ASSESSMENT OF OVARIAN RESERVE. Ovarian reserve is defined as the pool of ovarian follicles that can be stimulated to produce oocytes to achieve conception. Ovarian reserve tests are divided into. 1 ) Clinical markers : age,menstrual pattern and previous cancelled cycle. 2 ) Endocrine static markers.: FSH,LH,E2,PROGESTERONE( P4 ),FSH /LH RATIO P4/E2 RATIO.,AMH,TESTOSTERONE,VASCULAR ENDOTHELIAL GROWTH FACTOR,INSULIN GROWTH FACTOR - 1. 3 ) Endocrine dynamic tests.CCST,GAST,EFORT.@ 4 )Ultrasound markers.o Varian volume,ovarian follicular vascularity and ovarian blood flow. 5 ) Histology. Ovarian biopsy. CLINICAL MARKERS 1) Age. 2) Menstrual pattern. 3) Previous failed cycle. AGE : Natural fecundity and pregnancy rates decline as age of women advances.This is due to decrease in quality and quantity of ovarian follicles. MENSTRUAL CYCLE. Menstrual cycle length is dependent on the duration of follicular phase.Shortened cycle length is associated with decreased ovarian reserve. PREVIOUS FAILED CYCLE. Previous cancelled cycle is linked to cancellation in subsequent treatment cycles. ENDOCRINE STATIC MARKERS. FSH : High FSH levels are associated with decreased ovarian reserve and poor response to gonadotrophin stimulation in ART cycles.FSH levels of >>15 IU/L is an indicator of poor ovarian response and higher chances of ART cycle cancellation. LH : Mean LH,LH amplitude and LH response to GnRH were higher in women with imminent ovarian failure. FSH / LH RATIO An increase in FSH/LH ratio ,even with normal FSH is a sign of decrease ovarian reserve. ESTRADIOL E2 : Decrease in E2 levels with increasing FSH levels is a more certain sign of decreasing ovarian reserve. INHIBIN A & B: INHIBIN are glycoproteins secreted by granulosa and theca cells of the ovarian follicle.I INHIBIN B inhibits FSH release. Inhibin B as a test of ovarian reserve is investigational. AMH : AMH is produced by granulosa cells of growing pre- antral and small antral ovarian follicles as soon as they are recruited prior to their responsiveness to FSH. Follicles secrete AMH till they are about 6 mm in size.AMH is an important clinical marker in the assessment of female infertility. AMH levels <<< 1ng / ml =poor response. AMH levels of 1 - 4 ng/ml =Normal response. AMH levels >>> 4 ng/ml =high response. ENDOCRINE DYNAMIC TESTS. CLOMIPHENE CITRATE CHALLENGE TEST (CCCT) Test involves administering 100 mg of clomiphene daily from day 5-9 of Menstrual cycle.FSH levels are measured on day 3 and day 10.DIMINISHED OVARIAN RESERVE IS DETERMINED BY DAY 10 FSH MORE THAN DAY 3 FSH. AN ELEVATED SERUM PROGESTERONE LEVEL >>1.1ng /ml ON DAY 10 OF CCCT IS ALSO PREDICTIVE OF DECREASED OVARIAN RESERVE. GONADOTROPHIN ANALOGUE STIMULATION TEST (GAST ): GAST involves sub cutaneous administration of gonadotrophin analogue leuprolide acetate on day 2 and looking at change in FSH,LH,inhibin- B,E2 concentration from day 2 to day3. EXOGENOUS FSH OVARIAN RESERVE TEST (EFORT) 300 mg of recombinant FSH is given on day 3. FSH,E2,INHIBIN - B levels are measured prior to FSH administration and 24 hours after FSH administration. ULTRASOUND MARKERS. ANTRAL FOLLICLE COUNT.(AFC) AFC is measured as follicles measuring between 2 - 10 mm between day 2 and day 5 of Menstrual cycle.L ow numbers of antral follicles are a sign of ageing. OVARIAN VOLUME : OV has little applicability in prediction of poor response. OVARIAN BLOOD FLOW Not significant. OVARIAN BIOPSY. Not recommended. FINAL WORD. FSH,LH,E2,P4,T,AMH LEVELS. ULTRASOUND -AFC. Mostly followed.