Antral follicle count (AFC) is the number of antral follicles present in the ovaries and detectable by transvaginal ultrasound scan on day 2 or 3 of the period. It is commonly estimated by counting all identifiable antral follicles of 2–10 mm in diameter in both the ovaries [1]. A major technical improvement in ultrasound has been the development of three-dimensional (3D) automated follicular tracking, which can substantially decrease both intra- and inter-observer variability [2]. Antral follicle count is a good marker to predict the number of oocytes retrieved with false-positive rate of 15–20 % and can identify the expected poor, normal and high responders (Fig. 2.3).

However, there is considerable variability in agreed AFC cut-off levels used for predicting poor response. It may vary between AFC of 3 [3] and 12 [4]. A possible reason for such variability is the absence of a standardized measurement of antral follicles with different studies measuring different follicle populations 2–5, 2–9 or 5–9 mm. Most frequently reported cut-off values of AFC for prediction of poor response ranged between 5 and 7 [5]. In order to identify high responders [6], reportedly an AFC value of 16 had apparent sensitivity of 89 % and a specificity of 92 %. Other smaller prospective studies found values ranging between 9 and 14 as the most appropriate cut-off to identify hyper-responders [7, 8].

An easy-to-use algorithm to calculate the gonadotropin dose based on AFC has recently been published [9]. The nomogram calculated the gonadotropin dose based on the age of the woman, Day 3 serum FSH level and AFC. For example, in a woman aged 30 years, with a Day 3 FSH of 4 IU/l and an AFC of 16, the most appropriate gonadotropin dose is 150 IU daily.

AMH is a dimeric glycoprotein and a member of the transforming growth factor b (TGF-b) family of growth and differentiation factors. AMH is produced by granulosa cells of small growing follicles, is gonadotropin independent and remains relatively consistent in between and within the menstrual cycle. It has been shown to have inhibitory effect on primordial-to-primary follicle transition. AMH also reduces follicle sensitivity to FSH in vivo, and in vitro AMH inhibits FSH-induced pre-antral follicle growth [10]. Thus, there is clear evidence that AMH is involved in the regulation of follicle growth initiation and the threshold for FSH sensitivity. The intrafollicular concentrations of AMH in normal human antral follicles show a gradual reduction as the diameter of the follicle increases, and a sharp decline is observed around 8 mm [11]. The rapid decline in AMH expression corresponds with the selection of follicles for dominance.

Anti-Mullerian hormone was assayed previously using primarily two different assay kits that have now been replaced by a newer assay. Evaluation of AMH levels prior to COS has several clinical utilities. There is substantial evidence in literature that AMH is superior to female age in assessing the quantitative aspects of the ovarian reserve, but its value is much more limited in the prediction of ongoing pregnancy.

Circulating anti-Müllerian hormone (AMH) can predict excessive as well as poor response to ovarian stimulation. A linear relationship exists between AMH and oocyte yield. At one extreme of the response, it helps to identify women at risk of ovarian hyperstimulation syndrome (OHSS) [12]. According to NICE guidelines of in vitro fertilization, an anti-Müllerian hormone level less than or equal to 5.4 pmol/l (0.8 ng/mL) predicts a low response to ovarian hyperstimulation, while a level greater than or equal to 25.0 pmol/l (3.6 ng/mL) predicts a high response [13]. Bologna’s criteria for defining poor responders suggest AMH cut-off of 0.5–1.1 ng/ml [14]. But single value of low AMH especially in young women should not be used to deny treatment as even women with AMH concentrations at the limit of assay sensitivity have a significant chance of conception through IVF. AMH serves as a valuable tool in counselling the patient and may set the patient’s expectations appropriately particularly at the bottom end of the spectrum where only a few oocytes may be retrieved. Nelson et al. have suggested an AMH-based strategy for deciding the protocol and gonadotropin dose for stimulation [15]. Tailoring the dosage of gonadotropin administration to AMH level has been shown to reduce the incidence of excessive response and cancelled cycles.

AMH is also useful in assessing the risk of ovarian damage secondary to chemotherapy, radiotherapy and ovarian surgery. Post-treatment AMH therefore can identify young girls and women receiving cancer therapy likely to have premature menopause or require pubertal induction, distinct from others who may be able to be reassured as to the likelihood of satisfactory ovarian function later in life.

AMH has been found to have sensitivity 44–97 % and specificity 41–100 % in predicting poor response to stimulation. Most of the studies have determined that cut-off level AMH >3.6 ng/ml has sensitivity and specificity of 82 % and 76 %, respectively, for prediction of OHSS (Table 2.1)

Basal FSH levels increase on day 2, 3 or 4 of the menstrual cycle with advancing age. However, assays of FSH have significant inter- and intra-cycle variability which limit their utility. Despite its limitations, FSH is commonly used as a measure of ovarian reserve, and high values have been associated with but not necessarily predict poor response to stimulation and failure to concieve. The sensitivity of FSH in identifying poor responders varies from 10 to 80 % and decreases with increasing cut-offs. Recent study employing efficiency curves demonstrated 100 % specificity for failure to achieve live birth at levels more than 18 IU/l. A single elevated FSH level in women <40 years may not predict poor responders or failure to concieve. But clinical utility lies in being fairly certain that women with abnormally elevated FSH will have diminished reserve [16] (Table 2.2).

Advanced maternal age causes decreased success rates in ovarian hyperstimulation [17]. However, a younger woman with a raised FSH would respond better than an older woman with raised FSH. Age is one of the most important determinants of ovarian response.

All couples presenting with infertility should have had a detailed history and physical examination done, which should be reviewed prior to COS. This should usually include

The physical examination of the lady is performed to evaluate the pelvic organs and assess potential hormonal problems. It should include any thyromegaly, breast examination, signs of androgen excess, vaginal or cervical abnormality, secretions or discharge, pelvic or abdominal tenderness enlargement or masses, adenexal masses or cul-de-sac nodularity.