Ovarian Reserve Assessment
Anti-Müllerian hormone (AMH) and antral follicle count (AFC) are the primary markers used to assess ovarian reserve, with AMH being the most convenient and reliable hormonal indicator. 1
Primary Hormonal Markers
Anti-Müllerian Hormone (AMH)
- AMH is the best currently available hormonal measure of ovarian reserve and accurately reflects the pool of growing follicles in the ovary 1, 2
- AMH is produced exclusively by granulosa cells of small, growing ovarian follicles and correlates strongly with the number of antral follicles 1, 3
- Key advantage: AMH does not vary significantly by menstrual cycle day and is not affected by exogenous estrogen or progesterone, making it convenient for testing at any time 1, 4
- AMH is superior to age, basal FSH, estradiol, and inhibin B for assessing ovarian reserve in healthy women 1
- Very low AMH levels (below 0.7 ng/mL) indicate ovarian failure or severely diminished ovarian reserve 1, 5
Antral Follicle Count (AFC)
- AFC measured by transvaginal ultrasound is the most established method for assessing ovarian reserve and correlates well with AMH 1
- AFC directly visualizes the pool of small antral follicles available for recruitment 1
Secondary Hormonal Markers
Follicle-Stimulating Hormone (FSH) and Estradiol
- FSH remains a late marker of ovarian dysfunction and is less sensitive than AMH for early detection of diminished ovarian reserve 1
- Baseline FSH and estradiol should be measured on days 3-6 of the menstrual cycle for women with regular cycles 4
- FSH >35 IU/L suggests ovarian failure 4
- FSH is useful for diagnosing premature ovarian insufficiency (POI) but has limited predictive value for future fertility 1
Clinical Application Algorithm
For women ≥25 years with regular cycles:
- AMH testing is the preferred initial assessment, as validated normative data are available for this age group 1
- AFC can be added for comprehensive evaluation 1
For women <25 years:
- AMH interpretation is less reliable, as there is no evidence that low AMH indicates reduced fertility in this age group 1
- AFC by transvaginal ultrasound remains the gold standard 1
For women with irregular cycles or amenorrhea:
- AMH is particularly useful since it does not require cycle-specific timing 4
- FSH and estradiol should be measured to evaluate for POI 1
Important Caveats
- AMH assays lack international standardization, so results should be interpreted using laboratory-specific reference ranges 5, 6
- AMH reflects the "functional ovarian reserve" (growing follicles responsive to gonadotropins) rather than the total primordial follicle pool 7, 6
- Women using hormonal contraceptives should discontinue them at least 2 months before testing if assessing baseline reproductive function 4
- AMH has limited value in predicting actual pregnancy success or live birth rates, though it effectively predicts ovarian response to stimulation 6, 2