Samantha F. Butts, MD, MSCE Dr. Butts is Assistant Professor of Obstetrics and Gynecology, Division of Infertility and Reproductive Endocrinology, at University of Pennsylvania Medical School in Philadelphia.
David B. Seifer, MD Dr. Seifer is Co-Director of Genesis Fertility and Reproductive Medicine at Maimonides Medical Center in Brooklyn, NY, and Professor of Obstetrics, Gynecology and Reproductive Sciences at Mount Sinai School of Medicine in New York City.
Several tests of ovarian reserve are at your disposal. The help is welcome—but they’re not equally informative or reliable.
Ovarian reserve is infiuenced by age, genetics, and environmental variables
Commonly cited criteria for normal ovarian reserve are:
early follicular phase FSH <10 mIU/mL
estradiol <80 pg/mL.
An accurate antral follicle count requires an experienced sonographer and can be limited by fibroids or obesity
The age-related decline in AMH is gradual but measurable even in young women
The University of Medicine and Dentistry of New Jersey (UMDNJ) owns a patent relating to the use of anti-Müllerian hormone/Müllerian inhibiting substance for predicting ovarian response in women with infertility. The patent is based in part on work that Dr. Seifer carried out while employed at UMDNJ. In accordance with UMDNJ policy, Dr. Seifer, a named inventor on this patent, assigned his interest in the invention to UMDNJ. UMDNJ has a licensing agreement with Diagnostic Systems Laboratory for the use of the claimed invention. Dr. Seifer receives a portion of the royalties, as determined by UMDNJ policy, that UMDNJ gains from this licensing agreement.
CASE: Borderline test result prompts referral
A 36-year-old nulliparous woman is seen in your office for evaluation after 6 months of infertility. She is ovulatory, and has been using an ovulation-prediction kit to time intercourse. You learn that she had Chlamydia trachomatis infection in the distant past, but elicit no other significant medical or surgical history. She reports that she smoked approximately one pack of cigarettes a day for 15 years but gave up smoking 5 years ago.
You order a hysterosalpingogram, followed by day 3 testing of follicle-stimulating hormone (FSH). The hysterosalpingogram is normal; the FSH level is 7.5 mIU/mL and the estradiol level is 30 pg/mL—both in the normal range.
The patient asks for testing of anti-Müllerian hormone (AMH; also known as Müllerian-inhibiting substance) because she has read that it is a new marker of fertility. The result is 0.5 ng/mL, a borderline value. After reviewing these results, you refer her to a reproductive endocrinologist for further management.
Was the test for AMH indicated? And is this referral appropriate?
The referral is entirely appropriate, even though the patient has not been trying to conceive for a full year. Why? The AMH value suggests that her ovarian reserve is in early decline. She would benefit from evaluation by a subspecialist who can review the entire spectrum of treatments, including aggressive options such as ovulation induction and in vitro fertilization (IVF), to optimize her reproductive success.
This article reviews the various biomarkers available to assess ovarian reserve in women who experience infertility:
The AFC and AMH tend to detect the earliest changes in ovarian reserve, followed, sequentially, by inhibin-B, the clomiphene citrate challenge test (CCCT), and basal FSH.
The tests we describe are used primarily to assess treatment prognosis in infertile women. In time, however, appropriate population screening of ovarian reserve may be feasible to provide many more women with information about their reproductive potential and help them shape their life plan.
What makes a test valuable?
Ovarian reserve describes a woman’s reproductive potential—specifically, the number and quality of oocytes she possesses.1 Biochemical tests of ovarian reserve emerged during the rise of assisted reproductive technologies (ART) in the late 1980s to predict both responsiveness to superovulation drugs and the odds of pregnancy with treatment.
Ideally, a test that assesses ovarian reserve should be affordable, straightforward, rapidly interpretable, and minimally invasive. It also should be able to detect changes that begin early in reproductive life. To be applicable to large populations of reproductive-age women, it should be of use anytime in the menstrual cycle, and should provide reproducible and highly accurate assessment of the reproductive aging process.
Our ability to offer tests that accurately measure ovarian reserve has a significant impact on women at risk of infertility and early menopause and on those who choose to delay childbearing for personal (nonmedical) reasons. These tests have become increasingly relevant because women are choosing to have their first child at a later age than their counterparts did 20 years ago:
In 1980, 40% of women having their first baby were younger than 25 years, and only 5% were older than 35
In 2000, 25% of women were younger than 25 when their first child was born, and 15% were older than 35.
Who should be tested?
Ovarian reserve is a complex clinical phenomenon that is influenced by age, genetics, and environmental variables. The decline in a woman’s ovarian reserve over time is irreversible; the trajectory of this decline is fundamental to the odds of fertility with age and the timing of the menopausal transition. At present, the markers used most often in clinical practice have some utility but also suffer from several drawbacks (TABLE).
