Fertility Q&A: Miscarriage, Low AMH, PCOS & more

Main Ideas and Guidance

1. Turner Mosaicism and Recurrent Miscarriage

A 35-year-old listener reported a healthy pregnancy followed by three miscarriages and a karyotype showing 19% Turner mosaicism. Turner mosaicism means a person has more than one chromosome cell line; one may have a single X chromosome (45,X), alongside a typical female cell line (46,XX).

Turner syndrome or mosaicism can be associated with premature ovarian failure and pregnancy complications, including recurrent pregnancy loss. Dr. Crawford recommends discussing whether IVF with preimplantation genetic testing (PGT) could help identify embryos with a typical chromosome complement.

The discussion should also include ovarian reserve, particularly AMH; plans for family size; and how soon to pursue treatment, since ovarian function may decline earlier for some people with Turner mosaicism.

2. Interpreting LH, FSH, and AMH When Considering PCOS

A 32-year-old asked whether an LH-to-FSH ratio of 2.6 and AMH of 2.7 suggested PCOS. The blood test was taken around suspected ovulation.

LH and FSH vary across the menstrual cycle, so the cycle day matters. Baseline testing is generally done around cycle days 2–4, when both hormones are expected to be relatively low and similar. LH normally rises around ovulation and can remain elevated during the luteal phase. Therefore, an elevated LH-to-FSH ratio measured near ovulation is not a reliable way to assess PCOS.

If these hormones are being checked, Dr. Crawford recommends interpreting baseline LH and FSH alongside estradiol. The LH-to-FSH ratio is not part of current formal PCOS diagnostic criteria.

PCOS is generally diagnosed when at least two of these three features are present:

1. Irregular or absent periods.
2. High antral follicle count, which may correspond with elevated AMH.
3. Clinical or laboratory signs of elevated androgens, such as high testosterone or DHEA-S, acne, excess hair growth, or hair loss.

The listener’s AMH was described as within the usual range for her age; AMH is often elevated in PCOS. The speakers stressed that results should be interpreted in the context of the menstrual cycle and the person’s overall clinical picture, rather than in isolation.

3. Very Low AMH at Age 33

A 33-year-old trying to conceive for five months reported an AMH of 0.057 and otherwise normal labs.

Recommended next steps and interpretation

• Confirm the result with an antral follicle count on ultrasound and consider repeating the AMH. A single lab result can be inaccurate, and a very low result should be checked before major decisions are made.
• A very low AMH suggests fewer eggs available and may indicate earlier menopause, but it does not mean the person is in menopause now or cannot get pregnant.
• Low egg quantity does not necessarily mean poor egg quality; age remains relevant to egg quality.
• Consider a complete fertility evaluation, including assessment of ovulation. Very low AMH can be associated with ovulatory problems, such as luteal-phase issues or ovulation earlier in the cycle.
• Discuss possible treatment options, which may include ovulation induction, egg or embryo freezing, or other approaches depending on family-size goals and timing.

Potential contributors to investigate

• Genetic factors, including an abnormal karyotype or fragile X syndrome.
• Autoimmune conditions, such as autoimmune thyroid disease, ovarian antibodies, or celiac disease.
• Insulin resistance, including assessment of hemoglobin A1C and fasting insulin.
• Chronic inflammatory conditions, particularly endometriosis.
• Some circumstances can temporarily suppress AMH without meaning that eggs have been depleted, including prolonged hormonal contraception, pregnancy, and postpartum breastfeeding. If testing occurs during one of these periods, repeating it later may provide a more representative result.
• Environmental exposures and prior chemotherapy were also mentioned as possible factors, though they may not be controllable.

The speakers cautioned that some clinics may restrict IVF based on AMH cutoffs, partly because of how clinic success rates are calculated. A low AMH alone should not automatically be treated as proof that a patient must use donor eggs. For someone under 38 who is still having periods and is told donor eggs are the only option, Dr. Crawford recommends considering a second opinion.

She also emphasized investigating potential causes and focusing on modifiable factors, such as inflammation and insulin resistance, without assuming lifestyle changes can alter egg quantity.

4. CBD Products Containing Trace THC and Sperm Health

A listener asked whether her fiancé’s CBD gummies, which contain trace amounts of THC, could affect fertility.

Dr. Crawford said available research often groups THC and CBD together, and evidence suggests cannabis products may affect male fertility. Possible effects discussed include suppression of brain signals (FSH and LH) involved in testosterone and sperm production, as well as effects on sperm count, motility, and shape.

The speakers said use does not make pregnancy impossible, but may make conception more difficult and could be associated with miscarriage or poorer IVF outcomes. Their practical recommendation was to treat THC exposure as a modifiable factor and avoid it while trying to maximize fertility and treatment outcomes.

5. Donor-Sperm IUIs, Possible Endometriosis, and Next Steps

A 30-year-old listener and her 32-year-old partner had two unsuccessful donor-sperm IUIs. The listener would carry the pregnancy, had a normal workup, and suspected endometriosis. She was beginning a third IUI with letrozole.

The speakers cautioned against promises that pregnancy will occur within a fixed number of IUIs. Donor-sperm IUI success is limited by age-related chances; for this listener, Dr. Crawford estimated about a 20% chance per cycle. Several cycles may be needed, while donor sperm also involves significant cost and resources. If pregnancy has not occurred after roughly three or four cycles, it may be time to reassess the plan.

With suspected endometriosis, the evaluation should include a proper assessment of tubal anatomy. The speakers warned that some patients proceed through multiple IUIs without discovering that their tubes are blocked. Severe painful periods and relevant medical history may help inform whether endometriosis is a concern.

If endometriosis is present, success rates may be lower. Letrozole is one possible step, while other options may include surgical excision or moving to IVF.

For a same-sex couple, the partners may also discuss reciprocal IVF—using eggs from one partner and having the other carry—if that fits their preferences. The speakers recommended a shared, individualized plan that considers both partners’ evaluations, willingness to provide eggs or carry a pregnancy, budget, timeline, and the next steps if additional IUIs are unsuccessful.

Speakers and Sources Featured

• Dr. Natalie Crawford — Host and fertility specialist answering the questions.
• Emily Whitlock — Guest on the episode; contributes brief comments and discussion.
• Leah — Submitted the question about Turner mosaicism and miscarriage.
• Kate — Submitted the question about very low AMH.
• Katrina — Submitted the question about CBD gummies with trace THC and sperm health.
• Sarah — Submitted the question about donor-sperm IUIs and suspected endometriosis.
• An unnamed 32-year-old listener — Submitted the question about LH/FSH ratio, AMH, and possible PCOS.