Antral follicle count determines poor ovarian response better than anti-müllerian hormone but age is the only predictor for live birth in in vitro fertilization cycles

  • Mehmet Firat MutluEmail author
  • Mehmet Erdem
  • Ahmet Erdem
  • Sule Yildiz
  • Ilknur Mutlu
  • Ozgur Arisoy
  • Mesut Oktem



To determine the predictive value of serum anti-müllerian hormone (AMH) concentrations and antral follicle counts (AFC), on ovarian response and live birth rates after IVF and compare with age and basal FSH.


Basal levels of AMH, FSH and antral follicle count were measured in 192 patients prior to IVF treatment. The predictive value of these parameters were evaluated in terms of retrieved oocyte number and live birth rates.


Poor responders in IVF were older, had lower AFC and AMH but higher basal FSH levels. In multivariate analysis AFC was the best and only independent parameter among other parameters and AMH was better than age and basal FSH to predict poor response to ovarian stimulation. Addition of AMH, basal FSH, age and total gonadotropin dose to AFC did not improve its prognostic reliability. Area under curve (AUC) for each parameter according to ROC analysis also revealed that AFC performed better in poor response prediction compared with AMH, basal FSH and age. The cut-off point for mean AMH and AFC in discriminating the best between poor and normal ovarian response cycles was 0.94 ng/mL (with a sensitivity of 70 % and a specificity of 86 %) and 5.5 (with a sensitivity of 91 % and a specificity of 91 %), respectively. However, age was the only independent predictor of live birth in IVF as compared to hormonal and ultrasound indices of ovarian reserve.


AFC is better than AMH to predict poor ovarian response. Although AMH and AFC could be used to predict ovarian response they had limited value in live birth prediction. The only significant predictor of the probability of achieving a live birth was age.


Anti-müllerian hormone Antral follicle counts Ovarian response Live birth 



This research received funding from the Scientific Research Projects Coordination Unit of Gazi University (grant 01/2005-2).


  1. 1.
    Bancsi LF, Broekmans FJ, Eijkemans MJ, de Jong FH, Habbema JD, te Velde ER. Predictors of poor ovarian response in in vitro fertilization: a prospective study comparing basal markers of ovarian reserve. Fertil Steril. 2002;77(2):328–36.PubMedCrossRefGoogle Scholar
  2. 2.
    Bancsi LF, Broekmans FJ, Looman CW, Habbema JD, te Velde ER. Impact of repeated antral follicle counts on the prediction of poor ovarian response in women undergoing in vitro fertilization. Fertil Steril. 2004;81(1):35–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Bancsi LF, Huijs AM, den Ouden CT, Broekmans FJ, Looman CW, Blankenstein MA, et al. Basal follicle-stimulating hormone levels are of limited value in predicting ongoing pregnancy rates after in vitro fertilization. Fertil Steril. 2000;73(3):552–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Barad DH, Weghofer A, Gleicher N. Comparing anti-Mullerian hormone (AMH) and follicle-stimulating hormone (FSH) as predictors of ovarian function. Fertil Steril. 2009;91(4 Suppl):1553–5. doi: 10.1016/j.fertnstert.2008.09.069.PubMedCrossRefGoogle Scholar
  5. 5.
    Bersinger NA, Wunder D, Birkhauser MH, Guibourdenche J. Measurement of anti-mullerian hormone by Beckman Coulter ELISA and DSL ELISA in assisted reproduction: differences between serum and follicular fluid. Clin Chim Acta Int J Clin Chem. 2007;384(1–2):174–5. doi: 10.1016/j.cca.2007.05.011.CrossRefGoogle Scholar
  6. 6.
    Boomsma CM, Macklon NS. What can the clinician do to improve implantation? Reprod Biomed Online. 2007;14(Spec No 1):27–37. doi: 10.1016/S1472-6483(10)61456-3.PubMedGoogle Scholar
  7. 7.
    Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Updat. 2006;12(6):685–718. doi: 10.1093/humupd/dml034.CrossRefGoogle Scholar
  8. 8.
    Broer SL, Mol BW, Hendriks D, Broekmans FJ. The role of antimullerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. Fertil Steril. 2009;91(3):705–14. doi: 10.1016/j.fertnstert.2007.12.013.PubMedCrossRefGoogle Scholar
  9. 9.
    Broer SL, van Disseldorp J, Broeze KA, Dolleman M, Opmeer BC, Bossuyt P, et al. Added value of ovarian reserve testing on patient characteristics in the prediction of ovarian response and ongoing pregnancy: an individual patient data approach. Hum Reprod Updat. 2013;19(1):26–36. doi: 10.1093/humupd/dms041.CrossRefGoogle Scholar
  10. 10.
    Bukman A, Heineman MJ. Ovarian reserve testing and the use of prognostic models in patients with subfertility. Hum Reprod Updat. 2001;7(6):581–90.CrossRefGoogle Scholar
  11. 11.
    Buyuk E, Seifer DB, Younger J, Grazi RV, Lieman H. Random anti-Mullerian hormone (AMH) is a predictor of ovarian response in women with elevated baseline early follicular follicle-stimulating hormone levels. Fertil Steril. 2011;95(7):2369–72. doi: 10.1016/j.fertnstert.2011.03.071.PubMedCrossRefGoogle Scholar
  12. 12.
    Chang MY, Chiang CH, Hsieh TT, Soong YK, Hsu KH. Use of the antral follicle count to predict the outcome of assisted reproductive technologies. Fertil Steril. 1998;69(3):505–10.PubMedCrossRefGoogle Scholar
  13. 13.
    Durlinger AL, Kramer P, Karels B, de Jong FH, Uilenbroek JT, Grootegoed JA, et al. Control of primordial follicle recruitment by anti-Mullerian hormone in the mouse ovary. Endocrinology. 1999;140(12):5789–96.PubMedCrossRefGoogle Scholar
  14. 14.
    Durmusoglu F, Elter K, Yoruk P, Erenus M. Combining cycle day 7 follicle count with the basal antral follicle count improves the prediction of ovarian response. Fertil Steril. 2004;81(4):1073–8. doi: 10.1016/j.fertnstert.2003.08.044.PubMedCrossRefGoogle Scholar
  15. 15.
    Ebner T, Sommergruber M, Moser M, Shebl O, Schreier-Lechner E, Tews G. Basal level of anti-Mullerian hormone is associated with oocyte quality in stimulated cycles. Hum Reprod. 2006;21(8):2022–6. doi: 10.1093/humrep/del127.PubMedCrossRefGoogle Scholar
  16. 16.
    Eldar-Geva T, Ben-Chetrit A, Spitz IM, Rabinowitz R, Markowitz E, Mimoni T, et al. Dynamic assays of inhibin B, anti-Mullerian hormone and estradiol following FSH stimulation and ovarian ultrasonography as predictors of IVF outcome. Hum Reprod. 2005;20(11):3178–83. doi: 10.1093/humrep/dei203.PubMedCrossRefGoogle Scholar
  17. 17.
    Elgindy EA, El-Haieg DO, El-Sebaey A. Anti-Mullerian hormone: correlation of early follicular, ovulatory and midluteal levels with ovarian response and cycle outcome in intracytoplasmic sperm injection patients. Fertil Steril. 2008;89(6):1670–6. doi: 10.1016/j.fertnstert.2007.05.040.PubMedCrossRefGoogle Scholar
  18. 18.
    Faddy MJ, Gosden RG, Gougeon A, Richardson SJ, Nelson JF. Accelerated disappearance of ovarian follicles in mid-life: implications for forecasting menopause. Hum Reprod. 1992;7(10):1342–6.PubMedGoogle Scholar
  19. 19.
    Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L. ESHRE consensus on the definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod. 2011;26(7):1616–24. doi: 10.1093/humrep/der092.PubMedCrossRefGoogle Scholar
  20. 20.
    Ficicioglu C, Kutlu T, Baglam E, Bakacak Z. Early follicular antimullerian hormone as an indicator of ovarian reserve. Fertil Steril. 2006;85(3):592–6. doi: 10.1016/j.fertnstert.2005.09.019.PubMedCrossRefGoogle Scholar
  21. 21.
    Frattarelli JL, Lauria-Costab DF, Miller BT, Bergh PA, Scott RT. Basal antral follicle number and mean ovarian diameter predict cycle cancellation and ovarian responsiveness in assisted reproductive technology cycles. Fertil Steril. 2000;74(3):512–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Frattarelli JL, Levi AJ, Miller BT, Segars JH. A prospective assessment of the predictive value of basal antral follicles in in vitro fertilization cycles. Fertil Steril. 2003;80(2):350–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Freour T, Mirallie S, Bach-Ngohou K, Denis M, Barriere P, Masson D. Measurement of serum anti-Mullerian hormone by Beckman Coulter ELISA and DSL ELISA: comparison and relevance in assisted reproduction technology (ART). Clin Chim Acta Int J Clin Chem. 2007;375(1–2):162–4. doi: 10.1016/j.cca.2006.06.013.CrossRefGoogle Scholar
  24. 24.
    Gleicher N, Weghofer A, Barad DH. Anti-Mullerian hormone (AMH) defines, independent of age, low versus good live-birth chances in women with severely diminished ovarian reserve. Fertil Steril. 2010;94(7):2824–7. doi: 10.1016/j.fertnstert.2010.04.067.PubMedCrossRefGoogle Scholar
  25. 25.
    Gnoth C, Schuring AN, Friol K, Tigges J, Mallmann P, Godehardt E. Relevance of anti-Mullerian hormone measurement in a routine IVF program. Hum Reprod. 2008;23(6):1359–65. doi: 10.1093/humrep/den108.PubMedCrossRefGoogle Scholar
  26. 26.
    Hehenkamp WJ, Looman CW, Themmen AP, de Jong FH, Te Velde ER, Broekmans FJ. Anti-Mullerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation. J Clin Endocrinol Metab. 2006;91(10):4057–63. doi: 10.1210/jc.2006-0331.PubMedCrossRefGoogle Scholar
  27. 27.
    Hsieh YY, Chang CC, Tsai HD. Antral follicle counting in predicting the retrieved oocyte number after ovarian hyperstimulation. J Assist Reprod Genet. 2001;18(6):320–4.PubMedCrossRefGoogle Scholar
  28. 28.
    Jayaprakasan K, Campbell B, Hopkisson J, Johnson I, Raine-Fenning N. A prospective, comparative analysis of anti-Mullerian hormone, inhibin-B, and three-dimensional ultrasound determinants of ovarian reserve in the prediction of poor response to controlled ovarian stimulation. Fertil Steril. 2010;93(3):855–64. doi: 10.1016/j.fertnstert.2008.10.042.PubMedCrossRefGoogle Scholar
  29. 29.
    Klinkert ER, Broekmans FJ, Looman CW, Habbema JD, te Velde ER. The antral follicle count is a better marker than basal follicle-stimulating hormone for the selection of older patients with acceptable pregnancy prospects after in vitro fertilization. Fertil Steril. 2005;83(3):811–4. doi: 10.1016/j.fertnstert.2004.11.005.PubMedCrossRefGoogle Scholar
  30. 30.
    Klinkert ER, Broekmans FJ, Looman CW, Te Velde ER. A poor response in the first in vitro fertilization cycle is not necessarily related to a poor prognosis in subsequent cycles. Fertil Steril. 2004;81(5):1247–53. doi: 10.1016/j.fertnstert.2003.10.030.PubMedCrossRefGoogle Scholar
  31. 31.
    Kupesic S, Kurjak A, Bjelos D, Vujisic S. Three-dimensional ultrasonographic ovarian measurements and in vitro fertilization outcome are related to age. Fertil Steril. 2003;79(1):190–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Kwee J, Schats R, McDonnell J, Themmen A, de Jong F, Lambalk C. Evaluation of anti-Mullerian hormone as a test for the prediction of ovarian reserve. Fertil Steril. 2008;90(3):737–43. doi: 10.1016/j.fertnstert.2007.07.1293.PubMedCrossRefGoogle Scholar
  33. 33.
    La Marca A, Giulini S, Tirelli A, Bertucci E, Marsella T, Xella S, et al. Anti-Mullerian hormone measurement on any day of the menstrual cycle strongly predicts ovarian response in assisted reproductive technology. Hum Reprod. 2007;22(3):766–71. doi: 10.1093/humrep/del421.PubMedCrossRefGoogle Scholar
  34. 34.
    La Marca A, Nelson SM, Sighinolfi G, Manno M, Baraldi E, Roli L, et al. Anti-Mullerian hormone-based prediction model for a live birth in assisted reproduction. Reprod Biomed Online. 2011;22(4):341–9. doi: 10.1016/j.rbmo.2010.11.005.PubMedCrossRefGoogle Scholar
  35. 35.
    La Marca A, Sighinolfi G, Radi D, Argento C, Baraldi E, Artenisio AC, et al. Anti-Mullerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum Reprod Updat. 2010;16(2):113–30. doi: 10.1093/humupd/dmp036.CrossRefGoogle Scholar
  36. 36.
    La Marca A, Stabile G, Artenisio AC, Volpe A. Serum anti-Mullerian hormone throughout the human menstrual cycle. Hum Reprod. 2006;21(12):3103–7. doi: 10.1093/humrep/del291.PubMedCrossRefGoogle Scholar
  37. 37.
    Lashen H, Ledger W, Lopez-Bernal A, Barlow D. Poor responders to ovulation induction: is proceeding to in-vitro fertilization worthwhile? Hum Reprod. 1999;14(4):964–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Lass A, Gerrard A, Abusheikha N, Akagbosu F, Brinsden P. IVF performance of women who have fluctuating early follicular FSH levels. J Assist Reprod Genet. 2000;17(10):566–73.PubMedCrossRefGoogle Scholar
  39. 39.
    Lee TH, Liu CH, Huang CC, Hsieh KC, Lin PM, Lee MS. Impact of female age and male infertility on ovarian reserve markers to predict outcome of assisted reproduction technology cycles. Reprod Biol Endocrinol. 2009;7:100. doi: 10.1186/1477-7827-7-100.PubMedCrossRefGoogle Scholar
  40. 40.
    Lekamge DN, Barry M, Kolo M, Lane M, Gilchrist RB, Tremellen KP. Anti-Mullerian hormone as a predictor of IVF outcome. Reprod Biomed Online. 2007;14(5):602–10.PubMedCrossRefGoogle Scholar
  41. 41.
    McIlveen M, Skull JD, Ledger WL. Evaluation of the utility of multiple endocrine and ultrasound measures of ovarian reserve in the prediction of cycle cancellation in a high-risk IVF population. Hum Reprod. 2007;22(3):778–85. doi: 10.1093/humrep/del435.PubMedCrossRefGoogle Scholar
  42. 42.
    Muttukrishna S, McGarrigle H, Wakim R, Khadum I, Ranieri DM, Serhal P. Antral follicle count, anti-mullerian hormone and inhibin B: predictors of ovarian response in assisted reproductive technology? BJOG Int J Obstet Gynaecol. 2005;112(10):1384–90. doi: 10.1111/j.1471-0528.2005.00670.x.CrossRefGoogle Scholar
  43. 43.
    Nahum R, Shifren JL, Chang Y, Leykin L, Isaacson K, Toth TL. Antral follicle assessment as a tool for predicting outcome in IVF–is it a better predictor than age and FSH? J Assist Reprod Genet. 2001;18(3):151–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Nakhuda GS, Sauer MV, Wang JG, Ferin M, Lobo RA. Mullerian inhibiting substance is an accurate marker of ovarian response in women of advanced reproductive age undergoing IVF. Reprod Biomed Online. 2007;14(4):450–4.PubMedCrossRefGoogle Scholar
  45. 45.
    Nardo LG, Gelbaya TA, Wilkinson H, Roberts SA, Yates A, Pemberton P, et al. Circulating basal anti-Mullerian hormone levels as predictor of ovarian response in women undergoing ovarian stimulation for in vitro fertilization. Fertil Steril. 2009;92(5):1586–93. doi: 10.1016/j.fertnstert.2008.08.127.PubMedCrossRefGoogle Scholar
  46. 46.
    Nelson SM, Yates RW, Fleming R. Serum anti-Mullerian hormone and FSH: prediction of live birth and extremes of response in stimulated cycles–implications for individualization of therapy. Hum Reprod. 2007;22(9):2414–21. doi: 10.1093/humrep/dem204.PubMedCrossRefGoogle Scholar
  47. 47.
    Ng EH, Tang OS, Ho PC. The significance of the number of antral follicles prior to stimulation in predicting ovarian responses in an IVF programme. Hum Reprod. 2000;15(9):1937–42.PubMedCrossRefGoogle Scholar
  48. 48.
    Ocal P, Sahmay S, Cetin M, Irez T, Guralp O, Cepni I. Serum anti-Mullerian hormone and antral follicle count as predictive markers of OHSS in ART cycles. J Assist Reprod Genet. 2011;28(12):1197–203. doi: 10.1007/s10815-011-9627-4.PubMedCrossRefGoogle Scholar
  49. 49.
    Pache TD, Wladimiroff JW, de Jong FH, Hop WC, Fauser BC. Growth patterns of nondominant ovarian follicles during the normal menstrual cycle. Fertil Steril. 1990;54(4):638–42.PubMedGoogle Scholar
  50. 50.
    Penarrubia J, Fabregues F, Manau D, Creus M, Casals G, Casamitjana R, et al. Basal and stimulation day 5 anti-Mullerian hormone serum concentrations as predictors of ovarian response and pregnancy in assisted reproductive technology cycles stimulated with gonadotropin-releasing hormone agonist--gonadotropin treatmen. Hum Reprod. 2005;20(4):915–22. doi: 10.1093/humrep/deh718.PubMedCrossRefGoogle Scholar
  51. 51.
    Riggs RM, Duran EH, Baker MW, Kimble TD, Hobeika E, Yin L, et al. Assessment of ovarian reserve with anti-Mullerian hormone: a comparison of the predictive value of anti-Mullerian hormone, follicle-stimulating hormone, inhibin B, and age. Am J Obstet Gynecol. 2008;199(2):202. doi: 10.1016/j.ajog.2008.05.004. e201-208.PubMedCrossRefGoogle Scholar
  52. 52.
    Scheffer GJ, Broekmans FJ, Bancsi LF, Habbema JD, Looman CW, Te Velde ER. Quantitative transvaginal two- and three-dimensional sonography of the ovaries: reproducibility of antral follicle counts. Ultrasound Obstet Gynecol. 2002;20(3):270–5. doi: 10.1046/j.1469-0705.2002.00787.x.PubMedCrossRefGoogle Scholar
  53. 53.
    Scheffer GJ, Broekmans FJ, Dorland M, Habbema JD, Looman CW, te Velde ER. Antral follicle counts by transvaginal ultrasonography are related to age in women with proven natural fertility. Fertil Steril. 1999;72(5):845–51.PubMedCrossRefGoogle Scholar
  54. 54.
    Scott Jr RT, Hofmann GE, Oehninger S, Muasher SJ. Intercycle variability of day 3 follicle-stimulating hormone levels and its effect on stimulation quality in in vitro fertilization. Fertil Steril. 1990;54(2):297–302.PubMedGoogle Scholar
  55. 55.
    Seifer DB, Lambert-Messerlian G, Hogan JW, Gardiner AC, Blazar AS, Berk CA. Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome. Fertil Steril. 1997;67(1):110–4.PubMedCrossRefGoogle Scholar
  56. 56.
    Seifer DB, Scott Jr RT, Bergh PA, Abrogast LK, Friedman CI, Mack CK, et al. Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone. Fertil Steril. 1999;72(1):63–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Smeenk JM, Sweep FC, Zielhuis GA, Kremer JA, Thomas CM, Braat DD. Antimullerian hormone predicts ovarian responsiveness, but not embryo quality or pregnancy, after in vitro fertilization or intracyoplasmic sperm injection. Fertil Steril. 2007;87(1):223–6. doi: 10.1016/j.fertnstert.2006.06.019.PubMedCrossRefGoogle Scholar
  58. 58.
    Soldevila PN, Carreras O, Tur R, Coroleu B, Barri PN. Sonographic assessment of ovarian reserve. Its correlation with outcome of in vitro fertilization cycles. Gynecol Endocrinol Off J Int Soc Gynecol Endocrinol. 2007;23(4):206–12. doi: 10.1080/09513590701253776.CrossRefGoogle Scholar
  59. 59.
    Tremellen KP, Kolo M, Gilmore A, Lekamge DN. Anti-mullerian hormone as a marker of ovarian reserve. Aust N Z J Obstet Gynaecol. 2005;45(1):20–4. doi: 10.1111/j.1479-828X.2005.00332.x.PubMedCrossRefGoogle Scholar
  60. 60.
    Tsepelidis S, Devreker F, Demeestere I, Flahaut A, Gervy C, Englert Y. Stable serum levels of anti-Mullerian hormone during the menstrual cycle: a prospective study in normo-ovulatory women. Hum Reprod. 2007;22(7):1837–40. doi: 10.1093/humrep/dem101.PubMedCrossRefGoogle Scholar
  61. 61.
    van Disseldorp J, Eijkemans MJ, Klinkert ER, te Velde ER, Fauser BC, Broekmans FJ. Cumulative live birth rates following IVF in 41- to 43-year-old women presenting with favourable ovarian reserve characteristics. Reprod Biomed Online. 2007;14(4):455–63.PubMedCrossRefGoogle Scholar
  62. 62.
    van Rooij IA, Broekmans FJ, te Velde ER, Fauser BC, Bancsi LF, de Jong FH, et al. Serum anti-Mullerian hormone levels: a novel measure of ovarian reserve. Hum Reprod. 2002;17(12):3065–71.PubMedCrossRefGoogle Scholar
  63. 63.
    Weenen C, Laven JS, Von Bergh AR, Cranfield M, Groome NP, Visser JA, et al. Anti-Mullerian hormone expression pattern in the human ovary: potential implications for initial and cyclic follicle recruitment. Mol Hum Reprod. 2004;10(2):77–83.PubMedCrossRefGoogle Scholar
  64. 64.
    Yong PY, Baird DT, Thong KJ, McNeilly AS, Anderson RA. Prospective analysis of the relationships between the ovarian follicle cohort and basal FSH concentration, the inhibin response to exogenous FSH and ovarian follicle number at different stages of the normal menstrual cycle and after pituitary down-regulation. Hum Reprod. 2003;18(1):35–44.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Mehmet Firat Mutlu
    • 1
    • 4
    Email author
  • Mehmet Erdem
    • 1
  • Ahmet Erdem
    • 1
  • Sule Yildiz
    • 1
  • Ilknur Mutlu
    • 2
  • Ozgur Arisoy
    • 3
  • Mesut Oktem
    • 1
  1. 1.Department of Obstetrics & GynecologyGazi University Faculty of MedicineAnkaraTurkey
  2. 2.Department of Obstetrics & GynecologyElazig Training and Research HospitalElazigTurkey
  3. 3.Department of Obstetrics & GynecologySoke State HospitalAydınTurkey
  4. 4.AnkaraTurkey

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