Fertility Testing: Ovarian Reserve

Hi everyone and welcome to another episode. I hope you're liking the content so far. I'm really trying to make these short and sweet.

So getting back to a little bit more of the medical side of things today I wanted to begin talking about testing. So the next few videos we're going to be talking about the different aspects of fertility testing. And today part one, we're going to be talking about Ovarian Reserve testing. So if you've heard your doctor talk about Ovarian Reserve what we're talking about, the easiest way to explain it is egg quantity. So we know that all women are born with a set number of eggs they're going to have in their lifetime, and those eggs are slowly going to diminish as the woman gets older and older and the decrease is fairly stable like it does decline a little bit. But it's fairly stable until about age 35, and then after age 35, we definitely see a very real decline in fertility.

In terms of looking at ovarian reserve, if you think of a cone, in the cone, our peak fertility is up here, and if you think of a basket of fries, this is the analogy that I give at the top you have the warmest, the most seasoned, the crispiest the ones that are sort of fresh out of the oven or the fryer. And so those are going to be eggs in our 20s. And then that cone is going to slowly decline until you get about age 35 and then age 35 you're going to see a slow and progressive decline in fertility year over year, and the decline is in quantity and in quality. Today we're going to be focusing on quantity. We don't have a way, at least not in today's science, to focus on quality or to be able to test quality. When we talk about quality, we're going to be sort of inferring or assuming the quality of the eggs based on patient’s age; underlying diseases like PCOS or endometriosis or any, for example, chronic illnesses like obesity or lupus, or things like that.

So we're not testing quality. We're not talking about quality today we're strictly talking about quantity. Again that diagonal line 35 to 40, and then above age 40 we see that that decline in quantity and quality is much more dramatic. So year over year we see that the decrease is much more significant.

So how does a doctor test ovarian reserve or egg quantity? And there's a few different ways that we do that.

If the patient is on some form of birth control, so whether that's, you know, an IUD or birth control pills or something that has a hormone in it, we probably want to focus on two things: one is called AMH or Anti-Mullerian Hormone, and then the other one is called AFC or Antral Follicle Count. AMH is a hormone, it's tested in blood, it's a very simple blood test, it can be checked any day of the cycle, and it is a reflection of ovarian activity. So for general ObGyn’s we typically will tell them ‘Hey if you're checking an AMH. Generally speaking, over 1 is good, under 1 is bad’, so the number one is kind of that marker.

But really as fertility specialists, we know that it's a lot more detail than that. So we know that based on age there is an expected AMH value. For example, around age 30, the average AMH is around 1.5, by 35 the average is around one, by 40 the average is around 0.5. So it does vary with age, but it can also vary with other factors. For example, a patient who has been on birth control pills for a long time may have suppressed ovaries that AMH hormone may come back lower than expected. One thing to keep in mind when you're checking it.

The other thing is if the patient has Diminished Ovarian Reserve or PCOS. It can also show extremes. So generally speaking, an AMH of 1 is sort of the threshold for normal, but it does sort of dig a little bit deeper in that based on age, there are certain levels of normal. For example, if a patient comes to me and she's 24 and her AMH is 1.5 even though it's over 1, technically it's okay, but for her age it's actually lower than expected value, and so then we start kind of looking into the possibilities of why that is. So AMH blood test is checked any time of the cycle. It can be done either with a fingerpick with certain kits these days or at any major lab like Quest or LabCorp. Your fertility specialists may also run those hormones in-house in their office, so it just depends.

The second one is an Antral Follicle Count or AFC and that is actually looking at the ovary on ultrasound, so we typically do that with a transvaginal ultrasound. Now, if the patient is on hormone suppression, we do it random. If the patient is not on any hormone suppression, then we typically do it at the beginning of her cycle. So we count day 1 as the first day of full flow that is, cycle day 1, and so we typically will do the ultrasound cycles day 2, 3, 4. We could do 5, although it's less ideal but typically cycles day 2, 3 or 4.

And the way I explain it to my patients is think of the ovary as a chocolate chip cookie. So we're looking for the amount of cookie that's known as the ovarian volume. Typically, normal volumes are anywhere from 3-10cm3. And then we're looking at the number of chocolate chips. So if you don't have enough chocolate chips like, that's not a great cookie, but if you have too many chocolate chips, that could also be bad. So things to think about when we're doing the antral follicle count. So we're looking at the amount of cookie and then the number of chocolate chips. The number of chocolate chips on both ovaries is what gives us the antral follicle count. Normal for that is typically anywhere from 6 all the way up to 20. That it's a pretty broad range, and again that's gonna vary with age. So if a 40 year old patient has 4-6 eggs, that's probably normal for age. If a 30 year old has 4-6 eggs, that's probably abnormal. It's probably low for her age, so these are generalized ranges that we give. But it's aged dependent or age specific.

So AMH and antral follicle count are probably today the two most commonly used ovarian reserve tests.

Now there is a third one that was around a lot longer or before those two, which is called a cycle day three FSH or follicle-stimulating hormone. So your doctor may ask you to have your blood work drawn on cycles day two or three of your of your period. (Remember first day of full flow is cycle day one) They may ask you to go in to get blood drawn cycle day two or cycle day three. And they're looking for that FSH hormone or follicle stimulating hormone and that hormone is produced by the brain so that is literally the follicle or egg stimulating hormone. The brain is talking to the ovary saying ‘Hey ovary, it's time to go to work time to pick that egg for ovulation’, so we actually want that hormone to be low and FSH less than 10 is considered normal.

Once it gets over 10 then we know the brain is having to work overdrive to try and recruit that egg for ovulation every month. So if the FSH is 12 or 15 or even as high as 20, we know that the ovary is not responding and the brain is having to work harder and harder to recruit the egg for ovulation. So as the egg supply depletes or as it decreases significantly, we start to see a rise in that FSH hormone. Typically most people would accept that an FSH over 40 is considered menopausal range, so when a patient stops having periods and her FSH is in the 50 to 60 range, most likely she is now entered her menopausal state.

The important thing to remember about FSH is that it cannot be checked by itself. Why?

Because FSH has a very dependent relationship with estrogen specifically estradiol. So whenever you check FSH you always have to check estradiol with it. And the reason for that is because if the estradiol is low typically less than 70 to 80, we know that the level of FSH that we're seeing is a true representation. But if the estrogen is high, let's say the estradiol is 120 or 130, then that is signaling the brain. As estrogen rises, it's signaling the brain ‘Hey brain. We have enough estrogen around, turn off your FSH'.’ So the FSH value is actually going to be lower than expected or lower than baseline.

Any time your provider checks your FSH hormone, they also need to check an estradiol hormone. An FSH hormone alone cannot be interpreted and is not helpful in the diagnostic evaluation.

Recapping, we talked about AMH. We talked about antral follicle count or AFC, and we talked about FSH or follicle stimulating hormone as you're learning, we love our acronyms in medicine, but those are the three that we typically check: AMH, AFC, and FSH or follicle-stimulating hormone. And remember whenever you check an FSH, you always check an estradiol with it. The FSH and estradiol have to be done cycles day two or three, ideally. The AMH and AFC can be done at any time in the cycle.

Okay so hopefully that is helpful. There are a few other hormones that were looked at in the past inhibin, the clomiphene citrate challenge test, etcetera, but typically those are not currently used to check ovarian reserve.

So again recapping AMH or Anti-Mullerian Hormone, AFC or antral follicle count, and then FSH or follicle stimulating hormone THAT one has to be checked cycles day two or three of a full flow menses without any other hormone suppression and must be checked with an estradiol level.

Today we have the availability of a few home kits that can be done at home with a finger prick. If you see your fertility specialist you can definitely talk to them about that versus getting it done in the lab and how that complements the ultrasound that they will probably do.

Remember Ovarian Reserve is a measure of quantity, not quality. Ovarian Reserve helps your doctor know what is the likelihood of response to medication, dosing your medication, number of eggs to expect if you're doing IVF. So it is helpful in the journey. But all the data that we have available today tells us that Ovarian Reserve actually does not predict pregnancy. So as long as the patient is having regular monthly ovulatory cycles, diminished ovarian reserve alone does not seem to be a predictor for the likelihood or the chance of pregnancy. So it's important to make that distinction. It is important in the journey it helps us in terms of: ‘Does the patient have diminished ovarian reserve?’ ‘Does the patient have PCOS?’ ‘How am I going to dose this patient?’ ‘How many eggs can I expect?’, etc. So it does help in that evaluation. But it's not actually a predictor for the chance of pregnancy. I hope that distinction is helpful.

We believe that we are seeing more diminished ovarian reserve. We believe that that is due to a few things and I was actually asked this question last night. One of those things we believe is just environmental toxins. Post-industrial revolution toxins like phthalates and parabens just in our daily life. We as individuals are exposed to a lot more toxins that could potentially be impacting that ovarian reserve number. We also know that women tend to delay childbearing compared to 50 or 60 years ago and so with that delay again we know that ovarian reserve decreases with age and so that can go hand in hand. And there are also certain professions that are going to be at increased risk. There was a study done for example, on women who work at hair salons all day, every day and they're exposed to those toxins all day, every day they tend to have higher rates of diminished ovarian reserve and infertility.

So hopefully this was helpful if you have not subscribed please be sure to do so now, so that way you don't miss an episode. And if you have any questions, be sure to comment under the video. If not, you can always find me on social media: Instagram or Facebook as Dr. Carolina Sueldo. See you next time. Bye bye now.

*This content is intended solely for educational purposes and is not to be construed as medical advice. For personalized recommendations concerning your specific healthcare needs, kindly consult with your healthcare provider.