I recently finished a consultation with a woman who had a very low AMH level. I explained to her that it indicated she had poor ovarian reserve, and might have to consider using donor eggs. It was no surprise that she was upset- She asked me how this could be the case. She also told me that her gynecologist had done 4 IUI cycles for her and that she had at least two, 20, follicles in each of those cycles that would rupture on Day-14. The other thing she said was that since she was young and had good eggs, how was I telling her that her eggs were of a poor quality?

Ovarian reserve

Women are aware that their chances of getting pregnant are dependent on the quality and quantity of their eggs- this is called their ovarian reserve. They also know that if their cycles are regular, it is an indication that they are ovulating and that there is always a decline in egg quality as they grow older. This is also why young women who have ovulatory cycles also assume that the quality of their eggs must be up to the mark.  This is quite a reasonable assumption and one that most gynecologists share as well.

However, it's difficult to measure the quality of eggs. These are microscopic structures that can be evaluated only in an IVF treatment cycle; this is when the embryologist gets to see them under his microscope. Contrastingly, follicles are nothing more than black bubbles that can be tracked on serial ultrasound scans. Since most follicles also have eggs, we have conventionally measured the quality of eggs very indirectly, with the use of ultrasound scans to monitor follicles.

If these follicles grow well & they rupture, people conclude that the quality of the eggs that are in the follicles must also be good. Unfortunately, this isn’t always the case. The follicle is only a black bubble on the ultrasound screen; some follicles might be empty, while others might hold poor quality eggs. And the fact that you ovulate every month isn’t an indication that the quality of your eggs is good enough to make a baby.

Testing estradiol levels

This too has the same limitation; the eggs don’t produce estradiol, it’s the granulosa cells that line the ovarian follicle, which produce it. And so, even if the estradiol levels are good, the quality of the eggs may still be poor. At one point of time, FSH levels used to be the gold standard to assess egg quality; however, this too isn’t reliable for that same reason.

While most women who have high FSH levels have poor quality eggs (the quality as well as the quantity may be impaired), a number of women also can have poor quality eggs even if their FSH is normal. This is nothing more than an indirect marker of the quality of the eggs.

The reliable test

The new blood test which checks AMH levels, is the most reliable test to check egg quality. However this too isn’t a fool proof method, though the information it provides about ovarian reserve is far more accurate. If you are infertile, please ask your doctor to get your AMH level tested - or get this done yourself. It will give you a much better idea of your ovarian function !

Not happy with the attention you are getting from your IVF clinic? Need more information? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you!

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.

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