Ans. c. FSH /Ref Harrison 19e p2388, 18/e p17/e p2331]Ovarian reserve is the capability of ovary to produce egg. The methods for assessing ovarian reserve are classified into Passive testing and Dynamic testing. FSH level is a method for testing passive ovarian reserve."As woman ages FSH becomes elevated in an attempt to force the aging ovary to respond. Rise in early follicular phase FSH is also accompanied by a decline in oocyte quality. High FSH has been correlated with poor ovarian reserve but it is difficult to establish absolute values that define how high an FSH level can be and still achieve pregnancy."Ovarian reserve* Ovarian reserve is the capability of ovary to produce egg* During the first few days of each monthly cycle, under the influence of FSH and LH there is rapid growth of several follicles in the ovaiy. After a week or more of growth one of the follicles begin to outgrow. AH the others and the remaining follicles involute (a process called atresia), and these follicles are said to become atretic.* The process of atresia is important because it normally allow s only one of the follicles to grow large enough, each month to ovulate. This usually prevents more than one child from developing with each pregnancy.* The single follicle reaches a diameter of l-l .5 centimeters at the time of ovulation and is called the mature follicle.* With advancing age the capability of the ovary to produce eggs declines.Methods of assessing ovarian reserve:* With advancing age the capability of the ovary to produce egg declines i.e. ovarian reserve decrease with age.* Usually age is the best predictor of ovarian reserve but approximately 10% of women have an accelerated loss of ovarian reserve by their mid-30. So age alone does not tell the whole story. Consequently more refined methods for predicting ovrian reserve have been developed.* Goal of methods for assessing ovarian reserve is to provide information regarding oocyte quality and quantity.Methods for Assessing Ovarian ReservePassive testingDynamic testingFSH level:* Early folloicular phase FSH levels play an important role in pregnancy outcomes.* As woman ages FSH becomes elevated in an attempt to force the aging ovary to respond. Rise in early follicular phase FSH is also accompanied by a decline in oocyte quality.* High FSH has been correlated with poor ovarian reserve but it is difficult to establish absolute values that define how high an FSH level can be and still achieve pregnancy.Measurement of Inhibin B:* Inhibin B is an ovarian hormone that inhibits FSH release. Although present in ovulating women it is not normally found in postmenopausal women.* Low inhibin levels suggests poor ovarian reserve.Transvaginal ultrasound:* Diminshed ovarian reserve means that fewer follicles are available for stimulation and recruitment by fertility drugs.* Transvaginal ultrasound allows the observation of ovaries and assess the number of follicles (ovarian volume.)Ciomiphene citrate challenge test:* Clomiphene is an antiestrogen which inhibits the negative feedback of estrogen on hypothalamus i.e. the hypothalamus gets false signals that the patient does not have enough estrogen. In response, the hypothalamus induces the pituitary gland to produce more FSH and LH. This is turn initiates follicular growth to produce estrogen.* Clomiphene is able to exert this effect only when the estrogen level is low or the ovarian reserve is low.* In a normal woman with adequate ovarian reserve there is enough inhibin and estrogen to suppress FSH production through negative feedback and resist the effects clomiphene.* When undergoing clomiphene citrate challenge test. the first step is to measure day 3 FSH and estrogen. Then 100 mg of clomiphere is administered on cycle day 5 through 9 and FSH and estrogen measurement are repeated on cycle day 10.* In general, a high day 10 FSH suggests poor ovarian reserve.