Age

Fertility in women peaks between the ages if 20 and 24; decreases relatively little until approximately age of 30 to 32; and then declines progressively, more rapidly after the age 40.

In the average woman, accelerated follicular depletion and declining fertility begin at age 37-38, and menopause folows approximately 13 years later.

During the reproductive years the rate of follicular depletion is relatively constant and gradual until age 37-38, and acceleartes over the 10-15 years preceding menopause.

The uterus and the fallopian tubes remain relatively normal, it is the declining ovarian function ( decreased number of eggs in the ovary ) that is the cause of the decrease in fertlility in the older woman.

There are various tests to detect the ovarian reserve:

1)    Cycle day3 serum FSh concentration-
Currently, in most laboratories, levels above 10-15 IU/L are considered abnormal.  As values increase, the number of oocytes retrieved and the probability for pregnancy or live birth steadily decline.

2)    Cycle day3 estradiol concentration-
A high cycle day3 estradiol concetration ( greater than 80 pg/ml ) predicts low fecundability.

3)  Measurement of both FSH and estradiol on cycle day3

4)    Clomiphene citrate challenge test-
This involves measuring a day3 FSH; and a day10 FSH, afetr administering clomiphene citrate (100mg) from day5 to day9. If the sum of the FSH level is more than 25, it suggests a poor ovarian reserve.

5)    Inhibin B-
Inhibin B is a protein hormone produced by the ovaries. It acts to inhibit the FSH production. Inhibin B level decreases with decreasing ovarian reserve.

6)    Anti-mullerian hormone-

AMH, or anti-mullerian hormone is produced by granulosa cells in ovarian follicles. It is made in the smallprimary follicles and antral follicles.

Production decreases and then stops as the follicles grow larger. There is almost no AMH made in human follicles over 8mm in size. Because of this, the levels are quite constant and the AMH test can be done on any day of a woman's cycle.

Since AMH is produced only in small ovarian follicles, blood levels of this substance have been used to attempt to measure the size of the pool of growing follicles in women.

Therefore, AMH blood levels are thought to reflect the size of the remaining egg supply - or ovarian reserve.

With advancing age, the size of the pool of the remaining follicles decreases. Therefore, the blood AMH level and the number of antral follicles seen on ultrasound also decreases.

7)    Transvaginal ultrasound for ovarian volume and antral follicle count

Ovarian reserve testing is strongly justified for women with any of the following characteristics:

-    Age older than 35

-    Unexplained infertility, regardless of age

-    Family history of earky menopause

-    Previous ovarian surgery ( ovarian cystectomy or drilling, unilateral oophorectomy ), chemotherapy or radiation

-    Smoking

-    Demonstrated poor response to exogenous gonadotropin stimulation

Ovarian rserve tests are an important and uselful investigative tool but must always be interpreted and applied with caution.

Except when grossly abnormal, test results should, therefore, not be used to deny treatment, but only to obtain prognostic information that can help to guide the choice of treatment and best use of available resources.

Ultimately, regardless of what the statistical prognosis may be, the success rate for any individual woman will be 0 or 100 % !