Decreased Ovarian Reserve and AMH

Reduced Ovarian Reserve and AMH (Anti-Müllerian Hormone) Decreased ovarian reserve is the condition in which the number and quality of eggs (oocytes) in the ovaries decreases. This is an irreversible process and can reduce the success rate, especially in in vitro fertilization (IVF) treatments.The exact mechanisms by which diminished ovarian reserve develops, how it should be managed, and the impact of age, genetic, and environmental factors on this process are not yet fully understood.

However, it is known that there is a significant decrease in egg number and quality over time.Abnormal vascular structures developing due to age, oxidative stress, free radical imbalance, toxic effects, and genetic changes can lead to decreased egg quality, abnormal embryo development, and reduced chances of embryo implantation in the uterus. All these factors negatively affect IVF success rates.Reduced ovarian reserve is not the same as menopause or premature ovarian failure. Additionally, a woman's age alone is not a determining factor for ovarian reserve. What is the Weak Ovarian Response? Poor ovarian response is the condition of obtaining fewer eggs than expected during ovarian stimulation. Poor ovarian response can be considered if at least two of the following criteria are present: Being 40 years of age or older or having other known risk factors for reduced ovarian reserve Previous warnings indicating the retrieval of 3 or fewer oocytes despite induction with ≥150 IU FSH Abnormal ovarian reserve tests Your period is 2. the number of basal follicles on the day is less than 5 The AMH value is below 1.1 ng/ml Causes of Decreased Ovarian Reserve Conditions of unknown cause (idiopathic) Chemotherapy: Decrease in the number of primordial follicles that increases with age Radiotherapy: Damage depending on the dose and treatment area Genetic mutations Smoking Surgical procedures on the ovaries and fallopian tubes Autoimmune diseases Mumps Galactosemia How Is Ovarian Reserve Assessed? Ovarian reserve indicates a woman's fertility potential based on the number and quality of her eggs. Ovarian reserve tests; How the ovaries will respond to stimulation, The possible time of menopause, The risks that may occur during treatment It helps us predict. However, it is not a test that alone determines the decision to start IVF treatment.

Rather, it provides guiding information about reduced ovarian reserve. Current Ovarian Reserve Tests Currently, the following tests are used to assess ovarian reserve: Basal FSH level measured at the beginning of the cycle. In normal ovarian reserve, the FSH level is within normal limits. When ovarian reserve decreases, the secretion of inhibin and E2 from the ovary decreases, and consequently the FSH level increases. Basal E2 (Estradiol) E2 measured in the early follicular phase may be more valuable than basal FSH. A high E2 value along with normal FSH suggests poor ovarian response. AMH (Anti-Müllerian Hormone) It is secreted by the granulosa cells of antral follicles. The AMH level reaches its highest level around the age of 25 and gradually decreases until before menopause. Near menopause, it drops to undetectable levels. High AMH → Better ovarian reserve AMH begins to decline several years before FSH rises It is one of the most reliable tests for assessing ovarian reserve Basal Follicle Count On days 2–4 of the menstrual cycle , follicles with diameters of 2–10 mm are counted in the ovaries using ultrasound. This method provides a rapid and effective assessment of ovarian reserve. Treatment for Reduced Ovarian Reserve The treatment process is challenging in cases of reduced ovarian reserve and poor ovarian response. The primary goal is to obtain the highest possible number and quality of oocytes. Treatment must be individually tailored. The methods used include the following: High-dose gonadotropins Natural and modified cycles Estradiol (E2) and LH support Luteal antagonist protocols Letrozole and clomiphene Supportive treatments: aspirin, androgens, growth hormone, melatonin Oocyte donation Assisted hatching Brief Overview of Treatment Approaches High-dose gonadotropins: May increase the number of eggs but may negatively affect quality. Agonist and antagonist protocols: Produce similar results. Pregnancy rates are slightly higher in the microdose GnRH agonist protocol. Letrozole and clomiphene: May reduce the need for gonadotropins and slightly increase pregnancy rates. Androgens (DHEA, testosterone): May aid in the development of higher-quality oocytes. Estrogen (E2): Supports the balanced growth of follicles. Growth hormone: May enhance the effect of FSH on granulosa cells and increase pregnancy rates. Melatonin: May provide benefit in patients with PCOS, but its effect has not been demonstrated in those without PCOS. Aspirin: May support follicle development by increasing intrafollicular blood flow. New and experimental methods: Ovary transplantation, mitochondrial transfer, and stem cell studies are promising but are still in the research phase.

References:

• Broekmans FJ, et al. Female reproductive ageing: current knowledge and future trends. Trends Endocrinol Metab. 2009;20(5):192–198.

• Nelson SM, et al. Anti-Müllerian hormone: a marker of ovarian reserve and predictor of ovarian response. Reprod Biomed Online. 2012;24(6):601–611.

• Gleicher N, et al. Ovarian reserve testing and management of poor responders in IVF. Hum Reprod. 2011;26(3):457–465.

• La Marca A, et al. Anti-Müllerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum Reprod Update. 2009;15(3):357–371.

• Ferraretti AP, et al. ESHRE consensus on the definition of 'poor response' to ovarian stimulation for IVF. Hum Reprod. 2011;26(7):1616–1624.