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

1. Practice Committee of the American Society for Reproductive Medicine. Age and infertility in women. Fertil Steril. 2006;86:S248-S252.

2. Muasher SJ, Oehninger S, Simonetti S, Matta J, Ellis LM, Liu H-C. The value of basal and/or stimulated serum gonadotropin levels in prediction of stimulation response and in vitro fertilization outcome. Fertil Steril. 1988;50:298-307.

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.

5. Barnhart K, Osheroff J. Follicle stimulating hormone as a predictor of fertility. Curr Opin Obstet Gynecol. 1998;10:227-232.

6. Hofmann GE, Danforth DR, Seifer DB. Inhibin-B: the physiologic basis of the clomiphene citrate challenge test for ovarian reserve screening. Fertil Steril. 1998;69:474-477.

7. Yong PY, Baird DT, Thong KJ, McNeilly AS, Anderson RA. Prospective analysis of the relationships between the ovarian follicle cohort and basal FSH concentration, the inhibin response to exogenous FSH and ovarian follicle number at different stages of the normal menstrual cycle and after pituitary down-regulation. Hum Reprod. 2003;18:35-44.

8. Scott RT, Jr, Illions EH, Kost ER, Dellinger C, Hofmann GE, Navot D. Evaluation of the significance of the estradiol response during the clomiphene citrate challenge test. Fertil Steril. 1993;60:242-246.

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.

10. Bancsi L, Broekmans FJM, Wol BWJ, Habbema DK, te Velde ER. Performance of basal follicle-stimulating hormone in the prediction of poor ovarian response and failure to become pregnant after in vitro fertilization: a meta-analysis. Fertil Steril. 2003;79:1091-1100.

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.

56. Speroff L. Fritz M. eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2004.

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

5 | Antral follicle count—good predictor of IVF outcome

Transvaginal ultrasonographic determination of the number of ovarian follicles that measure between 2 mm and 10 mm in diameter in the early follicular phase of the cycle yields the AFC. As a direct marker of the cohort of growing follicles in the early menstrual cycle, the AFC is believed to correlate strongly with the number of primordial follicles present in the ovary and, therefore, ovarian reserve. Total AFCs of less than 5 to 10 are suggestive of diminished ovarian reserve.^24,25

In IVF cycles, AFC has proven to be an accurate predictor of number of oocytes retrieved, risk of cycle cancellation, and odds of conception.^24,25 Some investigators have even suggested that, compared with other markers of ovarian reserve, AFC is the best independent predictor of outcome in IVF cycles.^7,26-27

In a group of normally cycling women with proven fertility, AFC also showed a strong correlation with age, declining slowly until age 37 and more rapidly thereafter.^28,29

AFC sensitivity for pregnancy is moderate and varies widely in published reports (8% to 60%), whereas specificity tends to be higher (33% to 96%).¹⁹

Drawbacks of AFC

Because of the need to perform transvaginal ultrasonography, AFC is a more invasive and often more expensive test than hormonal biomarkers
Accurate assessment of AFC requires an experienced sonographer and can be limited in patients who have had pelvic surgery or uterine fibroids and in those who are obese
Moderate interobserver and intercycle variability of AFC determinations limits its reproducibility^29,30
As with basal FSH measurement, the intercycle variability of AFC does not correlate well with IVF outcome in individual patients.³⁰

6 | Anti-Müllerian hormone— many advantages

The drawbacks of the tests just described— e.g., intercycle variability, lack of uniform cutoffs, and limited ability to predict IVF outcomes—make the development of more reliable measures of ovarian reserve a priority in reproductive medicine. AMH is a highly promising marker that appears to have many advantages over other tests and may have the greatest power to predict ovarian aging in women of reproductive age.

How it works

AMH is a glycoprotein growth factor and a member of the transforming growth factor-ß superfamily.³¹ It is primarily produced by the pool of early-growing follicles, which are believed to serve as a proxy for the number of primordial follicles in the ovary. The number of primordial follicles at a given point in time represents the ovarian reserve. AMH levels above 0.7 ng/mL are considered normal; values between 0.3 ng/mL and 0.7 ng/mL are consistent with borderline ovarian reserve, according to 2007 data from Reprosource Corp.

AMH has been studied as a marker of ovarian reserve for 6 years, with multiple reports describing declines in levels with age and with diminishing oocyte numbers. It is undetectable at menopause.³²

The age-related decline in AMH is gradual but measurable even in young women, consistently preceding changes in other markers of ovarian reserve such as FSH and inhibin-B.^32-35 The longitudinal changes in AMH have been demonstrated in ovulatory premenopausal women and healthy volunteers with proven fertility.^33,34 In one series of women followed over a mean of 4 years (ages 25 to 46), AMH testing was superior to day 3 FSH, inhibin-B, and AFC in its ability to predict the onset of cycle irregularity and the menopausal transition.³³

Does it predict oocyte quality?

AMH has performed well as a biomarker, comparable in most series to AFC and superior to FSH. AMH levels are strongly correlated with the number of oocytes retrieved during IVF and the odds of cycle cancellation due to poor response^35-41—but does it accurately characterize oocyte quality, the other element of ovarian reserve?

Some reports have shown a strong association between AMH levels and surrogates of oocyte quality, including fertilization, oocyte morphology, embryo quality, and pregnancy and miscarriage rates,^36-41 but others have not.⁴² Some reports demonstrate a relationship between AMH and some but not all surrogate markers of oocyte quality.⁴⁰

Advantages of AMH

It demonstrates minimal intracycle variability.^32,43-45 Compared with other markers of ovarian reserve, which must be measured early in the follicular phase of the menstrual cycle, AMH can be assessed at random times, making it a more convenient method for patients and physicians
It demonstrates minimal intercycle variability^32,34
AMH levels are not significantly affected by the hormonal changes of pregnancy, oral contraceptive use, or GnRH treatment, and can be measured in these settings.^46,47

Utility of AMH is limited in PCOS and obesity

The ability to use AMH as a marker of ovarian aging in women who have polycystic ovary syndrome (PCOS) and in women who are obese may be limited by the ovulatory dysfunction in these populations. Circulating levels of AMH are higher in women with PCOS than in unaffected women, a finding thought to be indicative of oligo-ovulation and poor follicular development in polycystic ovaries.^48-53