In my last post, I explained the importance of ovarian reserve. Today, I review ovarian reserve testing.
Ovarian reserve testing is becoming commonplace in the fertility clinic world because it may significantly impact your ability to become pregnant. Several tests are used for ovarian reserve testing but be aware that these tests are just that, tests. The tests could be misleading and results showing low ovarian reserve do not necessarily mean that pregnancy isn’t possible. Here is a list of the current and most commonly used tests.
Cycle day 3 follicle-stimulating hormone (FSH) and estradiol (E2) blood levels
The first day of your period with full flow (not just spotting) is cycle day 1. The 3rd consecutive day of your period is cycle day 3, even if you are not bleeding on that day. Bleeding after taking progestin (usually ‘Provera’) does not count. The test relies on normal menstrual cycle physiology.
A review:
- FSH stimulates follicles to grow.
- As the follicles grow they produce estrogen (estradiol) and inhibin.
- Estrogen and inhibin suppress FSH levels.
- When there are fewer follicles, FSH rises above the norm, and there may be less estrogen and inhibin. A high FSH would suggest fewer eggs or ‘diminished ovarian reserve’ (DOR).
- Estrogen (and inhibin) may rise quickly and suppress the FSH value, so an increase in estrogen may also reflect DOR. (Inhibin is not routinely measured due to the cost).
In summary, an elevated FSH or estrogen level on cycle day 3 may reflect DOR. If you are in your early thirties or younger than thirty, a high FSH or estrogen will not be as reliable. For this age group there may be a decrease in the quantity, but not the quality of the eggs.
Clomiphene citrate challenge test (CCCT)
This test utilizes the cycle day 3 FSH and E2 levels, but also adds an FSH on cycle day 10. A CCCT may be useful if there is any doubt in your doctor’s mind about your levels, as it is more sensitive to changes that may not be obvious on CD3. CD3 FSH levels may be normal, but CD10 levels may not be.
Antral follicle count (AFC)
This test utilizes ultrasound images of your ovaries to count the number of follicles visible. The ultrasonographer has to be in tune to what he or she is doing for the count to be accurate. The AFC can be done at anytime during the menstrual cycle and takes 10 to 15 minutes. A transvaginal ultrasound is the preferred method. An abdominal probe is not as accurate.
Antimullerian hormone (AMH) levels
Here is another blood test, one of the latest tests for OR testing. The cells around the oocyte make AMH. Fewer cells, lower levels…
Summary
All the tests mentioned above don’t always agree so the results should be in context with the entire clinical picture. The very best test may be ovarian stimulation with FSH and luteinizing hormone (LH). Synthetic FSH and LH (identical to the hormones you make) are used to increase the number of follicles available for fertilization. If the ovaries don’t respond very well, then DOR is usually present. Options for diminished ovarian reserve include:
- Oocyte freezing – now becoming a reality just as sperm freezing has been for decades.
- Embryo freezing – which has excellent results.
- Egg ‘donor’ programs – where young women (usually having completed their childbearing) ‘donate’ (most of the time there is payment made to the donor) their eggs. The donors are usually anonymous, but at times it may be for a friend or relative.
Henry Bohler, Jr., M.D. ‘Major’ Bohler is Board Certified in Obstetrics and Gynecology and Reproductive Endocrinology and Infertility. He is also Medical Director at the University of Louisville’s Fertility Center, University OB/GYN Associates. Besides having a keen interest in IVF, Dr. Bohler other interests include polycystic ovary syndrome, recurrent pregnancy loss, and endometriosis.
