1. Dr. Jyoti Agarwal
Dr. Sharda Jain
Ovarian Reserve Testing in
Infertility

2. Over 300 ppts are available on slideshare.net
***for use of public/Doctors
www.slideshare.net / Lifecarecentre

3. The Best Gametes
Give The Best Result

4. OVARIAN RESERVE
• Plan fertility preservation
• Fertility outcome
• Response to ovarian stimulation
• Predict pregnancy rate
• Monitor fertility decline
• Fertility after chemotherapy and cancer
treatment

5. Events in Development of Gonads
3 weeks • Appearance of germ cells
4-6 weeks • Migration of germ cells
5 weeks • Appearance of gonadal ridge
6 weeks • Completion of indifferent stage
6-9 weeks • Differentiation of gonads (ovary or
testes)

6. REGULATION AND INITIATION OF
FOLLICLE GROWTH

7. Germ cell number in
relation of Age
Age Number of follicles
3 weeks 100
6 weeks 10,000
8 weeks 600,000
20 weeks 6-8 million
Birth 1-2 million
Puberty 300,000
35 years 25,000
Menopause 1,000

8. AGE & FERTILITY WORK-UP
< 34 yr - 1 year by age 30 - 7%
35 – 38 – after 6 months by age 35 - 11%
38 – yr – after 3 months 40 - 33%
45 – 87%
Age & fertility Work-up Infertility Incidence

9. Timely identification of patients with
Poor ovarian reserve is essential ….
In order to tailor their Treatment protocol by either
treating aggressively or choosing other modes
of treatment in patients with LOW RESERVE to avoid
financial loss and disappointment.

10. PREMATURE OVARIAN FAILURE
-1% women under 40 yrs.
-0.1% under 30 yrs.
-0.01% udder 20 yrs.

11. Less than 4 oocytes in mild IVF is now considered as POR
• Prevalence is 5-25 %
• Prevalence increases with age
* > 50 % over 40 years
** 1/3 of previous poor responders will have a
normal response in next cycle
***62.4% will have repeat poor response,
Klinkert et al 2004
POOR OVARIAN RESPONCE
Young poor responders have different
prognosis from older ones

12. Ovarian reserve tests
Sonographic markers
Age
Menstrual pattern
Clinical markers
AFC
Ovarian volume
Ovarian blood flow
Endocrine markers
Static markers
D3 FSH
D3 E2
D3 FSH:LH
Inhibin B
AMH
Dynamic tests
Clomiphene citrate
Challenge test (CCCT)
GnRH agonist
Stimulation test (GAST)
Exogenous FSH ORT
(EFFORT)

13. CRITERIA TO DEFINE POOR RESPONDER PRIOR
TO OVARIAN STIMULATION
TESTS ESHRE
Bologna
2010
ASRM
2012
NICE
2013
AGE > 40 years
FSH 10-20 IU/L ≥ 8.9 IU/L
AMH < 0.5 -1.1
ng/ml
0.2-0.7 ng/ml ≤ 5.4 pmol/L
(0.75 ng/ml)
AFC < 5-7 3-10 ≤ 4

14. POOR OVARIAN RESPONSE
Bologna Criteria
Two of the following three features must be present
Advanced maternal age (>40 years) or any other risk factor for POR
*A previous POR (<3 oocytes with a conventional ovarian
stimulation protocol)
**An abnormal ovarian reserve test (ORT)
antral follicle count (AFC) <5-7 or
serum anti-Mullerian hormone (AMH) <0.5-1.1 ng/ml.

15. Avoid Iatrogenic complication
Ovulation protocol strategy
Agonist protocol VS Antagonist protocol
Flare protocol VS MNC
Why to predict ovarian response
?

16. ETIOLOGY
• Age
• Genetics
• Iatrogenic
-Pelvic irradiation
-Chemotherapy :
Alkylating agents significantly diminishes
the pool of resting follicles
-Oophorectomy

17. -Genetics
-Age at which mother attained menopause
-Turner’s Syndrome
-FMRI mutation (Fragile X syndrome)
ETIOLOGY

18. Oocyte Quality And Age

19. Diagnostic Modalities
- Ovarian Reserve Testing
(ORT)
- Biochemical
- Ultrasonological

20. Ovarian Reserve Response prediction
 Age
 FSH
 Ovarian volume
 AFC
 AMH
El-Amal IVF Center

21. BIOMARKERS OF OVARIAN AGING
Basal Follicle stimulating hormone
Basal estradiol
Inhibin B
Anti Mullerian Hormone
Clomiphene citrate challenge test

22. Interpreting Basal DAY 3 FSH in patients
undergoing Infertility workup
• <10 Normal FSH level, Expect a good response to ovarian stimulation.
• 10 – 12 Borderline FSH, Response to stimulation is somewhat reduced,
Overall, a slightly reduced live birth rate.
• 13 – 15 Elevated FSH, Reduced ovarian reserve, Reduced response to
stimulation and some reduction in embryo quality with IVF,
Reduced live birth rates on the average.
• 16 – 20 Markedly elevated FSH, Marked reduction in response to
stimulation and usually a further reduction in embryo quality, Low
live birth rates. Very poor (or no) response to stimulation.

23. BASAL FSH
-Serum levels on Day2-3 of menstrual cycle
-Inter cycle variability present
-High value (greater than 10 IU/L)
associated with poor Reserve and
response to ovarian stimulation

24. BASAL ESTRADIOL
- Released from Granulosa cells & considered a
reflection of folliculogenesis.
- usually low on cycle days 2-4 (<50pg/ml).
- High values indicate ovarian aging (>60-80pg/ml)
<20pg/ml ..also have higher cancellation of cycles
- Central negative feedback on FSH

25. ANTI MULLERIAN HORMONE
-Glycoprotein growth factor, also called Mullerian
Inhibiting Substance (MIS)
*Belongs to transforming growth factor (TGF beta)
superfamily
*Granulosa cells of primary, pre-antral, Antral follicles
(2-6mm) ‘’Recruitment Regulator’’ – prevents all
follicles depleting at once.

26. AMH

27. AMH CUTOFFS
Levels > than 3.6 ng /mL
At risk for ovarian hyper stimulation syndrome
Low starting dose of stimulation drugs
Levels >= 2.5ng/ml
Better fertility outcomes
More eggs retrieved during OPU
Levels < 0.2 – 1 ng /ml
Increased cycle cancellations
Fewer eggs retrieved during OPU

28. DIAGNOSTIC UTILITY OF AMH
-Ovarian reserve –Best prediction , prior to enrolment of IVF
*Low ovarian reserve: low AMH with high FSH
**In PCOS in predicting hyper-stinulation on ovarian stimulation
***High AMH--Diagnosis and management of granulose cell
tumours specially after oophorectomy
- Successful treatment…/ disappearance of AMH
****Very high levels in girls with virilising Sterol
Leydig Cell ovarian tumours

29. OVARIAN RESERVE
 AMH: suppressed during pregnancy and prolonged
GNrHa , O C
 AMH may not retain its accuracy as predictor of ovarian
reseve in OC users
El-Amal IVF Center
Anderson 2006m, Nelson 2010 –Hadlow etal 2013

30. OVARIAN RESERVE:AMH
AMH in diagnosis amenorrhea
In hypogonadal Hypogonadism :FSL,LH low
AMH is low than normal
Hypergonadal Hypogonadism: AMH undectable
Granulosa cell tumors very heigh levels
Premature ovarian failure AMH may be undectable

31. OVARIAN RESERVE: AMH
Treatment of ectopic pregnancy with methotroxate
decreases AMH and AFC
Eur J Obstet Gynecol Reprod Biol 2014

32. AMH BETTER THAN FSH
-Recent studies show it is the better marker than
FSH/Estradiol / Inhibin B in ovarian reserve testing
-Levels display minimal variation during menstrual cycle
Unlike FSH
-Identifies low responders for tailored therapy
-Identifies high responders at risk of OHSS
-Less intra-individual variation

33. INHIBIN B
-Glycoprotein hormone
-Represent Granulose cells in pre antral and antral
follicles
-Serum Levels decrease with increasing age
-Negative feedback with increasing age
-Significant inter cycle variability
-Unreliable as a marker for ovarian reserve
- Not recommended

34. CLOMIPHENE CITRATE CHALLENGE TEST
- Serum FSH on Day 3
- Clomiphene citrate from Day 5..9
- Repeat Serum FSH on Day 10
- Elevated FSH LEVELS – s/o diminished reserve
- Cycle to cycle variability of other ovarian
biomarkers
- CCCT thus unreliable
- Can predict poor response
- Cannot predict failure to conceive

35. ULTRASOUND MARKERS
-Antral follicle count
-Ovarian volume

36. ANTRAL FOLLICLE COUNT
-AFC correlates with
-Quantity of remaining follicles
-Ovarian response during stimulation
-Good intercycle reliability
-Good interobserver reliability
-Not be used as sole criteria to plan
treatment

37. Ovarian Reserve AMH
AMH Vs AFC Ovarian response:Starting Dose
AMH is better in predicting hyporesponse
AFC is better in predicting hyperresponse

38. OVARIAN VOLUME
-Ovarian measurements in three planes
-Formula for volume of ellipsoid
-D1 X D2 X D3 X 0.52
-Mean ovarian volume (average of both ovaries)
-Correlates with ovarian response to stimulation
-Cannot predict failure to conceive
-Comparatively AFC still better marker for
Diminished reserve

39. ‘’When AFC was compared to, basal FSH, basal
estradiol, AMH,
inhibin B, ovarian volume,
Antral follicle count and AMH were found
To be the most significant predictors of poor
response to ovarian Stimulation but not of
failure to conceive’’
‘’Great Tip’’

40. ‘’ORTs are not infallible. Hence should not
be the sole criteria to deny patients
access to ART. Evidence of diminished
reserve does not necessarily equate with
Inability to conceive.’’
Practice committee of the American Society for Reproductive
Medicine, Testing And interpreting measures Ovarian reserve:
A committee copinion. Fertill Steril 2015; 103:e17

41. Current ovarian stimulation
approaches
• Aiming for maximum number of oocytes
• Time consuming and complex stimulation regimens
• High costs ,Much patient discomfort
• Short-term complications-ovarian hysterstimulation
syndrome(OHSS)
• Long –term health consequences/ uncertain High drop-out rates
• Supraphysiological steroid levels with possible implications
Pregnancy chances from cryopreserved embryos
•Emphasize maximizing pregnancy rates per cycle

42. Adjuvants
DHEA Supplementation
promotes ovarian unction
enhances pregnancy possibility
decreases aneuploidy
Decrease theme percentage of miscarriage
Minimum 75mg for 2-4 months usage to
notice benefits
Objectively enhances ovarian reserve
improves follicular microenvironment
Improves oxygen levels in follicular fluid

43. Adjuvants
Addition of Aspirin
enhancing ovarian vascularization
Prospective randomized trails demonstrated
that therapy with aspirin and prednisolone did
Not improve uterine blood flow, implantation,
and pregnancy .
Clinical pregnancy rate per embryo transfer was
not be different between patients who received
Low-donor and the control group
ARGININE

44. Oocyte Cryopreservation
Breakthrough in ART
Large cohort of oocytes in poor responders
Accumulation of vitrified oocytes over several stimulation
cycles
(Creating a similar situation as in normal responder patient
Higher live birth rate per patient treated
Potentially to reduce the dropout
Can also be used to preserve the fertility of all those women
risk to lose their Ovarian potential over time

45. Stem Cells
Stem cells extracted
Injected into ovarian cortex
Promising Results
Still experimental

46. Augment – The Latest!
STEP 1: Ovarian Biopsy –The patient undergoes an outpatient
procedure Where a sample of her ovarian tissue is removed
and the mitochondria are extracted from the Egg’’ cells.
STEP 2: IVF Cycle –The patient goes through an IVF cycle
where their eggs are retrieved, fertilized using ICSI and the
mitochondrial DNA cells extracted During the ovarian biopsy.
These resulting embryos are frozen.
STEP 3: Frozen Entity Transfer –Your uterine lining is prepared
and the best frozen embryos are selected and transferred in
your next cycle.

47. Egg Donation – The final answer!

48. WHAT WE DO
Decide protocol
Decide drug
Decide dose

49. Thus…..
• Identification and timely treatment very important
• Go optimal
• Individualize
• Be safe
• Adjuvants
• Cryopreserve at right time
• Augment
• Egg donation

50. ADDRESS
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