Endometriosis has been associated with a marker called Antimullerian hormone (AMH), which is a pivotal marker of ovarian reserve, and is commonly measured in women with endometriosis specifically in relation to fertility. There is debate among the community that your AMH level is what it is and it cannot change. I would challenge this notion though as I have seen people with endometriosis have significant increases after proper excision surgery, which is a point of debate. Recently, I had another patient send me lab work that demonstrated what some may call a low AMH, has confirmed endometriosis, but likely a surgery that was incomplete and is continuing to suffer ongoing symptoms. Though I have seen this change in my patients, I recognize this is only a small fraction of the people suffering, so it was time to review what the research says. This article aims to provide a review of the various studies conducted on this critical subject, exploring how endometriosis and AMH interact, the effect of surgical intervention on AMH levels, and the subsequent impact on fertility.
The Antimullerian Hormone (AMH): A Brief Overview
AMH, a hormone playing diverse roles during embryonic development and puberty, is produced by ovarian follicles smaller than 8 mm, hence linking ovarian reserve to AMH levels in the blood. The normal range for AMH hovers between 1 and 4 ng/mL. However, women’s AMH levels greatly vary based on factors like age, ethnic background, lifestyle, and genetics. Additionally, someone at the low end of range may still suffer problems despite them being “in range.”
AMH Testing in Reproductive Health
AMH testing is a crucial tool for evaluating female fertility. It can assist in:
- Assisting with understanding the prognosis of a woman’s response to assisted reproduction techniques (ART) such as in vitro fertilization (IVF)
- Confirming other markers of menopause
- Providing a more comprehensive evaluation when certain conditions are confirmed or suspected such as polycystic ovarian syndrome (PCOS), premature ovarian failure, and endometriosis
Endometriosis and AMH Levels
Endometriosis is a common culprit behind infertility, affecting nearly half of the women suffering from this ailment. This infertility arises from various factors, including inflammation in the reproductive tract, scar tissue-induced decreased blood supply to the ovaries, and pelvic anatomical distortions. Research reveals a significant correlation between endometriosis and lower than average AMH levels.
Some argue that surgical intervention of endometriosis often leads to a reduction in AMH levels, though many of us in the community may argue that this is a more nuanced topic and this highly depends on the skill of the surgeon, something that is often overlooked in endometriosis research. Various studies have attempted to decipher the impact of endometriosis surgery on AMH levels and fertility outcomes. A retrospective study conducted in 2016 found that preoperative AMH levels did not influence pregnancy rates after surgery. This is consistent with the literature we have on surgical impact, and thus the need for better research in the future. In my experience, this is the opposite of what I have seen, as many of us have seen when people get to the right surgeon.
Laparoscopic Cystectomy on AMH Levels
Laparoscopic ovarian cystectomy, a common surgical procedure to treat endometriomas, has been associated with decreased ovarian reserve. A study in 2019 demonstrated significantly lower AMH levels in women who underwent laparoscopic endometrioma cystectomy, especially in cases with bilateral cysts larger than 7 cm and stage 4 endometriosis.
Considerations: I want to highlight that we do not know the skill of the surgeon, but we do know that the skill of the surgeon matters. That being said, large endometriomas can often overtake ovarian tissue which is what happened to Christina. Hear her story here. This is why it is extremely important to find a knowledgeable surgeon that you feel comfortable with. If you need help finding a surgeon, you can start here.
Laparoscopic Endometriosis Surgery on AMH Levels
A literature review and meta-analysis of 19 studies conducted between 2010 and 2019 on the impact of laparoscopic endometriosis surgery on AMH levels post-surgery revealed a decline in AMH levels, extending beyond six months post-surgery. This decline was more pronounced in cases where surgery was performed on both sides of the body, compared to a single side.
Again, I would argue that we consider the quality of the research and the skill of the surgeon. Remember, ablation is different from excision and this may be another factor that is skewing results. I repeat this because, like many of us in the community, this is not our experience, thus I often read research with these things in mind. If many others in the community are also seeing this, there must be more to consider than what is presented. The bottom line is that we need better research.
AMH Levels Post-Surgery for Endometrioma
Several studies have observed that laparoscopic ovarian cystectomy results in a significant and progressive decrease in AMH levels post-surgery. However, other studies have noted that this decrease may only be temporary, with levels potentially returning to normal within a year. Another factor to consider is when the AMH was measured post-surgery and what other factors may have impacted the levels!
Certain studies have observed a temporary decrease in AMH levels following endometrioma ablation. However, this decrease did not persist beyond six months in most cases, suggesting a potential recovery of ovarian reserves.
Several studies have compared the decrease in AMH levels following ovarian cystectomy and endometrioma vaporization. The general consensus suggests a higher postoperative decline in AMH levels following cystectomy compared to vaporization, particularly in bilateral endometrioma cases.
This caught my attention and highlights my thoughts on how the surgery (excision) is being performed as to not compromise ovarian tissue. Using ablation, which is what the CO2 laser is referring to, may not compromise the ovarian tissue, but it also may not treat the disease. Paul Tyan, MD discusses this complex topic in our interview which you can find here.
The combined technique, involving partial cystectomy and ablation, has been shown to have less detrimental effects on the ovary, resulting in a lesser decline in AMH levels post-surgery.
The role of endometriosis surgery in improving pregnancy rates remains a topic of debate. Some studies suggest that surgery might improve the success rates of fertility treatment, while others highlight the risk of ovarian damage due to surgical intervention.
In conclusion, the Antimullerian hormone is a vital marker for assessing the impact of endometriosis and its surgical intervention on ovarian reserve and fertility. Understanding the complex relationship between AMH levels, endometriosis, and surgical intervention along with identifying gaps in the research can help medical professionals devise more effective treatment strategies, improve the quality of research studies which ultimately improves patient outcomes.
- Does Endometriosis Cause Infertility? Covering the Basics
- Endometriosis and Pregnancy: Natural, Medical, & Surgical Options