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    fertility basics

    Ovarian Reserve Testing

    • 10849 views
    • 4.5   (1 Votes)
    Medically Reviewed by Dr. Deepika Tiwari - MS, MBBS on 14 Jun 2019 - Written by Dr. Shilpa Goyal - MS, MBBS - Grammatically Approved by Dr. Kavita Jaggi Agrawal - MS, MBBS

    Ovarian Reserve Testing (ORT) analyzes the quantity and quality of the egg follicles in the ovaries. Popular ORT's are AMH Test, FSH Test, and Inhibin B tests. Quality of the eggs is precisely identified from genetic testing of an embryo. These medical tests also predict the response of the ovaries in infertility treatments.

    Infertility treatments involve certain medical tests which are performed as per the requirement of the patient's case. The concerned infertility specialist advises the same to the patient. Fertility experts prefer performing an Ovarian Reserve Test (ORT) on a patient before initiating the In Vitro Fertilization (IVF) treatment. The ORT series of medical tests follows a standard procedure of blood tests, and a urine test. In today's life, conceiving a baby has converted into a substantial problem of infertility among couples. Voluntary or involuntary, if pregnancy delays, then gradually the ovary reserve in the woman either starts declining its quality or quantity of follicles. Declining of ovarian reserve is a natural phenomenon these days. Women in mid to late 30s find it even more difficult to get pregnant. Turning over to these ORT tests reveal the deterioration in women's follicular pool and oocyte quality. The ovarian reserve testing additionally confirms the number of eggs left in the ovaries. Further, it helps in recognizing the reproduction ability of a woman to sustain a healthy and successful pregnancy. Growing older naturally decreases specific capabilities to perform in one's daily life. One such condition is to ovulate, fertilize, and achieve pregnancy. Unlike men, a woman carries all the limited number of eggs in her ovaries that she will produce in her entire life or most probably till the age of the 50s. Ovarian reserves work on the inverse correlation between female ovulation and age. Our most of the advanced infertility technologies still lack direct assessing and determining the condition of ovaries in women. However, infertility experts have discovered a few indirect ways or test to determine the condition and health of an ovary reserve. As soon as months pass every month, a healthy egg ovulates, and medical expert performs these tests during periods to check the desired hormonal levels in the body. A woman after trying for a minimum of 6 months, at the age of 35 should get her ovarian reserves tested on time. (1) (2)

    In this article, you will find useful content related to the following aspects:

    Women after their 30s undergo, a natural process of a gradual decline in their ovary sacs, both with respect to quality and quantity. As per one of the recent researches, particularly at the age of 37.5 years, the critical figure of egg cells prevails only 25,000 in women. ORT tests indirectly, provides some valuable facts about the remaining follicular pool in a woman's ovaries. The valuable results of the following tests help in determining the quality and quantity of viable eggs. These tests also define the accurate production of the following required hormones in the body:

    Follicle Stimulating Hormone (FSH)

    In this informative article, we will view the ovarian reserve tests and their significance. We will be compiling each and every key aspect of these tests to make the information useful.

    Significance of Ovarian Reserve Testing (ORT):

    A study performed on 750 women has shown evidence that Ovarian Reserve Testing (ORT) does not confirm the possibility of pregnancy with a high number of egg follicles. The three markers used in the study are:

    • Anti-Müllerian Hormone (AMH),
    • Follicle-Stimulating Hormone (FSH), and
    • Inhibin B

    Due to awareness about these tests and health conditions, women are more and more willing to undergo these tests to check their potential to achieve pregnancy in the future without artificial method. A boom in the ovarian testing has become prominent because a woman with their work commitments seeks to achieve pregnancy in their 30's. In the same study, women who were never found with any infertility problems were tested.

    Significance of Ovarian Reserve Testing

    The basic concept or reason behind the study was to find below-mentioned points:

    • A number of eggs or number of years left for fertility in women with advanced age.
    • The functioning of the remaining eggs in ovarian reserves.
    • How will the ovaries respond during IVF treatment?

    All the 750 women were in the age bracket of 30 to 44 years. These women were constantly trying to get pregnant within a time span of three months or less, but they were unsuccessful. Using the three biomarkers, both categories of a woman with lower and higher levels of egg reserves were tested and had the same results.

    It was found that women possessing a lower hormone level with diminished ovarian reserves conceived through natural stimulator similar to women with a high level of ovarian reserves. The first attempt was successful with hormone stimulators within one year. Therefore, the study created an impression that the entire ovarian reserve test does not give accurate results about their future chances of having children. As per the opinion of experts who conducted this study, a woman with low values of test unnecessarily bears the stress of being infertile, whereas a woman with a high level of ovarian reserves might incorrectly assure about her pregnancy. Many doctors also believe that these medical tests are very helpful and prominent in the short term rather than in the long term. (3)(4)

    Another important factor of Ovarian Reserve testing relies on the quality of eggs. A woman with poor egg quality struggles to achieve pregnancy even if she has a high number of egg follicles in her ovaries. Similarly, a woman with less number of reserves can achieve pregnancy fast if her quality of eggs is excellent. However, there is no specific test, which tells about the accuracy of egg quality.

    Cost of Ovarian Reserve Testing:

    Signs of Diminished Ovarian Reserve (DOR) include several important ORT tests like AMH Test, FSH Test, and Inhibin B test. These ORT tests assist in evaluating normal functions, reason, and ability of the ovary to perform fertility treatments. The ORT test identifies the competencies of an ovary to provide viable egg cells for retrieval in IVF procedure. These egg cells otherwise, later turn into mature eggs and rupture out of the small sacs in the ovaries. The cost of ovarian reserve testing is about Rs. 1400/- to Rs. 3500/-. The ORT tests also include FSH and AMH test costs. The cost may also vary depending upon the medical experts and location of clinic and hospital.

    Cost of Ovarian Reserve Testing

    Tests to identify the number of Eggs:

    We have mentioned below all the tests, which are useful in testing the number of immature eggs in the ovaries. These medical tests are usually performed on the 3rd day of the periods:

    • On Day 3, a patient is examined with a blood test to estimate the levels of FSH, LH, and estradiol.
    • On Day 5, doctors advise the patient to start a 5-day course of Clomiphene citrate.
    • On Day 10, the patient return to the clinic for another FSH/LH/Estradiol blood test.

    Here is the number of women's potential eggs according to their below age are:

    • At the time of birth: 1-2 million
    • Puberty: 1 million
    • At the age of 25: 300,000
    • Around the age of 35: It declines below 300,000 till menopause.

    Follicle Stimulating Hormone (FSH):

    Follicle-stimulating hormone (FSH): It is the chief hormone of the reproduction cycle. It is one of the essential hormones, which helps in the development of eggs and sperm. The FSH test majorly checks for FSH in the blood and urine. The hormone is specifically produced by the pituitary gland, which has a locus at the base of the brain. Another important part of the brain is Hypothalamus. Hypothalamus directly stimulates the pituitary gland to release the hormone FSH. The stimulation is of FSH is influenced by Gonadotropin-Releasing Hormone (GnRH) released by the hypothalamus. The GnRH hormone stimulates FSH and luteinizing hormone (LH) together, as both the hormones are fundamental in reproduction. (5) (6)

    • FSH helps in the growth and maturation of the egg in follicles during the follicular phase of 14 days with respect to the menses cycle.
    • It also initiates the production of estradiol from the egg follicles.
    • At the end of the follicular phase, the surplus FSH hormone is controlled by estradiol and progesterone only.
    • FSH enhances the ability of the ovary to respond to Luteinizing Hormone (LH). After menopause, both hormones, FSH and LH levels increase in a woman's body.

    Follicle Stimulating Hormone (FSH)

    Significance of FSH test:The FSH test to check a reserve as a marker was introduced over 30 years ago. The purpose was to use FSH to predict the response of the ovaries in In Vitro Fertilization (IVF) treatment. The test is an indirect method of checking the ovarian reserve. The test relies on feedback inhibition of FSH hormone from the pituitary gland. The test measures the feedback depending upon different ovarian factors, and the production of FSH hormones. A woman with a normal ovarian reserve usually has sufficient production of ovarian hormones. At the beginning of the menstruation cycle, FSH is substantially maintained completely with the assistance of ovarian hormones. A high level of FSH at the beginning of the menstruation cycle signifies poor ovarian hormone production. The test blood sample taken on the 3rd day of menses is used to check FSH levels in the body.

    Estradiol:

    Estradiol:It is a form of estrogen hormone, which is one of the key hormones for reproduction. The hormone is released from the ovaries, the adrenal cortex, and the placenta when the FSH hormone stimulates the ovaries to develop the eggs. The estradiol hormone is also released from breasts, outer genitals, uterus, fallopian tubes, and vagina. It also helps in balancing the growth of the same. Estradiol basically adjusts the excessive FSH level in the body. When the level of Estradiol is more than the desired levels, FSH levels become low or normal. FSH and estradiol tests are performed simultaneously on the 3rd day of menstruation or menstrual cycle. When ovaries are not growing the eggs, even after the release of FSH hormones means that the ovaries require more FSH hormone. To fulfill the requirement pituitary gland release more FSH hormone, it effectively elevates the additional quantity of FSH in the blood. This ensures the medical experts that ovaries are not performing efficiently in response to the FSH hormone. Once the estradiol is released in ample quantity, it will control the level of FSH in the body. A steep rise in the levels of estradiol during the test also indicates an early occurrence of puberty than usual known as precocious puberty.

    Estradiol

    The low level of estradiol indicates late puberty. The test assists the doctor in identifying to treat hypopituitarism or decreased function of the pituitary gland. The test is important in the following (7)(8):

    Clomiphene Citrate Challenge Test (CCCT):

    Clomiphene Citrate Challenge Test (CCCT): This test is traditionally carried out to evaluate the condition of the ovaries by giving a medicine clomiphene citrate. This is a fertility drug(Clomid, Milophene, Serophene). This medicine is taken orally in 100 mg to influence ovulation in the respective woman. The medicine induces the ovaries to release more than one egg per cycle, which eventually increases the chances of reproduction. An ultrasound monitors the effects of this medicine on the ovaries and finds out any prominent and visible effects on the ovaries. This test is substantial in infertility treatments like In Vitro Fertilization (IVF), Intrauterine Insemination (IUI), or artificial insemination in a woman. The successful test includes the following hormones to evaluate the positive response of the ovarian reserve:

    • FSH (Follicle Stimulating Hormone)
    • LH (Luteinizing Hormone)
    • Estradiol

    Inhibin B Test:

    Inhibin B: It is a key hormone in ovarian reserve testing. It is generated along with Inhibin A from specific small cells in the ovarian follicles. It is another chief hormone to suppress FSH hormones in the blood. A consistent reduction in inhibin B has been observed prior to the menopause in women. The test is likely to be performed on the 3rd day of the menstruation cycle. A level above 45 pg/ml blood is classified to be normal. Poor functioning of the ovary sacs is mostly affected by the changes in the secretion glycoprotein hormones like Inhibin B and Anti-Müllerian hormone (AMH). Inhibin B also helps in identifying certain types of ovarian tumors and the number of eggs available in the reserve to achieve pregnancy. With the increasing age of a woman, their decreasing ovarian follicles start declining the secretion of AMH and Inhibin B. Inhibin B hormones make it difficult to interpret the results in premenopausal women because of its fluctuations in a menstruation cycle. (11)

    Inhibin B Test

    Doctors have found two most effective and recent tests to count the number of eggs present or left in a woman's ovaries. These two medical tests are the following ones:

    AMH (Anti-Müllerian Hormone) Test:

    AMH (Anti-Müllerian Hormone) test: It is a protein hormone produced by special cell-based inside the follicles. The level of this hormone in the blood provides an estimation of the total number of egg cells in the ovaries. Due to the constant availability of the hormone in the blood, the doctor at any time is able to perform the test. A normal level of the hormone should be between 1.0–4.0 ng/ml. (9)

    The hormone refers to a protein, which helps in the development of the reproductive tract both in the male and female fetus during the pregnancy tenure. This hormone is produced before birth by testes and ovaries. In the 8th week of conception, the fetus has two sets of ducts. Both the sets of ducts are separate from each other. Out of them, one turns out to be a female reproductive system if female chromosomes are present in the body and the second duct disappears. Whereas, the presence of male chromosomes, disappears the female duct and continues to produce the male reproductive system. When the fetus is growing male reproductive part then it releases anti-Müllerian hormone, whereas female fetus releases Müllerian hormone. It becomes valuable to evaluate anti-Müllerian at the initial stage of developing follicles, which sustains the support to the eggs before the event of fertilization. The more follicles are present in the ovaries which reflects additional anti-Müllerian hormone produced by her ovaries. Therefore, assessing AMH can positively measure the number of follicles present in the woman and how many are left.

    Assessment of AMH is substantial in IVF treatment to measure the response of ovaries and what amount of medication is required in IVF. It is also observed that a high level of AMH sometimes identifies the presence of Polycystic Ovarian Syndrome (PCOS) in women.

    Antral Follicle Count Test:

    Antral Follicle Count Test: During Antral Follicle Count (AFC) test, a doctor with the help of an ultrasound counts the visible follicles during periods. Each follicle has unique formations as it carries an immature egg in it. These immature eggs have an appropriate, potential to grow as a baby if fertilize on time or goes through a normal process of ovulation. The test helps in evaluating the number of total eggs. It also provides a brief idea that how many eggs can be frozen by a woman during one cycle. If the doctors perform this test at the beginning of the menstruation cycle, then it provides with most prominent results which help the patient as well. The ovaries contain small antral follicles, which are filled with natural fluid and immature eggs. The test is performed on the menstruation cycle 2nd, 3rd, and 5th day. The shape and sizes of the follicles are different from one another in ovaries. Therefore, it becomes easy to identify and count them separately. The test also assists in predicting the chances of the success rate in the In Vitro Fertilization (IVF) cycle. The test helps in recognizing the presence of mature follicles in ovaries, which can be stimulated by medications for a successful IVF procedure. Retrieved eggs are directly linked with the IVF success rate. The test is more accurate and substantial than the FSH test during the IVF procedure. (10)

    Antral Follicle Count Test

    All the above-mentioned medical tests are very useful in examining and analyzing the good prognosis in the woman for reproduction. However, all the tests are usually helpful in unknown fertility, and advancing age. These tests are best used in apprehending the response of the ovaries towards IVF treatment. Though, analyzing the quality of the eggs is still a huge problem in the field of infertility medicine. None of the tests apparently states the quality of the eggs for the successful production of an embryo. It was clear from the beginning of this article that women with merely a high number of oocytes may not likely to get pregnant. Only a woman with good quality of eggs is able to conceive without much difficulty even in advancing age. A major drawback of these tests is their variation in each of menstrual cycles in women. The retrieval of the oocytes is postponed if the follicles are insufficient, and ovaries are not responding positively. In this condition, the tests are repeated in the subsequent month. (12)

    Thus, medical tests such as ovarian reserve testing (ORT) are some of the advanced and recommended tests which are advised by infertility experts for successful execution and completion of the chosen infertility treatment. To know more about different fertility issues you can visit our website elawoman.com. Our informative blogs will help you to understand clearly the infertility problems, treatments, and medications. You can also contact us to know further clarify your queries by calling us +918929020600.

    Dr. Shilpa Goyal

    Written by

    MS, MBBS
    Laparoscopic Surgeon, Gynecologist
    Udaipur

    Dr. Shilpa Goyal is a talented Obstetrician and Gynecologist in Udaipur, Rajasthan. Her area of expertise includes dealing with High-risk pregnancies, infertility treatments including IUI and IVF, Laparoscopic surgery and vaginal hysterectomy. Dr. Shilpa Goyal has over a decade of experience in infertility and laparoscopic surgeries.
    She completed her MBBS in the year 2000 from Chhatrapati Sahuji Maharaj University, Kanpur and further pursued MS in Obstetrics and Gynaecology in 2004 from GSVM Medical College, Kanpur. Thereafter she did her training in various fields of Gynecology and Obstetrics at institutions and hospitals in Delhi and Mumbai. She also worked with eminent personalities in the field like late Dr. Mandakini Parihar.
    She is an active member of the association of gynecologists of Udaipur(UOGS), Indian society of assisted reproduction (ISAR), Indian menopausal society (IMS), India medical association (IMA) has participated in various congresses and attended workshops and CMEs on laparoscopic and infertility. Moreover, she is a pioneer in establishing Laparoscopic gynecological surgery and non-descent vaginal hysterectomy in south Rajasthan.
    She is very committed to assisting infertile couples by effectively providing comprehensive fertility services to both female and male patients. She has received several prestigious awards and recognition for her contribution and consistent success rate in infertility treatments. She follows advanced methods and makes use of advanced medical equipment and instruments to perform every procedure with care and precision. Many of the patients return to her for further treatments as she is very friendly and is dedicated to helping patients.
    Presently, Dr. Shilpa Goyal is consultant obstetrician and gynecologist practicing at GBH American Hospital in Udaipur since 2008.
    GBH American Hospital is one of the best Multi-speciality hospitals located at Meera Girls College Road, Udaipur. Established in 2006, the hospital has now become the number one choice of patients in the state of Rajasthan. The hospital has all kinds of medical specialties under one roof which includes Neuro Surgery, Obstetrics, and Gynecology, Plastic Surgery, Radiation Oncology, Nephrology, Endocrinology, Dermatology, Dentistry and Physiotherapy services. Backed by a team of talented doctors like Dr. Shilpa Goyal, the hospital is proficient in providing a wide range of infertility treatments. The treatment services provided in the Obstetrics and Gynecology department of the hospital include Infertility Evaluation, In Vitro Fertilization (IVF), Intrauterine Insemination (IUI), Menstrual and Hormonal problems treatment, High-risk pregnancy care and Normal and Cesarean Delivery, Cervical Cancer screening procedures. The hospital is accredited under ISO 9001:2008 certification. Apart from the treatments, the staff at the hospital also provides 24-hour assistance and catering services.

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