Antral Follicle Count Using transvaginal ultrasound in the early follicular phase, all ovarian follicles 2 to 10 mm are counted and the total for both ovaries is called the basal antral follicle count (AFC). The AFC correlates well with chronologic age in normal fertile women and appears to reﬂect what remains of the primordial follicular pool (104). Decreases in AFC with age are gradual rather than sudden (118). A total AFC less than 4 is predictive of poor response and higher cancellation rates with IVF (119,120).
Treatment of Diminished Ovarian Reserve Treatments of diminished ovarian reserve include autologous IVF, use of donor oocytes or embryos, and adoption. Pretreatment of women with diminished ovarian reserve for 4 to 5 months with dehydroepiandrosterone (DHEA; 25 mg three times daily) has been described to improve oocyte yield and pregnancy rates with IVF (121–123).
Ovulatory Factor Ovulatory factor accounts for 30% to 40% of all cases of female infertility. Initial diagnoses among women with ovulatory factor infertility may include anovulation (complete absence of ovulation) or oligo-ovulation (infrequent ovulation). Menstrual history may be suggestive if oligomenorrhea, amenorrhea, polymenorrhea, or dysfunctional uterine bleeding is present (124). Menstrual dysfunction is present in 18% to 20% of the general population (125). Figure 32.5 shows the ﬂuctuations of E2, progesterone, FSH, and LH in a normal, 28-day ovulatory cycle. The normal length of the menstrual cycle in reproductive-age women varies from 21 to 35 days, with a mean of 27 to 29 days (126). Most of the variability in cycle length occurs during the follicular phase (127), but the luteal phase, often considered to be fixed at 14 days, can range from 7 to 19 days (128). Even women with regular monthly menses may have anovulation, although the presence of moliminal symptoms such as premenstrual breast swelling, bloating, and mood changes are much more suggestive of ovulatory cycles (125).
Methods to Document Ovulation
The “Fertile Window” The fertile window is the 6 day interval ending on the day of ovulation, but not after ovulation. Sperm can survive for up to 6 days in well-estrogenized cervical mucus, but the egg may be fertilizable for less than a day. Daily intercourse during this window may increase the probability of conception (32,127). The average woman is fertile between days 10 and 17 of the menstrual cycle, but many women can conceive outside of this range (128). Therefore, if timed intercourse is too cumbersome, intercourse two to three times weekly throughout the menstrual cycle will likely result in at least some of those occasions falling within the fertile window (129). Duration of abstinence prior to the fertile window has not been established, although one author suggests 5 days (127).
Basal Body Temperature This inexpensive method involves daily recording of oral or rectal temperature using a basal body temperature (BBT) thermometer before the patient arises, eats, or drinks. The secretion of progesterone following ovulation causes a temperature increase of about 0.5 to 1◦F over the baseline temperature of 97◦F to 98.8◦F that is typically recorded during the follicular phase of the menstrual cycle. Ovulation is assumed after 3 consecutive days of raised temperatures. Charting of daily BBTs produces a characteristic biphasic pattern in women with ovulatory cycles (130). Limitations to BBT include its inability to prospectively predict ovulation and its frequent false-negative results (131). Smoking and irregular sleep patterns can interfere with accurate BBT testing (130).