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Ovarian Reserve Assessment

Ovarian Reserve assessment is commonly performed as part of an infertility
evaluation. It is alternatively called an ovarian aging assessment or
reproductive aging assessment. It consists of two simple tests, day 3 FSH/E2
and antral follicle count, which may be done during the same or separate
menstrual cycles. Your primary physician will want to interpret these test
results together when directing your care. Plan on scheduling a follow-up
consultation with your primary MD after completing these two tests. We use
the information from these tests to determine if you have an average, or
possibly reduced egg number. This may direct how aggressive we are with
infertility treatments. We also use this information to determine how much
medication to prescribe during ovarian stimulation cycles.
Women are born with all the eggs they will ever have. By the time a woman
enters puberty around age 12, she has about 200,000 eggs left. By the time
she reaches menopause around age 50, she has no eggs. From puberty to
menopause, if ovulation were not interrupted with birth control pills or
pregnancy, a woman could expect to ovulate about 500 eggs. The remaining
eggs (from the initial 200,000) are all pre-programmed to die naturally, a few
hundred each month. Currently, there are no treatments to improve ovarian
reserve or restore egg numbers. There are a few things known which will
accelerate loss of eggs. This includes prior ovarian surgery, some
chemotherapy agents, radiation to the pelvis, and smoking cigarettes.
Smoking can decrease egg number and quality, so we advise all current
smokers to quit.
Day 2-4 Labs, FSH and E2
On the third day of your menstrual cycle, we will draw your blood and measure
2 hormones. The first is FSH, or Follicle Stimulating Hormone. This hormone is
secreted by the pituitary gland in the brain. FSH is responsible for stimulating
follicle growth in your ovaries.
Each egg in your ovary is surrounded by a small, fluid-filled sac called a follicle.
As your menstrual cycle progresses from day 1 to mid-cycle, follicles grow in
size. Eventually, one follicle gains dominance, and the other follicles begin to
recede. That follicle contains the egg that will be released during ovulation.
As women age, their ovaries gradual "run out of eggs." Each month brings a
new set of follicles containing eggs. One follicle releases its egg, but hundreds
of others are pre-programmed to die off naturally and never ovulate. The
fewer eggs you have in your ovaries, the higher the FSH level will need to be to
initiate follicle development. This is why FSH is able to tell us something about
ovarian aging.
The second hormone we will measure is estradiol, a form of estrogen. It is
frequently abbreviated and referred to as "E2." Estradiol is produced by the
growing follicles in the ovary. Once growth has been initiated, the E2 sends a
signal back to the pituitary gland to decrease the amount of FSH being secreted
so additional follicles are not recruited. Sometimes an early elevation in
estradiol indicates early follicle development, and that too can be a sign of
advanced ovarian age.
This test may be performed on the 2nd, 3rd, or 4th day of your menstrual
cycle, but is classically performed on day 3.
Antral Follicle Count (AFC) Ultrasound
The second test to assess ovarian age is called an Antral Follicle Count (AFC).
This test is complementary to the blood tests because we can see small antral
follicles in the ovaries by ultrasound which directly correlates with your ovarian
During a transvaginal ultrasound, we will look at both ovaries and count the
number of small follicles. Each follicle contains 1 egg. Counting the number of
small follicles is a way to estimate ovarian reserve, which declines naturally
with aging. The number of visible follicles reflects the larger number of non-
visible eggs. A normal count is about 5-10 antral follicles per ovary. Women
less than 30 frequently have 10 or more antral follicles per ovary, and women
40 and older frequently have fewer than 5 antral follicles per ovary.
This test may be performed any day of the menstrual cycle, but it is usually
best performed during the first or second week of the cycle, before ovulation.
Ultrasound examination during menstruation may be slightly more
uncomfortable due to uterine cramping. However, it is sometimes performed
the same day as the day 3 blood draw. An ultrasound in the second half of a
cycle may provide less than ideal visualization if a normal corpus lutem cyst is
To schedule day 3 labs and an AFC ultrasound, please call SRM on the first or
second day of your menstrual period, Monday through Friday. If you are
scheduling the AFC with your primary physician, you may want to combine this
with a brief consultaion, so please schedule 30 minutes. If your ultrasound is
scheduled with one of the other providers, plan on a 15 minute visit for the
ultrasound, and schedule an additional 30 minute follow-up consultation with
your primary MD on a different day.


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