What is an antral follicle count and what is it for?

By (gynecologist) and (embryologist).
Last Update: 07/01/2021

The antral follicle count(AFR) is a non-invasive test used to assess a woman's ovarian reserve - the number of eggs contained in her ovaries at any given time. Because of this, antral follicle counts are routinely performed in fertility studies in reproductive centers.

However, even if a pregnancy is not being sought, the assessment of the ovarian reserve would allow the woman to make reproductive decisions in advance to avoid possible problems when motherhood is desired in the future.

Currently, the RFA and the determination of anti-Müllerian hormone (AMH) are the most widely used methods to evaluate the ovarian reserve of women.

What is ovarian reserve?

The ovaries have a certain number of eggs at birth, which is reduced throughout the woman's life. At birth, there are approximately 1-2 million immature eggs in the ovaries. However, by puberty a woman's ovarian reserve will have been reduced to 400,000-500,000 immature eggs.

With the onset of menstrual cycles, the ovary will release a mature egg each month. Despite this, many other oocytes will fail to mature and will be lost in a process known as atresia. In this way, the number of oocytes is progressively reduced until their depletion at menopause, when menstruation disappears.

Therefore, from the age of 35 onwards, women's reproductive capacity begins to decline, which becomes more pronounced from the age of 40 onwards. Eggs are not only reduced in quantity but also in quality, so female fertility decreases with age.

However, although it is very important, age is not the only factor that determines ovarian reserve, as there may be cases of low ovarian reserve in young women. Hence the importance of assessing ovarian reserve in time to be able to make reproductive decisions, even if motherhood is not yet desired.

Antral follicles

Antral follicles are ovarian follicles that still contain immature eggs inside. However, these antral follicles are already sensitive to follicle stimulating hormone (FSH) and are likely to advance in their development to pre-ovulatory follicle. However, only one of the antral follicles will develop each month and give rise to a mature egg, which will be released from the ovary with ovulation.

Antral follicles are characterized by having a cavity inside, called antrum, in which follicular fluid accumulates. These antral follicles can be visualized on ultrasound when they are 1-2 mm in diameter, which allows them to be counted.

Antral Follicle Count (AFR)

Antral follicle count (AFR) is a method used to assess a woman's ovarian reserve. It is advisable to perform the RFA at the beginning of the menstrual cycle, between the second and fourth day, in the early follicular phase. This determination of the number of antral follicles is carried out by the gynecologist by means of a transvaginal ultrasound. Therefore, RFA is a non-invasive and painless method for women.

In general, the antral follicle count is considered normal when 5-10 follicles (2-10 mm) can be counted in each ovary. In this case, the diagnosis based on the RFA would be normal ovarian reserve.

However, three other situations can occur when performing the RFA:

  • Low reserve: the count is less than 5 antral follicles in each ovary.
  • High reserve: more than 10-12 follicles are counted in each ovary.
  • Polycystic ovaries: more than 12-13 antral follicles larger than 2 mm. The ovary is enlarged and an ultrasound image called a collar sign is seen.

Knowing the state of ovarian reserve at a young age will allow a woman to make decisions before it is too late to achieve her desire for motherhood. Thus, a young woman with low fertility reserve could decide not to postpone childbearing any longer or to preserve fertility by vitrification of eggs.

RFA and fertility treatments

On the other hand, within assisted reproduction treatments, the RFA is also a good predictor of how the ovary will respond to the ovarian stimulation performed. This is why RFA is related to the chances of success of in vitro fertilization (IVF) treatments. The explanation is that the higher the antral follicle count, the more oocytes can be expected to be obtained in the ovarian puncture after stimulation. In this way, starting from a good number of oocytes, the chances of success of the reproduction treatment increase.

Assisted procreation, as any other medical treatment, requires that you rely on the professionalism of the doctors and staff of the clinic you choose. Obviously, each clinic is different. Get now your Fertility Report, which will select several clinics for you out of the pool of clinics that meet our strict quality criteria. Moreover, it will offer you a comparison between the fees and conditions each clinic offers in order for you to make a well informed choice.

Therefore, the RFA before carrying out an assisted reproduction treatment will allow the specialist to personalise the dose and the ovarian stimulation protocol to the situation of each patient. This optimises the chances of success and avoids possible associated risks such as ovarian hyperstimulation syndrome (OHSS).

FAQs from users

Does the RFA establish the likelihood of IVF success?

By Dra. Lidia Pérez García (gynecologist).

The AFR or antral follicle count is one of the most widely used markers of ovarian reserve, together with AMH (Antimullerian Hormone). It consists of assessing the number of antral follicles in each of the ovaries by vaginal ultrasound, a normal value being considered to be around 8-12 follicles in total.

In general, ovarian reserve decreases with age, and therefore the RFA, however, not all women of the same age have the same ovarian reserve and it is therefore important to assess it for any assisted reproduction treatment and in patients who are infertile or wish to preserve their fertility.

The AFR can help us to predict the chances of success in IVF, but it is not the only parameter to take into account, since it tells us about quantity, but not oocyte quality.

Oocyte quality is mainly associated with the woman's age, and refers to the possibility of her oocytes giving rise to a healthy embryo with the capacity for evolutionary pregnancy. It has been established that in patients up to 35 years of age, each embryo generated with their oocytes has a 65-70% chance of giving rise to a healthy embryo. This percentage decreases as the years go by, and at 38 years of age we are talking about 30%, at 40 years of age 25% and at 42 or 43 years of age less than 20-10%.

There are also other factors that can have a negative influence on oocyte quality, such as the consumption of toxic substances, concomitant illnesses, ovarian endometriosis, stress and unhealthy lifestyle habits.

Can I have an antral follicle count at any time?

By Silvia Azaña Gutiérrez (embryologist).

Regarding the timing of the menstrual cycle, the antral follicle count (AFR) is recommended to be done between the second and fourth day of the cycle. It should be noted that day 1 of the menstrual cycle is considered the day on which menses ends.

On the other hand, as for the time in reproductive life, a woman not only can, but should have an AFR at a gynaecological check-up at a young age, even if she is not seeking pregnancy. In this way, the woman will be able to know her ovarian reserve in order to anticipate and avoid possible complications, for example through fertility preservation, if she wishes to become a mother in the future.

Will I be able to get pregnant if I have a low antral follicle count?

By Silvia Azaña Gutiérrez (embryologist).

The chances of getting pregnant with a low antral follicle count decrease with age, not only because of the decrease in the quantity of oocytes but also because of the decrease in quality. However, the specialist will be the one to assess each case and estimate the chances of success, and may opt for the reception of donated oocytes as an alternative to seek gestation.

If I have a high antral follicle count will I develop ovarian hyperstimulation syndrome (OHSS)?

By Silvia Azaña Gutiérrez (embryologist).

No, you don't have to. The antral follicle count prior to ovarian stimulation in IVF treatments will allow the specialist to adjust the stimulation protocol and dose to avoid the occurrence of OHSS. In addition, during ovarian stimulation, serum oestradiol levels are monitored by ultrasound and blood tests, which will allow the gynaecologist to assess how the ovaries are responding to the treatment and to see if the response is being exaggerated.

Suggested for you

If you would like more information, we recommend that you continue reading the article: How Many Eggs Does a Woman Have? - Your Egg Count by Age.

If, on the other hand, you are interested in knowing more about the anti-Müllerian hormone, we recommend you read this article: What Is the Function of Anti-Müllerian hormone (AMH)?

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

Broekmans FJ, de Ziegler D, Howles CM, Gougeon A, Trew G, Olivennes F. The antral follicle count: practical recommendations for better standardization. Fertil Steril. 2010 Aug;94(3):1044-51.

Broer SL, Dólleman M, Opmeer BC, Fauser BC, Mol BW, Broekmans FJ. AMH and AFC as predictors of excessive response in controlled ovarian hyperstimulation: a meta-analysis. Hum Reprod Update. 2011 Jan-Feb;17(1):46-54.

Coccia ME, Rizzello F. Ovarian reserve. Ann N Y Acad Sci. 2008 Apr;1127:27-30.

Hendriks DJ, Kwee J, Mol BW, te Velde ER, Broekmans FJ. Ultrasonography as a tool for the prediction of outcome in IVF patients: a comparative meta-analysis of ovarian volume and antral follicle count. Fertil Steril. 2007 Apr;87(4):764-75.

Hsieh YY, Chang CC, Tsai HD. Antral follicle counting in predicting the retrieved oocyte number after ovarian hyperstimulation. J Assist Reprod Genet. 2001 Jun;18(6):320-4.

Iliodromiti S, Anderson RA, Nelson SM. Technical and performance characteristics of anti-Müllerian hormone and antral follicle count as biomarkers of ovarian response. Hum Reprod Update. 2015 Nov-Dec;21(6):698-710.

La Marca A, Argento C, Sighinolfi G, Grisendi V, Carbone M, D'Ippolito G, Artenisio AC, Stabile G, Volpe A. Possibilities and limits of ovarian reserve testing in ART. Curr Pharm Biotechnol. 2012 Mar;13(3):398-408.

Maseelall PB, Hernandez-Rey AE, Oh C, Maagdenberg T, McCulloh DH, McGovern PG. Antral follicle count is a significant predictor of livebirth in in vitro fertilization cycles. Fertil Steril. 2009 Apr;91(4 Suppl):1595-7.

Ng EH, Tang OS, Ho PC. The significance of the number of antral follicles prior to stimulation in predicting ovarian responses in an IVF programme. Hum Reprod. 2000 Sep;15(9):1937-42.

Scheffer GJ, Broekmans FJ, Looman CW, Blankenstein M, Fauser BC, teJong FH, teVelde ER. The number of antral follicles in normal women with proven fertility is the best reflection of reproductive age. Hum Reprod. 2003 Apr;18(4):700-6.

Verdú V, Villafáñez VG, Lucas V. Estudios ultrasonográficos diagnósticos y de control de los ciclos en reproducción asistida. Sociedad Española de Fertilidad y Sociedad Española de Ginecología y Obstetricia (Ver)

Vrontikis A, Chang PL, Kovacs P, Lindheim SR. Antral follice counts (AFC) predict ovarian response and pregnancy outcomes in oocyte donation cycles. J Assist Reprod Genet. 2010 Jul;27(7):383-9.

FAQs from users: 'Does the RFA establish the likelihood of IVF success?', 'Can I have an antral follicle count at any time?', 'Will I be able to get pregnant if I have a low antral follicle count?' and 'If I have a high antral follicle count will I develop ovarian hyperstimulation syndrome (OHSS)?'.

Read more

Authors and contributors

Dra. Lidia Pérez García
Dra. Lidia Pérez García
Gynecologist
Dr. Lidia Pérez has a degree in Medicine and a Master's Degree in Human Reproduction from the Complutense University of Madrid. More information about Dra. Lidia Pérez García
License: 282870961
 Silvia Azaña Gutiérrez
Silvia Azaña Gutiérrez
Embryologist
Graduate in Health Biology from the University of Alcalá and specialized in Clinical Genetics from the same university. Master in Assisted Reproduction by the University of Valencia in collaboration with IVI clinics. More information about Silvia Azaña Gutiérrez
License: 3435-CV

Find the latest news on assisted reproduction in our channels.