Facts about fertility - Ovarian Reserve

Facts from Best Gynaecologist in Rohini practicing fertility treatments i.e Dr. (Mrs) Pulkit Nandwani 

What is ovarian reserve? 

The goal of any stimulation regimen for IVF is several good quality eggs and a healthy uterine environment. Ovarian reserve is a theoretical concept. As a practical matter, it refers to the ease at which an individual’s ovaries can be successfully stimulated with fertility drugs. The single most consistent variable affecting ovarian reserve is the woman’s age. This is because a woman is born with all the eggs she will ever have. In most women a majority of the eggs are genetically normal or balanced.

Women Age vs Fertile Eggs

 However, there will be some that are genetically abnormal or unbalanced. It appears that the best eggs are ovulated first. The older a woman is, the fewer genetically balanced eggs she has left to respond to fertility drugs. This age relationship holds true even in the fertile population.

 In older women fewer normal embryos are available for implantation into the uterus. Hence, healthy women over 35 are less fertile than their younger counterparts. Women 40 and over may have only a 20% live birth rate with IVF treatment using their own eggs. This is why donor egg therapy has become so popular in this age group.

Poor  Responders

Unfortunately, there are some young women who respond poorly to attempts at ovarian stimulation. Perhaps these so called “poor responders” are born with more genetically unbalanced eggs such as in a Turner’s mosaic syndrome patient or they may have fewer eggs or poor quality eggs because of past surgical treatment, pelvic infections, cancer treatment, cigarette smoking, ovarian scarring associated with endometriosis, or unexplained infertility, etc. It is this group of patients that has presented the biggest challenge to IVF practitioners.

What ovarian reserve tests are commonly used? 

There are several clinical markers used to identify the so called “poor responder”. Today the most commonly used are the basal follicle stimulating hormone (FSH) and the clomiphene citrate challenge test (CCCT) . More recently, ultrasound has also been used to anticipate stimulation response  as recommended by Best Gynaecologist in North Delhi!

The basal follicle stimulating hormone (FSH)

The basal FSH test is a blood test drawn on the second or third day of the menstrual cycle. FSH released from the pituitary gland stimulates the ovaries to recruit and select eggs so that one will grow and eventually ovulate. When there are few eggs available the pituitary gland has to send a much stronger signal so the FSH level will be higher in those women. A high FSH level points towards women being a “poor responders”. Women who fall into the normal range are believed to be better candidates for IVF.

An estradiol level may be drawn at the time of the basal FSH to help verify the fact that the patient is having the test drawn on the correct day. This is because if the estradiol level is elevated, the FSH level will be suppressed. Sometimes women in early menopause will have elevated day three estradiol levels with suppressed FSH levels giving false negative results.

The clomiphene citrate challenge test (CCCT)

The CCCT test was developed as a refinement to the basal FSH test for women 35 years of age or older. With this test the patient has a basal FSH level drawn on cycle day 3 and another one on day 10, following the administration of 100 mg clomiphene citrate on cycle days 5 through 9. The test is interpreted by comparing the basal to stimulated levels of the test results. Those women who demonstrate an exaggerated FSH release after clomiphene stimulation are said to have failed the test. Some women with normal basal FSH levels will be identified as poor responders when they are given the CCCT test. Unfortunately, as more individuals are assigned the “poor responder” label, more normal patients are inaccurately assigned to the abnormal group.

Ultrasound screening for ovarian volume and antral follicle count is a promising approach. With this technology patients are assigned to an anticipated ovarian response group based on follicle number. Clinically, women with very low numbers will have very few eggs at oocyte retrieval. Those patients with adequate follicle numbers may have a reasonable quantity of oocytes at retrieval despite abnormal pre-treatment blood test results.

What does an abnormal result mean?

A true “poor responder” will have a lower chance of conception and live birth compared to members of the normal responder group regardless of the age. The problem lies in assigning patients to the wrong response group on the basis of pre-treatment testing alone.

Many centers  have come to rely on ovarian reserve testing in order to identify those patients unlikely to become pregnant prior to initiation of a first IVF treatment cycle. In theory, women unlikely to conceive can be given the opportunity to avoid the financial disappointment associated with an IVF failure. If a patient should still choose to use her own oocytes, then appropriate counseling can be given.

Continual pursuit of insemination cycles is costly . A properly planned IVF cycle can lead to answers and may help a couple conceive. And, there will be some patients who actually take home miracles when given the opportunity for a treatment cycle despite dismal treatment pre-screening test results.

Conclusion

Ovarian reserve testing identifies patients that have a lower probability of conceiving.

Curious about your level of ovarian reserve and your options?  To consult with a top gynaecologist , please click on the link below.

Find out about your Ovarian Reserve Level .