IVF utilizes fertility drugs to stimulate the development of multiple
eggs in the ovaries at the same time. Women can respond differently to these
medications. It is important to measure the function of the ovaries before
starting stimulation in order to allow the doctor to estimate your prognosis
for a successful IVF and to choose the correct IVF stimulation protocol.
In 2020, the optimal evaluation of the ovaries which is also called ovarian reserve testing
is done with a combination of blood tests and ultrasound.
If you are a woman who ovulates and gets her periods on her own, these tests should be done on the
second or third day of your period. Day one is considered the first day of full
flow bleeding - spotting does not count. If you are a woman who does not get
periods or gets them infrequently because you don't ovulate then you can
do these tests any time. First, let's talk about ultrasound. This is an ultrasound
image of an ovary. Those black spots are small cysts called follicles. Each
follicle contains fluid, follicle cells and an egg. At the beginning of your
cycle, when the follicles are small, the eggs inside are immature. It's important
for your doctor to count how many follicles are visible in each ovary.
Women who have a lot of follicles like this are typically going to respond
better to fertility medication and get more eggs than women who have fewer
follicles - like this. In fact, the dose of fertility medications in women who have
a very high number of follicles should be reduced to prevent the complication
called ovarian hyperstimulation syndrome. Women who have few follicles will likely
need a more aggressive medication protocol with higher doses of medication
but may still get fewer eggs during IVF. There are three blood tests that IVF
experts recommend before starting IVF two are absolutely mandatory, the third
one is newer but may become more important in the future. The first
mandatory blood test is called AMH. AMH is a hormone that is produced from the
follicles in the ovary. Similar to the follicle count on ultrasound, a higher
AMH level indicates a better response to fertility medication; more eggs retrieved
and the need to lower the dose of medication to help reduce the risk of
hyperstimulation. Younger women, who generally have ovaries that are more
likely to produce more eggs, tend to have higher AMH levels. Another group of women
with high AMH levels are women with an ovulation problem called polycystic
ovary syndrome or PCOS. The second mandatory hormone blood test you need to
have before starting IVF is called FSH. FSH comes from the pituitary gland not
the ovaries. I like to think of FSH as the opposite of AMH. This means that you
would like to have low FSH levels as opposed to high AMH levels. Women with
high FSH levels have a number of problems when they do IVF. They have a
higher chance for not responding to fertility medications and not making it
to the point of an egg retrieval. When they do get to an egg retrieval, they
produce less eggs and therefore get less embryos. There is some evidence that even
in younger women, a high FSH level may predict a higher chance for
chromosomally abnormal embryos though this is still somewhat uncertain. One
word of caution about FSH levels. The levels can vary from month to month so
you could have a normal FSH level in one month and it could be abnormal on
another month. The older you are, the greater the chance that a normal FSH
level on one month could be abnormal on another month. FSH levels are also
affected by the levels of estrogen. Both hormones should always be measured
together. If your FSH level is normal your estrogen level is elevated at the
same time, you shouldn't put too much faith in that FSH level it could be a
lot higher than you think. Finally, a new study has found that in women who don't
respond well to fertility medications, measuring a hormone called IGF-1, could
be helpful. This study found that poor responders were more likely to have high
IGF-1 levels and that suppressing IGF-1 levels with a medication may result in
a stimulation with more eggs. This is still preliminary evidence though. Our
InfertilityTV-- bottom line is this: before starting IVF, your doctor should
do a thorough assessment of the function of your ovaries with blood tests and
ultrasounds and adjust your IVF medication protocol based on the results.
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