Infertility
Nazar N. Amso, Saikat Banerjee in Endometriosis, 2022
Knowing the detrimental effect endometriomas and their management can have on ovarian reserve, there would appear to be an increasing place for fertility preservation (egg or embryo freezing) in women with endometriosis. With recent improvements in the performance of cryopreserved oocytes (67), this is now an option available to women regardless of relationship status. In women with mild endometriosis, where the ovaries are unaffected, this conversation may not be necessary. However, in women with more severe endometriosis and known endometrioma, particularly if bilateral, a conversation regarding ovarian reserve and future fertility should be conducted. This should be ideally at an early stage, given that success with egg freezing is greater in women who freeze eggs under the age of 35, and ideally prior to first endometriosis surgery. An assessment of ovarian reserve as part of the pre-operative workup may be helpful. NICE guidance (68) suggests this is best achieved with either an antral follicle count (AFC) or AMH. Given the impact an endometrioma may have on AFC, an AMH level is preferable. Whether a woman wishes to proceed with fertility preservation is likely to depend on her age, current ovarian reserve, the severity of endometriosis and likelihood of requiring further surgery, relationship status and availability of funding.
The Ovaries and the Adnexa
Arianna D'Angelo, Nazar N. Amso in Ultrasound in Assisted Reproduction and Early Pregnancy, 2020
As discussed earlier, at the beginning of the menstrual cycle, the ovaries contain a wealth of antral follicles seen on transvaginal ultrasound as simple sac-like pockets that contain anechoic fluid between 2 and 10 mm arranged at the periphery of the ovary. Quantification of these follicles is a direct assessment of a woman's ovarian reserve as the number of antral follicles that emerge will reflect the number of primordial follicles available to start the journey of maturation approximately 180 days earlier [9]. The subpopulation of antral follicles that best correlates with ovarian reserve includes those between 4 and 6 mm [10]. Counting smaller ones is likely to include atretic follicles and therefore be an overestimate. However, to avoid the time-consuming process of measuring each follicle individually, by convention, all follicles measuring 2–10 mm are included in antral follicle counts (AFCs) [11].
The Infertility Workup
Steven R. Bayer, Michael M. Alper, Alan S. Penzias in The Boston IVF Handbook of Infertility, 2017
The assessment of ovarian reserve begins with the onset of menses and is generally performed during day 2 to day 4 of bleeding. Reserve testing usually entails both blood work and a pelvic ultrasound. Hormonal levels from the pituitary gland and ovary are evaluated and correlated with the total antral follicle count (AFC) obtained during the pelvic ultrasound. Collectively, an estimate of the patient’s reproductive potential can be made [18]. A patient’s ovarian reserve best describes oocyte quantity and a patient’s age best depicts oocyte quality. For young women under the age of 35, each oocyte has roughly a 10% probability of pregnancy and live birth. However, this rate declines rapidly with advancing age with pregnancy and delivery rates declining to 5% per oocyte by age 40 and to 1% or less by age 45 [19,20]. It is for this reason that young patients with diminished ovarian reserve have a better chance of pregnancy and live birth compared to women with advanced maternal age and a robust ovarian reserve [21].
Which is more predictive ovarian sensitivity marker if there is discordance between serum anti-Müllerian hormone levels and antral follicle count? A retrospective analysis
Published in Journal of Obstetrics and Gynaecology, 2022
Kiper Aslan, Isil Kasapoglu, Cihan Cakir, Meltem Koc, Murat Deniz Celenk, Baris Ata, Berrin Avci, Gurkan Uncu
Female age, serum anti-Müllerian hormone (AMH) levels and antral follicle count (AFC) are commonly used to assess ovarian reserve and predict response to ovarian stimulation (Ferraretti et al. 2011). Antral follicle count is the total count of 2–9 mm follicles in both ovaries measured by transvaginal ultrasound and reflects ovarian reserve (Chang et al. 1998; Broekmans et al. 2010). It is widely known that AFC has a good predictive value for IVF cycle outcomes like; ovarian response, number of retrieved oocytes (Chang et al. 1998; Hsu et al. 2011; Tsakos et al. 2014). Similar to AFC, AMH also has a good predictive value for ovarian response. AMH is produced by granulosa cells from pre-antral and antral follicles and inhibits follicular burn-out (Weenen et al. 2004). As it reflects the ovarian follicular pool, a decreasing number of follicles reduces serum AMH. Anti-Müllerian hormone and AFC are both positively correlated with ovarian reserve, and they are expected to be concordant with each other. Nevertheless, some women present with discordant AMH and AFC results, e.g. low AMH with a normal AFC or vice versa. Such discordance presents a challenge in predicting ovarian response and chances of success with an ART cycle. Limited evidence is available with regard to individual accuracy of AMH and AFC in predicting ovarian response in the presence of discordant results.
Diagnostic value of anti-Müllerian hormone combined with androgen-levels in Chinese patients with polycystic ovary syndrome
Published in Gynecological Endocrinology, 2023
Lingling Jiang, Xiangyan Ruan, Yanqiu Li, Muqing Gu, Jiaojiao Cheng, Yuejiao Wang, Yu Yang, Che Xu, Zhikun Wang, Lili Liu, Alfred O. Mueck
Age, height, body mass, body mass index (BMI), waist circumference, hip circumference, systolic blood pressure, and diastolic blood pressure were collected. Blood samples were collected on the second to third day of the menstrual cycle, and in amenorrheic cases, blood was drawn when no follicles ≥10 mm in diameter were seen on ultrasound, and blood was collected from the brachial vein between 8:00 to 10:00 am after 12 h of fasting. The antral follicle count was determined using transvaginal ultrasound. In amenorrheic cases, we measure progesterone and human chorionic gonadotropin to exclude possible ovulation or pregnancy. Serum anti-müllerian hormone was determined by the Elecsys AMH Plus immunoassay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland). The levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), prolactin (PRL), progesterone (P), thyroid stimulating hormone (TSH), cortisol (F) were determined by ADVIA Centaur XP automatic chemiluminescence immunoassay produced by Siemens Company in Germany. Total testosterone (T), free testosterone (FT) (calculated), sex hormone binding globulin (SHBG) (calculated on website http://www.issam.ch/freetesto.htm), bioavailable testosterone (BIOT) (calculated),17-hydroxyprogesterone (17-OHP), and dehydroepiandrosterone sulfate (DHEAS), androstenedione (A2), were determined by liquid chromatography-mass spectrometry tandem method (LC-MS/MS), which were performed using an AB Sciex 5500 mass spectrometer coupled with a Shimadzu Nexera X2 high-performance liquid chromatography (HPLC) system[22].
Dual trigger with the combination of gonadotropin-releasing hormone agonist and standard dose of human chorionic gonadotropin improves in vitro fertilisation outcomes in poor ovarian responders
Published in Journal of Obstetrics and Gynaecology, 2022
Ilknur Mutlu, Erhan Demirdag, Funda Cevher, Ahmet Erdem, Mehmet Erdem
Antral follicle count (AFC) measurements were carried out on the 3rd day of the cycle. GnRH antagonist protocol was used for all poor-responder patients. The stimulation protocol in both groups included exogenous gonadotropins to a maximum of 375 units in the form of recombinant FSH (Gonal-F, Merck Serono, Turkey) in combination with hMG (Menogon, Ferring, Turkey). Follicular growth monitorization and gonadotropin dose adjustments were performed with serial transvaginal ultrasound and serum E2 measurements to determine the ovarian response to the gonadotropin stimulation. All the sonographic exams were conducted by the Voluson 730 Pro machine (GE Healthcare Austria GmbH & Co OG). 0.25 mg/day subcutaneous cetrorelix (Cetrotide; Asta Medica, Frankfurt, Germany) was started when the leading follicle ≥13 mm or E2 > 300 pg/mL and was continued until the day of ovulation trigger. When at least two follicles were 17 mm or more in mean diameter, final oocyte maturation was triggered by 250 mcg of recombinant hCG (choriogonadotropin alfa) (Ovitrelle, Merck Serono, Turkey) alone in the control (hCG trigger) group or by 250 mcg of recombinant hCG (choriogonadotropin alfa) (Ovitrelle, Merck Serono, Turkey) plus 0.2 mg of triptorelin (Decapepty, Ferring, Turkey) in the study (dual trigger) group. None of the patients were given adjuvant treatments.
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