Anti-Müllerian hormone and somatic ovarian function: a new perspective

Anti-Müllerian hormone (AMH) is widely used as a clinical biomarker of ovarian reserve and is traditionallyinterpreted as a surrogate measure of remaining oocyte quantity. However, accumulating biological and clinicalevidence challenges this quantitative paradigm. AMH is exclusively produced by granulosa cells of growing folliclesrather than by primordial follicles themselves, suggesting that circulating AMH primarily refl ects somatic follicularactivity instead of dormant oocyte pool size. Here, we propose a conceptual framework redefi ning ovarian aging as aprocess that may be strongly infl uenced by progressive somatic ovarian dysfunction.

In this model, granulosa cells, stromal integrity, vascular support, immune regulation, and metabolicenvironment collectively form a somatic support network that determines follicular survival and developmentalcompetence. Disruption of this somatic ecosystem, through aging, surgery, chemotherapy, autoimmunity,environmental toxicants, smoking, or metabolic stress, results in reduced granulosa cell functionality, declining AMHsecretion, impaired follicle maturation, and secondary oocyte loss. Evidence from granulosa cell biology, controlledovarian stimulation, ovarian surgery, autoimmune ovarian disease, chemotherapy exposure, and fertility outcomestudies consistently demonstrates that AMH responds dynamically to changes in somatic ovarian health and doesnot reliably predict natural fecundability or absolute follicle number.

Primordial follicle depletion progresses continuously throughout life, yet circulating AMH levels often showabrupt declines in response to somatic ovarian injury such as surgery, chemotherapy, or metabolic stress.Continuous primordial follicle attrition therefore does not translate into continuous AMH decline, supporting the viewthat AMH represents the functional cohort of biologically supported follicles rather than the total ovarian reserve. It isimportant to recognize, however, that ovarian reserve markers including AMH have limited predictive value fornatural fecundability with area under the curve values ranging from 0.60 to 0.65.

We introduce the concept of somatic ovarian function as an integrated framework for AMHinterpretation, proposing AMH as a biomarker of ovarian functional capacity. Reframing AMH from a purelyquantitative reserve marker to a functional systems biomarker that refl ects granulosa cell integrity, metabolichealth, and environmental infl uences may help reconcile longstanding clinical paradoxes and open new translationalavenues for fertility preservation, ovarian aging research, and therapeutic intervention.