Ask Dr. Marc: AMH & Morphology

Dear Dr. Marc,

I am 36. Husband is 42.  Neither one of us has kids, and I have never been pregnant. 

In my early twenties I had a laparoscopy done due to bad cramps, and slight endometriosis was found.  It was lasered.  A few years later I was on Lupron to assist with endometriosis.  I had been on the pill when not on Lupron since age 18.  4 years ago I went off the pill. 

A year ago I had another laparoscopy and stage 1 endometriosis was found.  No serious concerns from the Dr. I also had my tubes checked and all was clear. 

I went on Clomid 50mg first month then 100mg for another 2 months.  In September and October we tried Clomid with IUI. 

My husband’s sperm was checked in April and again in August and it showed less then 1 percent morphology.  High count though. 

We then did a round of IVF using Bravelle and Menopur. I was on the pill for 21 days to suppress ovulation and then began injections with a 3 to 1 ratio.  No response.  Increased to 3 to 2 ratio, very little response. 

Converted to IUI.  Not pregnant. 

Had an AMH level drawn and it showed .16.  We were encouraged several times to consider donor eggs due to low ovarian reserve. We decided to do another round of IVF. Pill first then using maximum dose of Bravelle and Menopur 4 to 2 ratio.  Had an excellent response with a retrieval of 6 eggs.  4 fertilized and one split to make 5 embryos.  Did a day 3 transfer.  The other 2 did not make it to be able to freeze. 

Not pregnant. 

We got a second opinion and some more labs drawn.  My husband’s sperm was 23% morphology.  However, first two sperm counts were done using strict criteria.  This last one, which showed an improvement, was done not using strict criteria.  However my AMH this time was .56.  My FSH was 7.2 done at day 2.

The second opinion suggests another IUI this time. 

I have asked about the significant difference in the AMH level and the second opinion feels the first test was just simply wrong.  He feels that yes donor eggs would increase my chances drastically but did not think that was necessary yet.  We feel strongly about trying as hard as we can to have a child genetically our own if possible.  I feel confused by the numbers but also feel we are sort of going backwards by trying an IUI again. 

Any thoughts would be greatly appreciated.



Hi J,

I can see how you might feel confused and a bit frustrated at this point.  Let me address a few points from your question.

Why did your AMH change?

Doctors use a variety of tests to predict how the ovaries will respond to stimulation (ovarian reserve).  The most common of these tests include FSH/estradiol, AMH and antral follicle count.  Importantly, none of these tests by themselves are perfect.  There can be significant variation in their results from month to month and from lab to lab.  When the tests are combined with a complete history and physical, doctors can usually do a pretty good job of anticipating the right dose of medication required and the number of eggs a woman will produce during and IVF cycle.  With that being said, no single test should be relied upon too much.  Remember, the human body is always changing, but the tests reflect a static moment in time.   Interestingly, AMH was popularized in the past few years as a more stable test of ovarian reserve.  As it is being used more commonly now, we are finding that it is not as stable as once believed.  Your case demonstrates that perfectly.

What about the sperm morphology?

Morphology, the percentage of “normally” shaped sperm, is the trickiest part of a semen analysis.  The 2 most common grading criteria for “normal” are the WHO (world health organization) guidelines and the Kruger (strict) guidelines.  The WHO is considerably less stringent and therefore, a higher percentage of sperm are considered “normal”.  The Kruger, or strict, criteria are more stringent, thus less sperm are considered “normal”.  It is difficult to compare WHO to Strict, but either way, it sounds like there are a low number of “normal” sperm.

Is doing another IUI a step backwards?

In your situation, yes, IUI is a step backwards.  As a rule, the chance for success with IUI is less than that for IVF.  Considering that you demonstrate some degree of diminished ovarian reserve and that your husband has low sperm morphology and you have already been unsuccessful with IUI, you are best off trying to optimize each cycle going forward.  To optimize, IVF is a better choice.

I hope this helps, good luck!

Dr. Marc