Various tests have been described to measure ovarian reserve. In the past, the commonest test used was one which measures the level of FSH (follicle stimulating hormone) in the blood - the basal (day 3) FSH level. A high level suggests poor ovarian reserve; and a very high level (more than 20 mIU/ml, though this varies from lab to lab ) is diagnostic of ovarian failure. A test that can provide earlier evidence of declining ovarian function is the clomiphene citrate challenge test (CCCT). This is similar to a " stress test " of the ovary; and involves measuring a basal Day 3 FSH level; and a Day 10 FSH level, after administering 100 mg of clomiphene citrate from Day 5 to Day 9. If the sum of the FSH levels is more than 25, then this suggests poor ovarian function, and predicts that the woman is likely to have a poor ovarian response (she will most probably grow few eggs, of poor quality) when superovulated. Remember that a high FSH level does not mean that you cannot get pregnant - it just means that your chances are dropping because your egg quality is impaired.
Some women find it difficult to understand why FSH levels are high in women with poor quality eggs. Intuitively, more is better, so higher levels should mean better eggs, shouldn't it? As one patient asked me, " If FSH stands for Follicle Stimulating Hormone, and I have high levels of FSH, then doesn't that mean that I have the ability to stimulate lots of follicles? A high FSH should mean that I should have lots of eggs ! " I had to explain the basic biology to her. Normally , FSH is produced by the pituitary, and this is the hormone which is responsible for the growth of the egg from the ovary every month. In young women with lots of good quality eggs, low levels of FSH are enough to grow the eggs. However, as the woman grows older and egg quality and quantity decline, the pituitary needs to produce more and more FSH to stimulate egg growth, because the FSH has to work harder to stimulate egg growth.
It's also useful to check your FSH:LH ratio. A normal FSH:LH ratio is 1. However, if your FSH level is much higher than your LH level, then this suggests poor ovarian reserve.
It's also a good idea to test your estradiol (E2) level on Day 3 at the time you check your FSH level. A high E2 level can artificially suppress the FSH back to normal, thus lulling you into a false sense of security. However , a high E2 level suggests poor ovarian reserve.
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Another test which has been recently developed is the measurement of the level of the hormone AMH , in the blood. Low levels of AMH (which is produced by " good " follicles) suggest a poor ovarian reserve. However, just because a test result is normal does not mean that the quality or number of the eggs produced will be good - the final proof of the pudding is always in the eating ! This is why one of the most useful ways of making a diagnosis of poor ovarian reserve is when the patient gives a history of responding poorly to medications used for superovulation in the past.
Along with using biochemical tests to assess ovarian function, we can use biophysical markers to test these too. These biophysical tests use ultrasound technology to image the ovaries and the follicles. The most useful test is called an antral follicle count (AFC) , in which the doctor counts the number of antral follicles (also referred to as resting follicles) present in the ovary on Day 3 using vaginal ultrasound scanning. Antral follicles are small follicles , usually about 2-8 mm in diameter. The number of antral follicles correlates well with ovarian response. A normal total antral count is between 15 and 30. If the count is less than 6, the prognosis is poor. You can read more about the antral follicle count and see ultrasound images of these at the
www.advancedfertility.com website . The volume of the ovaries also correlates with ovarian response. The volume of each ovary is calculated using the formula (length x width x height x 0.5 ) and the normal ovarian volume of both ovaries combined is 10 ml. Women with small ovaries (volume of less than 4 ml) have a poor ovarian response.
Ovarian Fertility Potential pmol/L ng/mL
Optimal Fertility 28.6 - 48.5 4.0 - 6.8
Satisfactory Fertility 15.7 - 28.6 2.2 - 4.0
Low Fertility 2.2 - 15.7 0.3 - 2.2
Very Low / undetectable 0.0 - 2.2 0.0 - 0.3
High Level > 48.5 > 6.8
I'm hoping it's going to be soon!
. DH and I had BD'ed the two nights before... but I think I missed the 'best' day. Is there still a chance I could have cought the lucky egg? 
