Assessment of ovarian reserve—should we perform tests of ovarian reserve routinely?

How old are your eggs?

PURPOSE OF REVIEW

It is estimated that 10% of women experience a rapid decline in their ovarian reserve from the early 30s. This is called 'early ovarian ageing'. With the development of the so-called 'ovarian reserve tests', it was hoped that it would be possible to assess each woman's ovarian biological age and screen for 'early ovarian ageing' in the general population. This review examines the progress that has been made in this area.

RECENT FINDINGS

Almost the entire literature on ovarian reserve tests refers to women having IVF, rather than women in the general population. Recent systematic reviews have shown that the currently known 'ovarian reserve' tests are reasonably good at predicting the number of eggs that are collected following ovarian stimulation with gonadotrophins in the context of an IVF cycle. They show very poor correlation with live-birth rates. The reason is that they cannot directly assess oocyte quality.

SUMMARY

Screening for 'early ovarian ageing' in the general population is desirable but still not possible. Therefore, postponing childbearing to the late 30s remains a risky gamble. Advice to individual women should be given by specialist reproductive endocrinologists, though home-testing is not advisable.

Predicting fertility

Various predictors of fertility have been described, suggesting that none are ideal. The literature on tests of ovarian reserve is largely limited to women undergoing in vitro fertilization, and is reliant on the use of surrogate markers, such as cycle cancellation and number of oocytes retrieved, as reference standards. Currently available prediction models are far from ideal; most are applicable only to subfertile women seeking assisted reproduction, and lack external validation. Systematic reviews and meta-analyses of predictors of fertility are limited by their heterogeneity in terms of the population sampled, predictors tested and reference standards used. There is an urgent need for consensus in the design of these studies, definition of abnormal tests, and, above all, a need to use robust outcomes such as live birth as the reference standard. There are no reliable predictors of fertility that can guide women as to how long childbearing can be deferred.

Ovarian reserve

As a result of temporary social trends, many women elect to postpone their first pregnancy to a later stage in life. A large part of this population will be infertile by the time they opt to conceive, mainly because of a decreasing ovarian reserve and low oocyte quality resulting from age. Aging oocytes have been widely suggested to be the major cause for the decline in fertility. In a subfertile population, the availability of an accurate screening test of ovarian reserve would provide a valuable means of predicting the chances of pregnancy and live birth with or without treatment and selecting an optimal dose of ovarian stimulation where treatment using ovarian stimulation is planned. The following hormonal markers and ultrasound parameters have been used to attempt to estimate ovarian reserve and predict those with a poor chance of success in assisted reproductive techniques: age; concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, inhibin, anti-Müllerian hormone; ovarian volume, ovarian antral follicle count; and ovarian biopsy. Further studies have introduced the use of dynamic tests-using gonadotropin-releasing hormone agonist, FSH, or clomiphene citrate-to assess ovarian function. The use of a wide range of tests suggests that no single test provides a sufficiently accurate result. But the simultaneous evaluation of a combination of tests could be used as a marker of diminished ovarian reserve and a sensitive predictor of response to ovarian stimulation in patients undergoing in vitro fertilization treatment.

Antral follicle count (AFC) can be used in the prediction of ovarian response but cannot predict the oocyte/embryo quality or the in vitro fertilization outcome in an egg donation program

OBJECTIVE

To verify whether the antral follicle count (AFC) could predict ovarian response, oocyte/embryo quality, and IVF outcome.

DESIGN

Prospective study.

SETTING

Instituto Universitario-Instituto Valenciano de Infertilidad, Valencia, Spain.

PATIENT(S)

One thousand seventy-four donors and 975 oocyte recipient cycles.

INTERVENTION(S)

Controlled ovarian hyperstimulation (COH), endometrial preparation, IVF/intracytoplasmic sperm injection, ET.

MAIN OUTCOME MEASURE(S)

COH and oocyte/embryo quality parameters and IVF outcome.

RESULT(S)

We observed lower E(2) levels and fewer mature retrieved oocyte numbers among donors who showed an AFC that was <10. These donors also showed significantly higher cancellation and no-donation rates; poor and/or insufficient response was the principal cause (82%). However, there were no differences among the groups regarding embryo development parameters and IVF outcome.

CONCLUSION(S)

AFC is a noninvasive and simple tool that can improve the oocyte donor's selection of an egg donation program. This study suggests that AFC is a good predictor of ovarian response but cannot be used to predict oocyte/embryo quality or IVF outcome.

Three-dimensional ultrasound improves the interobserver reliability of antral follicle counts and facilitates increased clinical work flow

OBJECTIVES

To compare the interobserver reliability of antral follicle counts made using real-time two-dimensional (2D) ultrasound with offline counts made from stored three-dimensional (3D) data and to assess the time required for such counts.

METHODS

Two observers conducted transvaginal ultrasound examinations in 45 subfertile women in the early follicular phase of the menstrual cycle. Antral follicles were counted using real-time 2D ultrasound and the time taken was recorded. A 3D volume was then acquired from each ovary and stored for subsequent offline analysis using the multiplanar view. The time taken for each step was recorded and the total time was calculated. Intraclass correlation coefficients (ICC) and limits of agreement were used to assess reliability.

RESULTS

There was no difference in the mean antral follicle counts using real-time 2D (16.51 +/- 11.51) and 3D (16.33 +/- 12.13) ultrasound. According to ICCs, there was a significantly higher interobserver reliability for counts made using 3D (mean, 0.992; 95% CI, 0.986-0.996) compared with real-time 2D (mean, 0.961; 95% CI, 0.940-0.977) (P < 0.01) ultrasound. 3D ultrasound was also associated with narrower limits of agreement (-2.7 to + 3.1) than was 2D ultrasound (-6.9 to + 6.4). Whilst the total time taken was significantly longer for the 3D technique (239.3 +/- 71.4 s vs. 103.1 +/- 28.6 s, P < 0.001), the time required for the actual ultrasound examination was significantly less (46.4 +/- 7.4 s vs. 103.1 +/- 28.6 s, P < 0.001).

CONCLUSIONS

3D ultrasound significantly improves the interobserver reliability of antral follicle counts. While this is at the expense of time overall, the duration of the actual ultrasound examination and patient exposure is significantly reduced using 3D compared with real-time 2D ultrasound.

Does measuring early basal serum follicular luteinising [correction of lutinising] hormone assist in predicting in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcome?

BACKGROUND

The aim was to examine the correlation of early follicular serum lutinising hormone (LH) and the clinical outcome of assisted reproduction technique (ART).

METHODS

An observational study included 1333 consecutive women undergoing in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). 964 women were having their first cycle of ART. Data were entered prospectively. All women had serum LH measured in the 6 months before the index cycle studied. No repeat cycles were included. The main outcomes measured were clinical pregnancy (CP) and live birth (LB) correlation to serum LH. Forward multivariate stepwise regression analysis was applied, and other statistical tests were used as appropriate.

RESULTS

There was non significant correlation between basal serum LH and CP and LB in the polycystic ovary syndrome group (R2 = 0.02, F = 1.7 and P = 0.76) (R2 = 0.01, F = 2.6 and P = 0.77) respectively after adjusting for age, BMI, day of oocyte retrieval, starting dose, total dose of stimulation, type of gonadotrophin used, number of oocytes retrieved, fertilization rate and number of embryos transferred. Other aetiological causes group there was similarly non significant correlation between basal serum LH and CP (R2 = 0.05, F = 13.1 and P = 0.66), nor for LB (R2 = 0.007, F = 4.5 and P = 0.9).

CONCLUSION

Early follicular serum LH measurements in the 6 months before IVF/ICSI treatment cycle did not correlate with the clinical pregnancy or the live birth rate.