Ovarian Reserve and Antral Follicle Count: Chips in the Cookie
Who doesn’t like a good gooey, moist, chocolate-filled chocolate chip cookie? The more chips the better, says every part of your body but your tush! The same can be said for the follicles (and eggs) in your ovaries. The more, the better—at least most of the time!
A big part of a fertility assessment in Western medicine is ovarian reserve. You probably hear your fertility doctor throw this term around like it’s candy (or cookies! ): “Your ovarian reserve looks good!” “Your ovarian reserve is not so good.” You may be nodding and thinking, “What in the world are they talking about?”
Ovarian reserve is the medical way of estimating how many eggs you have in your ovaries on any given cycle. While most of a Western medical assessment comes from hormones and blood work (cue FSH and AMH), a big “bite of the cookie” comes from an ultrasound where we can get a visual on the ovaries and uterus. This ingredient is as basic as sugar and flour to making a finger-licking calorie worth its cookie.
An ultrasound performed in the early part of your menstrual cycle (a.k.a. post period until ovulation known as the “follicular phase”) can tell us a lot about what your ovaries have left to give. Is your bag of chips half full, or are you running dangerously low on supply? By measuring the follicles (a.k.a. “chocolate chips”), we can get a good idea about the egg quantity (a.k.a. ovarian reserve). We call this measurement of follicles your antral follicle count (nicknamed AFC).
An AFC is ideally done on day 2–5 of the menstrual cycle, day 1 being the first day of your period. By doing it early, we can catch you at what we like to call baseline. This “home base” is when we can get the best idea about what is going on in those ovaries because no follicles have yet to start running the bases.
Eggs are invisible (to the naked human eye). It doesn’t matter how high we crank the ultrasound waves, we will never be able to see those eggs unless we bust out our microscopes and speed-dial our embryologist friends. Eggs live in follicles, one egg per follicle. We count follicles in each ovary to find out about the number of eggs available for that cycle. Although it is an indirect measure of ovarian reserve, it is pretty on point.
We do a lot of ultrasounds. We can look at the screen and pretty quickly size up those ovaries. But a little baker’s secret for all of you laypeople—the little black circles in the ovaries are the follicles. (Anything fluid filled on an ultrasound will be black). The ovaries are usually grayish/white. So put that together, and what do you get? Bibbidi bobbidi CHEW! You probably get the visual at this point…the more follicles (number of chocolate chips) in the ovaries, the chewier they look. The chewier they are, the more eggs you have!
On the flip side (or the less tasty side), the fewer the follicles and the more white/gray ovary, the lower the antral follicle count. The lower the antral follicle count, the fewer the eggs. It’s a simple as your most basic recipe! Some of us may have chocolate chips galore while others of us are more like a sugar cookie.
Surprisingly there are some times when cookies can be just too sweet. You know when you take that first bite, and you think, hmm, I can’t go much further? Well, the same goes for ovaries. There are some with too many chips. Polycystic ovaries can have too many follicles or structures that look like follicles. There is a plethora (think many, many bags) of these small follicles/cysts that can impact the regularity with which you ovulate and your ability to make a baby on your own. It can also lead to elevated testosterone levels and cause unfavorable side effects (think excess body and facial hair and pimples).
While antral follicle count tells us a lot about what your egg number may be, it does not mean that just because your bag is a bit low, you won’t have a baby. For an IVF, it just helps us pick the right ingredients (fertility meds) in the right amount to make your cookie!
So can the AFC change? Woman are born with millions of eggs in tiny storage follicles that start to wake up around puberty, but over time the number naturally decreases with age, even if you are not ovulating or on hormonal contraceptives (aka “the pill”). When we are younger in our 20s, our ovaries are chock-full of “chocolate chips” and AFC is higher, but as we age, it decreases. Some of us at any given age bracket have more chips" than others, but as we age, this number always goes down, not up. It’s natural and healthy for this number to decline over time, but when it comes to fertility treatments like IVF, the more chips we see on the ultrasound, the more eggs we can likely retrieve turn into healthy embryos in the lab. No known treatments can increase AFC, but a recent study showed that combining acupuncture with IVF drugs resulted in more mature eggs retrieved and fertilized each cycle, which is another way of saying it doesn’t make more “chips” appear, but it helps maximize the eggs you’ve got left in them! So while we can’t change the AFC, with the write combination of Western and Eastern fertility treatments, we can make the most of them!