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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3. Scott RT, Toner JP, Muasher SJ, Oehninger S, Robinson S, Rosenwaks Z. Follicle stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil Steril. 1989;51:651-654.

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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9. Esposito MA, Coutifaris C, Barnhart KT. A moderately elevated day 3 FSH concentration has limited predictive value, especially in younger women. Hum Reprod. 2002;17:118-123.

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11. Jain T, Soules MR, Collins JA. Comparison of basal follicle-stimulating hormone versus the clomiphene citrate challenge test for ovarian reserve screening. Fertil Steril. 2004;82:180-185.

12. Toner JP. Modest follicle-stimulating hormone elevations in younger women: warn but don’t disqualify. Fertil Steril. 2004;81:1493-1495.

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.

15. Bulkulmez O, Arici A. Assessment of ovarian reserve. Curr Opin Obstet Gynecol. 2004;16:231-237.

16. Ranieri DM, Quinn F, Makhlouf A, et al. Simultaneous evaluation of basal follicle-stimulating hormone and 17-beta-estradiol response to gonadotropin-releasing hormone analogue stimulation: an improved predictor of ovarian reserve. Fertil Steril. 1998;70:227-233.

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.

18. Galtier-Dereure F, De Bouard V, Picto MC, et al. Ovarian reserve test with the gonadotrophin-releasing hormone agonist buserelin: correlation with in-vitro fertilization outcome. Hum Reprod. 1996;11:1393-1398.

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.

In some women, day 10 FSH is elevated even after a normal day 3 value. This makes the CCCT more sensitive than basal FSH testing; it can identify women who might go unrecognized if evaluated by day 3 FSH and estradiol levels alone.

More expensive and labor-intensive than the alternatives

Interpretation of the CCCT requires that FSH and estradiol both be assessed on days 3 and 10. An elevated FSH (≥10 mIU/mL) on either day indicates diminished ovarian reserve. As with basal FSH testing, elevated estradiol (≥80 pg/mL) on day 3 is considered abnormal. The day 10 estradiol value of the CCCT reflects whether or not clomiphene citrate was administered appropriately, and should be elevated. However, the significance of the day 10 estradiol level has been debated with respect to its predictive value for pregnancy in infertile populations.⁸

The addition of day 10 FSH assessment improves the sensitivity of the CCCT over basal FSH measurement, but makes it a more expensive and labor-intensive test ( TABLE ).^5,6 The CCCT involves administration of clomiphene citrate, a safe drug (though it can have side effects), and two blood draws instead of one. Nevertheless, both tests are relatively noninvasive, rapid measures of ovarian reserve.

Drawbacks of the tests

Both basal FSH testing and the CCCT are widely used, although support for their ability to predict ovarian reserve in the infertile population has been challenged recently. Newer data demonstrate that these tests are limited in their ability to predict outcome (pregnancy and response to superovulation drugs) in all but a narrow group of patients undergoing IVF. Performance is particularly limited in:

young women
women in the general infertility population who are not utilizing IVF.^9-13

Additional drawbacks of basal FSH testing and the CCCT include:

significant variability of test results from cycle to cycle (intercycle variability)
limited time frame within which the tests can be performed (intracycle variability).

The basal FSH test and CCCT have high specificity (98% to 99% for each) as an assessment of reproductive performance in infertile women and generate few false-positive results.^5,6 However, the high screen cutoffs that allow for such specificity come at a price: Few women will screen positive, and sensitivity of the tests is low (between 7% and 8% for basal FSH and between 25% and 40% for the CCCT). Such low sensitivity means that many women will not conceive after infertility treatment despite a normal test result.^5,11 Overall, the tests are not highly informative for many women who get tested.

Once abnormal, normal results are meaningless

Once an FSH level or the CCCT has ever been abnormal, the patient has diminished ovarian reserve; normal values in subsequent menstrual cycles do not improve the odds of pregnancy with treatment.¹⁴ This fact can be a significant source of confusion and frustration for patients.

3 | GnRH agonist stimulation —no better than FSH testing

This test was developed in the search for a very sensitive assessment of ovarian reserve. It was designed to uncover subtle abnormalities in pituitary and ovarian dynamics. It involves administering a gonadotropin-releasing hormone (GnRH) agonist such as leuprolide acetate (Lupron) on day 2 or 3 of the menstrual cycle and measuring pituitary and ovarian hormone responses.^5,15

One group of investigators demonstrated a correlation between stimulated estradiol levels and responsiveness during IVF,¹⁶ but other studies have shown that the test does not perform significantly better than day 3 FSH in predicting ovarian reserve.^17,18

The sensitivity of GnRH agonist testing for pregnancy is moderate (32% to 89%); specificity ranges from 79% to 97%.¹⁹

4 | Inhibin-B—not helpful when used alone

This glycoprotein hormone produced by granulosa cells of developing follicles is a direct measure of ovarian reserve when assessed in the early follicular phase of the menstrual cycle.²⁰ Women treated with IVF who have a low inhibin-B level—particularly when using cutoffs below the range of 45–80 pg/mL—have been shown to respond poorly to superovulation and have a lower pregnancy rate than women with high inhibin-B.^21,22 One group of investigators demonstrated that women with clinical evidence of diminished ovarian reserve but a normal FSH level also had low inhibin-B production, suggesting that it may be a more sensitive marker than FSH.²²

Inhibin-B testing involves a simple blood draw. However, the test has been incorporated into clinical assessment of ovarian reserve only to a limited degree, due to the lack of reliable assays and controversy concerning its prognostic value.²³

Because of these limitations, routine testing of serum inhibin-B in isolation of other markers of ovarian reserve is not recommended.