Homepage Ovarian Reserve
Category: DiagnosesYour egg quantity is also known as your ovarian reserve.
Your ovarian reserve is not quite the same thing as egg quality. But when you have a good ovarian reserve, you most likely will have some good quality eggs in there too.
Ovarian Reserve: definition
You were born with millions of immature eggs.
Most of the immature eggs will be housed in microscopic follicles (small baskets of cells) that will lie quietly for months and years at a time. But every cycle during your fertile years, there will be some follicles that are primed to grow. These primed follicles are known as antral follicles.
Ideally, you will have a good-sized pool of these antral follicles each month.
Why Ovarian Reserve Matters
Why is it so important to have a good-sized pool of antral follicles?
Actually, if you are trying to get pregnant naturally, ovarian reserve doesn’t matter too much. After all, up until menopause, your body will generally find 1 egg a month from the pool to mature and ovulate. I’m not saying ovarian reserve doesn’t matter with natural cycles at all, but, we have all seen natural conceptions in women who have very low reserves.
However, if you want to access fertility treatments, a good ovarian reserve is extremely helpful. For example, in IVF, we find our best pregnancy rates occur when we generate 3-5 high quality embryos. The best predictor for this outcome is 10-15 eggs at retrieval. (It is possible to have 3 good embryos from 3 eggs, but less likely). And the best predictor for 10-15 eggs is a good ovarian reserve.
Tests of Ovarian Reserve:
Antral Follicle Count (AFC)
The AFC is an ultrasound test. The u/s tech counts your antral follicles.
The ideal AFC is 15-20 over the two ovaries. If your AFC is <10, your ovarian reserve may be low (assuming the tech is counting accurately).
As a test, AFC is very much technician-dependent: not every ultrasonographer can measure AFC well, and there tends to be a lot of inter- and intra-observer variability (i.e. everyone measures a different number). If you are a bit gassy (or a bit overweight), it can be difficult.
Our newest 3D ultrasound machines have the ability to record AFC’s automatically. However, the technology isn’t perfect, and we still prefer the accuracy of our clinical team to that of the computer.
Anti Mullerian Hormone (AMH)
AMH is a newer blood test, and in my opinion, the most accurate test of ovarian reserve.
AMH is a hormone released by cells that are involved with the growth of antral follicles. AMH levels correlate with the number of active antral follicles present; the higher the antral follicle count, the higher the AMH levels. I trust it more than AFC, because it seems to correlate with the number of active follicles.
AMH can be tested through a regular blood test. It can be drawn during any day of the menstrual cycle whether or not you are on the birth control pill. In my opinion, AMH is the single most helpful test for women looking to understand their own fertility.
That said, if you get an unusual number, it is reasonable to repeat the test. AMH can be difficult to process in the lab, so the occasional incorrect number will be generated. Ask to do it again if you are making important decisions based on AMH.
FSH
FSH is a blood test, and is the traditional test of ovarian reserve, perhaps because it was more accurate than ultrasounds used to be. These days, ultrasounds are incredibly accurate, and AMH has taken over as the more accurate blood test.
FSH is the hormone that drives your antral follicles to grow.
If you have a good ovarian reserve, your body doesn’t need to make very much FSH to start the process of egg maturation. A number less than 10 IU/L is good; less than 8 is ideal. Greater than 12 is a worry.
FSH levels change month-to-month, as the number of antral follicles change.
FSH levels are brought lower by the presence of estrogen, so your FSH level is only an accurate indicator of your ovarian reserve when Estradiol levels are <200pmol/l. Estrogen is lowest on day 3 of the cycle, which is why we usually measure FSH on day 3.
Summary
The main tests of ovarian reserve used to be day 3 FSH, but today we prefer antral follicle count studies and AMH to guide our care.
Ovarian reserve is not the same thing as egg quality, but the two can be related. Women can achieve healthy pregnancies with a low ovarian reserve. Tests of ovarian reserve are important, but they are not your only measurement of future success. They are, however, a very helpful guide to optimizing and personalizing your fertility treatments.
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Erica
Hello,
I’m 33 and my reproductive endocrinologist just gave me the news that my egg reserve is diminished. My FSH was 16, and my Anti Mullerian Hormone was less than 1. My periods went from 28 days last year to 22 days this year and I am sure that endometriosis is the cause (I’ve never been diagnosed.)
While my hopes for a pregancy are dashed, my concern now is that this will cause the early onset of menopause. Could this happen? And if so what can I do to prevent it?
TGH replies:
Dear Erica
Yes, you are looking at the real possibility of an earlier-than-expected menopause. After all, menopause is simply the moment when a woman run out of viable eggs. As your ovarian reserve is now very low, that moment would be expected at a younger age for you than for most women. It is impossible to know exactly when it would occur, but with 22d cycles, it is more likely to be a few years away rather than the two decades away that you otherwise would have expected.
Erica, for more answers and emotional help you might appreciate the “POF Clinic” run through Mount Sinai Hospital in Toronto. It is run as part of their Women’s Unit and is very comprehensive.
Yours,
Tom Hannam
Stela
Dear Dr.Hannam,
I’m 28 years old and we are trying to conceive more than 3 years. I have 2 biochemistry pregnancies. We made most of the examinations - laparoscopy, hormone tests, sperm analysis, immunology tests, but nothing found. I have PCOS but my period is regular - 30 days, I do have ovulation. Also we had 3 unsuccessful IVF. After last IVF the doctor said that my eggs had no good quality.
A month ago I decided to make Insulin Resistance test. Below is the result:
Glucose -0 min. 5,82 /ref.3,8-6,1/
Glucose -60 min. 11 /ref. < 8,9/
Glucose -120 min. 9,23 /ref. < 7,8/
Serum Insulin -0 min. 10,61 /ref.3-25/
Serum Insulin -60 min. 67,62 /ref.3-25/
Serum Insulin -120 min. 87,39 /ref.3-25/
Do you think that the main reason for infertility could be Insulin Resistance?
TGH Replies
Two chemical pregnancies (pregnancies that end too early to be seen on ultrasound) and three IVF cycles is significant Stella.
Your glucose/insulin levels are a little off -maybe they show a trend that could point to glucose intolerance one day- but, unfortunately, they are not so out-of-line as to provide sufficient explanation for the troubles that you have faced.
I would be happy to provide a true second opinion for your situation, but this won’t be the forum for it. I would need to see your previous records, for example.
I hope that you will find the answers you need.
Yours,
Tom Hannam
Ioana
Dear Dr.Hannam,
I’m 38 years old and have done 3 ICSI cycles at TCART due to male factor (mostly morphology issues). I produced over 10 eggs each cycle however there seems to be a problem with quality (dark color). The resulting embryos are graded high based on number of cells and fragmentation however the embryologist called them poor quality due to morphological appearance. We transfered 5 or 6 embryos each time and none ever implanted. We used a different drug protocol each cycle but this didn’t seem to improve the quality of the eggs and I’m not sure what else could be done. Your advise would be really appreciated.
N
Dear Dr. Hannam,
I hope you can give me some advice. I am currently having fertility treatment with ’sperm washing’ as my husband is HIV positive. We have already had 7 unsuccessful IUI attempts over a period of 18 months and have been advised to now try IVF. (I started on down regulation drugs 3 days ago). I am 33 and in good health although I have a concern (and so does my clinic) about my ovarian reserve. I have had 2 FSH tests which came back as 13 then later 9.
4 years ago I had a cystectomy to remove a large dermoid cyst from my left ovary. This resulted in the majority of the ovary being removed. Since then it is always my right ovary that releases the monthly matured egg and my ob-gyn has since concluded that blood supply has been ‘cut off’ from the ‘bit’ left on my left side. As such I consider that I only have one ovary which (according to the scan nurse) is very “striking” in size!
I have recieved very conflicting advice regarding my ovarian reserve. One doctor has told me that I am likely to run out of eggs at around age 37 (very specific I thought), but another doctor laughed at this and said that such a prediction is impossible and that my FSH levels are bound to be slightly higher due to only having half as many eggs/only one ovary. Another doctor told me that FSH is only a predictor of egg quantity and not egg quality and that age is a better indicator of quality. Please help me to understand all of this.
Most of my other tests were fine; progesterone, estrogen, thyroid, my tubes are open. My husband’s sperm tests have been fine. The only other test which was queried was a raised prolactin level (608) but no doctor has ever flagged this up as a concern. Could it be in your opinion?
I would appreciate any advise you could give me,
Kind regards
N
Dear N
I am glad that you have turned to IVF. You have a plausible, non-egg-related reason for thinking that IVF might work where the inseminations could not: you’ve had previous pelvic surgery. It is reasonable to speculate that, despite the normal imaging studies, you have bilaterally compromised fallopian tubes as a result of the post operative healing process. Such compromises can be subtle, but enough to make for challenges getting pregnant. So IVF makes sense at this point.
For IVF to be successful we need to believe that egg quality will be good. In the end, the conflicting advice you’ve had can be summarized this way: the primary driver of oocyte quality may be age, but life events (like pelvic surgery, endometriosis, etc) can speed up the process. Nonetheless, by “speed up” I mean advance your ovarian age by, say, 5 years. I would expect that your remaining ovary is still producing good eggs, and will for a while yet.
I cannot offer a true second opinion without meeting you, of course, but from what you’ve written, you have every reason to try IVF.
__________
N, our usual maximum PRL is <25 ng/ml. Please confirm with your clinical team that your prolactin is in the normal range before the stimulating medications start. Did you mean to write 608? That would be a very high number indeed.
Best,
TGH
Darma
Dear Dr. Hannam:
I am 34 years old, and my husband and I have been trying for a baby for about one year, I had a miscarriage last year in August - it was very early though. I went to see an OB GYN afterwards and she did a lot of tests as I was worried about my fertility, I get regular periods but they are longer (33 or 34 days) and I have hypothryoidism. She said that everything was fine, my tubes were open, blood tests were fine and my husband sperm count for normal and to just keep trying.
I went to see her 5 months later, she put me on clomid 50mg, and did some blood tests. When I saw her this week, she said that she had bad news, my FSH was 12, (but estradiol was fine)and that my thyroid was abnormal and it might be due to low functionining thyriod but she said my T4 was good - I take Eltroxin 0.1mg. I am devasted, she said that I wont have many good eggs and time is running out and that I need to see a fertility clinic immediately.
I dont understand how I went from, everything is fine, dont worry and 5 months later, I dont have many eggs left. I am being referred to a clinic but I am worried that I wanted too long to even try IVF.
Could my throid affect my FSH? Will increasing my dose for Eltroxin help?
Thank you
TGH replies
Dear Darma,
At age 34years, assuming your health is stable (no surgeries or cancer), your egg quality would not have changed very much over a 5 month period, and I don’t believe the thyroid imbalance would have had that effect either.
I would expect that your Ob was reassuring at first because your story included the early pregnancy; but the situation is less clear now and i agree that it is time to go to a fertility clinic to clarify what exactly is happening..
You can get the day 3 FSH re-tested,, an antral follicle count (ultrasound) and, if they offer it, AMH levels. The results of all these tests should be back withiin 3 weeks. When you know these results, you’ll know your ovarian reserve. Prognosis will be clearer, and your treatment options will be tailored to you.
Darma
Thank you for your quick reply doctor.
I called my OB to get my old results from 5 months ago (when she said everything looked fine), my FSH was 12 - which isn’t really good. And, when I went to see her last week, it was FSH 11. I am not sure why she told me everything was fine.
But I am waiting to see a fertility clinic and I am going to start seeing an accupunturist as well who helps with fertility. I hope everything works out - I feel healthy, I exercise regularly and try to eat well.
Thank you again