Assessment of Ovarian Reserve
Pretesting is a big step in the IVF world. You might assume you will pass with flying colors because you have conceived easily on you own- the first month trying even! Well, you cannot assume anything about your ovarian reserve. Even the most seemingly fertile woman can have poor pretesting. There are some things you can do though if your pretesting comes back with a poor prognosis for IVF success.
Depending on the individual couple’s situation, various blood tests on either the female or the male may be needed. Blood tests that might be needed include:
- day 3 follicle stimulating hormone (FSH)
- estradiol (E2)
Day 3 FSH– It can actually be done anywhere from day 2-4 and it is a simple blood test meant to measure the amount of FSH in your bloodstream. FSH, otherwise known as follicle stimulating hormone, is a hormone that tells oocytes, or premature eggs, to begin growing. Each oocyte is contained within a follicle, or little fluid sac. In general, under 6 is excellent, 6-9 is good, 9-10 fair, 10-13 diminished reserve, 13+ very hard to stimulate
Estradiol(E2)- Also done between days 2 and 4 and 25-75 is considered normal. Levels on the lower end tend to be better for stimulating. Abnormally high levels on day 3 may indicate existence of a functional cyst or diminished ovarian reserve. If your e2 is abnormally high, it can make your FSH appear to be falsely low.
AMH– anti-mullerian hormone is a substance that is produced by granulosa cells in ovarian follicles. It can be done any day of your cycle. AMH blood levels are thought to reflect the size of the remaining egg supply – or ovarian reserve. AMH levels probably do not reflect egg quality. An AMH over 1 is in the normal range and 3+ is considered possible PCOS range.
You can have these tests ordered by your OB and it could be covered by insurance if you have diagnostic coverage, which most plans do.
They will also require you and your DH to have a full infectious disease panel done.
Antral Follicle Count(AFC)
This test is also done between days 2-4 of your cycle. Antral follicles are small follicles (about 2-8 mm in diameter) that they can see – and measure and count – with ultrasound. Antral follicles are also referred to as resting follicles. Some Res do not use or rely on AFC at all because it changes from month to month. What I do know is that the month you cycle, they will have you come in prior to starting your meds and see what your AFC is. So whether or not they tell you it matters, you will want to know what your AFC is to be able to make an informed decision about your protocol and if IVF is even an option for you so know your AFC!
Generally, less than 4 is not good. 7-10 is a reduced count and anything over 10 is definitely workable with IVF. Don’t get too hung up about AFC though because it does change.
The testing is more of a big picture summation. Meaning, if your FSH is good, your AFC is average and you AMH is normal, you should stim well. If you FSH is just okay, your AFC is low and your AMH is normal, you might still respond just fine but you won’t know until you try, unfortunately. Just remember this- Proven fertility trumps bad pretesting any day of the week! You can have poor pretesting and still have IVF work for you. They do not have statistics on what “normal levels” for fertile women should be.
This is only required when using MicroSort. MicroSort has specific morphology and motility requirements in order to be able to use MicroSort. When just doing IVF with PGD, a SA is not required.
The hysterosalpingogram, or HSG is done in order to assess the anatomy of the endometrial cavity of the uterus, such as an abnormal shape or structure, an injury, polyps, fibroids, adhesions, or a foreign object in the uterus. The HSG is usually scheduled to be done between days 6 and 13 of the cycle – this also depends on the specifics of the woman’s normal cycle.
- The RE’s office can perform this test OR you can ask your OB to do it.
Clomid Challenge Test
This test is ordered by some RE’s to help predict how one might respond to the fertility meds and it is another indicator of ovarian reserve. Basically, they draw blood to test your Day 3 FSH and then have you take 100mg of clomid day 5-9 and then take a Day 10 FSH level. If either the Day 3 FSH level or the Day 10 FSH level in a clomid challenge test is elevated, it is considered abnormal. A high FSH level is a sign of poor ovarian reserve. This is true if either the first or second FSH level is elevated. If your FSH comes back elevated, it does not mean that you cannot attempt IVF. It just means that you are going to have to use a more aggressive protocol and have to potentially use a higher dosage of stimulating drugs.