What Can Ovarian Reserve & AMH Tests Tell Us?

By BSc, MSc (embryologist), MD, FACOG, FACS, FACE (reproductive endocrinologist), MD, PhD (gynecologist), BSc, MSc (embryologist) and (invitra staff).
Last Update: 06/04/2020

The study of the ovarian reserve can be carried out by means of different tests. The most common tests for measuring the ovarian reserve are:

  • Antral follicle count by ultrasound
  • Assessment of basal endocrine markers such as FSH, estradiol, AMH or Inhibin B
  • Dynamic tests that study the response of the ovary to certain drugs

In this article we will explain the main methods that are applied to know the ovarian reserve of a woman in a certain moment of her reproductive life.

Antral follicle count by ultrasound

Follicles are the ovarian structures where eggs mature. In each menstrual cycle, a set of follicles starts the maturation process, but only one of them will be able to reach the last stage and release a mature egg in what we know as ovulation.

The stages through which the ovarian follicles pass are:

  • Primordial follicle
  • Primary Follicle
  • Secondary or preantral follicle
  • Tertiary or antral follicle
  • Pre-ovulatory follicle or Graff follicle

The antrum, which is the structure formed by the accumulation of fluid inside the follicle, allows the visualization of the follicle on the ultrasound. Thus, by means of transvaginal ultrasound we can count the number of follicles in the antral phase (diameter between 2 and 9 mm).

This count provides us with very valuable information on how the follicular reserve of the ovary is located.

To make a good assessment it is advisable to perform this test in the follicular phase of the woman's ovarian cycle, that is, between the 3rd and 5th day of the cycle.

A woman's cycle is considered to begin on the day her period begins.

This marker is one of the most accepted in assisted reproduction. In IVF cycles it even has a more predictive value than the baseline values of the FSH hormone, which we will see below.

This is what Dr. Miguel Dolz tells us:

We think that counting antral follicles to assess the ovarian reserve ultrasonographically is better than determining the anti-mullerian hormone.

The ovarian volume is another ultrasound marker that can also provide information on the state of the ovary and its effect on fertility.

Like the number of follicles, ovarian volume decreases with age. In fact, it goes from 4.9 ml in the fertile stage to 2.2 ml in the post-menopausal stage.

Endocrine markers of follicular reserve

A woman's ovarian cycle is controlled by hormones (endocrine system). For this reason, the analysis of the values of certain hormones involved in the development and maturation of the eggs can be of help when studying the ovarian reserve to analyze the state of the woman's fertility.

The main hormones that are measured are:

Follicle Stimulating Hormone (FSH)

As a woman's age increases, her ovarian reserve decreases and the value of FSH (follicle-stimulating hormone) increases.

FSH levels should be measured between the 3rd and 5th day of the menstrual cycle. A level of FSH above 10 mUI/ml indicates a low ovarian reserve.

You can read more about follicle-stimulating hormone in this article: What is FSH?

Antimullerian Hormone (AMH)

HMA is a glycoprotein that is expressed in women from puberty until they reach menopause. Its levels decrease as a woman's age increases.

Unlike FSH, AMH can be measured at any time during the cycle and for many, it better reflects the ovarian reserve. In fact, it is one of the preferred tests for studying a woman's egg reserve. It is also a good measure of a patient's response to fertility treatments and her chances of pregnancy.

AMH levels between 0.7 and 3.5 ng/ml are considered normal. Levels below 0.7 ng/ml are associated with a decreased ovarian reserve.

It is used as an additional test when FSH results are inconclusive. If you want more information about it, you can read this article: What is the function of the antimullerian hormone?

Inhibin B

The concentration of inhibin B is inversely proportional to the FSH values. Its serum determination is a good indicator of the functioning of the follicles and the ovarian reserve.

An inhibin B value lower than 35-40 pg/ml is an indicator of poor prognosis, since it reveals alterations in the ovarian reserve and a poor response to in vitro fertilization treatments (IVF).

Estradiol

Estradiol testing is also performed in the first days of the menstrual cycle (between 3.) Most of the estradiol is secreted by the woman's preovulatory follicles.

Normal values of estradiol at the beginning of the cycle are less than 40 pg/ml. Low ovarian reserve has been associated with high oestradiol values at the beginning of the menstrual cycle. In any case, the estradiol value is not one of the best markers for the study of ovarian reserve.

Dynamic tests

The response of the ovary to the stimulus of drugs such as clomiphene citrate (CC) or GnRH analogues is assessed.

Clomiphene citrate test
the ovary is stimulated with clomiphene citrate for 5 days, usually from the third or fifth day of the cycle. Afterwards, the response of the ovary is assessed by ultrasound and hormonal controls. An abnormal test result, such as very high FSH, indicates a poor prognosis in relation to pregnancy.
GnRH analogues test
changes in serum estradiol are measured between the second and third day after administration of a GnRH agonist analogue. In a normal result (good ovarian reserve), basal estradiol levels appear elevated due to the medication administered.

Ovarian reserve and fertility

One of the main causes of female infertility is age, since the ovarian reserve decreases as the woman's age increases, especially after 37 years of age.

The reduction in the number of antral follicles seen on ultrasound, as well as a change in the values of female hormones (estradiol, FSH, anti-mullerian hormone and inhibin) are the main indications that fertility has decreased.

The results obtained from the above tests help to predict, to a large extent, a woman's ability to achieve a pregnancy naturally.

These tests are also of great help to know, quite reliably, the probability of success of the fertility treatment, as they help to obtain information about the patient's response to the ovarian stimulation treatment applied in most assisted reproduction techniques (e.g. artificial insemination and in vitro fertilization)

When the examination of the ovarian reserve shows a very low egg count, associated also with a decrease in quality, it is usually recommended to resort to egg donation to achieve pregnancy. In this link you can find detailed information about this: What does egg donation consist of?

We must bear in mind that this type of test gives an idea of the state of the ovarian reserve of a woman at a certain moment of her reproductive life, but does not indicate 100% the probability of pregnancy.

It is essential to combine this type of test with other studies of female fertility that help to assess with greater certainty the reproductive potential of each woman before indicating the need for a particular assisted reproduction treatment.

Costs

Female fertility studies cost around $300-450 depending on which tests are included.

In the most basic ones, a vaginal ultrasound is performed to assess the ovarian reserve and observe the uterus. Others also include a hormonal analysis to see how well the ovary is functioning and possible menstrual cycle imbalances.

The determination of the anti-mullerian hormone is considered a separate analysis and therefore makes the fertility study more expensive if requested.

In assisted reproduction, like any medical treatment, it is necessary for you to trust the professionalism of the doctors and the clinic you choose.

This Tool generates you a personalized report with all information necessary about the treatment you will need. Besides, there is a list of clinics in your area which we have chosen based on our selection criteria with their budget plan included. Last but not least, you will find a series of useful tips for your first clinic visit.

FAQs from users

Is there a relation between ovarian reserve and egg quality?

By Mark P. Trolice MD, FACOG, FACS, FACE (reproductive endocrinologist).

Ovarian reserve is a measure of the quantity and quality of the eggs; it is best measured by a combination of chronological age, antral follicle count (AFR) on ultrasound, and anti-mullerian hormone (AMH).

An AFR of less than 11 reflects diminished ovarian reserve and less than 6 is severe. AMH levels below 1.6 have been shown to reduce the number of eggs retrieved with IVF and may predict pregnancy outcome. Levels below 0.4 are severe.
Read more

What do I have to do to know my ovarian reserve?

By Andrea Rodrigo BSc, MSc (embryologist).

To find out about the ovarian reserve, you should go to an infertility and assisted reproduction specialist for a detailed study of the ovarian reserve. To analyze your egg reserve, he will mainly perform an ultrasound scan (to count the antral follicles) and a blood test (to measure the hormones that we have mentioned in the section Endocrine markers of follicular reserve within this article).

Can I become a mother with low ovarian reserve?

By Andrea Rodrigo BSc, MSc (embryologist).

Yes, it may be difficult to achieve a natural pregnancy, but assisted reproduction offers several solutions. Among them, we find in vitro fertilization with a previous cycle of ovarian stimulation.

On the other hand, in the most serious cases in which the ovarian reserve is very low, egg donation is perhaps the most appropriate reproductive solution.

By Andrea Rodrigo BSc, MSc (embryologist).

Artificial insemination is generally not recommended when a woman has a low number of eggs, as the chances of success are low. It is usual to perform an IVF, although it will depend on the results obtained in the evaluation of the ovarian reserve of each case.

Suggested for you

We have discussed some of the main hormones that are indicative of the ovarian reserve. If you want to know other hormones related to female fertility and their normal values, I recommend you to consult this article: Female Hormone Check- How Are Hormone Levels Monitored?

As we have seen, the ovarian reserve test is one of the main tests for analyzing a woman's fertility. However, there are others that can complement the study of the ovarian reserve. Do you want to know what they are? Find out here: Female Fertility Tests- How Do You Know if You Can't Get Pregnant?

Finally, we recommend you read this article to learn more about the ovarian reserve and its influence on fertility: How Many Eggs Does a Woman Have?

Our editors have made great efforts to create this content for you. By sharing this post, you are helping us to keep ourselves motivated to work even harder.

References

Authors and contributors

 Andrea Rodrigo
Andrea Rodrigo
BSc, MSc
Embryologist
Bachelor's Degree in Biotechnology from the Polytechnic University of Valencia. Master's Degree in Biotechnology of Human Assisted Reproduction from the University of Valencia along with the Valencian Infertility Institute (IVI). Postgraduate course in Medical Genetics. More information about Andrea Rodrigo
 Mark P. Trolice
Mark P. Trolice
MD, FACOG, FACS, FACE
Reproductive Endocrinologist
Mark P. Trolice is the Director of Fertility CARE – The IVF Center and Clinical Associate Professor in the Department of Obstetrics & Gynecology (OB/GYN) at the University of Central Florida College of Medicine. He is Board-certified in REI and OB/GYN, and maintains annual recertification. His colleagues select him as Top Doctor in America® annually, one among the top 5% of doctors in the U.S. More information about Mark P. Trolice
License: ME 78893
 Miguel Dolz Arroyo
Miguel Dolz Arroyo
MD, PhD
Gynecologist
Bachelor's Degree in Medicine and Surgery from the Medicine Faculty of the University of Valencia (UV) and Doctor in Medicine, finished in 1988 and 1995, respectively. Physician specialized in Obstetrics & Gynecology. Expert in Reproductive Medicine, with more than 20 years' experience in the field. He is the Medical Director and founder of FIV Valencia. More information about Miguel Dolz Arroyo
License: 464614458
 Teresa Rubio Asensio
Teresa Rubio Asensio
BSc, MSc
Embryologist
Master's Degree in Medicine and Reproductive Genetics from the Miguel Hernández University of Elche (UHM). Teacher of different Clinical Embryology courses at the UHM. Member and writer of scientific contents at ASEBIR and ASPROIN. Embryologist specializing in Assisted Procreation at UR Virgen de la Vega. More information about Teresa Rubio Asensio
Adapted into english by:
 Romina Packan
Romina Packan
inviTRA Staff
Editor and translator for the English and German edition of inviTRA. More information about Romina Packan

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