Ovarian reserve Ovarian reserve and infertilityand infertility

Dr. Sundus Yousif KellowDr. Sundus Yousif Kellow

C.A.B.O.GC.A.B.O.G

DefinitionDefinition

• Ovarian reserve is a term used to describe the Ovarian reserve is a term used to describe the functional potential of the ovary and reflects the functional potential of the ovary and reflects the number and quality of oocytes within it.number and quality of oocytes within it.

• A good test of ovarian reserve should be A good test of ovarian reserve should be predictive of conception (with or without predictive of conception (with or without treatment) and should indicate how long current treatment) and should indicate how long current levels of ovarian activity can be maintained levels of ovarian activity can be maintained before ovarian ageing sets in.before ovarian ageing sets in.

Ovarian ReserveOvarian Reserve

• Ovarian reserve is a complex clinical phenomenon Ovarian reserve is a complex clinical phenomenon that is influenced by age, genetics, environmental that is influenced by age, genetics, environmental variablevariable

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

• • women over 30 years of agewomen over 30 years of age

• • women with a history of exposure to a confirmed women with a history of exposure to a confirmed gonadotoxin, i.e., tobacco smoke, chemotherapy, gonadotoxin, i.e., tobacco smoke, chemotherapy, radiation therapy.radiation therapy.

• • women with a strong family history of early women with a strong family history of early menopause or premature ovarian failure.menopause or premature ovarian failure.

• • women who have had extensive ovarian surgery, i.e., women who have had extensive ovarian surgery, i.e., cystectomy and unilateral oophorectomy.cystectomy and unilateral oophorectomy.

In a subfertile population attending for fertility In a subfertile population attending for fertility treatment, a test of ovarian reserve should guide treatment, a test of ovarian reserve should guide us in prognosticating outcome in individual cases us in prognosticating outcome in individual cases byby

(i) predicting the chances of pregnancy and live (i) predicting the chances of pregnancy and live birth with or without treatment and ;birth with or without treatment and ;

(ii) selecting an optimal dose of ovarian stimulation (ii) selecting an optimal dose of ovarian stimulation where treatment using ovarian stimulation is where treatment using ovarian stimulation is planned. planned.

Markers of ovarian reserveMarkers of ovarian reserveA/Static tests A/Static tests         

1 - Age     1 - Age     

2 - Basal serum FSH     2 - Basal serum FSH     

3 - Basal serum estradiol     3 - Basal serum estradiol     

4 - Basal LH/FSH ratio     4 - Basal LH/FSH ratio     

5 - Basal serum inhibin-B level     5 - Basal serum inhibin-B level     

6 - Basal serum anti-Müllerian hormone level     6 - Basal serum anti-Müllerian hormone level     

7 - Basal ovarian volume     7 - Basal ovarian volume     

8 - Basal antral follicle count     8 - Basal antral follicle count     

9 - Ovarian stromal blood flow     9 - Ovarian stromal blood flow     

B/Dynamic tests B/Dynamic tests         

1 - Clomiphene citrate challenge test (CCCT) 1 - Clomiphene citrate challenge test (CCCT)         

2 - GnRH agonist stimulation test (GAST)     2 - GnRH agonist stimulation test (GAST)     

3 - Exogenous FSH ovarian reserve test (EFORT)3 - Exogenous FSH ovarian reserve test (EFORT)

The ideal ORT that may be usefule clinically has yet The ideal ORT that may be usefule clinically has yet to be ascertained.to be ascertained.

Age and fertility:Age and fertility:

In many cases, a woman’s age is the single most In many cases, a woman’s age is the single most important indicator of fertility potential. A important indicator of fertility potential. A woman’s fertility starts decreasing in her late woman’s fertility starts decreasing in her late twenties, and decreases further after age 35. twenties, and decreases further after age 35.

While a 20 year old woman and a 40 year old While a 20 year old woman and a 40 year old woman ovulate the approximate same number of woman ovulate the approximate same number of times each year, their monthly pregnancy rate, or times each year, their monthly pregnancy rate, or fecundity, is much different. fecundity, is much different.

Natural Decline of Oocytes with Age Natural Decline of Oocytes with Age

FSHFSH• FSH is the hormone released by the pituitary FSH is the hormone released by the pituitary

gland in the brain to stimulate the ovaries to gland in the brain to stimulate the ovaries to produce a dominant follicle (which contains an produce a dominant follicle (which contains an egg). egg).

• A “good quality” egg releases certain substances A “good quality” egg releases certain substances (e.g. inhibin-B, estrogen) that suppress the FSH (e.g. inhibin-B, estrogen) that suppress the FSH level (negative feedback). When the egg quality level (negative feedback). When the egg quality is compromised, these negative feedback signals is compromised, these negative feedback signals are weak and there is a resultant increase in FSH are weak and there is a resultant increase in FSH levels.levels.

• Day 3 FSH is an indirect measure of the size of Day 3 FSH is an indirect measure of the size of the follicle cohort and is regulated by various the follicle cohort and is regulated by various factors, including inhibins, activins, estradiol and factors, including inhibins, activins, estradiol and follistatins . follistatins .

It is important to realize that FSH levels have low It is important to realize that FSH levels have low sensitivity, meaning that not everyone with a sensitivity, meaning that not everyone with a diminished ovarian reserve will have an diminished ovarian reserve will have an abnormally elevated FSH level.abnormally elevated FSH level.

Large inter-cycle variations in basal FSH remain a Large inter-cycle variations in basal FSH remain a frequent problem. frequent problem.

An elevated FSH does mean that achieving a An elevated FSH does mean that achieving a successful pregnancy with any type of fertility successful pregnancy with any type of fertility treatment, including with IVF, will be treatment, including with IVF, will be compromised. At the same time, a mild elevation compromised. At the same time, a mild elevation in the FSH level may be a reason to pursue in the FSH level may be a reason to pursue infertility treatment more aggressively and infertility treatment more aggressively and proceed directly to IVF. proceed directly to IVF.

Antral follicle count measurementsAntral follicle count measurements **A normal ovary should have a volume of at least 3 A normal ovary should have a volume of at least 3

cc with at least 6 – 15 antral follicles. cc with at least 6 – 15 antral follicles.

**Antral follicles are small, fluid filled cysts that are Antral follicles are small, fluid filled cysts that are normally found in the ovaries. The higher the normally found in the ovaries. The higher the antral follicle count, the better the fertility antral follicle count, the better the fertility potential. potential.

**Small ovaries may indicate compromised fertility Small ovaries may indicate compromised fertility potential, as there may be less follicles - and potential, as there may be less follicles - and therefore less eggs - available within the ovaries.therefore less eggs - available within the ovaries.

**The performance of AFC for predicting failure to The performance of AFC for predicting failure to achieve pregnancy is poor. This is because while achieve pregnancy is poor. This is because while AFC determines the number of oocytes, a clinically AFC determines the number of oocytes, a clinically relevant outcome (pregnancy or live birth) relevant outcome (pregnancy or live birth) depends on oocyte quality as well as quantity. depends on oocyte quality as well as quantity.

5-10 per side

Low A F Count <6 in total

PCO

Factors affecting AFC measurements:Factors affecting AFC measurements:• • Oral contraceptive use (decreases)Oral contraceptive use (decreases)

• • Polycystic ovary syndrome (PCOS) (increases).Polycystic ovary syndrome (PCOS) (increases).

Drawbacks of AFC:Drawbacks of AFC:

• • Accurate assessment of AFC requires an Accurate assessment of AFC requires an experienced sonographer and can be limited in experienced sonographer and can be limited in patients who have had pelvic surgery or uterine patients who have had pelvic surgery or uterine fibroids and in those who are obesefibroids and in those who are obese

• • Moderate interobserver and intercycle variability Moderate interobserver and intercycle variability of AFC determinations limits its reproducibility. of AFC determinations limits its reproducibility.

• • As with basal FSH measurement, the intercycle As with basal FSH measurement, the intercycle variability of AFC does not correlate well with IVF variability of AFC does not correlate well with IVF outcome in individual patients.outcome in individual patients.

Serum estradiolSerum estradiol

• Elevated basal estradiol may predict the poor Elevated basal estradiol may predict the poor response even when basal FSH is normal. response even when basal FSH is normal.

The value of cycle day 3 estradiol levels in the The value of cycle day 3 estradiol levels in the prediction of ovarian reserve is still debatable.prediction of ovarian reserve is still debatable.

Inhibin-BInhibin-B

• Inhibin-B is mainly produced by the granulosa Inhibin-B is mainly produced by the granulosa cells in growing follicles and offers a more cells in growing follicles and offers a more immediate assessment of ovarian activity than immediate assessment of ovarian activity than other serum tests.other serum tests.

• A fall in day 3 inhibin-B levels may predict poor A fall in day 3 inhibin-B levels may predict poor ovarian reserve before the expected rise in day 3 ovarian reserve before the expected rise in day 3 FSH. FSH.

**Factors affecting Inhibin-B measurements:**Factors affecting Inhibin-B measurements:

• • Obesity (decreases)Obesity (decreases)

• • PCOS (increases)PCOS (increases)

• • Exogenous FSH administration (increases)Exogenous FSH administration (increases)

• • Oral contraceptive use (decreases).Oral contraceptive use (decreases).

Anti-Müllerian hormoneAnti-Müllerian hormone

Antimüllerian hormone (AMH) also known as Antimüllerian hormone (AMH) also known as Müllerian Inhibiting Substance (MIS) is a new Müllerian Inhibiting Substance (MIS) is a new diagnostic marker of ovarian function. The diagnostic marker of ovarian function. The existence of AMH was first proposed in 1947 by existence of AMH was first proposed in 1947 by Professor Alfred Jost. This hormone is made in the Professor Alfred Jost. This hormone is made in the testes of men. It was thought not to exist in testes of men. It was thought not to exist in women. In recent years, it has been found in women. In recent years, it has been found in women starting at puberty.women starting at puberty.

Anti-Müllerian hormone (AMH) is produced by the Anti-Müllerian hormone (AMH) is produced by the granulosa cells of the recruited follicles until they granulosa cells of the recruited follicles until they become sensitive to FSH . AMH has been identified become sensitive to FSH . AMH has been identified as a regulator of the recruitment, preventing the as a regulator of the recruitment, preventing the depletion of all primordial follicle pool at once. depletion of all primordial follicle pool at once.

AMH is a glycoprotein growth factor and a member of AMH is a glycoprotein growth factor and a member of the transforming growth factorthe transforming growth factor superfamily(TGF-superfamily(TGF-B)with a molecular weight of 140kDa. It is primarily B)with a molecular weight of 140kDa. It is primarily produced by the pool of early-growing follicles, which produced by the pool of early-growing follicles, which are believed to serve as a proxy for the number of are believed to serve as a proxy for the number of primordial follicles in the ovary primordial follicles in the ovary

Copyright ©2010 Society for Reproduction and Fertility

Reproduction. 2006 Jan;131(1):1-9AMH expression in mouse ovaries. (A) AMH is expressed in granulosa cells of primary (P), preantral (PA) and small antral (SA) follicles. (B) AMH expression disappears in antral (A) and atretic (At) follicles. Expression is lost last in the granulosa cells surrounding the oocytes. AMH expression was detected using a monoclonal antibody that recognises rat, mouse and human AMH.

Model of AMH action in the ovary. Progressing stages of Model of AMH action in the ovary. Progressing stages of folliculogenesis are depicted. AMH is produced by the small folliculogenesis are depicted. AMH is produced by the small growing (primary and preantral) follicles in the postnatal ovary growing (primary and preantral) follicles in the postnatal ovary and has two sites of action. It inhibits initial follicle recruitment and has two sites of action. It inhibits initial follicle recruitment (1) and inhibits FSH-dependent growth and selection of (1) and inhibits FSH-dependent growth and selection of preantral and small antral follicles (2).preantral and small antral follicles (2).

What is the role of AMH in assessing ovarian What is the role of AMH in assessing ovarian aging and ovarian reserve? aging and ovarian reserve?

• • AMH levels decrease over time even in “fertile” AMH levels decrease over time even in “fertile” women who have regular menstrual cycles. women who have regular menstrual cycles.

• • AMH levels correlate well with the ovarian antral AMH levels correlate well with the ovarian antral follicle count and were the only levels that follicle count and were the only levels that decreased longitudinally over time compared with decreased longitudinally over time compared with FSH, estradiol, and inhibin-B levels. With ovarian FSH, estradiol, and inhibin-B levels. With ovarian aging, the first change is a decrease in AMH aging, the first change is a decrease in AMH levels, followed by a decline in inhibin-B and levels, followed by a decline in inhibin-B and finally by an increase in FSH levels. finally by an increase in FSH levels.

• • AMH levels do not vary significantly during AMH levels do not vary significantly during the menstrual cycle and can therefore be the menstrual cycle and can therefore be drawn on any day of the cycle! drawn on any day of the cycle!

• • Women who are overweight have 65% lower Women who are overweight have 65% lower AMH levels than thin women, indicating that AMH levels than thin women, indicating that obesity may be associated with decreased obesity may be associated with decreased ovarian reserve and/or with ovarian dysfunction. ovarian reserve and/or with ovarian dysfunction.

  

What are the factors that influence AMH levels? What are the factors that influence AMH levels?

A.A.Factors that decrease MIS/AMH Factors that decrease MIS/AMH

• • Increasing age Increasing age

• • Obesity Obesity

• • Administration of gonadotropins Administration of gonadotropins

• • Administration of chemotherapy or radiation Administration of chemotherapy or radiation

• • Surgical removal of one or both ovaries Surgical removal of one or both ovaries

B. Factors that increase MIS/AMH B. Factors that increase MIS/AMH

• • Polycystic Ovarian Syndrome Polycystic Ovarian Syndrome

C. Factors that do not influence MIS/AMHC. Factors that do not influence MIS/AMH

• • Day of menstrual cycle Day of menstrual cycle

• • GnRH agonists GnRH agonists

• • Birth Control Pills Birth Control Pills

• • Pregnancy Pregnancy

What are “normal” and “abnormal” levels of What are “normal” and “abnormal” levels of AMH? AMH?

• • AMH levels less than 0.2 - 0.5 ng/mL are AMH levels less than 0.2 - 0.5 ng/mL are associated with increased IVF cycle cancellation associated with increased IVF cycle cancellation rates and fewer eggs retrieved from the ovaries. rates and fewer eggs retrieved from the ovaries.

• • AMH levels greater than 2.5 ng/mL are AMH levels greater than 2.5 ng/mL are associated with greater number of eggs associated with greater number of eggs retrieved and a better fertility potential. retrieved and a better fertility potential.

• • Recent data suggest that AMH levels may reflect Recent data suggest that AMH levels may reflect fertility potential more accurately than fertility potential more accurately than conventional markers like FSH, inhibin-B or conventional markers like FSH, inhibin-B or estradiol levels.estradiol levels.

• • AMH levels may be better indicators of the AMH levels may be better indicators of the ultimate chance that a woman will achieve a ultimate chance that a woman will achieve a pregnancy than FSH levels. pregnancy than FSH levels.

• • A high AMH level (greater than 3.6 ng/mL) may A high AMH level (greater than 3.6 ng/mL) may predict that a woman is at increased risk for predict that a woman is at increased risk for ovarian hyperstimulation syndrome. In such ovarian hyperstimulation syndrome. In such women, the dose of medications with IVF can be women, the dose of medications with IVF can be reduced to avoid this side effect of fertility reduced to avoid this side effect of fertility treatments. treatments.

• AMH levels have been found to be two to three AMH levels have been found to be two to three times higher in PCOS women , making it difficult times higher in PCOS women , making it difficult to find a threshold value for poor ovarian reserve to find a threshold value for poor ovarian reserve without a significant overlap with normal values. without a significant overlap with normal values.

Dynamic testsDynamic tests

Another approach towards identifying ovarian Another approach towards identifying ovarian reserve involves dynamic testing. This involves reserve involves dynamic testing. This involves taking a baseline serum sample, stimulating the taking a baseline serum sample, stimulating the ovaries (FSH/Clomiphene/GnRH agonist) and then ovaries (FSH/Clomiphene/GnRH agonist) and then retesting the serum level again for the same retesting the serum level again for the same marker. All the dynamic tests are more marker. All the dynamic tests are more expensive, invasive and associated with the side expensive, invasive and associated with the side effects of administered stimulation regimens. effects of administered stimulation regimens.

Combination of testsCombination of testsCombinations of various markers (AFC, AMH and Combinations of various markers (AFC, AMH and

inhibin-B) have been tried, and a joint scoring inhibin-B) have been tried, and a joint scoring system has been developed which predicts a poor system has been developed which predicts a poor response to gonadotrophin stimulation at best response to gonadotrophin stimulation at best with 87% sensitivity and 80% specificity and a with 87% sensitivity and 80% specificity and a positive likelihood ratio of 4.36%. However, they positive likelihood ratio of 4.36%. However, they have not been tested for prediction of have not been tested for prediction of pregnancy .pregnancy .

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