News for Your Practice

6 office tests to assess ovarian reserve, and what they tell you

OBG Manag. 2008 November;20(11):29-40

References

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4. Toner JP, Philiput CB, Jones GS, Muasher SJ. Basal follicle stimulating hormone level is a better predictor of in vitro fertilization outcome than age. Fertil Steril. 1991;55:784-791.

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13. Van Rooij IAJ, de Jong E, Broekmans FJM, Looman CWN, Habbeman DK, te Velde ER. High follicle-stimulating hormone levels should not necessarily lead to the exclusion of subfertile patients from treatment. Fertil Steril. 2004;81:1478-1485.

14. Scott RT, Hofmann GE, Oehninger S, Muasher SJ. Intercycle variability of day 3 follicle-stimulating hormone levels and its effect on stimulation quality in in vitro fertilization. Fertil Steril. 1990;54:297-302.

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17. Fujimoto VY, Klein NA, Battaglia DE, Bremmer WJ, Soules MR. The anterior pituitary response to a gonadotropin-releasing hormone challenge test in normal older reproductive age women. Fertil Steril. 1996;65:539-544.

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19. Broekmans FJ, Fwee J, Hendricks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update. 2006;12:685-718.

20. Klein NA, Illingworth PJ, Groome NP, NcNeilly AS, Battaglia DE, Soules MR. Decreased inhibin B secretion is associated with the monotropic FSH rise in older, ovulatory women: a study of serum and follicular fluid levels of dimeric inhibin A and B in spontaneous menstrual cycles. J Clin Endocrinol Metab. 1996;81:2742-2745.

21. Seifer DB, Lambert-Messerlian G, Hogan JW, et al. Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome. Fertil Steril. 1997;67:110-114.

22. Seifer DB, Scott RT, Jr, Bergh PA, et al. Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone. Fertil Steril. 1999;72:63-65.

23. Corson SL, Gutmann J, Batzer FR, Wallace H, Klein N, Soules MR. Inhibin-B as a test of ovarian reserve for infertile women. Hum Reprod. 1999;14:2818-2821.

24. Tomas C, Nuojua-Huttunen S, Martikainen H. Pretreatment transvaginal ultrasound examination predicts ovarian responsiveness to gonadotrophins in in-vitro fertilization. Hum Reprod. 1997;12:220-223.

25. Chang MY, Chiang CH, Hsieh TT, Soong YK, Hsu KH. Use of the antral follicle count to predict the outcome of assisted reproductive technologies. Fertil Steril. 1998;69:505-510.

26. Hung E, Tang OS, Ho PC. The significance of the number of antral follicles prior to stimulation in predicting ovarian responses in an IVF programme. Hum Reprod. 2000;15:1937-1942.

27. Bancsi LFJMM, Broekmans FJM, Eijkemans MJC, de Jong FH, Habbema JDF, te Velde ER. Predictors of poor ovarian response in in vitro fertilization: a prospective study comparing basal markers of ovarian reserve. Fertil Steril. 2002;77:328-336.

28. Ng EH, Yeung WS, Fong DY, Ho PC. Effects of age on hormonal and ultrasound markers of ovarian reserve in Chinese women with proven fertility. Hum Reprod. 2003;18:2169-2174.

29. Scheffer GJ, Broekmans FJ, Dorland M, Habbema JD, Looman CW, te Velde ER. Antral follicle counts by transvaginal ultrasonography are related to age in women with proven natural fertility. Fertil Steril. 1999;72:845-851.

30. Hansen KR, Morris JL, Thyer AC, Soules MR. Reproductive aging and the variability in the ovarian antral follicle count: application in the clinical setting. Fertil Steril. 2003;80:577-583.

31. Cate RL, Mattaliano RJ, Hession C, et al. Isolation of the bovine and human genes for Müllerian inhibiting substance and expression of the human gene in animal cells. Cell. 1986;45:685-698.

32. de Vet A, Laven JSE, de Jong FH, Themmen APN, Fauser BCJM. Anti-Müllerian hormone serum levels: a putative marker for ovarian aging. Fertil Steril. 2002;77:357-362.

33. van Rooij IAJ, Broekmans FJM, Scheffer GJ, et al. Serum anti-Müllerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: a longitudinal study. Fertil Steril. 2005;83:979-987.

34. van Rooij IAJ, Tonkelaar I, Broekmans FJ, et al. Anti-Müllerian hormone is a promising predictor for the occurrence of the menopausal transition. Menopause. 2004;11:601-606.

35. Tremellen KP, Kolo M, Gilmore A, Lekamge DN. Anti-Müllerian hormone as a marker of ovarian reserve. Aust N Z J Obstet Gynaecol. 2005;45:20-24.

36. Silberstein T, MacLaughlin DT, Shai I, et al. Müllerian-inhibiting substance levels at the time of HCG administration in IVF cycles predict both ovarian reserve and embryo morphology. Hum Reprod. 2006;21:159-163.

37. Seifer DB, MacLaughlin DT, Christian BP, Feng B, Shelden RM. Early follicular serum Müllerian-inhibiting substance levels are associated with ovarian response during assisted reproductive technology cycles. Fertil Steril. 2002;77:468-471.

38. Ebner T, Sommergruber M, Moser M, Shebl O, Schreier-Lechner E, Tews G. Basal level anti-Müllerian hormone is associated with oocyte quality in stimulated cycles. Hum Reprod. 2006;21:2022-2026.

39. Hazout A, Bouchard P, Seifer DB, Aussage P, Junca AM, Cohen-Bacrie P. Serum anti-Müllerian hormone/Müllerian-inhibiting substance appears to be a more discriminatory marker of ART outcome than follicular stimulating hormone, inhibin B or estradiol. Fertil Steril. 2004;82:1323-1329.

40. Nelson SM, Yates RW, Fleming R. Serum anti-Müllerian hormone and FSH: prediction of live birth and extremes of response in stimulated cycles—implications for individualization of therapy. Hum Reprod. 2007;22:2414-2421.

41. Fanchin R, Mendez DH, Frydman N, et al. Anti-Müllerian hormone concentrations in the follicular fluid of the preovulatory follicle are predictive of the implantation potential of the ensuing embryo obtained by in vitro fertilization. J Clin Endocrinol Metab. 2007;92:1796-1802.

42. Smeenk JM, Sweep FC, Zielhuis GA, Kremer JA, Th omas CM, Braat DD. Anti-Müllerian hormone predicts ovarian responsiveness, but not embryo quality or pregnancy, after in vitro fertilization or intracyoplasmic sperm injection. Fertil Steril. 2007;87:223-226.

43. Hehenkamp WJ, Looman CW, Themmen AP, de Jong FM, Te Velde ER, Broekmans FJ. Anti-Müllerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation. J Clin Endocrinol Metab. 2006;91:4057-4063.

44. La Marca A, Stabile G, Artenisio AC, Volpe A. Serum anti-Müllerian hormone throughout the menstrual cycle. Hum Reprod. 2006;21:3103-3107.

45. Tsepelidis S, Devreker F, Demeestere F, Flahaut I, Gervy A, Englert C. Stable serum levels of anti-Müllerian hormone during the menstrual cycle: a prospective study in normo-ovulatory women. Hum Reprod. 2007;22:1837-1840.

46. La Marca A, Giulini Orvieto R, De Leo V, Volpe A. Anti-Müllerian hormone concentrations in maternal serum during pregnancy. Hum Reprod. 2005;20:1569-1572.

47. Somunkiran A, Yavuz T, Yucel O, Ozdemir I. Anti-Müllerian hormone levels during hormonal contraception in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2007;134:196-201.

48. Al-Qahtani A, Groome NP. Anti-Müllerian hormone: Cinderella finds new admirers. J Clin Endocrinol Metab. 2006;91:3760-3762.

49. La Marca A, Orvieto R, Giulini S, Jasonni VM, Volpe A, De Leo V. Müllerian-inhibiting substance in women with polycystic ovary syndrome: relationship with hormonal and metabolic characteristics. Fertil Steril. 2004;82:970-971.

50. Piltonen T, Morin-Papunen L, Koivunen R, Perheentupa A, Ruokonen A, Tapanainen JS. Serum anti-Müllerian hormone levels remain high until late reproductive age and decrease during metformin therapy in women with polycystic ovary syndrome. Hum Reprod. 2005;20:1820-1836.

51. Pigny P, Merlen E, Robert Y, et al. Elevated serum level of anti-Müllerian hormone in patients with polycystic ovary syndrome: relationship to the ovarian follicle excess and to the follicular arrest. J Clin Endocrinol Metab. 2003;88:5957-5962.

52. Cook CL, Siow Y, Brenner AG, Fallat ME. Relationship between serum anti-Müllerian substance and other reproductive hormones in untreated women with polycystic ovary syndrome and endometriosis. Fertil Steril. 1997;67:962-965.

53. Pellatt L, Hanna L, Brincat M, et al. Granulosa cell production of anti-Müllerian hormone is increased in polycystic ovaries. J Clin Endocrinol Metab. 2007;92:240-245.

54. Freeman EW, Gracia CG, Sammel MD, Lin H, Lim LC, Strauss JF, 3rd. Association of anti-Müllerian hormone levels with obesity in later reproductive-age women. Fertil Steril. 2007;87:101-106.

55. Scott RT, Opsahl MS, Leonardi MR, Neall GS, Illions EH, Navot D. Life table analysis of pregnancy rates in a general infertility population relative to ovarian reserve and patient age. Hum Reprod. 1995;10:1706-1710.

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57. Lim AS, Tsakok MFH. Age-related decline in fertility: a link to degenerative oocytes? Fertil Steril. 1997;68:265-271.

For the general practitioner performing an infertility evaluation, we recommend focusing on the following groups of women for ovarian reserve testing:

women over 30 years of age
women with a history of exposure to a confirmed gonadotoxin, i.e., tobacco smoke, chemotherapy, radiation therapy
women with a strong family history of early menopause or premature ovarian failure
women who have had extensive ovarian surgery, i.e., cystectomy and unilateral oophorectomy.

Testing tends to have the highest yield in these groups. Women who have abnormal results should be referred to a reproductive endocrinologist for further evaluation and treatment.

The six tests are described below.

TABLE

How six markers of ovarian reserve stack up

Test (year described)	Timing	Intracycle and intercycle variability	Sensitivity (specificity)	Reflects changes in ovarian reserve	Normal levels	Confounders	Out-of-pocket cost
Basal follicle-stimulating hormone (FSH) (1988)	Day 3 of menstrual cycle	Clinically significant	7%–8% (98%–99%)	Late	• Early follicular phase FSH level <10 mIU/mL • Estradiol level <80 pg/mL	• High estradiol level (decreases) • Oral contraceptive use (decreases) • Pregnancy (decreases)	$125–$150
Clomiphene challenge test (1989)	Days 3 and 10 of menstrual cycle	Clinically significant	25%–40% (98%–99%)	Late	• Day 3 FSH level <10 mIU/mL; day 3 estradiol level <80 pg/mL • Day 10 FSH level <10 mIU/mL	• High day 3 estradiol level (decreases day 3 FSH) • Low day 10 estradiol (increases day 10 FSH) • Oral contraceptive use (decreases) • Pregnancy (decreases)	$550–$600
GnRH agonist (1988)	Early follicular phase of menstrual cycle	Clinically significant	32%–89% (79%–97%)	Late	Variable	• Oral contraceptives (decrease estradiol levels) • Pregnancy (increases estrogens)	$300–$350
Inhibin-B (1997)	Early follicular phase of menstrual cycle	Clinically significant	33%–81% (29%–95%)	Early	Variable in the literature; normal cutoffs range from ≥45–80 pg/mL	• Obesity (decreases) • PCOS (increases) • Exogenous FSH administration (increases) • Oral contraceptive use (decreases)	$150–$200
Antral follicle count (1997)	Early follicular phase of menstrual cycle	Clinically significant (includes interobserver variability)	8%–60% (33%–96%)	Earliest	≥5–10 total antral follicles	• Oral contraceptive use (decreases) • Polycystic ovary syndrome (PCOS) (increases)	$300–$500
Anti–Müllerian hormone/Müllerian-inhibiting substance (2002)	At any time; not cycle-dependent	Minimal	49%–76% (89%–94%)	Earliest	>0.7 ng/mL	• PCOS (increases) • Obesity (decreases) • Exogenous FSH administration (decreases)	$150–$400

1 | Basal FSH—widely used but only moderately informative

Day 3 FSH and the CCCT are the most widely used measures of ovarian reserve in ART practice. The use of early follicular-phase FSH as a marker of ovarian reserve and fertility was proposed 20 years ago with the emergence of IVF.^2-4 The test is an indirect assessment of ovarian reserve in that it measures pituitary production of FSH in response to feedback from ovarian hormones. Estradiol and inhibin-B reach a nadir early in the menstrual cycle; measuring FSH on day 3 offers a glimpse of the functioning of the hypothalamic–pituitary–ovarian axis before ovarian hormone levels rise later in the cycle ( FIGURE 1 ).^5,6

FIGURE 1 The HPO axis

The FSH level opens a window onto the function of the hypothalamic–pituitary–ovarian axis before ovarian hormone levels rise in the cycle. Women who have normal ovarian reserve have sufficient ovarian hormone production early in the menstrual cycle to maintain FSH levels within the normal range. Conversely, a “monotropic” elevation in FSH—one that is unaccompanied by a rise in luteinizing hormone (LH)—reflects poor hormone production from an aging pool of ovarian follicles and disinhibition of FSH production.^5,6

FSH measurements are typically combined with estradiol to enhance the sensitivity of testing ( FIGURE 2, ). Premature elevations of estradiol early in the follicular phase are driven by rising FSH levels in women with declining ovarian reserve. Abnormally elevated estrogen levels then feed back negatively on pituitary production of FSH and mask an elevation that might otherwise reveal diminished ovarian reserve. Measurement of both FSH and estradiol on cycle day 3 may therefore help decrease the incidence of false-negative testing.

Commonly cited criteria for normal ovarian reserve are:

early follicular phase FSH, <10 mIU/mL
estradiol, <80 pg/mL¹

It is extremely important to note, however, that these are general guidelines and that cutoffs are both laboratory- and practice-specific.

FIGURE 2 Monthly and lifetime variations in estradiol and FSH

How 17ß-estradiol and follicle-stimulating hormone levels vary over the menstrual cycle (top) and a woman’s lifetime (bottom).

2 | Clomiphene citrate—more sensitive than FSH testing

Like basal FSH testing, the CCCT is an indirect assessment of ovarian reserve. Unlike FSH testing, the CCCT is provocative. It involves administration of 100 mg of clomiphene citrate (Clomid) on days 5 through 9 of the menstrual cycle, with FSH and estradiol measured on days 3 and 10. Once clomiphene citrate is administered, FSH and LH levels rise, followed by an increase in estradiol and inhibin. Evidence suggests that the smaller follicular cohorts in women with diminished ovarian reserve produce less inhibin-B and estradiol and, therefore, less negative feedback on clomiphene-induced pituitary FSH release.^6,7 The result: persistent elevation of the day 10 FSH value and a positive screen for diminished ovarian reserve.