••• Chapter 54^ Infertility^543
❍ What are the screening tests for DOR?
(1) Anti-Müllerian hormone (AMH)—a promising screening test, low levels are associated with poor response to
ovarian stimulation; however, threshold values have not yet been determined to be used confidently in clinical
practice.
(2) Antral follicle count (AFC)—2 to 10-mm follicles are counted in both ovaries on TVUS, this is an indirect
measure of ovarian reserve because as the number of small antral follicles decreases, the supply of primordial
follicles decreases.
(a) AFC correlates well with oocyte yield in IVF cycles, a threshold of 3 to 4 has high specificity for poor
response to ovarian stimulation.
(3) Inhibin B concentrations and ovarian volume have limited clinical utility as ovarian reserve tests.
(4) Basal FSH concentration on days 2 to 4 of the cycle is the simplest and most widely used test of ovarian
reserve, levels >10 IU/L had high specificity for poor response to IVF, levels >18 are 100% specific for failure.
(b) Sometimes increased estradiol levels suppress FSH in patients with DOR, if the estradiol is >60 to
80 pg/mL, the FSH may be normal, and if both estradiol and FSH are elevated, there is poor prognosis
for success with IVF.
(c) Measuring a stimulated FSH level on day 10 of the cycle using CC 100 mg po qd from day 5 through
day 9 of the cycle has increased sensitivity but decreased specificity for DOR compared with a basal FSH
concentration.
❍ Can testing be combined for higher detection rates for DOR?
No. Use the tests individually because combining various tests does not result in higher detection rates for poor
performance.
Cervical Factors
❍ How does estrogen affect cervical mucus?
As estrogen increases, cervical mucus becomes more copious and watery allowing sperm to penetrate.
❍ How does progesterone affect cervical mucus?
Progesterone inhibits production causing mucus to become more viscous.
❍ Is there a role for postcoital testing to look for cervical factor infertility?
No longer recommended!
❍ Which uterine abnormalities affect fertility and also affect pregnancy outcomes?
(1) Submucosal leiomyoma—Can distort anatomy interfering with sperm and egg transport, can affect
implantation causing glandular atrophy overlying myoma from mechanical pressure, causes threefold increased
risk of miscarriage and may decrease IVF success by up to 70%.
(2) Intramural leiomyoma—Decreases IVF success by 30%, myomectomy should be considered in women who
fail IVF treatment.
(3) Subserosal fibroids have no effect on fertility.
(4) Asherman syndrome—Any insult that causes destruction or removal of the endometrium can result in
adhesions, endometrium most fragile between 2 and 4 weeks postpartum, 90% of adhesions due to curettage,
in developing countries, genital tuberculosis (TB) causes adhesions.
(5) Polypectomy may improve reproductive performance in infertile women.