China's Ovarian Reserve Assessment Technology: AMH Combined with Ultrasound Antral Follicle Count is the Mainstream Method

====== Beginning of Content ======

📋 Real Consultation Process · Reproductive Center Records

In reproductive center outpatient clinics, ovarian reserve assessment is the most common first step for women preparing for pregnancy. Regardless of age, doctors typically prescribe a fixed set of tests after the initial consultation: a transvaginal ultrasound on days 2–4 of the menstrual cycle + fasting blood draw for AMH, FSH, LH, and E2. This combination is standard procedure in almost all reproductive centers in China, aiming to understand the number of "available follicles" remaining in the ovaries in the shortest possible time.

This article, based on actual clinical pathways in domestic reproductive centers, outlines the current mainstream ovarian reserve assessment technologies, indicator interpretation methods, and management approaches for different situations. The content is for reference for those preparing for pregnancy and medical professionals and does not constitute individual treatment advice.

====== H2: Common Technical Methods ======

1. Common Technical Methods for Ovarian Reserve Assessment

Chinese reproductive centers currently routinely use three main techniques for ovarian reserve assessment: AMH serum testing, ultrasound antral follicle count (AFC), and basal endocrine hormone testing. Each method has its own focus, and they are typically used in combination clinically, without relying on any single indicator alone.

1. AMH Serum Testing

Anti-Müllerian Hormone (AMH) is secreted by the granulosa cells of small antral follicles (2–6 mm in diameter) in the ovaries. It is currently recognized as the most stable and convenient marker of ovarian reserve. Its advantages include:

• Not affected by the menstrual cycle — blood can be drawn at any time, no need to wait for a specific day.
• Not affected by hormonal medications — can still be tested during contraceptive pill use or hormonal regulation.
• Reflects the total ovarian "stock" — AMH levels are positively correlated with the number of primordial follicles in the ovaries.

Most tertiary hospitals and reproductive centers in China can order the AMH test. Results are usually available within 1–3 working days, costing between 200–400 RMB (varies slightly by region).

2. Ultrasound Antral Follicle Count (AFC)

Counting the number of antral follicles (2–10 mm in diameter) in both ovaries via transvaginal ultrasound is an imaging method to directly observe ovarian reserve. AFC should be performed on days 2–4 of the menstrual cycle, when follicles are in their basal state, yielding the most accurate results.

Domestic reproductive centers typically use AFC in conjunction with AMH: if AMH is low but AFC is normal, the doctor tends to rely on AFC; and vice versa. Combining both is more reliable than a single indicator.

• AFC > 12 (total for both ovaries) — Normal ovarian reserve
• AFC 6–12 — Mildly diminished reserve
• AFC < 6 — Significantly reduced reserve

3. Basal Endocrine Hormone Testing

Drawing blood on days 2–4 of the menstrual cycle to check FSH, LH, and E2 is a traditional method for ovarian reserve assessment. Among these, FSH level is the most commonly used reference indicator:

• FSH < 8 IU/L — Normal ovarian reserve response
• FSH 8–12 IU/L — Mildly diminished reserve, requires attention
• FSH > 12 IU/L — Significantly reduced reserve, suggesting possible poor ovarian response
• FSH > 25 IU/L — Reaches the range of premature ovarian failure (needs to be combined with age and FSH re-testing)

The limitation of basal FSH is that it is significantly affected by the menstrual cycle and hormonal medications, and a single elevation does not necessarily indicate permanent decline. Doctors usually require a repeat test for confirmation.

====== H2: Differences by Age Group ======

2. Differences in Evaluation Criteria by Age Group

Ovarian reserve assessment does not have a one-size-fits-all normal value; it must be interpreted in the context of age. The same indicator has completely different meanings for a 25-year-old woman and a 40-year-old woman.

Age Group	AMH (ng/mL)	AFC (Both Ovaries)	Basal FSH (IU/L)	Clinical Interpretation
25–30 years	2.5–6.8	≥12	<8	Normal reserve, suitable for conventional ovulation induction protocols
31–35 years	1.8–4.5	8–15	<9	Possibly mildly diminished reserve, requires individualized protocol
36–40 years	0.8–3.0	5–12	<11	Significantly diminished reserve, active fertility planning recommended
41–45 years	0.2–1.2	3–8	<15	Markedly reduced reserve, may require luteal phase protocol or mild stimulation
>45 years	<0.5	<5	Usually >12	Very low natural pregnancy rate, early consultation with reproductive center advised

It should be noted that the above table represents commonly used reference ranges in domestic reproductive centers. Specific judgments still need to be made in conjunction with personal menstrual history, previous ovulation induction response, ovarian surgery history, etc.

====== H2: Clinical Evaluation Process ======

3. Clinical Evaluation Process: From Initial Diagnosis to Protocol Formulation

Step 1: Initial Consultation

The doctor will ask about age, menstrual cycle regularity, previous pregnancy history, ovarian surgery history, history of radiotherapy/chemotherapy, family history of early menopause, etc. This background information is very important for assessing ovarian reserve status.

Step 2: Ordering Tests

Standard test combination:

• Menstrual cycle days 2–4: Transvaginal ultrasound (AFC + ovarian volume + endometrium)
• Same-day fasting blood draw: AMH, FSH, LH, E2, PRL, T (thyroid function and vitamin D checked if necessary)

Step 3: Result Interpretation and Protocol Discussion

Test results are usually all available within 1–3 days. The doctor will comprehensively assess the ovarian reserve grade based on the three indicators and provide corresponding fertility recommendations:

• Normal reserve → Conventional ovulation induction protocol, proceed with the cycle as planned.
• Mildly diminished reserve → Appropriately increase the dose of ovulation induction medication, or consider a mild stimulation protocol.
• Significantly reduced reserve → Recommend luteal phase stimulation, mild stimulation, or natural cycle egg retrieval, and advise prompt fertility planning.
• Reaches criteria for premature ovarian failure → Recommend genetic counseling, cardiac function and bone density tests, and discuss alternative options such as egg donation.

====== H2: Most Easily Overlooked Details ======

4. Most Easily Overlooked Details

In clinical work, several details are often overlooked by patients but significantly impact the assessment results:

• AMH testing does not require fasting, but it is best to use the same laboratory — Results from different kits can vary; re-testing at the same institution provides better comparability.
• AFC count is influenced by operator experience — It is recommended to have it done by an experienced ultrasound doctor at a正规 reproductive center; counting errors of 2–3 follicles may exist between different operators.
• Don't over-anxious about a single elevated basal FSH — Stress, late nights, and recent hormonal medications can cause a transient FSH elevation. Doctors usually require a repeat test in the next menstrual cycle for confirmation.
• AMH does not fully equate to "egg quality" — AMH reflects the quantity of follicles, not the chromosomal normality rate of eggs. Age is the core factor affecting egg quality.

====== H2: Management of Special Situations ======

5. Management of Special Situations

1. Premature Ovarian Failure (POF)

Persistent FSH > 25 IU/L, AMH < 0.2 ng/mL, and amenorrhea or oligomenorrhea before age 40 can be clinically diagnosed as premature ovarian failure. These patients require:

• Complete chromosomal karyotype analysis (to rule out Turner syndrome, etc.)
• Test thyroid function and autoimmune antibodies
• Bone density test and cardiovascular risk assessment
• Discuss hormone replacement therapy (HRT) and fertility alternative options

2. Polycystic Ovary Syndrome (PCOS)

PCOS patients typically have high AMH (often > 5.0 ng/mL) and high AFC (> 12 per ovary), but this does not mean "good reserve." Follicle development disorders in PCOS patients lead to a reduction in mature follicles, and they are prone to Ovarian Hyperstimulation Syndrome (OHSS) during ovulation induction, requiring the doctor to formulate a meticulous stimulation protocol.

3. History of Ovarian Surgery (e.g., Chocolate Cysts, Teratomas)

Procedures like ovarian cystectomy or salpingectomy may damage normal ovarian tissue, leading to decreased AMH and AFC. Postoperative assessment should be performed at least 3 months after surgery, when ovarian blood supply and function have stabilized. If postoperative AMH is more than 50% lower than peers of the same age, early fertility planning or consideration of egg freezing is recommended.

4. Ovarian Function Protection After Radiotherapy/Chemotherapy

For young women requiring radiotherapy or chemotherapy, AMH testing should be completed before treatment, and options for egg freezing or ovarian tissue cryopreservation should be discussed. AMH drops sharply after chemotherapy. Some patients may experience partial recovery 6–12 months after chemotherapy ends, but the degree of recovery varies individually.

====== H2: Frequently Asked Questions ======

6. Frequently Asked Questions

Q1: Does low AMH mean I cannot get pregnant?

Not necessarily. AMH reflects the quantity of follicles, not egg quality. Young women, even with low AMH, still have a chance of natural pregnancy or success through assisted reproduction as long as follicles are developing. The main impact of low AMH is a lower number of eggs retrieved during ovulation induction, but it does not mean there is no chance.

Q2: Which is more accurate, antral follicle count or AMH?

Both have their advantages. AMH is more stable and not affected by the operator; AFC is more intuitive and allows direct visualization of follicle morphology. The current standard practice in domestic reproductive centers is to use both in combination. If there is a discrepancy (e.g., low AMH but normal AFC), the doctor will make a comprehensive judgment based on age and previous ovulation induction response.

Q3: My FSH was 15 on day 3 of my period. Is this premature ovarian failure?

A single FSH of 15 IU/L cannot directly diagnose premature ovarian failure. The doctor will request a repeat test of FSH, AMH, and AFC in the next menstrual cycle. Only if FSH remains persistently > 12 IU/L and AMH is low after re-testing is diminished ovarian reserve considered. Transient FSH elevation is common in women under 35, so there is no need to be overly anxious.

Q4: Do I need to fast for the AMH test? Can blood be drawn at any time?

Fasting is not required for the AMH test, and it is not affected by the menstrual cycle; blood can be drawn at any time. However, to minimize errors, it is recommended to have follow-up tests at the same medical institution and on the same testing machine for comparison.

Q5: I am 35 years old with an AMH of 1.2 ng/mL. Can I still get pregnant naturally?

An AMH of 1.2 ng/mL at age 35 indicates mildly diminished reserve, but natural pregnancy is still possible. If your periods are regular, fallopian tubes are open, and partner's semen analysis is normal, you can try to conceive naturally for 3–6 months. If unsuccessful, it is advisable to seek evaluation at a reproductive center early and consider assisted reproductive intervention if necessary.

====== H2: How Doctors View It ======

7. How Doctors View Ovarian Reserve Assessment

In clinical work, doctors do not draw conclusions based on a single indicator. AMH, AFC, basal FSH, age, menstrual cycle pattern, medical history, etc., need to be considered together for a comprehensive judgment. Here are some real observations from reproductive doctors:

• "For patients with low AMH, we focus more on their egg quality rather than quantity." — By adjusting the ovulation induction protocol and improving the follicular development environment, usable embryos may still be obtained.
• "Don't give up on trying to conceive because of one high FSH." — We have seen many cases in clinical practice where FSH transiently elevated and then naturally recovered; re-testing is important.
• "The significance of ovarian reserve assessment is to help patients establish a sense of time." — For those with diminished reserve, clearly informing them "not to wait indefinitely" helps them make timely decisions.
• "AFC can sometimes better reflect the ovary's responsiveness to ovulation induction drugs than AMH." — In choosing an ovulation induction protocol, the reference value of AFC can sometimes be even higher than that of AMH.

====== H2: Why Does Ovarian Reserve Decline ======

8. Why Does Ovarian Reserve Decline

The core reason for declining ovarian reserve is the natural depletion of the follicular pool. The number of follicles in a woman's lifetime peaks during the fetal period (about 6–7 million), decreases to about 1–2 million at birth, leaves about 300,000–400,000 at puberty, accelerates after age 35, and drops to fewer than 1,000 by menopause.

In addition to natural aging, the following factors can accelerate follicular depletion:

• Genetic factors — FMR1 gene premutation, Turner syndrome, etc.
• Iatrogenic damage — Ovarian surgery, radiotherapy, chemotherapy
• Autoimmune diseases — Autoimmune oophoritis
• Environmental toxins and smoking — The average age of menopause for smokers is 1–2 years earlier.
• Idiopathic premature ovarian failure — Unknown cause, possibly related to genetic polymorphisms.

It is important to note that regular menstruation does not mean normal ovarian reserve. Some women with diminished ovarian reserve still have regular periods in the early stages, and menstrual changes only appear when the reserve is depleted to a certain extent. Therefore, for those with fertility plans, having an ovarian reserve assessment in advance is meaningful.

====== Conclusion: Doctor's Advice ======

9. Doctor's Advice

If you are currently trying to conceive, or planning to conceive within the next 1–2 years, consider having an ovarian reserve assessment, especially for the following groups:

• Age ≥ 35 years
• History of ovarian surgery (chocolate cysts, teratomas, ectopic pregnancy, etc.)
• History of radiotherapy or chemotherapy
• Family history of early menopause (mother or sister who reached menopause before age 40–45)
• Menstrual cycle shortened to less than 25 days or lengthened to more than 35 days
• Unsuccessful attempts to conceive for more than 6 months

If the assessment reveals diminished reserve, do not panic. Modern assisted reproductive technology offers various strategies: mild stimulation, luteal phase stimulation, egg freezing, embryo freezing, etc. The key is to know your reserve status early so you can make the best time plan for yourself.

Ovarian Reserve Assessment AMH Antral Follicle Count FSH Fertility Assessment Reproductive Center Ovarian Function Anti-Müllerian Hormone

Content Source: Clinical Practice in Domestic Reproductive Centers · Knowledge Base Version V2.3