In connection with conception, fertility or infertility, a woman’s age is often mentioned. A modern woman can experience such information as a pressure to make decisions about having children earlier. However, it has been proven that a woman’s age, ovarian reserve and egg quality are the most important factors in infertility in modern society.

Unlike men, who produce sperm all the time, women are born with a certain number of eggs, which serve them for the rest of their lives. A woman is born with approximately 700.000 to 2 million eggs (oocytes). Around 11.000 of them are lost every month until the onset of puberty. At the onset of puberty or entering her teenage years, she still has about 300.000-400.000, but less than 500 ovulate during her lifetime.

As a woman ages, the oocytes also age, which means that in addition to the decline in quantity, there is also a decline in quality.

The importance of oocyte quality

This means that despite regular ovulation, the woman still might not get pregnant. The quality of the egg determines whether or not this cell will be useful or not, whether it can be fertilized or not. Immature, degenerated, abnormal cells are not suitable for fertilization.

The poor quality of egg cells is not only a problem for conception, but also a problem in case of possible pregnancy – there are increased chances of spontaneous abortion, chromosomal defects in the embryo or the fetus and the possibility of the pregnancy ending in a stillborn child.

Age is not a sufficient indicator of ovarian reserve and oocyte quality, but we must always use it in the context of several parameters:

• AMH values
• number of antral follicles (AFC) 
• FSH levels in the follicular phase.

AMH

Levels of AMH (Anti-Muellerian hormone) are measured in the blood. It is a hormone, produced by the granulosa cells of the antral follicles in the ovaries, which tells us about the number of follicles in the ovaries or ovarian reserve. The more follicles, the higher the AMH values ​​and vice versa. The value of AMH is used as one of the criteria in assessing fertility. It is used in women already involved in the MAR process, as well as a potential indicator/predictor of success before starting the procedure.

Important AMH values:

• high AMH values ​​(typical of PCOS) => above 7 ng/ml
• normal AMH values ​​=> 1.4 to 7 ng/ml
• reduced AMH values ​​=> 0.7 to 1.26 ng/ml
• extremely low AMH values ​​=> less than 0.7 ng/ml

AMH as a predictor of infertility

It is important to know that the value of AMH is always evaluated according to the age of the woman, as it is completely normal for the value to decrease with age and with a decrease in the ovarian reserve. It is always necessary to interprete the results, using the reference values ​​of the laboratory where the test was performed. AMH is only one of the indicators for the assessment of fertile potential and is not sufficient in itself to establish a final assessment or diagnosis.

NUMBER OF ANTRAL FOLLICLES (AFC)

Unfortunately, it is impossible to count how many follicles are left in the ovaries because they are too small to visualize. We can see them in a certain stage of development. The antral follicle is filled with fluid in a cavity known as the antrum. Follicles with an antrum are called antral follicles. They measure between 2 and 10 mm in diameter. 

Antral follicles are visible on ultrasound. Research has shown that the number of active antral follicles in the ovaries corresponds to the potential number of remaining eggs. We still cannot know how many total follicles there are, but when a woman has very few antral follicles in her ovaries, we can suspect that her ovarian reserves are low. Antral follicles produce high levels of AMH. 

Antral Follicle Count (AFC): AFC is one of the fertility tests done via transvaginal ultrasound, between days 2 and 5 of the cycle. Their number in both ovaries, together with the value of AMH, shows the state of the ovarian reserve: 

• <5 = extremely low reserve
• 5-10 = low reserve
• 11-30 = normal or good reserve
• >30 = indication for PCOS 

Like AMH, AFC also speaks about a woman’s poor or good response to stimulation in MAR procedures and, consequently, about their success or failure.

FOLLICLE-STIMULATING HORMONE (FSH)

Measurement of follicle-stimulating hormone (FSH) used to be the most commonly used endocrine test for premature ovarian failure. This is because it is non-invasive, inexpensive and provides information to understand a woman’s fertility. FSH is measured in the blood on the 3rd day of the menstrual cycle. High levels of this hormone are a sign that the follicles are maturing faster and the ovarian reserve is decreasing faster than usual. 

Symptoms of premature ovarian reserve are difficult to detect. Often, women have normal periods, but a reduced supply is detected only when there are problems with conceiving.