This at-home ‘egg timer’ test is an Aussie first. What does it tell us about fertility?

Last year, Claire Kennett and her husband started trying for a baby. After six months with no success, her GP suggested she take an AMH blood test, which measures the ovarian reserve.

Then 30, the secondary school teacher received what her GP called a low result. Kennett says she spiralled into a depression, thinking she’d have difficulty conceiving or be unable to have kids.

Often referred to as the “fertility” or “egg count” test, an AMH test measures the level of the Anti-Mullerian hormone in the blood, which is an indicator of the number of eggs left in the ovaries. Despite its nickname, it is not a marker of fertility and can only measure the quantity, rather than the quality, of eggs.

Claire Kennett thought a low AMH result meant she had fertility issues. She gave birth to a baby girl this year.Credit: Simon Schluter

Kennett was referred to a fertility specialist, who reassured her the result was not an indicator of fecundity. “Without having gone to see her [the fertility specialist], I probably would have just stayed in that really dark place and blamed myself in thinking that everything was my fault,” she says.

The night before she and her husband were due to start fertility treatment, Kennett found out they had conceived naturally. They welcomed a baby girl, Wren, this year.

As the age of first-time mothers rises, and with it the use of technology such as IVF, conversations around fertility are changing. On social media, more women interested in their reproductive health are talking about their experiences with the test – both good and bad.

Ben Mol leads the evidence-based Women’s Health Care Research Group in the Department of Obstetrics & Gynaecology at Monash University. He calls the AMH test the “anxiety-making hormone test” and says while it’s great in theory, in practice it’s just not accurate enough yet to play any role in family planning.

“The principle is OK, but the test is not good enough to justify its use.”

AMH levels can fluctuate throughout the month and be skewed by things such as the contraceptive pill and polycystic ovarian syndrome.

Dr KK Cheung – who chairs the Royal Australian College of General Practitioners’ (RACGP) specific interests antenatal and postnatal care group – says the AMH test has typically been the domain of obstetricians and gynaecologists, but has noticed more women asking for one from GPs.

AMH is mainly used to determine if someone is a strong candidate for egg-freezing or assisted reproductive technology such as IVF. Since it can provide a rough estimate of the number of eggs someone has, it can help shape expectations around how successful egg retrieval might be.

“Fertility is multifactorial, rather than a reflection of one biomarker,” says Cheung.

“A GP will consider and discuss all these aspects with a patient who’s thinking about pregnancy, as well as the health of any reproductive partner.”

Kennett and her husband have always dreamed of having two children. While she says the information she’s received since taking the AMH test has been reassuring, that anxiety from hearing about her low result will never completely leave her.

“It is something that’s always going to be in the back of my mind. Once you know, you can’t ‘unknow’ it,” she says.

AMH goes commercial

For Maz Coote, a Sydney-based publicist, her experience with the AMH test led her to found WHEN, an at-home, commercial version of the test and the first of its kind in Australia, where it is typically done at a pathology clinic via GP or specialist referral.

Coote first had the test when she was single, in her early 30s and considering having her eggs frozen. She got the test and received what her doctor told her was a low result of 7.8. Despite this, Coote says the doctor gave little context to what this number meant and so, reassured and sensing no urgency to act, did nothing. A few years later, after meeting her husband, she went back to do the test and received a lower result of 3.6, and was incorrectly told by her doctor this meant she was infertile. She panicked.

Coote, now 37, has gone on to have a daughter naturally. But she says the lack of information around the test caused unnecessary stress. Her low AMH also meant she had to go through several rounds of egg retrieval, which may not have been the case had she frozen her eggs earlier.

“I crawled through those rounds and that was one of the most frustrating parts: egg freezing is something I’d intended to do,” says Coote.

“But because I delayed it not understanding my result... there was the financial toll of three rounds, the toll on my body, the personal toll, and it didn’t necessarily have to be like that.”

“What it really comes down to is education and resources and giving people the tools.”

Maz Coote, founder of WHEN

Coote and her husband raised $1.1 million from investors in Australia and New Zealand, and are looking raise more funds soon, after launching in August. Manufactured by Trajan Scientific and Medical, WHEN is a TGA-listed mail order kit that collects a sample of blood via pinprick. The brand charges $249 for the test, while pathology clinics typically charge between $80 and $120.

While the test is identical to the one performed by a pathology clinic, Coote says the key difference is that participants receive their results alongside a report with commentary from Australian fertility experts. It also includes a telehealth consultation with an accredited nurse if low AMH levels are detected.

She believes this is lacking in the health system and that many GPs do not have the specialist knowledge to accurately counsel patients on their AMH result. She urges women to seek the advice of GPs with an interest in women’s health and fertility. Coote also hopes the test increases accessibility for women in rural areas who might not have access to the specialists she did.

“What it really comes down to is education and resources and giving people the tools to start a fertility conversation earlier.”

Maz Coote is a Sydney-based publicist and founder of WHEN, Australia’s first at-home AMH test.Credit: Janie Barrett

Not a fertility – or menopause – test

Some experts are concerned about the framing of the test as a fertility test and believe it has no use beyond egg freezing or IVF.

Dr Tessa Copp, a research fellow at the University of Sydney’s School of Public Health, believes the language used by many commercial companies promoting their products is unclear.

In February this year, Copp led a study that looked at how corporations use feminist messaging to promote non-evidence based health interventions, including the AMH test.

“The language used in [WHEN’s] advertising shares the same characteristics we’ve found in our research on other companies across the globe. They’re using feminist rhetoric promising empowerment, selling it as a way for women to gain personalised insights into their fertility.

“The test is not powered for these purposes. It should not be used to inform your reproductive timeline because it’s just too unreliable and could really mislead if it gives the wrong information.”

A major US study from 2017 concluded that decreased AMH levels were not associated with infertility, while another from 2021 found it was not a reliable predictor of natural pregnancy in women across all age groups.

While studies have shown an association between AMH levels and the age of menopause, Mol stresses that it cannot predict menopause on an individual level.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists was unable to provide comment but does not recommend the AMH test to diagnose or predict menopause.

Coote is conscious of the criticisms around the marketing of the test and agrees it is not a fertility test.

“It’s about interpretation,” says Dr Raelia Lew, a CREI fertility specialist and medical director of Women’s Health Melbourne. “Without education, any test in medicine has the potential to do harm ... but it also has the potential to empower patients to make decisions that may ultimately be in their best interests.”

“[So] It’s a complex conversation of which AMH is one piece of a much bigger puzzle.”

Lew adds that men should also be a bigger part of the conversation.

A study from the University of Sydney, co-authored by Copp, recruited women aged 25 to 45 in Australia and the Netherlands to review their attitudes to the test. It found that women who viewed evidence-based information about the AMH test showed less interest in it than those who viewed the information presented by online companies selling the test.

Assisted reproductive technology on the rise

The age of first-time mothers in Australia is rising (from 28.3 years in 2010 to 29.8 in 2022) and with it demand for assisted reproductive technology such as IVF. The number of women freezing their eggs in Australia has doubled, with one-third choosing to do so for lifestyle reasons, such as not having a partner.

Professor William Ledger, medical advisor with WHEN and the former director of the Fertility and Research Centre at the Royal Hospital for Women, says that as Australians start to delay parenthood for various social and economic reasons, an AMH test can be a useful part of family planning, particularly if someone is expecting egg collection to be part of their journey.

“People are waiting, and if they’re in the 30 to 40 age group, they should have a look at their egg count. Because if it’s low, they might need to move a bit quicker, whereas if it’s OK, they’ve got time.”

While it has the potential to create anxiety – as it did with Coote – Ledger believes that “it can give reassurance” with the right education.

“It’s not designed to worry people, it’s designed to be honest.”

Lew has seen many women come through her doors seeking help with their fertility. She says as women start to delay motherhood, fertility, which of course declines with age, is a growing concern. Starting conversations around fertility younger, she believes, would help relieve the “cost burden” of assisted reproductive technology on the health system. Like bra sizes, she says there is no such thing as a “normal” AMH level.

“Some people are born with more eggs and others are born with fewer eggs. And that doesn’t actually have a direct correlation or relationship to quality or the chance that an egg will make a baby.”

Deb Nazareth.Credit: Justin McManus

Deb Nazareth, a facilities manager based in Melbourne, starting to think about having a child with her now ex-partner last year. Then 38, Nazareth decided to go to her GP to explore her options, who suggested she have an AMH test. What her GP failed to tell her was that the contraceptive pill can produce false readings of the test.

“It was really upsetting to hear that my AMH levels were quite low, and I felt like I needed to do everything very quickly and there was not much chance that I would be able to have a baby,” she says.

After seeing a specialist, Nazareth stopped taking the pill and retook the test, which provided a higher reading. Now single, she has recently frozen her eggs to keep her future options open.

Nazareth wants to see more education for women about what the test means and the fertility options available to them to prevent them experiencing the upset she did.

She says it’s also important to remember the test can only provide a rough estimate of the number of eggs to be retrieved – Nazareth got fewer eggs than the test indicated from her first round of retrieval.

While women cite many different reasons for wanting to do the test, Copp is cautious that the messaging around AMH tests may lead to an over-reliance on egg freezing. A recent systemic review on elective egg freezing found that only 11 per cent of women return to use their eggs, and of those, only 28 per cent go on to have successful live births.

“The way egg freezing is marketed is as a safeguard of women’s fertility gives a false impression of what egg freezing can do,” she says. “It’s not an insurance policy. There is no guarantee of the baby.”

Copp wants to see greater evidence-based research to help women make informed decisions because “these are such high stake decisions”.

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