The PCOS Puzzle: More Eggs, But Lower Pregnancy Success?
For millions of women with polycystic ovary syndrome (PCOS) seeking pregnancy through assisted reproduction, a critical question has long perplexed both patients and doctors: why do women with PCOS—who often have abundant egg reserves—sometimes experience lower success rates with in vitro fertilization (IVF)? The answer may lie in understanding a key hormone called Anti-Müllerian Hormone (AMH), and recent research is revealing surprising connections between AMH levels and IVF outcomes in PCOS patients.
PCOS affects approximately 5-15% of reproductive-aged women worldwide, making it one of the most common endocrine disorders and a leading cause of infertility.
While women with PCOS typically have ample egg supply, evidenced by high AMH levels, their reproductive journeys don't always follow expected paths. A comprehensive systematic review and meta-analysis published in 2023 finally sheds light on this paradox, offering crucial insights that could transform how we approach IVF treatment for women with PCOS 1 4 .
Anti-Müllerian Hormone is a protein produced by small, developing follicles in the ovaries. Think of it as a biological indicator of your ovarian reserve—the number of potential eggs remaining. In general fertility terms, higher AMH suggests better egg supply, while lower AMH indicates diminished reserve.
Indicates healthy ovarian reserve and typically predicts better response to fertility treatments.
Often two to three times higher than normal, but doesn't always translate to better fertility outcomes.
However, PCOS changes this equation. Women with PCOS typically have elevated AMH levels—often two to three times higher than women without PCOS. This makes biological sense since AMH is produced by the many small follicles that characterize polycystic ovaries. But does "more" always mean "better" when it comes to fertility treatment? The latest research suggests the relationship is more complex than we thought 1 4 .
In 2023, a comprehensive systematic review and meta-analysis tackled the critical question of how serum AMH levels affect IVF/intracytoplasmic sperm injection (ICSI) outcomes specifically in women with PCOS. Researchers analyzed data from 19 individual studies that met their rigorous inclusion criteria, creating one of the most complete pictures to date of this important relationship 1 4 .
The research team employed systematic review methodology—considered the highest standard of evidence synthesis—to ensure their findings were both comprehensive and reliable:
They comprehensively searched multiple major databases (PubMed, Embase, and Cochrane Library) up to July 2022, using precise keywords related to PCOS, IVF, and AMH 4 .
Two independent groups of researchers screened each potential study for relevance and quality, applying strict inclusion and exclusion criteria to ensure only high-quality research was included 4 .
Using standardized forms, researchers extracted key data from each eligible study. They then performed meta-analyses—statistical techniques that combine results from multiple studies—to identify patterns and relationships that might not be apparent in individual smaller studies 4 .
The primary outcomes examined were clinical pregnancy, live birth, and ovarian hyperstimulation syndrome (OHSS) incidence. Secondary outcomes included number of oocytes retrieved, fertilization rates, and embryo implantation rates 4 .
To quantify the relationship between AMH and outcomes, researchers compared PCOS women with AMH levels in the highest percentile (75-100th) against those with the lowest (0-25th percentile) 1 4 .
The analysis revealed a surprising paradox: while high AMH in PCOS patients indicates ample egg supply, it doesn't necessarily translate to better treatment outcomes—and in some cases, predicts reduced success.
Perhaps the most significant finding concerned live birth and clinical pregnancy rates:
| Outcome Measure | High vs. Low AMH Group | Statistical Significance |
|---|---|---|
| Clinical Pregnancy | 23% decreased odds | OR: 0.77, 95% CI: 0.63-0.93 |
| Live Birth | 29% decreased odds | OR: 0.71, 95% CI: 0.58-0.87 |
| Implantation Rate | No significant difference | OR: 0.82, 95% CI: 0.28-2.39 |
The data clearly shows that PCOS patients with the highest AMH levels had significantly reduced odds of both clinical pregnancy and live birth compared to those with lower AMH levels 1 4 .
23% decreased odds with high AMH
29% decreased odds with high AMH
The research also illuminated how high AMH affects the IVF process itself:
| Response Parameter | High vs. Low AMH Group | Statistical Significance |
|---|---|---|
| Number of Oocytes Retrieved | Significant increase | SMD: 0.90, 95% CI: 0.30-1.51 |
| Fertilization Rate | Slight decrease | OR: 0.92, 95% CI: 0.87-0.98 |
| Mature (MII) Oocytes | No significant difference | SMD: 1.85, 95% CI: -1.07-4.78 |
Women with higher AMH produced more oocytes—consistent with AMH's role as an ovarian reserve marker—yet showed slightly lower fertilization rates 1 4 . This suggests that while quantity is assured, quality may be compromised.
Crucially, researchers found significant dose-response relationships between serum AMH level and clinical pregnancy, live birth, number of oocytes retrieved, and fertilization in PCOS patients 1 4 . This means that as AMH levels increased, the changes in outcomes followed a predictable pattern, strengthening the case for a genuine biological relationship rather than a random association.
While the systematic review focused on serum AMH (measured in blood), emerging research suggests another important dimension: follicular fluid AMH (ffAMH). A 2025 systematic review found that higher ffAMH concentrations were associated with increased clinical pregnancy rates after IVF 3 8 .
Reflects the overall ovarian environment and reserve
May provide a direct window into the health and competence of individual oocytes
This emerging research suggests that ffAMH could potentially serve as a marker of oocyte quality, though substantial heterogeneity across studies means more research is needed before clinical implementation 3 8 .
These findings have important implications for women with PCOS considering fertility treatment:
Women with very high AMH may benefit from modified stimulation protocols to reduce risks while optimizing outcomes.
AMH is just one piece of the puzzle—age, overall health, and other factors remain critically important.
It's worth noting that for women without PCOS, the relationship between AMH and IVF outcomes may differ. Research has shown that in the general population, AMH is more predictive of ovarian response (number of eggs retrieved) than of pregnancy success itself 6 .
The relationship between AMH and IVF outcomes in women with PCOS reveals a complex biological story—one where "more" doesn't always mean "better." While high AMH indicates strong ovarian reserve, it may also reflect the underlying endocrine dysfunction that characterizes PCOS.
This research empowers patients and clinicians with evidence-based insights to guide treatment decisions and set appropriate expectations. By recognizing the nuanced role of AMH in PCOS, we move closer to truly personalized fertility care that acknowledges both the advantages and challenges unique to this common condition.
For women with PCOS navigating fertility treatment, these findings underscore the importance of comprehensive assessment and tailored approaches—recognizing that AMH is a valuable piece of information, but not the entire story of your reproductive potential.