A new approach to ovarian reserve testing

Abstract

Objective: To critically examine ovarian reserve testing before assisted reproduction.

Design: A PUBMED computer search to identify relevant literature.

Setting: Multiple sites.

Patient(s): Patients undergoing assisted reproduction.

Intervention(s): Testing for ovarian reserve.

Main outcome measure(s): Assisted reproductive technology (ART) and pregnancy outcomes.

Result(s): The prevalence of ovarian insufficiency varies significantly for women aged 30-45 years. Generalization or averaging of threshold values across different aged women leads to very poor sensitivity, specificity, and positive predictive value for all tests of ovarian reserve. Because of the changing prevalence of ovarian insufficiency, there is no single, suitable threshold value for any screening test of ovarian reserve. Our analysis supports dividing impaired ovarian reserve into two groups: age-dependent ovarian aging (physiologic) and premature (nonphysiologic) reductions in the oocyte pool. Interpretation of any screening test used requires that age is considered as a variable. To guide clinical interpretation of test results, we suggest using a nomogram of FSH values versus expected delivery rate-per-cycle-start with ART for a given age.

Conclusion(s): Proper interpretation of screening tests for ovarian insufficiency in couples considering ART is important as the presence of impaired ovarian reserve is associated with a low likelihood of pregnancy. The condition of premature (nonphysiologic) ovarian insufficiency warrants additional research.

Figure 1

Combined effect of age and FSH upon expected delivery rate with assisted reproduction. (A) Delivery rate per cycle start versus age. Optimal success at ART is present at age 30, denoted by the dotted line. Physiologic reduction delivery rate due to aging and the associated ovarian insufficiency is indicated by the hatched area (a) in red; and can be conceptualized as a reduction from that dotted line. In contrast, non-physiologic ovarian insufficiency associated with increased basal FSH (or other markers of ovarian insufficiency) indicated marked by (b) in the blue area is also associated with a reduction in live birth rate. (B) Nomogram of delivery rate per cycle-start versus age including basal FSH after Akande et al. (32). The dotted line represents a 5% expected delivery rate per cycle start. Note that the 5% expected delivery rate crosses FSH values at different ages. This nomogram (or a similar nomogram specific for an ART program) can be used to plot patient values of FSH and age to assess the likelihood of live birth with assisted reproduction. Use of a nomogram may provide more accurate assessment of ART outcome than either age or basal FSH as singular values.