When we retrieve eggs, a lot of them may look good under the microscope, but in fact not be functional. Not every IVF patient is the same but on average it takes four to five eggs to generate one blastocyst.

Blastocysts are the best developed embryos we have in the laboratory and will take five to six days to generate.

Blastocysts are associated with the highest pregnancy rates. Not every blastocyst is genetically balanced.

A blastocyst with the correct number of chromosomes is called “euploid”. For women that are thirty-five, on average 70% of blastocysts will be euploid; for women thirty-six to thirty-eight, it is closer to 50%; and over thirty-eight years, it is closer to 30%. By the time women are over forty-two, it is likely an even lower fraction.

Even euploid embryos may have smaller genetic or other irregularities such that it will be an approximately 80% implantation rate.

Looking at all the numbers above, then, for the average thirty-seven year-old patient, mathematically at least, we can expect pregnancy if there are three blastocysts to be transferred over one to two cycles. To generate three blastocysts, we would like to have generated fifteen eggs.

That is why our goal for IVF is to generate twelve to twenty eggs.

I have seen cases where there were only two eggs, leading to two blastocysts and an ongoing twin pregnancy. If you have a very low ovarian reserve, but every reason to believe you have extraordinarily high-quality eggs, it is reasonable to hope that IVF could work for you.

But for most women, if there are fewer than twelve to twenty eggs being generated through IVF, then there is a lower chance for success based on the math described above.

So why not more than twenty eggs? The answer is that over twenty-two eggs, there may be enough hormonal imbalances that pregnancy rates may start to fall again. With such high numbers, the current community standard is shifting to freezing all embryos and not completing the transfer at all, instead waiting for a future cycle when your hormones are likely to be in better balance.

The post Why do you want 12 to 20 eggs for IVF? Isn’t that a lot? appeared first on Fertility.ca.

But when you have a good ovarian reserve, you most likely will have some good quality eggs in there too.

You were born with millions of immature eggs.

Most of the immature eggs will be housed in microscopic follicles (small baskets of cells) that will lie quietly for months and years at a time. But every cycle during your fertile years, there will be some follicles that are primed to grow. These primed follicles are known as antral follicles.

Ideally, you will have a good-sized pool of these antral follicles each month.

Why is it so important to have a good-sized pool of antral follicles?

Actually, if you are trying to get pregnant naturally, ovarian reserve doesn’t matter too much. After all, up until menopause, your body will generally find 1 egg a month from the pool to mature and ovulate. I’m not saying ovarian reserve doesn’t matter with natural cycles, but we have all seen natural conceptions in women who have very low reserves.

If you are looking to to access fertility treatments, a good ovarian reserve is extremely helpful.

For example, in IVF, we find our best pregnancy rates occur when we generate 3-5 high quality embryos. The best predictor for this outcome is 10-15 eggs at retrieval. (It is possible to have 3 good embryos from 3 eggs, but less likely). And the best predictor for 10-15 eggs is a good ovarian reserve.

Tests of Ovarian Reserve

Antral Follicle Count (AFC)

The AFC is an ultrasound test. The u/s tech counts your antral follicles. The ideal AFC is 15-20 over the two ovaries. If your AFC is <10, your ovarian reserve may be low (assuming the tech is counting accurately).

As a test, AFC is very much technician-dependent: not every ultrasonographer can measure AFC well, and there tends to be a lot of inter- and intra-observer variability (i.e. everyone measures a different number). If you are a bit gassy (or a bit overweight), it can be difficult.

Our newest 3D ultrasound machines have the ability to record AFC’s automatically. However, the technology isn’t perfect, and we still prefer the accuracy of our clinical team to that of the computer.
Anti Mullerian Hormone (AMH)

AMH is a newer blood test, and in my opinion, the most accurate test of ovarian reserve. AMH is a hormone released by cells that are involved with the growth of antral follicles. AMH levels correlate with the number of active antral follicles present; the higher the antral follicle count, the higher the AMH levels. I trust it more than AFC, because it seems to correlate with the number of active follicles.

AMH can be tested through a regular blood test. It can be drawn during any day of the menstrual cycle whether or not you are on the birth control pill. In my opinion, AMH is the single most helpful test for women looking to understand their own fertility.

If you get an unusual number, it is reasonable to repeat the test. AMH can be difficult to process in the lab, so the occasional incorrect number will be generated. Ask to do it again if you are making important decisions based on AMH.

Follicle-stimulating Hormone (FSH)

FSH is a blood test, and is the traditional test of ovarian reserve, perhaps because it was more accurate than ultrasounds used to be. These days, ultrasounds are incredibly accurate, and AMH has taken over as the more accurate blood test.

FSH is the hormone that drives your antral follicles to grow.

If you have a good ovarian reserve, your body doesn’t need to make very much FSH to start the process of egg maturation. A number less than 10 IU/L is good; less than 8 is ideal. Greater than 12 is a worry. FSH levels change month-to-month, as the number of antral follicles change.

FSH levels are brought lower by the presence of estrogen, so your FSH level is only an accurate indicator of your ovarian reserve when Estradiol levels are <200pmol/l. Estrogen is lowest on day 3 of the cycle, which is why we usually measure FSH on day 3.

The main tests of ovarian reserve used to be day 3 FSH, but today we prefer antral follicle count studies and AMH to guide our care.Ovarian reserve is not the same thing as egg quality, but the two can be related. Women can achieve healthy pregnancies with a low ovarian reserve. Tests of ovarian reserve are important, but they are not your only measurement of future success. They are, however, a very helpful guide to optimizing and personalizing your fertility treatments.

The post What’s the difference between my ovarian reserve and egg quality? appeared first on Fertility.ca.

AMH is the hormone that is made by the cells surrounding each of your resting eggs. This means that the more eggs that you have, the higher your AMH level will be. The corollary is true too: if your AMH is low, you don’t have a large reserve of eggs.

Your ovarian reserve is not the same thing as your egg quality. However, egg quality is much more difficult to measure. As an inexpensive and simple screening test, your AMH level in combination with your age can be our best single predictor of your fertility success.

AMH can help set your expectations, particularly if you are hoping that a fertility clinic would be able increase your chances for success over trying naturally at home.

Why Is AMH Useful?

AMH is extraordinarily useful for patients who are contemplating fertility treatments, because it predicts how many eggs you may mature in response to fertility medications. The basis of fertility treatments is often the maturation of more than one egg at a time. With more eggs available, we have a greater chance of a higher-quality embryo forming, and therefore a higher chance for pregnancy.

Does AMH Tell Me If I Still Have Good Eggs?

No, AMH does not tell you if you have good-quality eggs. It simply tells you how many eggs you have.
Nonetheless, the number of eggs you have in combination with your age (which itself is actually quite a good predictor of quality), will let you know how successful fertility treatments may be if you are not conceiving on your own.

Does AMH Help Me Decide About My Fertility?

Yes, AMH is helpful in making your fertility choices. This is because fertility clinics rely on a good ovarian reserve. If you have a good ovarian reserve, as defined by a good AMH level, then your success rates will be at the highest level for your age bracket. Unfortunately, the corollary is true, too. If your AMH levels are low, the range of choices and expectations from treatments may be low. AMH may help guide your choices.

My Doctor Gave Me My AMH Number. What Now?

You might want to research your AMH values further. Online, you will quickly discover that AMH might be described in ng/ml, but if you multiply that value by 7.1, you will have your value in pmol/L. This is important if you are comparing your numbers against those of others.

Do you want help deciding if you should do active treatments in a fertility clinic? We use AMH and age as a guide to potential success. View the IVF table according to age and AMH. Bottom line: the higher the AMH the higher your chances for success in any age group.

AMH is not destiny! These odds may not reflect your chances at your clinic. But I think they can be helpful to provide direction.

If you are not sure what to do with your AMH level, get it repeated, get a second opinion if you need to, and speak with a counsellor if you don’t know how to move forwards. AMH doesn’t lead to a single best solution for everyone, but it can provide guidance as you make the decisions that fit with your larger goals for you and your family.

The post How does an AMH test help me? appeared first on Fertility.ca.

The basics

You were born with millions of immature eggs. Most of the immature eggs are snuggled inside microscopic follicles (small baskets of cells) that will lie quietly for months and years at a time. But every cycle during your fertile years, there will be some follicles that are primed to grow. These primed follicles are known as antral follicles.

Ideally, you will have a good-sized pool of these antral follicles each month.

Why do antral follicles matter?

Actually, if you are trying to get pregnant naturally, they don’t matter very much at all. After all, up until menopause, your body will generally find 1 egg a month from the pool to mature and ovulate. I’m not saying ovarian reserve doesn’t matter with natural cycles at all, but we’ve all seen natural conceptions in women who have very low reserves.

However, if you want to access fertility treatments, a good ovarian reserve is extremely helpful. For example, in IVF, we find our best pregnancy rates occur when we generate 3-5 high quality embryos. The best predictor for this outcome is 10-15 eggs at retrieval. (It is possible to have 3 good embryos from 3 eggs, but less likely). And the best predictor for 10-15 eggs is a good ovarian reserve.

How do we test your ovarian reserve?

Antral Follicle Count (AFC). The AFC is an ultrasound test. The ultrasound tech counts your antral follicles. The ideal AFC is 15-20 over the two ovaries. If your AFC is <10, your ovarian reserve may be  low (assuming the tech is counting accurately). As a test, AFC is very much technician-dependent: not every ultrasonographer can measure AFC well, and there tends to be a lot of inter- and intra-observer variability (i.e. everyone measures a different number). If you are a bit gassy (or a bit overweight), it can be difficult. Our newest 3D ultrasound machines have the ability to record AFC’s automatically.  However, the technology isn’t perfect, and we still prefer the accuracy of our clinical team to that of the computer.

Anti Mullerian Hormone (AMH). AMH is a newer blood test, and in my opinion, the most accurate test of ovarian reserve. AMH is a hormone released by cells that are involved with the growth of antral follicles. AMH levels correlate with the number of active antral follicles present; the higher the antral follicle count, the higher the AMH levels. I trust it more than AFC, because it seems to correlate with the number of active follicles. AMH can be tested through a regular blood test. It can be drawn during any day of the menstrual cycle whether or not you are on the birth control pill.  In my opinion, AMH is the single most helpful test for women looking to understand their own fertility. That said, if you get an unusual number, it is reasonable to repeat the test. AMH can be difficult to process in the lab, so the occasional incorrect number will be generated. Ask to do it again if you are making important decisions based on AMH.

FSH. FSH is a blood test, and is the traditional test of ovarian reserve, perhaps because it was more accurate than ultrasounds used to be. These days, ultrasounds are incredibly accurate, and AMH has taken over as the more accurate blood test. FSH is the hormone that drives your antral follicles to grow. If you have a good ovarian reserve, your body doesn’t need to make very much FSH to start the process of egg maturation. A number less than 10 IU/L is good; less than 8 is ideal. Greater than 12 is a worry. FSH levels change month-to-month, as the number of antral follicles change. FSH levels are brought lower by the presence of estrogen, so your FSH level is only an accurate indicator of your ovarian reserve when Estradiol levels are <200pmol/l. Estrogen is lowest on day 3 of the cycle, which is why we usually measure FSH on day 3.

Tests of ovarian reserve are important, but they aren’t your only measurement of future success. They are, however, a very helpful guide to optimizing and personalizing your fertility treatments.

The post “What’s my ovarian reserve and what do all those tests mean – FSH, AFC, AMH?” appeared first on Fertility.ca.