The ovaries are where all of a woman’s eggs are stored. Each month one egg is selected to grow and develop. This egg is released from the ovary. This process is called ovulation. If the egg meets a sperm then hopefully fertilization takes place and a baby is born 9 months later! If ovulation is irregular or absent i.e. an egg is not released on a regular basis then infertility can result.
Infertility can also result if there are a low number of eggs in the ovaries. Women are born with a given number of eggs. New eggs are not made. As women age the number of eggs in the ovaries constantly decreases. The number of eggs in the ovary is called the ovarian reserve.
There are many tests that can be performed to try to measure the ovarian reserve. Care must be taken with these tests because none of the tests are perfect. Also, none of the tests tell us if success will happen or not.
Some clinics use strict cutoff levels to determine if a patient is allowed to undergo fertility treatment. This can artificially increases the clinic's success rates. If a clinic chooses to avoid treating women with significant ovarian reserve issues then they are effectively screening out the patients with the lowest chance of success. This may make the clinic look good, but in actuality their numbers are falsely elevated.
At the Advanced Reproductive Center we do not use strict cutoffs. We believe that each patient is an individual and must be treated as such. We treat patients not numbers and care is individualized based on each specific situation.
The most common tests to evaluate the ovarian reserve are: baseline FSH level, AMH level, and antral follicle count.
Follicle stimulating hormone (FSH) is the hormone that causes the eggs in the ovary to grow and develop. If the number of eggs in the ovaries are low the brain produces more FSH to try and “push” the ovaries harder.
We can measure FSH early in the menstrual cycle. If it is elevated then it is a sign that the number of eggs in the ovaries is low. Low egg numbers may lead to difficulties trying to get pregnant.
It is important to remember that it is the low egg number that is the problem. The FSH is just a maker telling us that the egg number is low. Patients sometimes ask me if I can correct the FSH level. The answer is yes I can give estrogen which will force down the FSH level. However, while the FSH level will be lower, this will not fix the problem because the number of eggs in the ovaries will still be low. Unfortunately, while we can manipulate the FSH level and make it look like things are better we cannot put more eggs in the ovaries and truly fix the problem.
Anti-Müllerian hormone (AMH) is a hormone that is produced by the small resting follicles in the ovary. Each follicle contains one egg. So the more follicles the more eggs. Therefore we can measure AMH and get an idea of how many eggs are in the ovary.
The higher the AMH level the more eggs in the ovaries the lower the AMH level the lower the number of eggs in the ovaries.
Care must be taken in interpreting AMH levels. AMH is a newer test and as such is not as well understood as FSH. It is a good test and a useful test but like all ovarian reserve tests it is not perfect.
Antral follicle count (AFC) is done by performing a transvaginal ultrasound. During the ultrasound the ovaries are visualized and the number of small resting follicles in the ovaries are counted.
There is a relationship between the number of small resting follicles in the ovaries and the total number of eggs in the ovaries. The higher the AFC the higher the number of eggs in the ovaries and the lower the AFC the lower the number of eggs in the ovaries.
AFC is a quick and easy test that can be done anytime a transvaginal ultrasound is performed. AFC can also be useful in trying to predict how a person will respond to fertility drugs. However, just like the other ovarian reserve tests, its ability to determine who will or will not conceive is poor.
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