Ovarian Reserve Assessment

Primary Hormonal Markers

The American Society for Reproductive Medicine recommends Anti-Müllerian hormone (AMH) as the best currently available hormonal measure of ovarian reserve, accurately reflecting the pool of growing follicles in the ovary 1, 2
AMH is produced exclusively by granulosa cells of small, growing ovarian follicles and correlates strongly with the number of antral follicles, making it a reliable indicator of ovarian reserve 1
A key advantage of AMH is that it does not vary significantly by menstrual cycle day and is not affected by exogenous estrogen or progesterone, making it convenient for testing at any time 2, 3
AMH is superior to age, basal FSH, estradiol, and inhibin B for assessing ovarian reserve in healthy women, with very low AMH levels (below 0.7 ng/mL) indicating ovarian failure or severely diminished ovarian reserve 2

The American College of Obstetricians and Gynecologists recommends AFC measured by transvaginal ultrasound as the most established method for assessing ovarian reserve, correlating well with AMH 1, 2
AFC directly visualizes the pool of small antral follicles available for recruitment, providing a comprehensive evaluation of ovarian reserve 1

The Endocrine Society suggests that FSH remains a late marker of ovarian dysfunction and is less sensitive than AMH for early detection of diminished ovarian reserve, with FSH >35 IU/L suggesting ovarian failure 3, 4
Baseline FSH and estradiol should be measured on days 3-6 of the menstrual cycle for women with regular cycles, with FSH useful for diagnosing premature ovarian insufficiency (POI) but having limited predictive value for future fertility 3, 4

For women ≥25 years with regular cycles, the American Society for Reproductive Medicine recommends AMH testing as the preferred initial assessment, with AFC added for comprehensive evaluation 1, 2, 4
For women <25 years, AMH interpretation is less reliable, and AFC by transvaginal ultrasound remains the gold standard, while for women with irregular cycles or amenorrhea, AMH is particularly useful since it does not require cycle-specific timing 2, 3, 4

The National Institute of Child Health and Human Development notes that AMH assays lack international standardization, so results should be interpreted using laboratory-specific reference ranges, and AMH reflects the "functional ovarian reserve" rather than the total primordial follicle pool 5

AMH quantitatively reflects the pool of growing ovarian follicles and may also indicate qualitative aspects of the remaining oocytes, providing a stable measure of functional ovarian reserve【6】【7】.

In assisted reproductive technology (ART) cycles, women with low AMH have a 35 % higher odds of miscarriage compared with women with higher AMH (odds ratio 1.35; 95 % CI 1.10–1.66), based on meta‑analysis evidence【6】.

The increased miscarriage risk associated with low AMH is thought to stem from reduced oocyte quality due to meiotic errors, which leads to embryonic aneuploidy and subsequent pregnancy loss【8】【7】.

AMH can be measured at any point in the menstrual cycle because serum levels do not show significant variation across cycle days, allowing convenient testing without cycle timing. 9
Exogenous estrogen or progesterone therapy does not alter AMH concentrations, whereas follicle‑stimulating hormone (FSH) requires cycle‑specific timing for accurate assessment. 9

In the general female population, AMH concentrations peak at approximately 25 years of age; low AMH values in women younger than 25 do not correlate with reduced fertility. 10
Routine AMH testing is recommended only for women ≥ 25 years, where validated age‑specific reference ranges are available; it is not advised for pre‑conception counseling in younger, fertile women. 10

Among adult and pediatric cancer survivors treated with alkylating agents and/or radiotherapy, AMH serves as a promising biomarker to predict remaining ovarian reserve and to estimate the timing of menopause onset. 9
Cancer patients typically exhibit decreased AMH levels after treatment; modest recovery of AMH may occur following exposure to low‑dose alkylating chemotherapy. 9

AMH can help identify women at heightened risk for premature ovarian insufficiency, although it is not incorporated into the formal diagnostic criteria for POI. 10
The standard diagnostic work‑up for POI relies on elevated FSH and low estradiol; however, AMH may detect early declines in functional ovarian reserve before abnormal FSH levels become apparent. 10

In women who have undergone gonadotoxic treatment, the return of regular menstrual cycles does not reliably indicate normal ovarian reserve; many such patients continue to have compromised ovarian reserve and reduced fertility potential. 11