When I was 37, I did what many women facing a narrowing fertility window do: I booked an appointment with a reproductive endocrinologist to discuss egg freezing. The first step was a blood test to measure my ovarian reserve.
That’s when I was hit with shocking news.
After viewing my initial blood test results, the doctor promptly declared that not only was I not a candidate for egg freezing, but I had just a 1 to 2 percent chance — at best — of ever conceiving naturally. Two key hormone results led the doctor to that conclusion: a follicle stimulating hormone (FSH) level well above the typical cutoff of 10, and a corresponding anti-Mullerian hormone (AMH) count close to zero. I had, in short, diminished ovarian reserve.
My egg quality, the doctor extrapolated, had to be poor, too. The results, she said, were “abnormal” and “devastating,” and I’d need serious counseling to process the news. “Maybe,” she added, “your sister can be your egg donor.”
My sister? I could barely get her to return my calls.
New thinking on ovarian reserve
Turns out, I was on the receiving end of the kind of misinformation — and hysteria — that’s increasingly fed to women, as ovarian reserve testing gains in popularity.
And here’s the biggest misconception: Low ovarian reserve always equates with low egg quality.
A groundbreaking recent study led by Dr. Anne Z. Steiner, M.D., a professor of reproductive endocrinology and infertility at the University of North Carolina in Chapel Hill, effectively takes on that very misconception, essentially noting that while ovarian reserve testing may predict how many eggs a woman has left — and her corresponding ability to respond to ovarian-stimulating drugs to harvest eggs in bulk for oocyte freezing or traditional IVF — those same results do not definitively predict natural odds of conception and by extension, egg quality. In fact, no test can.
So why are doctors — such as the Ivy League-credentialed doctor I saw that day — continuing to say otherwise?
Reserve testing’s narrow past use
In the past, fertility specialists relied on ovarian reserve tests as a first measure in determining how well IVF patients, specifically, would respond to ovarian-stimulating drugs: The lower the AMH, and higher the corresponding FSH, the lower the overall odds of drug response was predicted to be.
Somewhere along the way, doctors began to extrapolate such findings onto the general population, concluding that any woman — even one who’d never tried to get pregnant before and still had regular cycles — would likely have difficulty conceiving if an ovarian reserve test revealed she had high FSH and low AMH.
That’s what makes the UNC study so eye-opening — and industry colleagues are taking note.
“We assumed, from all we know about treating patients with low ovarian reserve, that a low AMH in the general population would also be a harbinger of not getting pregnant [naturally],” said Dr. Nanette Santoro, M.D., an OB-GYN professor at the University of Colorado, who wrote an accompanying editorial on the UNC study, published in JAMA, the Journal of the American Medical Association. “The Steiner study shows that is not the case.”
Low AMH, low conception odds?
To test that question, UNC researchers tracked 750 women, between the ages of 30 and 44, who’d been trying to get pregnant for three months or less, and therefore lacked any prior history of infertility.
After following participants for six to 12 months (the time frame in which unassisted pregnancy typically occurs), researchers found that 487 of these women — 65 percent, in all — conceived naturally. Most significantly, participants’ levels of AMH, FSH and another critical hormone, inhibin B, played no significant role in who got pregnant.
For Dr. John Gordon, M.D., co-director of Dominion Fertility in Arlington, Va., the results confirm what he’s long seen in his own practice: While low AMH and high FSH may predict response to stimulating drugs, those levels do not unequivocally rule out the possibility of natural conception, or, in the case of his patients with diminished ovarian reserve, successful outcomes via “natural cycle” IVF. That is a form of treatment that foregoes the stimulating drug protocols of traditional IVF and, instead, works with the single egg that a woman typically produces each month on her own.
“When we’ve stratified patients by age — and grouped them by ‘women with good ovarian reserve,’ ‘OK ovarian reserve’ or ‘terrible ovarian reserve’ — there was basically no difference in the natural cycle IVF outcome,” Gordon said, “which is what you’d predict if ovarian reserve testing only predicts the response to fertility drugs — and not egg quality.”
Is ovarian reserve testing worth it?
If ovarian reserve testing doesn’t predict egg quality, what’s the use of the test, then?
About the only thing the results can suggest is what role medical intervention can play in prolonging fertility or hastening pregnancy odds, via egg freezing or traditional IVF, respectively, said Gordon of Dominion. Meanwhile, makers of direct-to-consumer ovarian reserve tests offer an impassioned, if somewhat contradictory, rationale for their product.
“Understanding one’s ovarian reserve helps women approach potential future fertility issues proactively instead of waiting to determine those levels once they are already struggling to get pregnant naturally or with fertility treatments,” said Claire Tomkins, CEO of Future Family, a start-up company that launched in June to provide funding options for fertility patients, as well as fertility testing kits.
Yet even as her company offers a “Fertility Age Test,” Tomkins concedes that no test can authoritatively predict a woman’s odds of natural conception. “Future Family supports the notion that measuring select hormones — like FSH, AMH and E2 [estradiol] — does not offer an absolute predictor for future pregnancy,” she said.
The UNC study essentially argues that point, suggesting that women with low ovarian reserve results may prematurely come to think they’re on the verge of infertility. (On the flip side, women with more generous AMH readings may be left with a false sense of reassurance, while downplaying the multitude of other factors, such as advancing age, which can impact affect fertility odds.) Ultimately, the same old rules apply: Delaying childbirth is always a gamble, yet no test can definitively say when you’ll reach the last good egg.
That’s what makes ovarian reserve testing — taken in a vacuum — potentially dangerous, Gordon said.
“When I talk to OB-GYNs, I caution them about getting involved in this type of discussion,” he said. “It worries me that, if we start to move toward a consumer-driven testing paradigm, we’re going to have a lot of patients who don’t understand what the results mean, perhaps making bad decisions or just making themselves unhappy [without real cause].”
So if you’ve just been hit with low ovarian reserve test results — and been told you’re essentially infertile — don’t panic. Reports of your looming barren-hood may be greatly exaggerated.
And you may not need your sister’s eggs, after all.
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