Ovarian reserve Predictors
What are the available tests apart from age to predict the poor ovarian response?
•             Basal serum FSH levels
•             Basal Estradiol levels
•             Antral follicle count
•             Ultrasound for volume and blood flow
•             Basal inhibin B level
•             Anti mullerian hormone levels
•             Dynamic tests
•             Clomiphene citrate challenge test
•             GnRH agonist  stimulation test (GAST)

Basal FSH levelS
When the ovarian reserve declines, there is an increased pituitary production of FSH.The selective rise in circulating FSH levels unaccompanied by a rise in LH as assessed between d2-4 of the menstrual cycle.
The problems with FSH estimation are

•             There may be significant variation between labs
•             There are no actual clear cut off point
•             Cyclical variation in the levels of FSH
As there is no definite cut off points ,some Centres counsels their patient at FSH level of 10iu/ml,The  cutoff point that we take is 12IU/ml in at least 2 cycles (some Centre takes this cut off as 15IU/ml)  it may fluctuate in different cycles, but a normal FSH cycle in between  does not mean that the response will be seen.

If a young patient has elevated level of FSH.The chances of response to gonadotropins is low, the cycle cancellation rate is high, but if the egg and embryos are achieved the chances of pregnancy can be expected, where as a women who is 40years old with normal FSH may show better response to gonadotropin stimulation but the chance of implantation and successful pregnancy is lower.
Age is a stronger predictor of pregnancy rate and basal FSH is a better predictor of cancellation rate.
Basal serum Estradiol level

This is one of the hormone tests, done between day2-4 of periods. Serum E2levels can predict decrease in egg quality and quantity .The cut off limit is around 80pg/ml with low Serum FSH levels. Elevated level of E2 with low level of FSH detects low ovarian reserve.
Serum Inhibin B level and Anti mullerian hormone level

Lower level of inhibin B and lower level of AMH suggests low ovarian reserve.
The normal level of AMH is over 1ng/ml, PCOS have high level of AMH around over 3.0ng/ml, low is around 0.3 -0.6ng/ml.
Serum AMH Strongly correlates with Antral follicle count, number of oocytes retrieved, age, FSH and inhibin B levels. AMH levels are predictive of cycle cancellation in poor responders in IVF cycle.
Antral follicle count

Antral follicular count and ovarian volume is done soon after the cessation of menstrual flow, by a transvaginal scan. Antral follicle and volume of ovaries are decreased in the women with poor ovarian reserve  It helps us predict the ovarian response of gonadotropin stimulation .
Good normal AFC is around 16-30,in this group one expects to see good response to low dose of gonadotropins.
PCOS have high count of over 30,the chances of OHSS is high in this group.

11-15 intermediate group,little lower than normal, would need a higher dose gonadotropins for stimulation.
Less than 7 ,is low and there is higher rate of cancellation.
Clomiphene citrate challenge test (CCCT)
This is a dynamic test to evaluate pituitary for the production of FSH in challenge to clomiphene citrate, a partial estrogen receptor antagonist, this blocks the negative feed back of estrogen on the HPO axis, leaving regulation of FSH release to inhibin B.

Method: on day 2 or day 3 of the period, an ultrasound of pelvis is done to rule out any cysts. And blood sample for serum FSH and E2 is collected.
From day 5 patients is given Clomiphene citrate 100mg tablet once a day for 5 days
On day 10 or 11 serum FSH is done. We can even do an ultrasound to determine for number and size of follicle that has been recruited. This will give us added information.

Interpretations: any elevation in day 3 and 10 serum FSH more than 10 or if the sum of both is more than 26IU/L then it is an abnormal CCCT.

CC increases the sensitivity of ovarian reserve, but a normal CCCT test tells you nothing, it is not an assurance of the fertility potential. The test is not very sensitive, but has a specific predictive value. An abnormal CCCT gives us the following information:
•             The response to injectable gonadotrophins will be poor.
•             Patient may have a higher cancellation rates in IVF
•             Will have fewer eggs retrieved in IVF
•             Pregnancy rates are lower following IUI/IVF
•             Have higher miscarriage rates
•             Increased risk for chromosomally abnormal embryos