FSH Ovarian reserve is the capability of ovary to produce eRg. The ovary is generally thought of as an egg bank from which the woman draws during the reproductive life. 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 ovary. After a week or more of growth one of the follicles begin to outgrow All the others and the remaining .follicles involute (a process called atresia), and these .follicles are said to become atretic. The process of atresia is impoant because it normally allows 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 1-1.5 centimeters at the time of ovulation and is called the mature follicle. With advancing age the capability of the ovan' 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 accelarated loss of ovarian reserve by their mid-30's. - So age alone does not tell the whole story. Consequently more refined methods for predicting ovarian reserve have been developed. The methods for assessing ovarian reserve are classified into two groups:- a)Passive testing b) Dynamic testing The goal of both the approaches is to provide information regarding oocyte (egg) quality and quantity. Passive testing FSH level Early, ,follicular phase FSH levels play an impoant role in pregnancy outcomes. As woman ages FSH becomes elevated in an attempt to force the aging ovary to respond. However, the exact mechanism responsible for this adaptive response remains unknown. A rise in early follicular phase FSH is also accompained 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. Generally FSH level are expected to be below 101uhn1in women with reproductive potential - In one study it was found out that 3 day FSH of less than 15 mlu/m1 were twice as likely to conceive than women with FSH values between 15 and 24.9 mlu/ml. - Cycle day 3 is chosen because at this time the estrogen level is expected to be low, a critical feature as FSH levels are subject to a negative feedback. - Thus any determination of FSH needs to include corresponding estradiol level to indicate that the FSH level was drawn when estrogen level was low. Other methods for passive ovarian reserve testing Measurement of Inhibin B Inhibit 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 Diminished ovarian reserve means that fewer follicles are available for stimulation and recruitment by feility drugs. Transvaginal ultrasound allows the observation of ovaries and assess the number of follicles (ovarian volume). Dynamic ovarian reserve testing Clomiphene 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 exe 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 clomiphene is administered on cycles day 5 through 9 and FSH and estrogen. measurements are repeated on cycle day 10. In general, a high day 10 FSH suggests poor ovarian reserve.