4. WHY TO MEASURE ??
Fertility varies among women of a
similar age
Unpredictability and individuality of the reproductive
aging process.
Ovarian Reserve Testing( ORT)-
Predicts reproductive lifespan
4
Help couples choose among treatment options
More prognostic information to the counselling and
planning
Identify infertility patients at risk for DOR who are more
likely to exhibit a ‘‘poor’’ response to gonadotropin
stimulation.
5. WHY TO MEASURE??
Not necessarily equate with inability to
conceive-should not be the sole criteria
used to deny patients access to assisted
reproductive technology (ART) or other
treatment.
5
7. OVARIAN RESERVE SCREENING
Accelerated loss of ovarian reserve - 10% population
1 out of 5 women – do not commence pregnancy by the age
of 35 years
Gaps of knowledge – substantial number of female do want
children but have simply not begun trying for a baby.
If testing of the partner indicates DOR-
7
48% would try to have a child sooner
21% would opt for oocyte cryopreservation
3% would select embryo cryopreservation.
14% would not actively pursue treatment
11. AGE
Fecundity - declines
with age
Begins in the late 20s
becomes more abrupt
in late 30s
Most important factor
determining the
pregnancy potential in
regularly cycling
women
11
13. CHARACTERISTICS OF OVARIAN AGEING
pace of
recruitment No.of follicles egg quality
A
G
E
Varying initial oocyte numbers at birth/menarche
Pace of follicular recruitment
Giecher et al Reprod Biol and Endo2011
13
15. AMH
Existence first proposed in
1947 by Prof Alfred Jost
Dimeric glycoprotein
Member of TGFβ family
Molecular weight – 140 kDa
15
16. AMH
Exclusively produced by - granulosa cells of preantral
(primary and secondary) and small antral follicles
16
17. AMH
Production in utero - at
about 36 weeks of
gestation
Levels rise in young
women- beginning in
adolescence
peak at about 25 years
of age
Gradually decline-
undetectable levels a
few years prior to
menopause
17
18. AMH
AFs with age- AMH production.
Strongly correlate with basal antral follicle count (AFC).
Gonadotropin independent
Menstrual cycle independent marker-Can be measured
on any day of the cycle
No intercycle variability
Overbeek A. Reprod
Biomed Online 2012
18
19. AMH
Significant fluctuations are limited to -
Younger women
Those with high basal AMH levels
Patients with low ovarian reserve - AMH fluctuations have
little clinical relevance
Measuring the hormone on a fixed day of the menstrual cycle
would not yield any advantage to random assessment
Sowers M et al, Fertil Steril, 2010 19
20. AMH
Earliest marker to show a
decline longitudinally
Most sensitive
Oocytes from follicles with
higher levels of AMH have a
better fertility potential
Fanchin R, J Clin Endocrinol Metab 2007.
0.5–1.26 ng/ml - indicate
perimenopausal transition within
3–5 years
Van Rooij IA et al, Menopause 2004
20
25. AMH
Storage of whole blood at room temperature –
After 20 h- 15%
After 3.5 days – 31%
Storage at 4C- 11% after 90 hrs
Separated serum samples, despite prolonged storage at
20C - negligible change (1%).
25
Richard Fleming, Reprod BioMed
Online, 2013
26. AUTOMATED AMH ASSAY
Elecsys AMH (Roche; Elecsys)
Access AMH (Beckman Coulter; Access)
Greater precision (4-fold)
Faster turnaround time (18 minutes vs 6 hours)
Greater sensitivity (10-fold)
As compared with Gen II assay-
Access AMH : 16% lower
Elecsys AMH: 20% lower
More strongly correlates to AFC
September
2014.
26
Tadros T1, Fertil Steril. 2016
28. SUMMARY: AMH
Promising screening test
Used for counseling couples wishing to delay
childbirth
Low cut-points - specific for poor ovarian
response but not for
pregnancy
Gnoth C et al,Hum
Reprod 2005
Testing and interpreting measures of ovarian reserve: a committee opinion ,Practice
Committee of the American Society for Reproductive Medicine, American Society for
Reproductive Medicine, 2015
28
29. BASAL FSH
FSH is commonly used as a measure of ovarian reserve
Basal serum FSH concentrations increase on day 2, 3, or 4 of
the menstrual cycle with advancing reproductive age.
Occurs due to follicular depletion
A “good quality” egg releases certain substances (e.g. inhibin-
B, estrogen) that suppress the FSH level (negative feedback).
When the egg quality is compromised- weak negative
feedback signals resultant increase in FSH levels.
Indirect measure of the size of the follicle cohort
31. BASAL FSH
Significant inter and intra-cycle variability
Elevated FSH is specific but not sensitive for
diminished ovarian reserve.
Accuracy in predicting poor response is adequate
only when high threshold values are used.
J Assist Reprod
Genetic(2008).
Cut points that yield high specificity have low
sensitivities(10%–30%)
DISADVANTAGES
32. Inconvenience of timing the sample
Cannot predict hyper response
Limited reliability
Absolute values differ among different FSH assays-
Thus, clinicians may find it difficult to generalize
FSH cut-points reported in the medical literature to
their practices unless they are using the very same
assay and reference preparation.
DISADVANTAGES
33. CONCLUSION
Ovarian aging begins several years before any elevation
in FSH levels is noted and hence a normal test cannot
rule out a poor ovarian response.
Combined with other markers it can be used to counsel
couples regarding a poor response but should not be
used to exclude regularly cycling women from treatment
Whereas consistently elevated FSH concentrations confer
a poor prognosis , a single elevated FSH value in
women<40 years of age may not predict a poor response
to stimulation or failure to achieve pregnancy.
High values have been associated with, but do not
necessarily predict, both poor ovarian stimulation and the
failure to conceive.
Roberts JE et al,Fertil Steril 2005.
35. ESTRADIOL
Basal estradiol does not
differ between women
with and without DOR.
Should not be used
alone to screen for
DOR.
Has value only as an aid
to correct interpretation
of a ‘‘normal’’ basal
serum FSH value. Testing and interpreting measures of
ovarian reserve: a committee opinion,
Practice Committee of the American
Society for Reproductive Medicine, ASRM,
2015
36. INHIBIN B
Inhibin B is a heterodimeric glycoprotein released by the
granulosa cells of the follicle.
Lower in poor responders than in women with normal
ovarian response to stimulation
Precedes the increase in the FSH concentration.
Cut points in the range of 40–45 pg/mL
37. INHIBIN B
High intra-cycle and inter-cycle variability
Assay variability
Lack of standardized international assay
Testing and interpreting measures of ovarian reserve: a committee
opinion, Practice Committee of the American Society for Reproductive
Medicine, ASRM, 2015
Routine use of inhibin B as a measure of
ovarian reserve is not recommended.
39. AFC
Sum of antral follicles
observed with TVS
during the early follicular phase
Mean of two max. perpendicular measurements
Different diameters to define AFs : 2–6 and 7–10 mm.
No consensus which size truly represent ovarian reserve
AF 2–6 mm in size declines with age - correlates with
other markers , a better marker of ovarian reserve
7–10 mm sized remains constant
39
40. AFC
Correlates with
Remaining follicular pool
Number of oocytes retrieved following stimulation
Best single predictor of ovarian response
Good inter-cycle and inter observer reliability in experienced
centres
Unaffected by the phase of the menstrual cycle, GnRH
agonist therapy, ovarian stimulation or OCPs
Does not reliably predict failure to conceive
Hendriks DJ et al, Fertil Steril 2005
40
41. AFC
AFC 8–10 predictor of a normal response
AFC 3–6 predictor of poor response
AFC >14 predictor of hyper-response
AFC OF 3-6 SENSITIVITY(%) SPECIFICITY(%)
DOR 73-100 9-73
41
Kwee J, Reprod Biol Endocrinol 2007
42. AFC
42
Immediate result
Easy to carry out
Good intercycle
reliability
Good interobserver
reliability when
measured in
experienced centers
using a minimal
number of
sonographers.
Inter and intra observer
variability - especially in
centers having less
expertise or lower-quality
ultrasound equipment
ADVANTAGES DISADVANTAGES
43. SUMMARY: AFC
.
AFC may help to predict poor
stimulation
but
should not be the sole criterion
for the application of ART
Testing and interpreting measures of ovarian reserve: a committee opinion
,Practice Committee of the American Society for Reproductive Medicine,
American Society for Reproductive Medicine, 2015
43
44. OVARIAN VOLUME
Formula -
VOL= D1 × D2 × D3 × 0.56
(TVS - measured in three perpendicular directions)
Mean ovarian volume- average volume of both ovaries
Basal ovarian volume - added volumes of both ovaries
Remains unchanged till the perimenopausal period
Decline noticed in women >40 years
Does not add to the predictive value of AFC
44
45. OVARIAN VOLUME
Correlates with
number of follicles
retrieved oocytes
Not with pregnancy rate
Ovarian volume <3 ml
specificity(80%–90%)
sensitivity (11%–80%)
DOR
45
46. SUMMARY: OVARIAN VOLUME
.
Ovarian volume - limited value
for detection of DOR
and
Antral follicle count is a better
imaging test
Testing and interpreting measures of ovarian reserve: a committee opinion
,Practice Committee of the American Society for Reproductive Medicine,
American Society for Reproductive Medicine, 2015
46
48. BRCA 1
BRCA gene- repair of double-
stranded DNA breaks
Mutations - accelerated oocyte
apoptosis and depletion
BRCA1 carriers - a 4-fold
higher odds of having AMH <1
ng/mL
BRCA2 carriers- no risk 48
49. FRAGILE X MENTAL
RETARDATION (FMR1) GENE
200 FMR1 CGG repeats -
silencing of the FMR1 protein and
Fragile X Syndrome (FXS)
55–199 - “premutation”,
45–54 - “grey zone” or
“intermediate”
<45 - phenotypically normal.
Premutation allele and grey zone -
increased risk of primary ovarian
insufficiency .
49
50. SUMMARY
AFC and AMH- simplest, most sensitive and specific
marker of ovarian reserve.
ORT – good predictors of oocyte yield, does not
necessarily equate with inability to conceive. Weak
association with oocyte quality, LBR, CPR
FSH - most commonly used screening test for DOR
There is fair evidence against the use of
basal estradiol concentration
basal inhibin B
ovarian volume
as a single screening test for DOR
50
