Two Peaks in a Pod

Low AMH, High Hopes: How Scheana Shay Conceived Despite a Low Egg Count

• Beverly Reed • Season 3 • Episode 5

Share episode

Send us a text

Dr. Amber Klimczak and Dr. Beverly Reed discuss how Scheana Shay from Vanderpump Rules conceived despite having an AMH of 0.28! The discuss what AMH is and how to interpret it. They discuss additional testing to consider if you have a low AMH. They review treatment options and provide real life examples of how checking an AMH can be life changing.

Watch this (Season 3, Episode 5) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

https://www.youtube.com/@peakfertility

https://podcasts.apple.com/us/podcast/two-peaks-in-a-pod/id1694248202

Links are in @drhappyeggs IG bio.

hi, I am Dr. Beverly Reed. And I'm Dr. Amber k Clack. And we are two peaks in a pod pod. Welcome back everybody. Today we have a fun topic that we're gonna be talking about.'cause I love the show Vanderpump Rules. It's actually about to have a huge changeup. Okay? So this is a reality show, but I guess the kind of the stars of the show, I don't know. Maybe they were getting too old or something. So they're, they all got let go and they're gonna start with a new cast and everything. But to me, the new cast is never gonna be as good as the old cast. And one of the old cast members is Sheena Shey, and she wrote a book, I don't know if I should. Even admit to this, should these people be writing books? I don't, well, I don't even know if I should admit to this.'cause I feel like people think if I'm a doctor, I'm probably reading much more sophisticated autobiographies. But I've been reading Sheena Shea's autobiography and she does describe a little bit of her fertility journey, which of course caught my attention. And so I wanted to see what you think about it. So let me grab my phone. Are you reading this or are you audio? Audio booking it? I'm reading it. Oh my gosh. I've been reading it. That's a lot of effort for she. That's right, that's right. It's, she's got no, no one fan. I actually am surprised. I didn't think I would like it. It was a pretty good book. She's, she's definitely dishing out the details. Um, and, but some of them, my, my heart goes out to her. It's pretty sad. She explains that when she, when she was pregnant, her husband cheated on her. Oh gosh. This was not in the show. She like kept this as a secret, but kind of is telling all for the book. Wow. So I definitely feel bad for her, but, um, but in her book, so she says. That her doctor told her her A MH levels. The hormone that determines egg count should have been her doctor gives her a range of between 1.4 and 4.2, and hers was 0.26. That is low. Okay. Pretty low, right? Yeah. Um, and so of course she says she was stressed out. She says she's such a perfectionist, and so she wanted to understand how can I get this number back up right? Um, and so she was wanting to do everything she could to fight this, to reverse it, but ultimately she realized she wasn't really able to do that. And so she said her fertility doctor cut straight to the chase and he said that she was not going to be able to get pregnant because of her low a MH and that she better hurry up and free some eggs. Um, so that ultimately she could have a child but her, that her low a MH would cause her to have fertility problems. And so of course I couldn't wait to talk to you about this because I already know what you would say. You would give a very different opinion than her fertility doctor. I'm kind of like, who is her fertility doctor? Because I don't think that's good advice. Right. It's questionable advice. For sure. Questionable advice. Yeah. And, and here's why it's so questionable. Then she says, I was so shocked when I did get pregnant all on my own. Yeah. Um, and good thing it was, was it planned? Well, no, I don't make it right. She was shocked. Okay. So, yeah, I think that she was totally shocked because she had been told by her doctor, you're not gonna be able to get pregnant naturally, that your egg counts are so low. And I do do, no, A MH is not a good form of birth control. Yeah, exactly. Just out there. Absolutely. Yes. So I wanted to get your take on this. So let's pretend I'm Sheena Shey. And I'm your patient. You, you are, you know, celebrity doctor to the stars here. And I'm stressed out because I come to you and I say, my OB GYN check this level on me is 0.2. What do I do? Am I gonna be able to get pregnant? Yeah, absolutely. I see this patient a lot actually. Yeah, I think we get referred for this. There's many women I think that just wanna get. You know, I am just curious, how's my fertility? Right. Ask your OB and they, they check this number for you and then if it is low, you kind of have panic. Yeah. Onset and, well, and can I even say too, I think what's challenging is a lot of patients can now order this testing on themselves. Mm-hmm. Even without seeing an ob, GYN. Right. Totally. So maybe that's. Full. There's certain companies, you can do this at home testing, you can get the test done, you can get the results, but then you panic when you don't know what the results mean. Right, right. Mm-hmm. Right. Exactly. Mm-hmm. Um, so if I have a patient that comes to me with low A MH mm-hmm. First of all, we kind of talk about what are their goals. Right. Are you looking to get pregnant right now? Have you been trying to get pregnant? Are you wanting to get pregnant in the future? Or maybe it's in the far future. Yeah. Things like that, right? Mm-hmm. Um, and then I do some counseling about what a MH means. Mm-hmm. And what a MH doesn't mean. Right? Yeah. And so, for example, for the patient that maybe has. Been trying on their own. Having low a MH by itself really is not a good explanation for why you wouldn't be successful at getting pregnant. That's not what we use it for. That's not really what it's indicative of. Right. Um, it's certainly not a good estimate of your ability to conceive moving forward either. So we have really. Studies to show that as well. We shouldn't be using it to assess fertility in terms of can you get pregnant? Mm-hmm. Just like what this doctor was kind of telling to her. Um, and so that's not what it's used for. Right. What is a MH really good at and what do the studies show us? They show us if you're gonna go through fertility treatment, how likely are you to respond to medications that we use for fertility treatment, and how should we dose you on those medications? It's really a. A fertility tool Yeah. That we fertility doctors use a lot. Um, but not necessarily a good predictor of these things that are probably more important to you. Right. You know, you're probably thinking, can I get pregnant with this low amh? The answer is yes. Mm-hmm. Just like she's proven. Mm-hmm. This celebrity, Sheena, she say her name, right? Mm-hmm. Yep. Sheena, she, she, it has a ring to it, right? It's, she, she, yeah. I'm wondering if that's a real name. But you know, just like you saw with her, she was able to get pregnant with a low A MH. And so I think one of the most telling, um, data sets that out that's out there is the study out of Duke, um, where they followed women and their A MH levels. And this is a really interesting study. They tracked women over time. They drew their a MH and they saw. How many children did they have? How long did it take for them to get pregnant? There's been a lot of studies that that have come out of this dataset and what they found is a MH is not correlated with your ability to get pregnant on your own or time to pregnancy. And in fact, when they released the data to the women that were in the study years later mm-hmm. There was a lot of women that called five, six years later saying, I just found out my a MH was really low when you took it. Yeah. What do I do? Well, are you okay? And they're like, yeah, I have four. Four children. No problem. So Ann Steiner, this was the doctor that headed up this data set when she came and told us about this. I thought that was the funniest anecdote that these women were like paranoid. And she's like, but you have four kids. Yes. Right, right, right. You're obviously, okay. So I think that's really reassuring data. Dr. Steiner is sharing with us, right? Mm-hmm. You can still get pregnant with your low A MH. It's not something that we should be using to counsel women about that. However, let's say you're planning to maybe not have children for a long time in the future. Um, and you're coming to see us because you're interested in a fertility preservation. It's relevant for us in that setting. Right. Because I would say, first of all, our answer to anyone who's considering egg freezing is do it. Mm-hmm. Right? Sure. It doesn't matter what your A MH is. Yeah. We pretty much always say, yeah, you should do that, and when's the best time? Probably right now when we're seeing you. Um, and so it will be relevant because what we'll use a MH for in that setting is we'll use it to say, okay, this is how much medication I think during your egg freezing cycle, and this is my prediction on how you'll respond. Maybe how many eggs we might be able to get. Right? So those are things that I can counsel patients with from am Mh yeah. Yeah, absolutely. Um, let's talk about. What is a MH? Right? So where does it come from? Why is it, you know, why is it even a tool that we use? And whenever we look at the ovary, if we look at it on ultrasound, typically we can see these little black circles on the ovary. Those are called follicles, and those are where eggs come from ultimately. But those little follicles. Also make a substance called a MH. And so that's kind of where the idea came about, that you can check this blood test as an indicator of how many follicles you have at any given time. But what's really hard is those follicles are always coming and going. I always say it's kind of like if you were to kick an ant pile and you see all those ants. And you try to count them, you're never gonna get a perfect count because they're always moving. Right. That's kind of like how follicles are too. Um, and so that number can change from month to month, but we tend not to see huge changes. So I wouldn't typically see an A MH go from 0.2 to 10 or something like that. Mm-hmm. Right. But, but there can be some variability where maybe the A MH might be 1.2 and then it's 1.6, and then it's 1.4. Really when I see changes like that, I don't really make too much, um, of the difference there. But I think one of the challenging parts, um, is that whenever you've got a low a MH test, you wanna make sure you're not only trusting the lab test. Right? And so I think one of the things you would hear from both of us if you came to see us to talk about low A MH, is I think we would say, well, what did your sonogram show? And what did your additional lab testing show as well? Because. Sometimes there can be a discrepancy between your blood a MH value and your sonogram. And if there's a discrepancy, we do know from studies you can probably trust the sonogram more than you can trust the lab result. And then of course, you could say, well, why don't you just do the sonogram instead of the lab result? But I think the lab result's a lot more convenient for patients, right, overall. Yeah, absolutely. Yeah. Yeah. And you know that I usually say there's. A few different markers of egg reserve. Even your sonogram is just a marker. Mm-hmm. No one knows for sure how many eggs you have left in storage. Yeah. But we wanna try and get as many data points as possible in order to give you a good estimate. Yeah, absolutely. So I would say maybe a normal number of follicles might be about. Six to 10 follicles on each ovary. Um, but if somebody has a low am mh, let's say an AMH of 0.2 like Sheena had, if I did the ultrasound, then I would expect to maybe see one or two follicles on each ovary. So if I saw that, then I would say, okay, you had a low A MH and now I'm doing this ultrasound. It looks to be pretty consistent, so I think we can trust this lab result. Versus let's say you come in with a low AMH and I see 10 follicles on each side, then I would say, you know what? It could be that this lab result is essentially a false positive for you. Mm-hmm. And it's hard'cause when it happens, we don't know why it can happen to certain patients. Um, but I think it's important that really, if you have a low A MH, it's at least worth a sonogram and perhaps some additional testing. Um, so let's talk about the additional lab testing. I'm bringing it up to you because I know it's one of your favorite tests. Do you wanna tell us how we can further evaluate, um, ovarian reserve? Yeah, so like we said, a MH is just one blood test that you can look at, but a lot of times what I'll recommend in my patients that are on the low side for a MH is a day three FSH. So remember you counter cycle day is day one, full flow of bleeding. If you get an FSH on day three and we are able to get an estrogen level as well, then we can help to estimate how hard is your brain working to try and convince your ovaries to ovulate each month. The lower your egg supply, usually the harder your brain's trying to work to get you to ovulate, and those FSH levels will be. Pretty high. And so when I see a high day three FSH level paired with a low A MH, then I really get pretty worried. Yeah, that definitely to me indicates that there's something real going on, so it's another marker that we can help to counsel our patients with. Absolutely, and I think that is so important because sometimes patients with low A MH will maybe go online and find other people with low A MH and hear maybe discouraging stories, but there is a huge difference. Between somebody who has, for example, an AM MH of 0.2, but let's say an FSH of six with an estradiol level of 25. With that, we're like, okay, everything is still looking good versus an am MH of A 0.2 with an FSH of 25. Um. I would be so concerned if I saw those results and I would say, oh my gosh, this is looking like you're in perimenopause if the patient is still having periods or maybe even getting close to menopause. And so I do think that is another really, um, important distinguishing factor there. Um, because you don't wanna be dismissive of anybody who has low a MH. It, it, it can be important, especially if you're showing those early signs of perimenopause or menopause, typically. The average age of menopause is 51, and so a woman usually enters perimenopause around age 46 or so. And so if we're seeing those signs way earlier, that can be a sign of premature ovarian insufficiency, which deserves its own kind of testing, um, and treatment regimen as well. Yeah, definitely. Mm-hmm. And I think the other important detail that FSH helps me to understand is maybe if we are concerned this is a false positive finding. Yeah. Um, there's certain medications you might be taking, et cetera, that could suppress, for example, patients who have been on birth control pill for. Pills for a long time. Maybe you're just getting your A MH checked to see where your fertility is. It could be falsely low. Mm-hmm. Um, and if your FSH level is also really, really suppressed, then it makes me think, okay, well let's go off of your pills or, you know, other medications and let's see if we get improvements in your A MH. So it can help us to interpret where you are. Yeah, absolutely. I think that's such a good point to just bring up things that can affect your A MH level, um, birth control pills. Sometimes even, and I know this is a little bit more controversial, but the IUDs that contain progesterone in them, sometimes I will see that be a little bit suppressive to the ovaries too. But it is important for you to know that even though those things like birth control pills or maybe a progesterone containing, um, IUD. Even though they may temporarily suppress your account level, it doesn't affect it overall. It's not like it drops your account levels lower than they otherwise would be at all. Um, it is important because these types of things are pretty controversial these days and um, and so what's important to know is once you stop those things, your ovaries bounce back and your a MH will increase. Um, again, if that was kind of what was causing the issue or the problem. So definitely important to know there. Um, how do you define kind of low egg counts? Because I do feel like there can be different definitions for low egg counts. Um, and, and maybe age is a factor there too. So how do you decide if you're gonna tell a patient that they have low egg counts? Yeah, I know this is actually really great. Mm-hmm. For me. So there are some criteria out there for studies. Mm-hmm. So if you look at fertility studies, which probably our listeners don't read a lot of fertility studies, but maybe you do. Some of I do. I feel like, yeah, they have. Some criteria because for research we really need specific definitions. Mm-hmm. Right. Of diminished ovarian reserve. Mm-hmm. Or low Ag reserve. Um, and so they have some criteria that exists that are out there, but quite frankly, I don't actually follow those for me. Mm-hmm. Okay. It's more so I look at a person's, um, age. Mm-hmm. And you know their status. Yeah. And what I would expect to see for that particular patient, for example. Like that person's doctor saying, I would expect your A MH to be between 1.4. Mm-hmm. And four, you know, I can't remember the exact Yeah. I'm like, where did he get those, exactly those numbers. Yes. It's pretty random. Right. And to me, yeah, totally random. Um, and so I really, if I have a 39-year-old for example, and they have an A MH,'cause I think that person said, you know, it should be 1.5 if they have an mh of one. Yeah. I'm like, hey, that's pretty good. Yeah. Like for your age. Right. Um, or follicle counts or for example, I saw a patient who had a BRCA one mutation mm-hmm. Um, this morning, and we know BRCA one can affect your egg reserve. Mm-hmm. And I put in the probe and she had five follicles on one side and two follicles on the other. And I said, wow, this is actually really good for your age and your circumstance. Mm-hmm. BRCA. Who have not really affected mm-hmm. Your ovaries, she had undergone chemotherapy Wow. For, um, breast cancer and her ovaries have maintained their follicles. Right. So Amazing. It really depends on the patient, right? Yeah. Your age, your setting. Yeah. In terms of whether I think your eggs supply is low, I see women that are in their twenties mm-hmm. Who might have, like Dr. Reed said. Six to 10 follicles on your side. Yeah. But if I see a 22-year-old with six follicles on each side mm-hmm. I would say, Hey, I think your ex, your egg reserve looks a little low for your age. Yeah, absolutely. You know? Absolutely. If you have nothing else going on, they're not on birth control pills. Yeah. So it really depends on who I'm looking at in front of me. Yeah, absolutely. Yeah. I think I'm pretty similar to, um, I kind of think about two things When I get those results back, I first ask myself. Is the A MH low overall. Mm-hmm. And then is it low for their age? Mm-hmm. Um, I know a normal A MH level is usually about 2.5 to three. So really anybody who has an A MH for example of one, then I'm probably gonna say, Hey, just so you know, your egg counts are a little bit on the lower side. Whereas if somebody's at like 0.5, then I'm kind of like, okay, it is, it is really getting quite a bit lower. Right. Um, we try to. Maybe almost have a threshold for how concerned you should be based on whichever result. Um, but then I also, um, think it's great because if you even Google a MH age chart, there's a great chart that can show you even percentile for each age what the A MH um, should be. And so I think that's helpful too. I, again, like if you're, let's say you're, you know, uh, well, actually me, 46, I just checked my MHI think it was 0.5. Okay, so hey. 46 year old's really good, right? Um, whereas if I saw 0.5 in a 25-year-old, I would be like, oh my gosh, that is way lower than what I would expect and let's talk about it more. Um, but the purpose is never to scare you or to panic you. Um, it's more so that you can walk with a purpose in the direction, um, that, that we would recommend for you and. I think a big part of how to interpret those results is oftentimes depending on your relationship status and whether you're wanting kids now or later, um, for patients that, for example, don't have a partner yet. It can be so stressful to find out this information, and I'm always actually reminded of a. Personal story of a friend. Um, you see, I'm old enough that a MH kind of came out while I was, um, a younger doctor. And so myself and a lot of other doctors were even drawing this test on ourselves to see what it was. And that was even really before we knew much about what a MH meant. And so one of my friends who's a doctor. Drew it on herself and she was so upset because her results were very low, I think probably like a 0.2 or something. And um, she was actually in just a fresh relationship with somebody and she stressed herself out so much. She said, oh my gosh, I'm gonna go try to freeze eggs right away. As we'll talk about when you have low A MH, sometimes you don't gr get a great yield. And so her clinic that she went to, I think was only able to freeze two eggs for her. And she thought, gosh, these are not gonna work. You know, very discouraged. And ultimately she ended up telling her partner. She said, look, I know we're really early in in this relationship, but just FYI. I'm probably not gonna be able to have kids. Is this a deal breaker for you? And all the rest of it. And of course, because he's such a wonderful person, he said, of course that's not a deal breaker. Whatever. Like, we'll adopt it doesn't matter. Um, and so they ended up getting engaged and got married. And then of course she easily got pregnant. I mean, she was shocked too. She was shocked. Again, I thought he was gonna be like, great. Now, now we don't have to worry about birth control. Well, yeah. But, and, and then, and then they have their second child too. No problem at all. No fertility issues. And so, gosh, when you look back at that and how stressed she was and how it could have even affected their relationship, what if he said, no, kids are a deal breaker for me, and they have broken up. That is scary. This is how serious this a MH test can be. And so I think it's. So good to get that message out there that no, you don't have to go tell your partner. I can't have kids. Yeah. Based on a single lab test alone. Um, because it just does not tell you if you're fertile or not. Um, as Dr. K was saying before too, if you are having trouble getting pregnant and you were incidentally found to have a low a MH, don't blame it on that. You still need all the other testing. We would typically recommend. You need to have this sperm checked, your tubes checked, and all these other things because you don't ever want to assume that your fertility, um, issue is just because of low a MH alone. For sure. Okay. I have another question for you. So let's say here I am, I'm Sheena again. Dr. K. My am MH is low. How can I increase my AM MH? No, this is, I don't have, do you have any help for me? I don't have a good answer for Sheena. Okay. Okay. But here's what I tell my patients though. It is what it is. And I don't think that my goal is actually to improve your A MH ever, right? Mm-hmm. But my goal is maybe to improve whatever aspect of fertility is important for you, you know? Um. So I talk to them about fertility preservation options if absolutely conceiving is not on the table right now. Or let's look into some ways that we can try and help you get pregnant quicker and faster time to pregnancy if they've been trying without success. Um, but I don't have a lot of. Hints or tips for how to improve a MH because it's just a lab marker and just having slight improvements on it don't necessarily mean there's actually a utility to that increase in the A MH. Um, and you know, something you should know about all lab values is that when your level is low. And pretty far away from the average that that lab is used to seeing. If you repeat your test a lot, you're gonna have more variation, right? So the lower end of the spectrum and the really higher end of the spectrum on this assay are gonna be more likely to be off, right? So you could check your amh, it might be 0.2, 0.7, 0.6, right? Like Dr. Re is saying, and my patients get really excited when their A MH goes from like. Maybe like 0.2. Mm-hmm. To 0.4. To me, that's not a really big difference. That's probably just deviations in the assay. Yeah. Yeah. Um, well, okay. I, I do have to share my story, which I have shared with you before. Mm-hmm. About identical twins. Mm-hmm. You know, I have this. Session with identical twins. Yeah. Um, for some reason, I have a lot of patients who are I, who are identical twins, and so I had the first twin come in, we checked her a MH level. It was very low and so we kind of, you know, talked about everything. But she had mentioned she had an identical twin, and I said, does she live here locally? I'm just curious. Does she have a low A MH as well? So we had her identical twin sister come in, we check her A MH, her twin sister's A MH is totally normal. And I'm like, wait a second, you guys are identical. Y'all should have the same A MH. So what's the difference, right? So I'm asking them all these questions. Have you always lived in the same place? What are your ex. Exposures. Have you had the same vaccines? What is your diet? What's your exercise regimen? Asking them everything. And there was only one difference between the two. And the difference is the twin with a normal H uh, normal. A MH had a totally normal diet. Um, and ate seafood and all these things. And that, uh, twin that had low a MH said, look, I forget to eat sometimes. And I'm like, what now? You know as me. I like don't even understand that concept. I never miss a meal. I'm like, how can you forget to eat? Right? And she's like, I'm just not a big eater. I don't really like to eat. You know? And she was like, and when I do eat, I eat like a toddler. Okay. I eat chicken nuggets, like whatever, processed foods and all the rest of it. And I said, do you eat seafood? And she was like, I would rather die. I'm not ever eating seafood. So I'm like, well that's interesting that that's the only difference. And I said, why don't we have you eat like a normal person and then just recheck your AM MH and see what happens? And sure enough, we rechecked it and it went up. Um, so I wanna say before, and I'm just estimating, maybe it was like a 0.4 and then it got up to like a 1.4 or something like that. Okay. Technically still not normal, but to make that improvement, I thought it was really interesting. So I think for most people, there's not really anything you can do about low A MH, but it's at least worth looking into because this is gonna be good for your health anyways of are you falling a healthy Mediterranean diet? Are you, um, exercising enough, but not too much? Are you avoiding all of the toxins? I will say Sheena, she says in her autobiography, she's doing a lot of, you know, she drinks, she does drugs. Like, I mean, she, so there was a lot going on, right? I think in her case, yeah, she probably could use some help there. We know smoking can lower your A MH. Um, I highly suspect alcohol really damages the ovaries. To, um, and so I think cutting out those things, maybe it won't increase your AM MH but maybe it can kind of stop the loss. What do you think of of Yeah, yeah. Absolutely. And I think that this is a really good point yeah. Where when you really think about what a MH and where it's being produced, yeah. It's new from those small resting follicles, if you're doing anything to inhibit that final development in those small resting follicles as they come to the surface, right? Like starving yourself where you don't have enough priming and fuel in the months leading up to it. You're gonna have less follicles sitting on your ovarian. Yeah. A MH is gonna be lower. Right? Yeah. So there are certain women who, and I would say maybe that's even falsely low a H, right? Yeah, sure. The true because AM H as a marker. Yeah. Egg reserve is not doing a good job. Mm-hmm. In that identical twin, right? Mm-hmm. It wasn't really telling us what we wanna know. Yeah. For supply is actually. Probably pretty normal, maybe low normal, but not severely, severely impacted. Yeah. But she is affecting her marker. Yeah. Oh, absolutely. Yeah. Yeah. Yeah. So I think that's interesting. And then, you know, my newest interest, which I just shared with you yesterday, is really trying to dig into nutrition more. Um, because I think we do just make the assumption that, you know, most of us try to be as healthy as we can, but I had a patient yesterday where I was really concerned about her egg. Quality. And so out of interest, I just offered her, Hey, do you want me to check your vitamin levels, your nutrition panel? And sure enough, she was low on many important vitamins. And so will correcting those things help? I don't know yet more to come, I guess on that. I'm gonna start kind of delving into that more, but I think it's logical to say, Hey, you know, if something is not making sense, for example, if you've got a really young patient with a low A MH and you've kind of ruled everything out. Hey, why not maybe dig in a little bit further and say, is there anything else we can correct and then see if we can make an improvement onto. Mm-hmm. So, but I would say that's definitely not standard or accepted, but Interesting. Yeah. But yeah, interesting to think about overall is how can we make this better? Mm-hmm. Um, okay. You did mention something earlier that I think is important, which you said if somebody asks, should I freeze eggs? The answer's always yes. Right? Mm-hmm. Can we dig into that a little bit more? Because I do feel like some people use a MH as the decider on whether to freeze eggs or not, right? Mm-hmm. Like if my A MH is five when I come to you, you would still tell me to freeze eggs? Yes. Okay. And then if my am MH is 0.5, you would tell me to freeze eggs? Yeah. I mean, I haven't, but when patients come to see me for fertility preservation and they're just learning about it. I always say at the close of the conversation, probably always my answer to you is going to be yes. Yeah, because you're always going to do better at pre preserving your fertility the younger you are. However, once we get your testing back, we can make an informed decision about, okay, do we think that you're actually gonna try and get pregnant in a year? Right? Like, what does it look like in feasibility, in your timeline? You know, how many children do you want moving forward? Do we think it's gonna be hard for you to get pregnant with baby number three when you're 41? Maybe? Yeah. Um, so we do the testing and then we talk about it and have a candid conversation, but it's just, to me, it's never. A wrong answer. Mm-hmm. To freeze your eggs. Yeah. Yeah. You know, we just can't predict, and I think what patients don't realize,'cause we do know as we get older, our A MH levels go down. But I think what people don't recognize is it may not be a steady decrease. And that's what's so hard, I think when we're talking to patients. So. You may have an A MH of 0.5 and it is certainly possible in five years, it may still be 0.5. For some people it may say very stable, but really what if next year it went from 0.5 to 0.1? Right? This is where we start to worry, um, in somebody with low a MH of how soon could they run out of eggs, and that's why it's usually kind of alarm bells at that point. If you're not in a relationship and currently trying to have a baby, or even if you're trying to have a baby and want future kids. It may not be affecting your fertility, but could this be a sign that we might need to bank or save some embryos for later? Um, or eggs? Yeah, either way. Um, but I think even when somebody has a normal A MH, like we talked about five, have I ever seen anyone have an a MH of five and they come back a year later and it's 0.9. I've seen it. And that's what's so frustrating for when it happens to people is they wanna know, why did this happen? We don't know why, but there's not a set trend for everybody, so you don't wanna get. False reassurance from a normal or high AMH level. So I really like your answer of, Hey, if you're concerned about future fertility, we are too. And could be, um, a good time to freeze eggs. Um, it's never gonna be wrong. Yeah, it's never gonna be wrong to freeze, to freeze eggs or embryos for the future. Yep. Um, okay. I wanna also just explain a little bit better why having low a MH doesn't affect trying on your own, or if you're doing I UI cycles. Okay. So I want the audience to picture an ovary, and let's say you've got an ovary that has 10 follicles on each side. Let's say this person's just gonna try on their own for the month. Out of those 20 follicles, the body is only going to recruit, mature, and ovulate. One egg. Okay? Now that person with 10 follicles probably has a pretty good am MH. Let's say her AMH is three, right? Am MH of three. She ovulates one egg. Okay. Let's compare that to somebody who has low A MH. So let's say we've got somebody with low A MH, and she has one follicle on her right and one on her left. And what's gonna happen to her if she tries on her own? She's gonna grow, mature, and ovulate One egg. Okay? So see how, whether you've got a high A MH or a low mh, either way you're ovulating an egg. That's why it doesn't affect your fertility in that case. Now, let's take a second example. Same two patients. Let's say they decide to do a Clomid IUI cycle. So the person starts off with 20, we give her Clomid, maybe we can get her to mature and ovulate two eggs. Okay, great. She's gonna have better chance of getting pregnant. Low a MH person, one follicle on each side. We give her Clomid. She is able to mature and ovulate two eggs as well. So again, no difference in pregnancy rates between IMH and low A MH. However, here's the difference. Let's say both of these patients decide to do IVF. Okay. With IVF, we're gonna give fertility injections. We're gonna try to get as many of those follicles to be able to produce eggs as possible. And so the person who had 20 may end up with a lot of eggs, maybe 15 to 20 eggs or something like that. Okay. Whereas the person who had two. We'll have probably at most two eggs, maybe even less than that. Okay. So that is where A MH is so important to us as fertility doctors. If you're gonna be doing egg freezing or IVF, we know a patient with low A MH is going to likely have a much lower response. Now, it doesn't predict quality of the eggs at all. Now they could be very good quality eggs and you can, with low am MH sometimes outperform somebody with a higher a MH if your quality is really good. But we have no test for egg quality, so we don't have a way of knowing that ahead, uh, ahead of time. But I think the big point of it is that A MH just tells us how efficient you will be in being able to produce eggs and embryos. It could just be when you have low MH, you may need more egg freezing or IVF cycles when compared to somebody that has a normal A MH. Yeah, absolutely. And I think it's important and encouraging for low A MH patients to know that your IVF outcome, even with low numbers. Mm-hmm. Still be really good. And we have data to support that, um, that young women with diminished ovarian reserve have egg quality, right. Or, um, really as a surrogate marker looking at number of normal genetic embryos they can make, or percentage of normal genetic embryos they can make With IVF. Similar to their peers. So if you're 30 and you have a low A MH, still probably the quality of your eggs is like your other peers that are 30. Yeah. You don't have low egg quality and quantity problems typically, although I do see it. Yes. Absolutely. I mean, just to give you an extreme example, let's say, uh, my A MH was five and I'm 46. Would you rather do IVF on me with an A MH of five at age 46? Or do IVF on somebody who's 25 with an A MH of 0.5, which would you want? A hundred percent? The 25, exactly right. They are gonna have much better chances of being able to get pregnant because we know quality is the number one factor. Um, and so really I would rank age than a MH as you know, important factors for IVF success. So, okay, good. Okay, well we hope this is really helpful for you guys. If you would be so kind, we'd really appreciate if you would leave us a positive review on whatever you're either watching or listening to us on, whether it's podcast, YouTube, or whatever. Um, and or if you are a patient of ours, we would love if you went to our peak fertility, um, Google site and left us a positive review and we hope you guys have a great week. Bye bye.