What test is used to assess ovarian reserve?

Ovarian Reserve Testing: Recommended Methods

The two primary tests for measuring ovarian reserve are anti-Müllerian hormone (AMH) serum concentration and antral follicle count (AFC) by transvaginal ultrasound, with AMH being the preferred biomarker due to its convenience and superior predictive value compared to other hormonal markers. 1

Primary Testing Methods

Anti-Müllerian Hormone (AMH)

AMH is the most established endocrine marker for assessing ovarian reserve and offers several advantages over other tests 1:

• Does not vary by menstrual cycle day, allowing untimed sampling
• Not affected by exogenous estrogen or progesterone use
• Superior to age, basal FSH, estradiol, and inhibin B in healthy women
• Correlates well with antral follicle count
• Very low AMH levels indicate ovarian failure

Important caveats for AMH interpretation:

• Wide range of normal values exists in healthy young adult women 1
• Limited normative data in pediatric patients 1
• Exercise caution when interpreting AMH values in women under age 25 years, as AMH rises to peak around age 25 and low AMH does not necessarily indicate reduced fertility in younger women 2
• Lack of standardization between different assay platforms remains a practical limitation 3

Antral Follicle Count (AFC)

AFC by transvaginal ultrasound is the most established method for assessing ovarian reserve in adult women 1, 2:

• Directly visualizes the antral follicle pool
• When ovarian volume is <3 cm³ and <5 antral follicles are present, this suggests diminished ovarian reserve 4
• Provides reliable estimate of ovarian reserve
• Particularly useful when AMH testing is unavailable or results are ambiguous

Limitations:

• Requires transvaginal approach for optimal visualization (may not be acceptable in all patients)
• Not part of current clinical criteria for premature ovarian insufficiency diagnosis 2
• Operator-dependent with moderate interobserver agreement 4

Secondary/Diagnostic Hormonal Tests

FSH and Estradiol

These are not primary screening tests for ovarian reserve but are essential for diagnosing ovarian dysfunction when clinical symptoms are present 1:

• FSH elevation is the hallmark of the menopausal transition and critical for diagnosing premature ovarian insufficiency 2
• Should be measured in early follicular phase (day 2-5) if oligomenorrhea present 2
• Can be measured randomly if amenorrhea present 2
• Recommended for evaluation only when there are clinical signs: delayed puberty, irregular menses, primary or secondary amenorrhea, or symptoms of estrogen deficiency 1

Critical distinction: In women with hypothalamic amenorrhea, gonadotropins will be falsely low, potentially masking primary ovarian insufficiency 5. AMH measurements can provide accurate ovarian reserve assessment in this scenario.

Clinical Application Algorithm

For asymptomatic women concerned about fertility potential:

1. First-line: AMH measurement (preferred for convenience and reliability) 6, 7
2. Alternative/complementary: Transvaginal ultrasound for AFC 4
3. Age-specific interpretation is essential

For women with menstrual irregularities or symptoms of ovarian dysfunction:

1. Detailed menstrual history and physical examination 2
2. FSH and estradiol levels to diagnose premature ovarian insufficiency 1
3. AMH and/or AFC to assess remaining ovarian reserve 2
4. Consider pregnancy test (hCG) to rule out pregnancy 8

For cancer survivors or those exposed to gonadotoxic therapy:

1. Regular screening with menstrual history 1
2. Baseline FSH and estradiol at age 13 years in prepubertal survivors 1
3. AMH shows promise for predicting ovarian reserve and timing of menopause, though not yet standard of care 1

Common Pitfalls to Avoid

• Do not use day 3 FSH as a primary screening test for ovarian reserve in asymptomatic women—it is inferior to AMH and AFC 6
• Do not over-interpret low AMH in women under 25 years—normative data show AMH peaks around age 25 2
• Do not assume normal menstruation equals normal ovarian reserve—women can menstruate regularly with diminished reserve 1
• Do not delay evaluation in high-risk populations (cancer survivors, family history of early menopause) 1
• Be aware that different AMH assay platforms yield different results due to lack of international standardization 3