Anti-Mullerian hormone (AMH) level
Follicle Stimulating Hormone (FSH)
Clomiphene citrate challenge test (CCCT)
Antral Follicle Count (AFC)
None of these tests alone will give a reliable answer. Therefore, it is usually recommended that a combination of tests are used when assessing the ovarian reserve.
What is AMH, FSH, Estradiol, Inhibin B and AFC
The AMH is a hormone that is produced by cells surrounding the dormant follicles. The levels of AMH remain steady irrespective of the day of the menstrual cycle. Hence the test can be done any time in the menstrual cycle.
A lower value of AMH will be indicative of the reduction in reserves. The lower the AMH value, the lower the reserve and the chance of getting pregnant when trying naturally, or with fertility treatment.
FSH is a hormone produced by a small gland in the brain called pituitary gland and it regulates the function of the ovaries. This test happens between day 2–4 of the menstrual cycle. Usually, the blood Estradiol levels are checked along with FSH for more accurate results.
The higher the FSH value, the lower the ovarian reserve. Like AMH, this would imply a decrease in the ovarian reserve, delaying conception or reducing the success rate following fertility treatment.
The Inhibin B is secreted by the cells surrounding the dormant follicles.
The levels may fluctuate and is usually not recommended as a reliable marker for assessing ovarian reserve.
Antral Follicle count or AFC is the number of small follicles in both ovaries. These are the follicles that are recruited for development in a natural cycle and lead to the dominant follicle that results in ovulation.
There is no single test in isolation that can give a 100% accurate answer. Therefore, specialists usually use a combination of tests to improve the predictive power and reliability of the assessment.
How does ovarian reserve affect female fertility?
Having understood the tests necessary to evaluate the ovarian reserve, we should also understand the mechanism that leads to a reduction in fertility.
Generally, the quality refers to both the reduction in quantity and quality. There is no clinically available diagnostic test that can accurately analyse these two parameters.
Eggs of poor quality experience a higher chance of error during the cell division and splitting of the genetic material between the cells. This creates a genetically abnormal embryo that the womb might prevent from implanting. It may also lead to miscarriage if it has managed to implant. So women with reduced ovarian reserve may also experience higher miscarriage rate.
What are my options if I have low ovarian reserve, low AMH, or high FSH?
It is important to stress that low ovarian reserve does not necessarily mean that you can never get pregnant. For some women, it may mean that it may just take longer when trying to get pregnant.
If you have been unsuccessful for some time, then you should see a fertility specialist for further advice. For others going through fertility treatments such as IVF, they may experience lower IVF success rates.
In a small proportion of women with very low ovarian reserve, they may have to consider using donor eggs to help get pregnant. In that case, the window of opportunity for trying naturally or with treatment is shorter, and they should seek early advice.
If I have low AMH or low ovarian reserve, am I menopausal?
No, low ovarian reserve does not imply that you are going through menopause or are perimenopausal. It simply indicates your fertility potential.
Women with reduced ovarian reserve usually have a regular cycle but have a lower chance of getting pregnant per menstrual cycle (also known as fecundity). However, if you do experience absence of menstrual cycles or irregular cycles, then you should consider seeing your doctor or gynaecologist.
What does London IVF and Genetics Centre recommend?
At London IVF and Genetics Centre, we always recommend our patients a combination of female fertility tests to check the ovarian reserve.