March 11, 2022

Limitations of Ovarian Reserve Testing

Author: Rita Health team

With age, there is an inevitable decline in the numbers and quality of human eggs, with the quality changes being an increase in chromosomal abnormalities. This is a fact that every person with ovaries is and should be aware of.  Still, we at Rita Health believe that with proactivity and comprehensive assessment, advancing age no longer has to be approached with fear, but instead with knowledge, creativity, optimism and resolve. To do this, we need to understand the entire story of a woman’s overall fertility health.
Ovarian reserve tests have become increasingly popular as a means of understanding a woman’s chances of getting pregnant in the future, often before she starts actively trying to conceive. We commonly refer to them as “egg count” and “deadline” tests as this is how they are often framed - but the truth is, these tests only show one side of the story. Recent studies have shown that while ovarian reserve tests are important for many reasons, they run the risk of giving women an inaccurate impression of their current and future chances of having children.

What are Ovarian Reserve Tests?

Typically, tests used to measure a woman’s ovarian reserve (the total number of eggs in the ovaries) include:

  • Anti-mullerian hormone (AMH) test and antral follicle count (AFC): We know, it’s a mouthful. The anti-mullerian hormone  is produced in small amounts by tiny follicles inside the ovaries.  Testing of this hormone will indirectly show how many small follicles are there. There generally is one egg per antral follicle, so fewer antral follicles/lower AMH mean fewer eggs remaining. Typically this number decreases naturally with age, and this process can be exacerbated by some other factors. AFC is counted during visualization of ovaries on transvaginal ultrasound.  When performed by an experienced provider, AFC is a reasonable alternative to AMH. Since ovarian aging and declining ovarian reserve can have significant consequences for fertility treatment, particularly IVF success, women who wish to preserve their fertility or understand their treatment prognosis should measure their AMH before starting treatment. 
  • Day 3 follicle-stimulating hormone (FSH) and estradiol testing: FSH is the hormone that sends a message to the ovaries to grow follicles with eggs. As the follicles respond and grow (and the egg inside them grows as well), they release more and more estradiol - the main form of estrogen, the female hormone. FSH then essentially slows down in response to the rising estradiol levels. If the eggs don’t respond, FSH levels will continue to rise in an attempt to push the process. FSH and estradiol tests are completed via a blood test on the third day of your period. High levels can indicate an issue with ovarian reserve, and low levels can indicate conditions with insufficient stimulation of ovaries by the brain.

While the results of these tests can give insight into the number of eggs remaining in a woman’s ovaries, they have many limitations. One of the more obvious examples of these limitations is that they measure the amount, but not the quality of a woman’s remaining eggs. Another limitation, specifically in measuring FSH levels, is that they may vary from one cycle to the next and are not always reliable as a single measurement. Estradiol measurement should always be interpreted in conjunction with FSH levels. 

The growing popularity of ovarian reserve testing can result in the belief that these tests are very accurate and comprehensive indicators of fertility health. Women might respond to poor test results by jumping to expensive procedures like egg freezing in hopes of “preserving” their fertility. On the other hand, women who receive normal test results might be falsely encouraged - taking no further action though there might be more information she should be taking into consideration.

Be Curious about the Whole Story of Your Fertility Health

Like many of the wonderful things we’ve experienced with modern-day western medicine, there is a real need in many instances for ovarian reserve testing to help us better understand our fertility health. These tests have certainly helped many women and their providers along their journey to parenthood. However, we do not always appreciate that there are other factors that can affect our ovarian reserve, usually in a negative way. Helping women to understand those will  empower them to take some corrective actions. 

Curiosity and proactivity is a skill that women from our community possess, and we know that our best decisions are the informed ones when we’re able to consider the whole picture and take many interrelated factors into account. If we want to achieve the highest level of reproductive wellness, our approach must be one that is ever evolving and optimistic - expanding our focus beyond singular parts, always taking into account the entire picture of a well designed and complex system. 

We invite you to stay curious and proactive and join our study.

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