Expert ReviewOvarian reserve testing: a user’s guide
Introduction
A woman is born with about 2 million primordial follicles, yet by the onset of menarche only about 400,000 follicles are left due to natural follicular atresia. As a woman reaches her mid-30s the pace of oocyte depletion begins to increase and by the time she reaches her late 30s, the number of follicles declines to approximately 25,000, concomitant with a significant increase in miscarriage rate. The term “ovarian reserve” has traditionally been used to describe a woman’s reproductive potential–specifically, the number and quality of oocytes she possesses.1 However, commonly used ovarian reserve markers serve as a proxy for oocyte quantity but are considered poor predictors of oocyte quality. Therefore, modern usage of the term pertains to the quantity of remaining oocytes rather than oocyte quality, for which age still remains the best predictor. Diminished ovarian reserve (DOR) describes women of reproductive age having menses whose response to ovarian stimulation or fecundity is reduced compared with women of comparable age.1 It is distinct from menopause or premature ovarian insufficiency.
Ovarian reserve is a complex clinical phenomenon influenced by age, genetics, and environmental variables.2 The decline in a woman’s ovarian reserve with time is irreversible and the rate at which women lose primordial follicles varies considerably, with wide variation regarding the onset of sterility and timing of the menopausal transition. Although it is challenging to predict the rate of an individual’s ovarian reserve decline, clinicians are often asked for advice about fertility potential and/or recommendations regarding the pursuit of fertility treatment options. Over the past few years, there have been several comprehensive reviews on ovarian reserve tests that focused mainly on ovarian response prediction in the context of assisted reproductive technology (ART).3, 4, 5, 6 The purpose of this review is to summarize the state-of-the-art of ovarian reserve testing, providing a practical guide for the obstetrician/gynecologist generalist and reproductive endocrinologist.
Section snippets
What makes a reliable ovarian reserve test?
Ovarian reserve tests started to emerge during the rise of ART in the late 1980s to predict both responsiveness to superovulation drugs and the odds of pregnancy with treatment. They include both biochemical basal and provocative tests and ultrasound imaging of the ovaries. The first test to be introduced was day-3 follicle-stimulating hormone (FSH) (1988), followed by clomiphene citrate challenge test (CCCT) (1989), gonadotropin releasing-hormone (GnRH) agonist (1989), inhibin B (1997), antral
Early follicular follicle-stimulating hormone
The use of early follicular phase (basal) FSH as a marker of ovarian reserve was proposed almost 30 years ago, as a tool to predict ovarian response to in vitro fertilization (IVF).11, 12, 13 This test is an indirect assessment of ovarian reserve and is based on the feedback inhibition of FSH pituitary secretion by ovarian factors. At the beginning of the menstrual cycle, estradiol and inhibin B levels reach a nadir, offering a glimpse to the unsuppressed hypothalamus-pituitary-ovarian axis
Antimüllerian hormone
AMH is a glycoprotein that belongs to the transforming growth factor-β superfamily and is produced in the female exclusively by granulosa cells of small and large preantral and small antral follicles.4 Although AMH was first noted to be present in follicular fluid in 1993,17 its function was incompletely understood. It was later that its clinical utility as an ovarian reserve marker was first reported18 following studies of AMH–deficient mice demonstrating accelerated atresia when the AMH gene
Sensitivity and specificity
Among all ovarian reserve tests, AMH is considered the earliest and most sensitive. It correlates strongly with the primordial follicle pool, has an inverse correlation with chronologic age,35, 36 reliably predicts ovarian response in ART,37, 38 and is predictive of the timing of the onset of menopause.39, 40, 41 In a systematic review of studies in women undergoing controlled ovarian stimulation with gonadotropins, low AMH cut-off points (0.1-1.66 ng/mL) have been found to have sensitivities
Limitations
The main limitations of the AMH test relate to assay variability and lack of standardized international assay. Prior to 2010, 2 different assays were used; the European and US assays were developed independently with different antibodies and reported very different results, using different units. That problem was thought to be resolved by the manufacture of both enzyme-linked immunosorbent assays by the same company and the development of a new assay (Gen II, Beckman Coulter Inc, Brea, CA) that
Age-specific AMH values
Age-specific AMH values have been provided by several studies52, 53, 54, 55, 56, 57, 58 and are informative for the population of women presenting to fertility clinics. Thus, the reference values are age appropriate and not referenced to a general population of women independent of age. Such values may be analogous to a Z score (compared to an age-matched cohort) for ovarian reserve. As a general guideline we consider the lower limit of age-appropriate serum AMH values for the following in
Factors affecting AMH results
In addition, when interpreting a patient’s AMH test results it is important for the clinician to consider the effects of possible influencing factors to avoid inaccurate assessment of ovarian reserve. Table 2 summarizes the biological, reproductive, and environmental/lifestyle factors suggested to affect AMH levels. For example, polycystic ovary syndrome (PCOS) is associated with elevated AMH levels,59, 60 while ovarian suppression related to oral contraceptive pills or GnRH agonist
Antral follicular count
AFC is the sum of follicles in both ovaries as observed on ultrasound in the early follicular phase (day 2-4) of the menstrual cycle. Antral follicles are defined as those measuring 2-10 mm in largest mean diameter on 2-dimensional plane. AFC is easy to carry out, provides an immediate result, and has good intercycle reliability and good interobserver reliability when measured in experienced centers using a minimal number of sonographers. Its precision is compromised with overweight and obese
Which ovarian reserve test should I choose?
A large body of evidence has demonstrated greater clinical value of AMH and AFC compared to FSH.5 AMH will decline years prior to a rise in FSH and thus, is an earlier, more sensitive real-time biomarker of ovarian reserve. It is now well recognized that AMH is a direct product of both cumulus and mural granulosa cells from preantral and small antral follicles during early folliculogenesis. AMH has a greater correlation with the primordial follicle pool (egg supply) compared to ovarian markers
What to do in case of discordance between ovarian reserve tests?
Since information about >1 ovarian reserve test is often available for infertility patients, it is not uncommon to have discordant test results that may complicate patient counseling and decision-making regarding the most appropriate treatment. In a large study of 5354 women that examined discordance between AMH and FSH results obtained by a single reference laboratory, 1 in 5 women were found to have discordant AMH and FSH values defined as AMH <0.8 ng/mL (concerning) with FSH <10 IU/L
Who should get ovarian reserve testing and how to use it in clinical practice?
Historically, ovarian reserve testing was used for prediction of ovarian response to controlled ovarian stimulation in ART, helping to identify patients who are more likely to have a poor response or hyperresponse to gonadotropins. Over the past decade, since the discovery of AMH as an ovarian reserve marker, it has been increasingly recognized that AMH testing may have utility for a variety of other clinical applications in reproductive medicine (Table 3).48, 88
Ovarian reserve screening for the general reproductive-age female population?
It is estimated that approximately 10% of the general female population will undergo accelerated loss of ovarian reserve leading to loss of fertility from their mid-30s and early menopause by age 45 years.108, 109 In the past, this was of minimal concern from a public health standpoint since most women had completed their family plans by their mid–30s. However, over the past 2 decades the average age of a mother at her first birth has steadily increased and is currently 30 years of age in the
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D.B.S. receives royalties from a licensing agreement between Rutgers Medical School/Massachusetts General Hospital and Beckman Coulter for the use of müllerian inhibiting substance/antimüllerian hormone in determining ovarian reserve. R.T. has no conflict of interest to disclose.