is made up.
Many people get the test sheet and see that AMH is low. The first reaction is "The ovaries are failing" and "Do you want to do test tubes right away?" This understanding is incomplete. **AMH is more like a reference index of ovarian reserve, which can help to evaluate the trend of follicular number, but it can not represent the natural pregnancy ability alone, nor can it determine the treatment path alone. The American Society of Reproductive Medicine (ASRM) pointed out that ovarian reserve detection includes AMH, basal FSH, estradiol and sinus follicle count under ultrasound; Moreover, the role of low AMH in predicting natural conception is limited, and it cannot be interpreted separately from age, menstrual condition and overall infertility evaluation. A prospective study cited by ASRM included 750 women aged 30-44. The results showed that the cumulative pregnancy rate of women with low AMH or high FSH after 6 and 12 trial cycles was not significantly different from that of the normal group.
Therefore, around the question "What additional tests are usually needed for patients with low AMH", the real answer is not "Which additional item", but: * * Do you want to judge the ovarian reserve and check the cause of infertility now, or are you going to enter the process of promoting ovulation or test tube? * * For different purposes, the make-up items are not the same.
Technical level: after AMH is low, six kinds of examinations are often made up in clinic.
Sinus follicle count (AFC) and transvaginal ultrasound
This is a key step outside AMH. AFC can observe the number of small follicles in both ovaries by Yin Chao, and can evaluate ovarian reserve together with AMH. Authoritative data generally believe that AFC and AMH are commonly used and relatively sensitive tools for evaluating ovarian reserve at present, which can better reflect the continuously changing ovarian function than FSH alone.
Yin Chao didn't just count follicles. It can also look at the ovarian volume, whether there are cysts, smart cysts, uterine fibroids, adenomyosis, abnormal endometrial thickness and other issues. That is to say, supplementing Yin Chao after AMH is low is not only to confirm the reserve, but also to exclude the structural factors that affect pregnancy and subsequent treatment.
Expert tip: AMH is low but AFC is acceptable, and AMH is low and AFC is low, so the clinical significance is not the same. The former often suggests that there is still a certain foundation for follicular recruitment, while the latter often suggests that the reserve has dropped significantly.
Basic FSH and Estradiol (E2)
ASRM suggested that basal FSH and estradiol should be detected jointly on the 2nd-4th day of menstruation. The reason is simple: FSH is sometimes "masked" by estradiol. When the ovarian reserve decreases further, estradiol may increase in early follicular phase, which in turn inhibits the increase of FSH, resulting in the illusion that "FSH looks OK".
Therefore, after AMH is low, these two indexes are often checked up in clinic, especially before preparing for ovulation promotion, artificial insemination or test tube. Their value is not to replace AMH, but to help judge to what extent the reserves have fallen and how they may react to drugs that promote excretion.
Evaluation of ovulation function
Not all people with low AMH need a complete set of ovulation tests. ASRM pointed out that if menstruation is regular and the cycle is roughly between 21 and 35 days, there is usually no need to do complicated ovulation confirmation tests; However, if irregular menstruation, amenorrhea, sporadic menstruation, or complicated with hirsutism and acne suggest endocrine abnormalities, it is necessary to further evaluate ovulation.
This kind of supplementary investigation commonly includes:
Progesterone in luteal phase
Continuous ultrasound monitoring follicular development
If necessary, combined with basal body temperature, ovulation test paper use history.
Check related endocrine indexes when menstruation is abnormal.
Many people mistakenly think that "low AMH = no ovulation". This is not right. * * Low **AMH mainly reflects reserves, and is not directly equivalent to ovulation. * * Some people have low AMH but regular menstruation and can still ovulate naturally; Some people have abnormal ovulation for a long time, although their AMH is not very low.
Tubal patency examination
If your goal is natural pregnancy or the doctor is doing a complete infertility assessment, you can't just stare at the ovaries after AMH is low. ASRM clearly pointed out that infertility evaluation should include ovulation status, female reproductive tract structure and patency evaluation, and male semen evaluation. Hysterosalpingography (HSG) or related contrast-enhanced ultrasound is commonly used in tubal examination.
This step is critical, because it is not uncommon to see such a situation in clinic:
Low AMH does exist, but the main reason that people can't conceive for a long time may be hydrosalpinx, tubal obstruction, pelvic adhesion or uterine cavity problems.
If you jump to conclusions only when you see the low AMH, it is easy to regard the "reserve problem" as the only problem.
Evaluation of uterine cavity and uterine structure
Some people have low AMH, are older at the same time, or have a history of abortion, abnormal menstrual flow, obvious dysmenorrhea, and a history of previous uterine cavity operation. At this time, it is often necessary to make up for the intrauterine environment. Common methods include Yin Chao, saline ultrasound and hysteroscopy when necessary. ASRM also emphasized the value of examining the structural problems of uterus and uterine cavity in the evaluation opinion of female infertility.
The reason is also very realistic: * * having eggs does not mean that you can get into bed smoothly. * * If endometrial polyps, submucosal fibroids, intrauterine adhesions or obvious adenomyosis exist, even if they enter the pregnancy assistance process later, the pregnancy outcome may be affected.
Male semen analysis
This is the most easily overlooked, but it should be done as soon as possible. ASRM clearly pointed out that female infertility assessment should be carried out in parallel with male infertility, and semen analysis is the basic component.
In reality, there is a common misunderstanding: the woman's AMH is low, so all the attention is focused on her. As a result, it took several months to find that the man's semen concentration, vitality or shape are also problematic.
If the pregnancy preparation time has reached the infertility evaluation standard, it is not an "optional" but a routine idea to check the man's semen after AMH is low.
Crowd angle: the focus of supplementary investigation is different in different situations.
People who have regular menstruation, are young and just started to prepare for pregnancy.
If this kind of people only find that AMH is low in physical examination, they should not be frightened by a single result first. Priority can be given to:
After Yin Chao +AFC, basic FSH and E2, review AMH if necessary.
The key point is to confirm whether this "low" is a real trend or a deviation caused by test differences, hormone fluctuations and medication background. ASRM also reminded that hormonal contraceptives and other factors may affect the interpretation of ovarian reserve indicators, so the results should be combined with the background of medication.
People who have been pregnant for six months to one year without results.
This kind of people can't just look at the ovaries, and usually have to enter a complete fertility assessment:
AFC, basic hormones, tubal patency, uterine cavity structure and male semen analysis.
Because at this time, the question has been upgraded from "how is my ovarian reserve" to "why not pregnant?"
People younger than 40 years old, but with obviously less menstruation, disordered cycle or even amenorrhea.
At this time, it is not only the "decline in reserves" that should be guarded against, but also the early-onset ovarian insufficiency (POI). International guidelines point out that AMH cannot be the primary diagnostic basis for POI diagnosis; If there is persistent menstrual abnormality, it should be evaluated with FSH and other indicators, and repeated detection after 4-6 weeks if necessary; At the same time, it is suggested to evaluate TSH when POI is diagnosed.
Expert tip: low AMH does not automatically equal POI. What really needs to be alert to POI is a combination of clues such as "younger age+abnormal menstruation+abnormal increase of FSH".
Someone who is going to make a test tube or promote excretion.
This kind of person's supplementary investigation project is more complete, with the focus on predicting drug reaction and making plans. It is usually combined with AFC, AMH, FSH/E2, as well as endometrial and basic ultrasound. According to Cleveland Medical Center, ovarian reserve assessment is often done by combining blood tests with Yin Chao.
How to arrange the process so that it is not easy to take detours?
A more practical order is usually like this:
First confirm whether the AMH report itself is comparable, such as whether it is completed in a regular laboratory, whether hormone drugs have been used recently, and whether there is a big difference in test time.
Then do Yin Chao and AFC, and then supplement the basic FSH and E2.
If you are already in the infertility evaluation group, then do the male semen analysis, fallopian tube evaluation and uterine cavity evaluation simultaneously.
If abnormal menstruation is obvious, check whether there are ovulation disorders, thyroid abnormalities, hyperprolactinemia and so on. ASRM's opinion is that hyperprolactinemia is not a general routine infertility screening item for women with regular menstruation, but it is indicated in anovulatory women.
The principle behind this is simple:
First, judge the ovarian reserve, then judge whether ovulation can occur, then judge whether the road is impassable, and finally judge whether the embryo and implantation environment are qualified.
This is closer to the real clinical path than staring at an AMH value and worrying repeatedly.
Frequently asked questions: After AMH is low, several things that people are most likely to ask wrong.
Q: With low AMH, is it difficult to get pregnant naturally?
Not necessarily. Existing studies and guidelines suggest that **AMH is better at reflecting ovarian reserve and ovulation-promoting response, which is not equal to the direct judgment of natural pregnancy probability. * * Especially in people who have regular menstruation and are not too old, we can't directly equate low AMH with "natural infertility".
Q: AMH is low. Do you need repeated blood tests?
It depends on the purpose. If it is accidentally found to be low in a single physical examination and does not match the clinical manifestations, it can be rechecked at the doctor's suggestion; However, if there are already manifestations such as low AFC, older age and decreased menstruation, the significance of simply measuring AMH repeatedly is often not as good as making a complete evaluation as soon as possible.
Question: AMH is low. Should we check the woman first or the man first?
If you have entered the stage of infertility assessment, both men and women should try their best to synchronize. * * This is the direction explicitly suggested in the guide.
Q: Should I make a test tube immediately when AMH is low?
You can't draw conclusions automatically. We should make a comprehensive judgment based on age, pregnancy duration, menstrual condition, AFC, FSH/E2, fallopian tube condition, male semen condition and previous pregnancy history. AMH low is only a variable in decision-making, not all.
summary
Around "What additional tests are usually needed for low AMH", the answer that is closer to the clinical practice is: * * AFC and menstrual Yin Chao, basic FSH and estradiol, necessary ovulation assessment, tubal patency examination, uterine cavity and uterine structure assessment, and male semen analysis are usually supplemented. * * Which of them must be done depends on whether you have a low AMH after a simple physical examination, or whether you have difficulty preparing for pregnancy, or are preparing for ovulation promotion, artificial insemination and test-tube treatment.
What really deserves vigilance is not the low AMH itself, but taking AMH as the only answer.
Medical research shows that fertility evaluation has never been "a numerical result", but put age, ovulation, fallopian tube, uterine environment and male factors together in the same picture. In this way, the judgment is closer to the truth, and the decision is less likely to go astray.
Common aliases:Kyrgyzstan Tulip Reproductive Center, Tulip IVF, Tulip Reproductive Center, Tulip Hospital, Kyrgyz Tulip Reproductive Center, Kyrgyz Tulip Hospital
