(Originally published on INCIID. Article by Scott Roseff, MD –  Editorial notes and INCIID update May 2026 )

 EGG QUALITY starts declining when a woman is in her mid-20s. There is a slow decline in quality from about age 24 to age 30, followed by a fairly quick decline between age 30 and age 35, with a rapid decrease between ages 35 and 40. And, over age 40, egg quality is generally quite poor. All of this may make it difficult to get pregnant.

OVARIAN RESERVE describes a woman’s capacity to produce a reasonable quantity of good quality eggs. Of course, measuring a woman’s ovarian reserve is very important in determining why someone may not be getting pregnant, as well as in finding out the ease (if she has good eggs) or difficulty (if she has poor eggs) with which a pregnancy may be realized.

Women with normal ovarian reserve (good eggs) may conceive via simple therapies (such as timed intrauterine insemination), while women with abnormal ovarian reserve (poor eggs) may require in-vitro fertilization (IVF) or even IVF with donor eggs.

Until the time Dr. Roseff wrote this article, we had only been able to INDIRECTLY measure a woman’s ovarian reserve via a cycle day 3 FSH/estradiol blood test, or through a Clomiphene Citrate Challenge Test (CCCT). These tests measured the brain’s hormones which were indirectly affected by the ovary’s egg quality. While these tests were the best available at the time, AMH offered a more modern and sensitive blood test which more directly reflects a woman’s ovarian reserve.

[INCIID Editor’s Note, 2026: The FSH and CCCT tests described above remain in use today, but AMH testing is now the standard first-line assessment for ovarian reserve at most fertility clinics. ASRM guidelines confirm that AMH and antral follicle count (AFC) together provide the most reliable picture of ovarian reserve currently available. The CCCT is rarely ordered today.]

The human egg is “housed” inside a structure called the follicle. The follicle is comprised of specialized cells called granulosa cells. The granulosa cells produce a specific hormone directly and predictably linked to egg quantity, and that hormone is called AMH. While other means of examining ovarian reserve may offer indirect tests of egg quality (such as cycle day 3 FSH/estradiol levels and the CCCT), many reproductive endocrinologists believe women are better served by examining their AMH level — a more direct, more accurate, more specific, and more predictive test of ovarian reserve.

[INCIID Editor’s Note, 2026: It is important to understand that AMH reflects egg quantity — the size of your remaining follicle pool — not egg quality. A good AMH result tells your doctor that your ovaries are likely to respond well to stimulation and produce eggs. It does not tell you whether those eggs are chromosomally normal or capable of resulting in a healthy pregnancy. Egg quality is most strongly determined by age, not by AMH level. See the 2026 Update below for more detail on this critical distinction.]

The AMH test has been found particularly useful in the following clinical situations:

• Women who either need a Clomiphene Citrate Challenge Test (CCCT) or previously had a CCCT and want to confirm or refute the results
• Women of advanced reproductive age (35 years or older)
• Any woman with a diagnosis of unexplained infertility
• Women who have shown a poor response to ovulation induction with either Clomid/Serophene or injectable fertility drugs
• Women who have been told they need IVF with donor eggs — a normal AMH level may permit them to do IVF with their own eggs, while an abnormal AMH level may confirm the need for IVF with donor eggs
  
  This article was written and originally published Scott Roseff, MD Editorial notes and peer reviewed research added May 2026 Update added by INCIID.

2026 Update: AMH — What We Know Now

Editorial update by INCIID, 2026. All updates reflect current peer-reviewed literature and ASRM guidance.

When Dr. Roseff wrote the article above, AMH testing was a relatively new tool in reproductive medicine. In the years since, AMH has become the cornerstone of ovarian reserve assessment worldwide. We now understand it far more completely — including both its remarkable usefulness and its important limitations. This update expands on what Dr. Roseff introduced and brings patients and providers up to the current state of the science.

What AMH Actually Measures — and What It Does Not

AMH is produced by the granulosa cells surrounding the small antral and preantral follicles in the ovaries. Because those follicles each contain a developing egg, AMH levels reflect the size of the remaining follicle pool — in other words, how many eggs a woman has left in reserve.

This is genuinely valuable information. AMH is one of the best predictors available of how a woman’s ovaries will respond to stimulation during an IVF cycle. It helps clinicians plan medication protocols, anticipate how many eggs are likely to be retrieved, and identify women at risk of poor response or ovarian hyperstimulation.

However, AMH does not measure egg quality. It does not tell you whether your eggs are chromosomally normal. It does not predict whether fertilization will succeed, whether an embryo will implant, or whether a pregnancy will result in a live birth. These outcomes depend primarily on egg quality — and egg quality is most strongly determined by age, not by AMH level.

This distinction matters enormously for patients. A woman in her late 30s with a normal AMH result may feel reassured — but her eggs are still subject to the age-related decline in chromosomal integrity that affects all women as they age. A woman in her early 30s with a low AMH result may be anxious — but her eggs, being younger, may still be of good quality even if fewer in number.

As ASRM and current research consistently confirm: AMH tells you how many eggs you have. It does not tell you how good they are.

Understanding Your AMH Result

AMH is measured in nanograms per milliliter (ng/mL). Unlike FSH, AMH does not need to be drawn on a specific day of your menstrual cycle, which makes it more convenient and consistent from month to month.

Reference ranges vary slightly by laboratory, but the following provides a general clinical framework based on current literature:

Above 3.5 ng/mL: High ovarian reserve. Likely to produce a strong response to IVF stimulation. Women with very high AMH, particularly above 5.0 ng/mL, should be aware of an elevated risk of ovarian hyperstimulation syndrome (OHSS), a potentially serious condition. High AMH without other symptoms may also prompt evaluation for polycystic ovary syndrome (PCOS).

1.0 to 3.5 ng/mL: Normal range for most reproductive-age women. Suggests adequate ovarian reserve and a reasonable expected response to stimulation.

0.5 to 1.0 ng/mL: Low-normal to low. Suggests diminished ovarian reserve. Fewer eggs are likely to be retrieved during IVF. Natural conception remains possible, particularly in younger women.

Below 0.5 ng/mL: Very low. Associated with significantly diminished ovarian reserve and poor response to stimulation. Fewer than three retrievable follicles may be available. Consultation with a reproductive endocrinologist is strongly recommended to discuss options.

Below detectable threshold: Very rare. Associated with severely depleted reserve and possible premature ovarian insufficiency (POI). Requires comprehensive evaluation.

These ranges are guidelines, not absolute cutoffs. AMH results should always be interpreted alongside age, antral follicle count (AFC), FSH, estradiol, and the full clinical picture. No single number determines your fertility.

AMH and Age: The Most Important Relationship

AMH declines steadily and predictably with age. As a general reference point based on large population studies: the median AMH value at age 30 is often above 2.0 ng/mL; at age 35, approximately 1.5 ng/mL; and at age 40, approximately 1.0 ng/mL. Values below 1.2 ng/mL are common by age 36.

This age-related decline is expected and does not in itself indicate a fertility problem. What matters is your AMH level in the context of your age. A 38-year-old with an AMH of 1.2 ng/mL is in a very different situation than a 28-year-old with the same result.

Importantly, a low AMH for your age does not mean pregnancy is impossible. Women with diminished ovarian reserve can and do conceive, both naturally and through IVF. What low AMH does signal is that time may be a factor — fewer eggs remaining means fewer chances, and pursuing evaluation and treatment sooner rather than later is generally advisable.

AMH and the Antral Follicle Count (AFC): Better Together

AMH is most valuable when interpreted alongside the antral follicle count (AFC), a transvaginal ultrasound performed early in the menstrual cycle that directly counts the small visible follicles in both ovaries. ASRM guidelines note that when performed in an experienced center, AFC is a reasonable alternative to AMH — and together, they provide the most complete picture of ovarian reserve currently available.

When AMH and AFC results agree, clinicians can be more confident in the assessment. When they diverge — for example, a low AMH but a reasonable AFC, or vice versa — the picture is more nuanced and typically results in a response to stimulation that falls somewhere between the two predictions.

AMH, PCOS, and High Results

Not all high AMH results indicate strong fertility. Women with polycystic ovary syndrome (PCOS) typically have AMH levels two to four times higher than normal, reflecting the large number of small antral follicles characteristic of the condition. However, high AMH in the setting of PCOS does not guarantee easier conception — in fact, women with PCOS may experience irregular or absent ovulation, immature egg development, and lower fertilization rates despite their large follicle pool.

Very high AMH in the context of PCOS also significantly increases the risk of OHSS during IVF stimulation. Clinics managing PCOS patients typically use lower starting doses of gonadotropins, antagonist protocols, and may recommend freeze-all cycles — freezing all embryos for transfer in a later cycle — to reduce this risk.

AMH and Fertility Preservation: Egg Freezing

AMH has become a central tool in counseling women who are considering egg freezing for future family planning — sometimes called elective fertility preservation. A woman’s AMH level, combined with her age and AFC, helps estimate how many eggs are likely to be retrieved in a single stimulation cycle and how many cycles may be needed to bank a sufficient number for future use.

For women who have not yet decided when or whether to have children, AMH testing can provide important information about how much time they may have. A significantly lower-than-expected AMH for age may suggest that egg freezing sooner rather than later is advisable, since reserve will continue to decline.

It is worth noting that egg freezing is not a guarantee of future pregnancy. The number and quality of eggs retrieved, the woman’s age at the time of freezing, and subsequent fertilization and embryo development all affect outcomes. AMH helps with the quantity side of that equation; it does not predict quality.

AMH in Cancer Patients and Fertility Preservation

AMH has become an important tool in oncology-related fertility care. For women facing cancer treatment — particularly chemotherapy or pelvic radiation — AMH is measured before and after treatment to assess the impact on ovarian reserve.

Chemotherapy can cause significant, sometimes permanent, damage to the follicle pool. AMH is a reliable marker for detecting this damage early, often before menstrual cycles are disrupted. For women who want to preserve their fertility before treatment begins, AMH and AFC together guide decisions about whether and how urgently egg or embryo freezing should be pursued.

Research also suggests AMH itself may one day serve a protective role: studies are investigating whether pharmacologic AMH administration during chemotherapy could protect primordial follicles from gonadotoxic damage by suppressing their activation during treatment. This remains an area of active research and is not yet a clinical option.

Beyond AMH: What Comes Next in Assessment

For patients proceeding to IVF, AMH and AFC guide stimulation planning — but once eggs are retrieved, newer tools are available to assess the embryos that result.

Preimplantation Genetic Testing for Aneuploidy (PGT-A) allows a small biopsy of cells to be taken from a blastocyst-stage embryo before transfer. The chromosomes in those cells are analyzed to identify euploid embryos — those with the correct chromosome number — which are significantly more likely to implant and result in a live birth than aneuploid embryos.

PGT-A is the closest we currently have to a direct measure of egg quality at the embryo level. A woman with low AMH who retrieves only a small number of eggs may find through PGT-A that one or two are euploid and viable. A woman with high AMH who retrieves many eggs may find that the proportion of euploid embryos is still governed primarily by her age.

PGT-A is not appropriate or necessary for all patients and remains a subject of ongoing clinical discussion regarding its use as a universal screening tool. ASRM’s 2024 Committee Opinion recommends it be used thoughtfully and in the context of individual clinical circumstances.

Time-lapse imaging and artificial intelligence tools are also increasingly used in IVF laboratories to monitor embryo development and identify developmental patterns associated with better outcomes. These technologies complement PGT-A rather than replacing it.

A Note on Interpreting Your Own Results

AMH results can provoke significant anxiety, particularly when they come back low. It is important to remember that:

A low AMH does not mean you cannot get pregnant. It means your reserve may be lower than expected for your age and that time is a relevant factor.

A normal or high AMH does not guarantee pregnancy. Reserve tells us about quantity. Quality, the single most important factor in whether a pregnancy will succeed, is determined primarily by age and cannot yet be directly measured before egg retrieval.

AMH is one data point. It should be interpreted by a reproductive endocrinologist in the context of your age, cycle history, AFC, FSH, estradiol, and your personal reproductive goals.

If you have questions about your AMH result, the INCIID forum and advisory board are available to provide support and guidance.

References

1. ASRM Practice Committee. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertility and Sterility. 2020.
2. ASRM Practice Committee. The use of preimplantation genetic testing for aneuploidy: a committee opinion. Fertility and Sterility. 2024.
3. Endotext/NCBI Bookshelf. Ovarian Reserve Testing. Updated December 18, 2025. https://www.ncbi.nlm.nih.gov/books/NBK279058/
4. Karaviti E, et al. The role of anti-Mullerian hormone: insights into ovarian reserve, primary ovarian insufficiency, and menopause prediction. Endocrine. Published May 23, 2025. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12289849/
5. MSD Manual Professional Edition. Diminished Ovarian Reserve. Updated February 2024. https://www.msdmanuals.com/professional/gynecology-and-obstetrics/infertility-and-recurrent-pregnancy-loss/diminished-ovarian-reserve
6. Broer SL, et al. AMH and AFC as predictors of excessive response in controlled ovarian hyperstimulation. Fertility and Sterility. 2011;96(2):382-388.
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8. Tal R, Seifer DB. Ovarian reserve testing: a user’s guide. American Journal of Obstetrics and Gynecology. 2017;217(2):129-140.
9. Carnesi E, et al. Diminished ovarian reserve is associated to euploidy rate: a single center study. Frontiers in Endocrinology. 2025;15:1535776.
10. High impact of chemotherapy on ovarian reserve in breast cancer survivors of reproductive age: A systematic review and meta-analysis. PMC12221882. 2025.
11. Zaninovic N, Rosenwaks Z. Artificial intelligence in human in vitro fertilization and embryology. Fertility and Sterility. 2020;114(5):914-920.
12. ASRM Ethics and Practice Committees. Report on preimplantation genetic testing for polygenic disorders (PGT-P). Fertility and Sterility. December 2025.