Current markers for ovarian reserve are AMH & Antral follicle counts. AMH levels have been used to stratify patients with respect to fertility & further used in appropriate treatment options for successful pregnancy in an infertile couple.

1. Recent Diagnostic tests inRecent Diagnostic tests in
Ovarian ReserveOvarian Reserve
DR RAJESH V BENDRE
MD (Path), DNB (Path), DPB
Chief Pathologist

2. Follicles Over the Lifespan:
Germ cell attrition and follicular atresia according to Kaipia & Hsueh 1997. Germ cells migrate to the ovary
during early embryonic development. Their number increases through mitotic divisions but most of the
oocytes formed during development do not survive to the time of birth.
FSH
LH

3. What is Reproductive Aging?
 Quantity: Natural process
of oocyte loss
 Fourth month of fetal
development
 6-7 million
 Birth
 1-2 million
 Menarche
 400,000
 Loss acceleration
(approx. age 37)
 25,000
 Menopause
 1000
 Process: Apoptosis
Loss ofLoss of OocyteOocyte QuantityQuantity
Faddy, et al., Human Reproduction 1992;7:1342-6

4. What is Reproductive Aging?
 Quality: decreased implantation potential
 Increase in meiotic non-disjunction
 “Production-line” theory
 Accumulated damage
 Deficiencies of the granulosa cells

5. Loss of Ooctye Quality
 Abnormal fertilization, arrest of early development
 Failure to implant
 Post-implantation problems
 recognized loss
 developmentally delayed child (down syndrome)
Fertility decline with ageFertility decline with age
Menken, et al., Science 1986, 233:1389-94

6. Concurrent Loss in Quantity & Quality

7. Reproductive Aging:
Why do we care?
 Changing Demographics
 20% of women wait until they are at least 35
years of age before having their first child
 Establishment of a career
 Awaiting a stable relationship
 Desire for financial security
 False sense of security provided by high-tech
fertility procedures

8. Assessing Reproductive Age
What are you measuring?
And Why?
Reproductive performance
Response to stimulation
Live-born

9. Assessing Reproductive Age
 Direct measures
 AFC/ovarian volume
 Anti-mullerian Hormone (AMH)
 Inhibin B
 Indirect measures
 FSH

10. Evaluation of the Ovary
Testing of Ovarian Reserve
 Antral follicle count
 Cycle day
 Follicle size
 < 3 – diminished
reserve
AFC = 18
AFC= 4

11. Ovarian Reserve Testing
 Goal: To determine the functional
capacity of the ovary. Specifically the
quantity and quality of oocytes
remaining.
General Population
Chance of conception
Determine the time before
ovarian aging begins
Sub-fertile Population
Chance of conception, with or without
treatment
Optimal dose or protocol for treatment
Maheshwari, et al, 2006

12. Does Quantity = Quality?
 Quantity  number of oocytes retrieved
 Allows for selection
 Allows for freezing
 Affect on pregnancy rate/retrieval
 BUT does quantity = quality??
 Quality
 Pregnancy rate
 Surrogate marker: Implantation rate per
embryo transferred

13. Does Quantity = Quality?
Markers of ovarian reserve, such as basal AMH or FSH levels and AFCs, can
predict quantity of oocytes, but are not good predictors of oocyte quality
(defined as pregnancy success).

14. What Is Ovarian Reserve?
 Refers to:
 Size of the ovarian follicle pool
 Quality of the oocytes within that pool
 Number also influenced by genetics, environmental
factors
 Related to reproductive potential
# eggs to recruit 
chance of successful pregnancy

15. Assessing Ovarian Reserve:
o Cannot directly measure the primordial follicle pool…
o May presume that number from the number of growing (antral) follicles…
o “Gold Standard” assessment of ovarian reserve is antral follicle counts
(AFC) by ultrasonography
Schaffer et al., Hum Reprod (2003);18:700

16. Surrogate Marker for Ovarian Reserve?
 Ideal assay would:
 Be independent of variation in menstrual cycle
 Direct correlation with antral follicle counts
 Non-invasive
 Reproducible
 Efficient
 Cost-effective
 Why test?
 Infertility, family planning,
menopause, gonadotoxicity, others

17. • Each month one ovulatory egg is
released & rest of recruited ovarian
follicles undergo atresia
• As maternal age advances, number of
eggs that can be successfully recruited
for a possible pregnancy declines
• Ovarian reserve -Capacity of the ovary
to provide eggs
– Capable of fertilization
– Result in healthy / successful
pregnancy
• Important in the treatment of infertility
Need for noninvasive assessment of
potentially useful oocytes
Reproductive hormones

18. Ovarian Reserve:
Anti-Müllerian Hormone (AMH)
♀♀ ♂♂
Matzuk et al., Nat Med (2008) 14:1197

19. Newer Markers of Ovarian Reserve:
Anti-Müllerian Hormone (AMH)
 Regulates folliculogenesis:
 Recruitment and selection of a dominant follicle
 Limits the number that progress thru cycle

20. AMH & Age
Kelsey et al., PLoS ONE (2011) 6:e22024

21. Anti Mullerian Hormone
 Structurally related to inhibin and activin, and a
member of the transforming growth factor-β
(TGF-β) family.
 Tissue growth and differentiation -
In female embryogenesis the absence of AMH
allows for the development of upper vagina, uterus
and cervix, and oviducts.
 Produced directly by growing primary, preantral
& small antral ovarian follicles
 Measuring ovarian aging-As number of antral
follicles decrease with age, Anti-Müllerian
hormone (AMH) serum levels also become
diminished –undetectable(<0.3ng/ml) near
menopause
 Independent of menstrual cycle phase
 Evaluates fertility potential and ovarian response
in IVF (<1ng/ml poor reserve)
 In anovulatory conditions including PCOS
(> 6.7 ng/ml)

22. AMH Strongly Predicts Oocyte Numbers and
Ongoing Pregnancy:
Blazar et al., Am J Obstet Gynecol (2011) 205:223

23. AMH Positively Correlates with
Follicle Counts:
de Vet et al., Fertil Steril (2002) 77:357
van Rooij et al., Hum Repro (2002) 17:3065

24. AMH Utility: Cautions
 Extremely low AMH concentrations do not rule out
successful pregnancy outcome
Weghofer et al., Hum Reprod (2011) 26:1905
 “AMH supports clinical decisions, but alone it is not a
suitable predictor of IVF success.”
Gnoth et al., Hum Reprod (2008) 23:1359

25. Additional AMH Utility: Overall
 Better predictor of ovarian response to IVF than inhibin B, FSH,
E2 van Rooij et al., Hum Reprod (2002) 17:3065
 ART: may identify extremes of ovarian stimulation (hypo- and
hyper-), thus use to individualize treatment
La Marca et al., Hum Reprod Update (2010) 16:113
 Better correlation with follicle pool depletion in young women
with ovarian failure than AFC or inhibin B
Knauff et al., JCEM (2009) 94:786
 Stronger predictor of time to menopause than FSH or inhibin B
Freeman et al., JCEM (2012) 97:1673; Sowers et al., JCEM (2008) 93:3478
 Marker of gonadotoxicity post-chemotherapy in pre-and
postpubertal girls
Brougham et al., JCEM (2012) 97:2059

26. Other Uses of AMH:
Non-Fertility Related
 Ambiguous genitalia
 Undescended testes
 Polycystic ovarian
syndrome (PCOS)
 Ovarian and germ cell
tumors

27. Inhibin A
 During the menstrual cycle and early
pregnancy, inhibin A is produced by
the corpus luteum.
 Levels increase dramatically in the
late follicular phase and maximize in
the mid - luteal phase.
 During pregnancy, inhibin A levels in
maternal serum increase during the
first trimester and decline after
about 10 weeks. Levels remain stable
at 15 to 25 weeks and then increase,
reaching peak at term
 The feto-placental unit appears to be
the major source of increased
circulating concentrations of inhibin
A in early pregnancy
 Although the function of inhibin A
in pregnancy is unknown, inhibin A
may be involved in fetal and
placental development.
Inhibin B
• Inhibin B Test -predicts ovarian reserve,
including egg quality and egg quantity.
• Because Inhibin B is produced directly by FSH-
sensitive cohort of antral follicles, the amount of
Inhibin B in the blood directly correlates to the
number of eggs in the ovaries.
• Inhibin B can also predicts the ability of
ovaries to produce more follicles. This suggests
that the hormone can predict the success of
certain ovulation-inducing drugs, like Clomid.
• Low levels of Inhibin B(< 45pg/ml) are
associated with:impaired ovulation , decreased
success with IVF & lower pregnancy rates
• Who Can Benefit from the Day 3 Inhibin B
Test?
patient with poor response to fertility drugs
patient with unexplained infertility
patient over the age of 35
Inhibins