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What is ovarian reserve test?

A female child is born with a limited number of eggs, unlike the male counterpart, who is born with unlimited number of sperm cells. The countdown to a woman reproductive potential begins at puberty and concludes at menopause. Beginning at puberty, a woman ovarian stock begins to undergo cyclic depletion both in quantity and in quality, this helps explain why a woman ability to conceive decline with age.

Ovarian reserve test, are non-invasive diagnostic tests used to determine/estimate a woman’s ovarian reserve (i.e. the quantity of eggs remaining in her ovaries). The outcome of this test will be used to estimate how a woman will respond to ovarian stimulatory agent (Gonadotrophin), as well as guide the fertility specialist in choosing the appropriate ovarian stimulation protocol suitable for the woman. Ovarian reserve tests include;

Day 2 or 3 FSH

 Follicle stimulating hormone (FSH) is a peptide hormone produced in the anterior pituitary gland, which is a small gland located in the brain. FSH is the main stimulator of ovarian follicular development its level gradually increases during the follicular phase of menstrual cycle in an attempt to stimulate the maturation of eggs in the ovary. The value of FSH is assayed on cycle day 2 or 3. Most healthy and young reproductive age women will have the value of day 2 or day 3 FSH level within the lower limit of the normal (2 -12IU) range i.e. below 5IU which suggest reach ovarian reserve. While most women above 35 or with premature ovarian failure will have day 2 or day 3 FSH level at the upper limit or even above the normal range suggesting depleted ovarian reserve.

The limitation of FSH test is that the test can only be done in the early follicular phase of menstrual cycle day 2 or day3 because the concentration FSH vary from cycle to cycle and most times need to be combined with Estradiol and Luteinizing Hormone (LH) tests. Thus, may be unreliable for those less than 40 years old.  

Anti – Mullerian Hormone (AMH) Testing

AMH is a dimeric glycoprotein hormone produced predominantly by pre-antral follicles (i.e. small follicles <4mm) in the ovary. Unlike FSH Test that can only be done on cycle day 2 or day 3, AMH test can be done on any day of a woman’s cycle, because its level is fairly constant throughout a woman’s cycle.

The level of AMH in the blood reflects the pool of remaining pre-antral and small antral follicles in the ovary. Blood level of AMH is influenced by increasing female age, as female age increases the pool of remaining preantral follicles in the ovary decreases, at the same time the blood level of AMH decreases.

According to fertility literature and based on our experience AMH level of 1.5 – 4.0ng/ml is considered as normal, 1.0 – 1.5ng/ml low normal range, 0.5 – 1.0ng/ml low and less than 0.5ng/ml very low. Studies have shown that women with higher level of AMH tend to respond well to controlled ovarian stimulation for IVF, with multiple eggs recruited and retrieved during egg collection. In IVF the higher the number of eggs retrieved, the higher the success rate, while women with low or very low AMH level respond poorly to control ovarian stimulation   

AMH testing is a more reliable test for estimating ovarian reserve since AMH is produced only in preantral ovarian follicles, although combination of two or more tests will give a better result.

Antral follicular count

A transvaginal ultrasound scan of the ovaries at the beginning of a woman’s menstrual cycle is routinely used by physicians to estimate a woman’s ovarian reserve. The aim of this investigation is to count the number of recruitable follicles on both ovaries. Women with high antral follicular count, most likely will have reach ovarian reserve, while women with low antral follicular count, most likely will have poor ovarian reserve.    

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