Ovarian reserve is an expression of the number and quality of eggs available for conception. As a parameter for predicting pregnancy, ovarian reserve testing is often part of a fertility evaluation. Such testing requires specific measurement, and clinical judgment to interpret the results.

Egg numbers are at a maximum before birth, at around 20 weeks gestation. After birth, there is a progressive decline in the number of eggs from roughly one million at birth to 300,000 at puberty. Through the reproductive years the remaining eggs are lost, with the rate accelerating around the mid-30s, resulting in few eggs left at menopause, around age 50-52. The number of eggs available for reproduction at a certain age is the ovarian reserve, which is the target of the diagnostic tests described here.

Age is the most accurate predictor of egg health, but within age groups, there is considerable variation in the number of eggs remaining for reproduction. Age alone as a predictor of ovarian reserve is not sufficient, since, for individuals, fertility may be better or worse than the average for that age. Extreme examples of this variability include the teenager in menopause and the 59 year-old that delivered a natural pregnancy in 1997. This variability in pregnancy rates within an age group is present in all reproductive age groups.

To predict an individual woman’s fertility rate, in addition to her age, both clinical and laboratory methods are available to evaluate ovarian reserve. The best tests are direct measures of the ovary, such as the Antral Follicle Count (AFC) and Anti-mullerian Hormone (AMH) level; indirect measures, such as clinical history and levels of pituitary hormones, are common tools for prediction of ovarian reserve.

The simplest method of predicting fertility rates is clinical history, of both the individual and her closely related family. The number of months spent attempting to conceive predicts fertility. A couple that has been trying for some time will naturally have a lower fertility rate than a woman that has not had unprotected intercourse. Response to ovarian stimulation can also be used as a marker, as it is fairly consistent between cycles. Family history, i.e., the fertility of the woman’s mother or sisters reflected in age at menopause and age at conception are useful predictors. Such factors from clinical history can help define the risk of a problem with ovarian reserve.

Ultrasound is a useful tool for predicting ovarian reserve, as in measuring the Antral Follicle Count (AFC). Antral follicles are the smaller follicles, visible on ultrasound, between 2 and 10 mm, that are lost as a woman ages. In younger women, the AFC is 10-20, declining by 5% per year through age 37, and then accelerating to a loss of 10% per year thereafter. Women show a fairly consistent AFC loss rate of one follicle every two years.

AFC predicts the response to ovarian stimulation at least as well as blood tests, but its ability to predict pregnancy outcomes is limited, particularly when low. A woman with a higher AFC will show a better response to fertility drug treatments. A high AFC seems to predict pregnancy rates, but data remains limited, as there are no prospective studies published. A low AFC seems to be a less accurate predictor of ovarian reserve, particularly in older age groups. AFC may help predict outcomes, but should not be used to exclude patients from treatment.

Anti-mullerian hormone (AMH) is a blood test that directly measures ovarian reserve. Produced directly by early stage ovarian follicles, high levels (over 1.0) are favorable, while low levels (less than 1.0) indicate decreased ovarian reserve. AMH may be the best measure of the menopausal transition and ovarian age. It may also be useful in predicting ovarian hyperstimulation syndrome, the effects of chemotherapy, and in determining the treatment of PCOS.

AMH seems a superior predictor of ovarian response compared to other markers, including age, and day 3 FSH and estradiol. It offers similar predictive value compared to AFC. AMH can be drawn at any time in the menstrual cycle, and is not affected by hormonal therapy, including oral contraceptives.

AMH still requires further study. The range of normal variation is still being determined, and the true predictive value of the test requires a great deal more analysis. The specific range of reliability and predictive value by age is yet to be established.

Cycle day three FSH and estradiol, and, to a lesser extent, the clomiphene challenge test, remain viable tests for estimating ovarian reserve. These tests are established as predictors of response to ovarian stimulation. Prediction of pregnancy rates is more difficult. Recent studies concentrating on the predictive value of these tests have shown that they cannot be used to determine which patients cannot conceive, but are useful for screening and counseling.

All in all, these tests are only rough predictors of ovarian reserve. They are moderately good predictors of ovarian response to stimulation, and relatively poor predictors of pregnancy outcome. In a particular patient, the tests can be used to counsel about potential response to ovulation induction, but it remains difficult to predict pregnancy outcome based on the test results.

The ultimate test of ovarian reserve is response to treatment and whether a pregnancy results from that treatment. Stay tuned as we evaluate further research to establish the validity of ovarian reserve testing methods.

— Philip Chenette, M.D.

Many populations of the world have specific genetic conditions that are prevalent within their ethnic group. Consequently, numerous medical organizations have recommended that genetic screening for these conditions should be offered when women are either planning for, or are currently pregnant. We are all carriers of genetic conditions: generally this is of little concern, as it is highly unlikely that we would have children with a partner who is a carrier for the same condition.

The genetic conditions listed in the table below are recessive. A recessive gene mutation is “carried” by someone who is unaffected by the disease, and thus unaware of their carrier status. Men and women have equal potential to be carriers for recessive conditions. Even if someone is a carrier, we would not expect to see a family history of the disease. If there is a family history, the likelihood of being a carrier of that condition is generally greater than in the general population. Being a carrier for a genetic condition typically has no impact on the carrier’s health and development. However, if a carrier has a child with another carrier of the same genetic disease, the chance that the child will be affected with the disease is 1 in 4 (25%).

If only one partner is a carrier, and the other tests negative, then the risk of an affected child is low, but not zero (a result of the limited ability to test for all defects that would make one a carrier; see table). These genetic screening tests are typically performed on a blood sample.

Below is a table listing the minimum number of tests for various ethnic groups recommended by the physicians at Pacific Fertility Center prior to starting assisted reproduction treatment. Additional genetic tests may be considered after a discussion with your physician.

If you know that both you and your partner are carriers of the same genetic defect, you may be able to have embryos created in an IVF cycle and tested for their status. Preimplantation genetic diagnosis (PGD) is a technology that allows embryos to be tested for specific disease causing mutations. PGD can identify unaffected embryos for transfer back to the uterus or freezing.

—Guest Contributor – Certified Genetic Counselor Lauri Black, M.S., C.G.C

*See lab specific accuracies on test result

Question: I’m 38 years old and have been trying to get pregnant for about a year. All of my lab tests and my husband’s semen analysis have been normal. What do you think is the problem?

Answer: For women in their late 30s, it is naturally going to take longer to get pregnant. They are experiencing what I like to call “age-related sub-fertility.” Some may be lucky and become pregnant right away. However, for the majority of women, as we age fewer of the eggs we ovulate are chromosomally normal; and therefore fewer ovulations result in the release of a normal egg. It just may take more ovulations before that normal egg is released, fertilized, implants, and succeeds in becoming a baby. It is estimated that about 1 in 5 eggs are normal at age 35, about 1 in 10 at age 40, and only 1 in 25 at age 45. So, at age 38, if about 1 in 8 eggs are normal, you may have only 1 or 2 chances a year for successful conception. If your intercourse was not well-timed that cycle or there was some other subtle inefficiency, the chance for conception may be lost. The catch-22 with age-related sub-fertility is that it takes longer to get pregnant and meanwhile, you are getting older and your egg quality is also declining. For this reason, many women seek treatment with fertility medications or IVF as they get older. These treatments can increase the number of eggs produced and exposed to sperm in a single month, thus improving the odds that normal eggs will be found. The good news is that for most women still in their 30s, fertility treatments for age-related sub-fertility are often successful.

– Carolyn Givens, M.D.

Question: Can I collect my sperm sample at home?

Answer: Yes, sperm samples can be produced at home and brought into our office provided that you follow some simple guidelines. Most importantly, the instructions for producing a sample must be followed as if you were producing a sample in one of the two dedicated rooms in our office. You should shower in the morning and wash the genital area with soap and then rinse with plenty of water. Most of the samples we receive are produced by masturbation and you should be careful to wash your hands immediately before and after the collection. If you need lubrication and/or a condom to produce the sample, these must be supplied by PFC. Most condoms and commercially available lubricants are toxic to sperm in some way, but we can supply you with materials that we have tested and that we know do not kill sperm. You can take them home if that’s where you’ll produce your sample. Similarly, we must provide the container into which you will collect; again to ensure that it is sperm friendly.

The most important part of producing the sample at home is getting it to our office within 60-90 minutes of collection. Your semen sample contains sperm but also many enzymes that are important in the natural process of reproduction. One part of your reproductive tract, the seminal vesicles, produces enzymes that coagulate the semen immediately upon emission. This allows the viscous sample to remain within the vagina, a process that might be an evolutionary vestige of the copulation plugs that are seen in other mammals and that prevent the female from mating with a second male. Within 5-20 minutes however, other enzymes in the semen (this time from the prostate gland) liquefy the clotted semen, liberating the trapped sperm so that they can enter the cervix. Sperm in the first fraction of the semen are bathed in prostatic secretions and have better motility and survival than sperm in latter fractions which are bathed in vesicular fluid, since the seminal vesicles emissions are last in the ejaculatory sequence. This is why we always ask if any part of the ejaculate was lost during collection. If the first few drops of semen don’t get into the collection cup, we may have lost the best sperm and we may underestimate the quality of your sample.

All of these enzymes in the semen make it a hostile environment. Sperm trapped or left in semen will die relatively quickly, but sperm washed out of this enzyme bath can survive easily for 4 or 5 days in the laboratory. Semen can also cause uterine contractions, which is why we have to process sperm samples and remove it before performing your intra uterine insemination. Getting your semen sample to the laboratory within 60-90 minutes of collection allows us to assess your sperm before the enzymes can do any damage.

It is important that you have an abstinence period of at least 48 hours but not more than 7 days before giving us a sample. Samples produced after 2 days abstinence will usually have the highest numbers of motile sperm with the greatest forward velocity, when compared to samples produced after shorter or longer abstinence. Waiting too long between ejaculates is the biggest mistake we see, possibly because some men think that they can save all their sperm for the day of their big test. However, older sperm begin to die if ejaculations are infrequent and we see the percentage of live sperm decrease with increasing abstinence. Also, please remember that abstinence means no ejaculation, not just no intercourse!

Once your sample has been collected, it is important to avoid exposing it to extremes of heat or cold before bringing it to us in the laboratory. Don’t put it in the refrigerator while you take a shower. Don’t leave it on your dashboard in the sun while you pick up your dry cleaning. And don’t leave it in the glove compartment, forget about it for a week, and then deliver it to the lab. The sample will be fine at room temperature, and you don’t have to break the speed limit in trying to get it to us.

You will need to have made an appointment with us so that we know you will be bringing in a sample, and when you arrive in our office, a member of our staff will check your specimen in. We need to be sure that it is labeled properly and we will get some details from you regarding your abstinence period and how and when you produced the sample. And we will check your identification (usually your driver’s license). This last step is important in establishing the identity of the sample and is part of a “chain of custody” procedure that we use with all samples passing through our facility. We will examine and if appropriate, process the sample within 30 minutes of receiving it, or immediately if the sample is already 1 hour old. Hopefully we won’t be calling you to say that we need to repeat the test! Joe Conaghan, PhD

Joe Conaghan, PhD, HCLD, PFC’s ART Laboratory Director, is internationally known for his work with embryos. He helps to train and certify embryologists and andrologists via the American Board of Bioanalysts, (ABB) of which he is a member of the Board of Directors. He is an inspector for CAP, the USA licensing authority for IVF laboratories. He teaches reproductive technologies at San Francisco State University and is the Chair of the College of Reproductive Biology (CRB). CRB is a special interest group within the American Board of Bioanalysts (ABB).

An Example X-Ray of a normal HSG	An example X-Ray of an abnormal HSG

Infertility due to blocked fallopian tubes was a common cause of infertility in the 1970’s and 1980’s. Some textbooks from that era quote an incidence as high as 25% of all infertility causes. At Pacific Fertility Center in 2005, only 10% of our in vitro fertilization patients were noted to have a tubal factor contributing to their infertility. Fallopian tube damage is most commonly due to prior infection with a sexually transmitted disease such as gonorrhea or Chlamydia. Most chlamydial pelvic infections are relatively asymptomatic and may go unrecognized; therefore many patients with tubal obstruction are unaware they have a tubal problem. Better safe-sex practices and improved screening of young women are possible factors for the lower incidence of tubal disease we are seeing, at least in our Bay Area infertility population.

Even though there is less tubal factor infertility these days, if there is a tubal obstruction, the course of fertility treatment becomes quite definitive: in vitro fertilization. No other treatments, including surgery, are likely to result in a healthy intra-uterine pregnancy. Therefore, we are still advocating some type of screening test for tubal factor in the evaluation of infertile couples.

There are two common ways to determine whether there is tubal obstruction. One is surgery, where dye is passed through the cervix, uterus and tubes, and there is direct visualization of the flow of the dye out the ends of the tubes into the pelvis. The other is the HSG, or hysterosalpingogram. The HSG is an X-ray procedure that involves placing into the cervix a small flexible catheter with a balloon around the tip to hold the catheter in place and close off the cervical opening. Radiographic contrast dye is then instilled into the uterine cavity, using a syringe attached to the tube. Under X-ray visualization, the dye is tracked into the uterine cavity and into the tubes. Pictures are taken during this process to document the shape of the uterine cavity and whether or not the dye enters and flows through both tubes into the pelvis.

HSG procedures are usually performed by radiologists; however, if there is difficulty placing the catheter securely into the cervix, the radiologist may ask the patient’s gynecologist to assist. This test is valuable in determining tubal blockages, but it has some disadvantages. It is very important to get the balloon properly inflated in the cervix to keep enough pressure on the fluid (no back flow into the vagina) so it will enter the fallopian tubes. Unfortunately, this pressure on the walls of the uterus can cause the uterus to contract, causing the patient to experience significant cramping. For this reason, it is recommended the patient take 2 or 3 ibuprofen prior to the procedure.

In some cases, the pressure is enough to cause the smooth muscle walls of the fallopian tubes themselves to spasm, blocking any dye from entering the tube. Sometimes the dye flows so easily through one tube that there is not enough pressure generated to get the dye to fill the other tube. These are some of the drawbacks of the procedure. This is why, even when we get a report of one-sided tubal obstruction, we are often skeptical that this is really due to some abnormality of the tube.

Although there are some false positives associated with this test, if the dye fills both tubes and does not flow out the ends of the tubes, this is highly suggestive of true tubal obstruction. In this instance, IVF is indicated. Carolyn Givens, M.D.

Carolyn Givens, M.D. was the first in San Francisco to successfully initiate a pregnancy using intracytoplasmic sperm injection (ICSI). She currently co-directs the Bay Area Pre-Implantation Genetic Diagnosis Program (PGD) and is director of PFC’s PGD program.

Interested in self-diagnosis of fertility? The ability to screen for fertility in private, on one’s own schedule, with an at home diagnostic kit is an appealing option. A company from the UK, Genosis, has developed such a kit, called Fertell.

Fertell is a testing kit that offers a basic assessment of male and female fertility.

Fertell for the male is a specimen collection and testing kit that measures the concentration of motile sperm. A sperm specimen is collected into a cup and allowed to liquefy and then warmed to body temperature. Motile sperm pass through a filter and are colored red by exposure to a gold-coated antibody. Appearance of two red lines in a testing chamber indicates a sperm count over 10 million total motile.

Fertell for the female is a conventional urine test strip very similar to an ovulation prediction kit. The female places the absorbent tip in her urine stream for 5 seconds. FSH in the urine reacts with antibodies on the test strip and shows as a red line in the result window. The intensity of this line reflects the FSH concentration (the darker the line, the more FSH present in urine). High FSH levels are indicated by two dark red lines.

Traditional semen analysis measures sperm volume, count, and motility. Multiplied together, these numbers yield the total motile sperm count, that is, the number of moving sperm in the ejaculate. Total motile sperm count is a reasonable predictor of fertility for men. Fertell establishes that the sperm count is over a specific value of 10 million total motile, a reasonable threshold for male fertility.

The male test kit is not able to determine subtle gradations of male fertility. It cannot detect the effects of treatment or change in lifestyle that may cause improvement in sperm count, nor can it detect alterations in sperm morphology (shape). More sophisticated testing is available at a sperm lab.

The female test kit is used as a screening test, and cannot detect subtle gradations in FSH levels, or the relationship of FSH to other important hormones such as estradiol. Such issues have dramatic effect on the patient’s prognosis.

Neither of these tests can replace an expert’s opinion. An expert’s ability to interpret test results with a broad knowledge base and experience remains the best way to diagnose and treat infertility problems.

Of primary importance is that, while both test kits have been correlated with existing assays, neither has been evaluated for its ability to predict pregnancy. Such research takes time, and hopefully will be forthcoming. For now, Fertell is an interesting option for those seeking a private screening assessment of their fertility.

Philip Chenette, M.D. has spent over a decade specializing in the treatment of patients with complex infertility diagnoses, especially in women with decreased ovarian reserve and women over 40.