Ovarian Reserve – Woman's Potential of Natural Conception
The term 'Ovarian Reserve' refers to a woman's reproductive potential with respect to the number of eggs in the ovary and the quality of those eggs.
Once the eggs are outside the body and under the microscope its obviously easier to speak about its quality but the whole idea is to be able to predict the outcome even without handling the eggs.
The following are used:
Age as discussed earlier is in itself a predictor of the outcome. The chances of getting good number and quality of eggs after the age of 40 are quite remote. Although even spontaneous pregnancies do happen they cannot be used as a yardstick to treat women at higher age groups.
In case of female infertility at the age of 40 which is very common, IVF treatment is considered best because of 40% IVF success rate at the very first attempt.
Antral Follicle Count:
As I have said before, women recruit about 15 to 20 eggs just before the beginning of each menstrual cycle. Of these, depending on the stimulation given, one or many will eventually grow to mature size. This baseline pool of eggs can be counted on Day 2 or 3 of the periods by Trans Vaginal Ultrasound. Folliculometry test is very common and essential to know the status.
Follicular study with folliculometry ultrasound must be done under the supervision of best clinician and infertility specialist.
If more than 5 are present then the woman stands a good chance to produce eggs with stimulation.
Baseline FSH and Estradiol (E2) levels:
As normal values(done on Day 2 or 3 of periods), the FSH levels should be less than 10 and E2 levels between 20 and 80pg/ml. FSH levels are one of the earliest parameters to rise, long before the eggs actually finish. To give you an idea, you can imagine FSH to be the whip which stimulates the ovary to produce eggs.
Under normal circumstances, less whipping is required and the levels of FSH are thus low. When the ovary is failing, the whipping required is far greater resulting in high FSH levels. Sometimes the FSH levels tend to fluctuate between abnormal (high) and normal (low) levels. However one must remember that even a single FSH level above 10 means that the eggs may not be of very good quality, even though the levels may come down later.
Clomiphene Challenge Test:
In this test the baseline FSH is tested on Day 3. Thereafter Clomiphene Citrate 100mg tablets are given orally from Day 5 to Day 9 of the periods. Fsh values are again tested on Day 10 of periods. A normal value would be to have both Day 3 and Day 10 FSH values to be below 10.
While FSH tends to rise in ageing women, the Inhibin levels tend to fall. Infact it has been suggested that Inhibin levels are more sensitive and detect more subtle changes than baseline FSH levels. However as the test is still experimental, not widely available and quite expensive, it is not used in routine practise.
AMH or Anti Mullerian Hormone is like the new kid on the block that seems to show a lot of promise. Being a measure of the smallest follicles or antral follicles, it gives somewhat an numerical figure or value to the Antral follicle count done by USG and removes the human errors. AMH levels tend to fall with age and decreased ovarian reserves. What is promising is that it does not need to be done only on Day 2 or 3, it is not influenced by Depot injections of GnRH analogues and seems more accurate than FSH level or Clomiphene Challenge tests. It is also a good predictor of the specific profile of patients who may have Ovarian Hyperstimulation.
Thse are the common parameters used by us in day to day practise but like they say "nothing prepares you for life' similarly nothing can predict how the ovary will ultimately behave once we start to stimulate it. Well either as doctors we dont yet know the whole story or as we commonly say' maybe there is someone else above us all who controls everything'.
But it is always advisable to consult with the best infertility specialist to diagnose the real cause of your infertility and also for the patient counseling.
There are top fertility clinics in Kolkata, but very few of them conduct patient counseling before the enrollment for infertility treatment.
Dr. Rajeev Agarwal (gynecologist and infertility specialist), director of Care IVF conducts the patient counseling first not only to understand the pregnancy issues the patients are suffering from, but also to make the patient understand about the situation.
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