WHAT is Ovarian Reserve?
Ovarian reserve in simple terms means fertility potential. Ovarian reserve is a terminology used to determine the capacity of the ovary to produce eggs. It is the evaluation of the quantity of the remaining oocytes in the ovary. It can be further classified as normal and diminished ovarian reserve. Normal ovarian reserve is when women respond well to fertility medications and vice versa for diminished ovarian reserve.
WHY should we assess OR (Ovarian Reserve)?
We should assess OR for many reasons including to identify the individuals with decreased or diminished ovarian reserve (DOR). Also, if you are planning to delay childbearing, you should get your OR test done. By knowing the ovarian reserve, we can formulate a treatment plan and also discuss prognosis as to how early and how fast one should try to conceive and what is the likelihood that she will become pregnant. When it shows a reduced ovarian reserve, it is very important to counsel the lady that she should plan to conceive earlier. The treatment would then depend on how low the reserve is.
In WHOM Ovarian Reserve Test should be done?
It is especially important to know your ovarian reserve in case you are older than 35 years and have not conceived within 6 months of trying. Also, in women who have had previous ovarian surgery, endometriosis, or have a medical condition treated with gonadotoxic therapies (eg. Rheumatoid Arthritis) or history of cancer requiring chemotherapy or pelvic irradiation, ovarian reserve testing should be done at the beginning and treatment planned accordingly.
These days, even young couples are coming to us with low ovarian reserve. These days, with stress, pollution, poor diet, the ovarian reserve seems to be declining at a faster pace. In analysis of 158 cases at our centre we found a shocking incidence of DOR as below:
Risk factor for decreased ovarian reserve from ASRM, 2012
Advanced reproductive age (> 35 years)
Family history of early menopause
Previous ovarian surgery (endometriosis / ovarian cyst)
Genetic conditions eg. turner’s
History of medical conditions requiring chemotherapeutic drugs
History of cancer requiring pelvic irradiation / gonadotoxic therapies
HOW to assess OR?
Female of same age respond differently to ovarian stimulation and have different responses to ovarian. Ovarian Reserve provides an indirect estimate of a woman's remaining follicular pool. Certain biochemical tests should be done in order to assess the OR. Some of them are listed below:
1. Biochemical tests
- a. Basal FSH with estradiol (day 2) FSH is an important part of men and women's reproductive system. It is mainly responsible for the growth of ovarian follicles. The FSH test measures the level of FSH found in your blood. High FSH value is associated with poor response to ovarian stimulation. Although, less reliable than AMH, a day 2 FSH with estradiol can also provide us with an estimate of ovarian reserve.
- b. AMH stand for Anti-Mullerian Hormone which is a hormone secreted by cells in developing eggs follicles. The high the level of AMH in a woman’s blood there will be high possibility of the ovarian reserve
AMH Blood Level Interpretation:
|Status||AMH Blood Level|
|High||Over 4.0 ng/ml|
|Normal||1.5 to 4.0 ng/ml|
|Low Normal Range||1.0 to 1.5 ng/ml|
|Low||0.5 to 1.0 ng/ml|
If the AMH blood level is low,
- a. Plan early, go for early treatment.
- b. If you are planning to delay child bearing then get your eggs frozen
- a. AFC or Antral follicle counts by Ultrasound on day 2 of periods to look for no. of eggs.
Small Case Study at First Step IVF
A 32 year old lady visited our clinic – First Step IVF.
She came with complaints of being unable to conceive her second baby since last 2 years. She was prescribed ovulation, egg making medicines for the last 6 months, with NO result.
After doing the AMH, we found that the lady is having very low reserve and she might require IVF for planning the pregnancy.
She visited many senior gynecologists who prescribed her medicine for making eggs (Commonest – clomiphene). She was given these medicines for 6 months. When she came to us, and we did her USG and blood test – AMH, we and the lady herself were shocked! Because we found only 1 egg in her ovaries and her AMH was .01 ng/ml which is very low. That means, her ability to develop eggs is very low and she would now require IVF with egg donation.
Had she undergone ovarian reserve test earlier. She would probably have undergone IVF earlier with her own eggs and had her own baby.
- Ovarian Reserve assessment is important
- to tailor treatment to a woman’s individual needs
- for counseling
- planning treatment
- For those women and couples planning to delay childbearing
Dr. Priti Gupta is the Senior Consultant in Fertility & IVF Specialist in Delhi. She is trained and worked at the Best IVF Center in West Delhi, which is quite prominent & popular in west Delhi.