*3.1.2 Basal follicle stimulating hormone*

*Innovations in Assisted Reproduction Technology*

**3.1 Ovarian reserve testing**

to any interventions for infertility through various ovarian reserve tests (ORTs) in an effort to predict the response and outcome in couples seeking help for infertility treatment such. The widely used tests are basal follicle stimulating hormone, Anti-Mullerian Hormone (AMH) and Antral Follicle Count (AFC). Ovarian reserve reduction is a physiological phenomenon characterized by declining follicular pool and oocyte quality. The reduction of ovarian reserve starts at about 30 years in south Asian population and at 35 years in Caucasians [3].This rate of age-related reduction of follicle count in the human ovary is more than doubles when numbers

Ovarian reserve tests (ORT) serve as an indirect measures of a woman's remaining follicular pool when she presents herself for infertility treatment. ORT should be easy to perform, should be sensitive, specific, valid, and help to individualize the starting dose of gonadotropins for multifollicular development. The ovarian reserve testing helps to differentiate normoresponders, hyporesponders, and hyperresponders. Ovarian reserve is deciphered through a number of markers. These markers also help to prognosticate poor responders. Ovarian reserve is predicted clinically using a combination of clinical, biochemical and biophysical tests.

The tests are being used all over the world but the sensitivity and specificity of these test to detect the oocyte number, quality, and fecundity has to be still ascertained with further research [5]. More recently, their value in predicting hyperresponse and hypo response and thus using safe stimulation regimes to prevent OHSS is also explored [2]. The interpretation of the results of the ovarian reserve test is complicated by the lack of uniform definitions for hypo or hyper-responders and uniform threshold values to identify abnormal results. Several static and dynamic ovarian functional markers like biological (age), biochemical, biophysical,

In most cases of decreased ovarian reserve, the cause remains undetected. In specific cases like exposure to chemotherapy, pelvic irradiation, and genetic abnormalities there is a premature decrease in ovarian pool of oocytes. Cigarette smoking has been associated with a decrease in ovarian reserve. With diminished ovarian reserve a reproductive age woman has regular periods with normal or shortened duration of menstrual cycles but there is a decrease in response to ovarian stimulation and fecundity. Thus women of same age can differ in their response to ovarian

It is long established that ovarian reserve reduces progressively with age. This is due to a combination of two factors the body 'spending' the eggs through routine ovulation and the ovaries aging and preparing for menopause. Individual variation of the ovarian reserve can be explained by the two instances given as- a young woman with certain reproductive health problems may start out with smaller than the normal reserve of healthy eggs, and some women's reserves decrease more quickly than others with age. Fecundity in both natural and stimulated ovarian cycles declines with maternal age, beginning in the late 20s and becoming more abrupt in the late 30s. The fall in ovarian reserve with age in is a universal phenomenon in all ethinic groups. The initiation and rate of this decline varies considerably with ethinicity. Calender Age *per se* cannot determine ovarian responses. Ovarian reserve can also be traced indirectly by other biochemical and biophysical markers

and histological tests have been used to identify ovarian reserve [1, 2].

stimulation and thus the fecundity can vary.

fall below a critical figure of 25,000 at ~37.5 years of age [4].

**66**

of ovarian function [6–11].

*3.1.1 Age*

One of the most classically used biochemical levels to measure ovarian reserve is the Basal follicle stimulating hormone (FSH) levels measured on day 3 of the menstrual cycle. An increase in FSH levels occurs due to follicle depletion as the age of the woman progresses [9, 10]. The measurement of FSH is easy, and inexpensive reproducible and its specific. FSH levels are known to have diurnal, intraand intercycle variations that have to be kept in mind. There is definite precise parameter value to detect a woman with poor ovarian reserve. A vague demarking values more than 25 IU/L was used arbitrarily in some studies to detect high basal FSH. Several subsequent reviews did not identify values to satisfy the specificity and sensitivity for basal FSH as a test for poor ovarian response to stimulation or prediction of non-pregnancy. In women with regular menstrual cycles, FSH can predict a poor response adequately only at very high levels, and hence will be helpful only to a small number of women as a screening test for ovarian reserve testing and further counseling. It is thus clear that the ovarian aging begins several years prior to any elevation in FSH levels is noted and thus a normal test cannot rule out a poor ovarian response in some women. When FSH level is combined with other markers it can be used to counsel couples and planning treatment option regarding a poor response but it should not be used to exclude regularly cycling women from ART. The specificity of basal FSH testing in a general sub-fertile population or elevated levels in young, regularly cycling women is thus unclear and needs further studies [11–13]. Additionally the reliability of FSH is challengeable because of its pulsatile and circadian release and its isoforms. There are no cut off values available to predict poor responders.
