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Poor Ovarian Response

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One of the most frustrating problems in IVF today is that of poor ovarian response. This is also known as poor ovarian function, poor ovarian reserve, occult ovarian failure, or the oopause. It's well known that pregnancy rates in IVF are directly dependent upon the quality and number of embryos transferred, and the more the eggs a woman grows, the better the embryos we can select from. This is why women with a good ovarian response have much higher pregnancy rates than women with a poor ovarian response.

Usually, ovarian functions goes hand in hand with age, and as a women becomes older, her ovarian response starts declining. Every girl is born with a finite number of eggs, and their number progressively declines with age. A measure of the remaining number of eggs in the ovary is called the "ovarian reserve"; and as the woman ages, her ovarian reserve gets depleted. The infertility specialist is really not interested in the woman's calendar (or chronological age), but rather her biological age - or how many eggs are left in her ovaries.

Various tests have been described to measure ovarian reserve. In the past, the commonest test used was one which measures the level of FSH ( follicle stimulating hormone) in the blood - the basal ( day 3) FSH level. A high level suggests poor ovarian reserve; and a very high level ( more than 20 mIU/ml, though this varies from lab to lab ) is diagnostic of ovarian failure. A test that can provide earlier evidence of declining ovarian function is the clomiphene citrate challenge test ( CCCT). This is similar to a " stress test " of the ovary; and involves measuring a basal Day 3 FSH level; and a Day 10 FSH level, after administering 100 mg of clomiphene citrate from Day 5 to Day 9. If the sum of the FSH levels is more than 25, then this suggests poor ovarian function, and predicts that the woman is likely to have a poor ovarian response ( she will most probably grow few eggs, of poor quality) when superovulated. Remember that a high FSH level does not mean that you cannot get pregnant - it just means that your chances are dropping because your egg quality is impaired.

As a woman ages, her supply of eggs gradually declines over time until the eggs are depleted at menopause. Although we expect the ovary to age in a certain way, there are times when it doesn't behave as predicted. That's why screening for ovarian reserve is a fundamental part of the initial evaluation for infertility patients of any age.

The term "ovarian reserve" refers to a woman's current supply of eggs, and is closely associated with reproductive potential. In general, the greater the number of remaining eggs, the better the chance for conception. Conversely, low ovarian reserve greatly diminishes a patient's chances for conception.

Methods of Assessing Ovarian Reserve Since a woman's chronological age is the single most important factor in predicting a couple's reproductive potential, age has often guided infertility treatment choices. However, age alone doesn't tell the whole story. Consequently, researchers have developed (and are continuing to develop) more refined methods of predicting a couple's response to infertility treatment. Some of the more sophisticated tools for assessing fertility potential include the measurement of FSH, LH, estradiol, and inhibin-B [Table 1]. Additionally, because patients should not be subjected to all tests, decisions regarding which method(s) to use are guided by practitioner experience.

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