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Tan Xiaojun
·Senior reproductive medicine expert
·Postdoctoral fellow at Peking University
·PhD candidate at Xiangya School of Medicine, Central South
University
·Master’s tutor at Central South University
· Master's degree candidate in reproductive
medicine at the University of South China
· Professional training at Huazhong University
of Science and Technology and Tongji
Hospital Reproductive Center
Expertise:
diagnosis and treatment of infertility, first/second/third generation IVF (including
egg/sperm donation), microsperm retrieval, embryo freezing and resuscitation, artificial
insemination (including husband's sperm and sperm donation), paternity testing, chromosomal
disease
diagnosis, high-throughput gene sequencing, endometrial receptivity gene testing and other
clinical
technology applications. Many of these technologies are at the leading level both domestically
and
internationally.
There are only 4 basal follicles. Can it wait any longer? Ovarian reserve declines, AMH examination, IVF process, Guangzhou assisted reproduction, 4 AFC basal follicles, pregnancy assessment, and pregnancy preparation for the elderly.
There are only four basal follicles. Can it wait any longer? Understand the ovarian reserve, the opportunity of seeing a doctor and the follow-up process from six judgment points
There are only four basal follicles. Can it wait any longer? This does not mean that there is no chance at all, but it often suggests that the ovarian reserve is low. This paper systematically combs the crowd judgment, examination significance, medical treatment process and common questions and answers.
Let's start with the conclusion: there are 4 basal follicles, and it is not recommended to simply "continue to wait"
* * The number of basal follicles (AFC) is only four, which usually suggests that the ovarian reserve is low in clinic, and a complete fertility assessment should be made as soon as possible, instead of just "waiting" to decide the next step. * * But we should also directly point out a common misunderstanding: low AFC does not mean that you must not conceive naturally in the current month; The low AFC mainly reflects that the ovarian response to ovulation promotion may be weak and the number of collectable follicles is small. ASRM pointed out that the ovarian reserve index can not predict the natural pregnancy ability, but it can help doctors to judge the ovulation reaction and treatment rhythm. NICE also pointed out that both AFC and AMH can be used to predict ovarian response in assisted reproduction.
In other words, the essence of this question is not "can you wait", but: * * Your age, menstrual condition, AMH, basic FSH, whether pregnancy has failed, whether fallopian tubes and semen are normal, and whether you are allowed to continue to consume time. * * If the female is over 35 years old, ASRM suggests that the assessment should be started when she has not been pregnant for 6 months without contraception; If you are over 40 years old, you usually put more emphasis on early assessment.
1. What is "only four basal follicles"?
Basal follicles usually refer to the number of antral follicles (AFC) visible by transvaginal ultrasound in early menstruation. These small follicles can reflect the ovarian follicular reserve in the current cycle and the near future to some extent. Medical research and guidelines generally list AFC and AMH as commonly used indicators to evaluate ovarian response.
When there are only four AFC's, the following things are often associated clinically:
The possibility of ovarian reserve decline increases.
The number of eggs obtained during ovulation induction may be small.
The time window left for pregnancy decision-making may be tighter.
It is necessary to combine age with other indicators, rather than just looking at a number.
It should be emphasized that AFC is affected by examination time, ultrasonic equipment, operator's experience, and whether there is hormone medication or not. ASRM mentioned that hormonal contraceptives and other factors may affect the interpretation of ovarian reserve indicators, so the examination results can not be separated from the specific background to draw conclusions.
Expert tip: 4 basal follicles does not mean "no eggs" or "immediate menopause". It's more like a hint: there are too few ovarian mobilizable resources, and decision-making can't be delayed any longer.
Second, which people are less suitable for waiting?
Whether it is "can wait" or not, the core is not emotional judgment, but risk stratification. For the following groups of people, it is usually not recommended to continue spending time on "wait and see".
1. People who are already older.
It is one of the most stable consensus in assisted reproduction that the increase of female age is related to the decrease of fertility. Both ASRM and ACOG emphasize that the increase of age not only affects the number of eggs, but also affects the quality of eggs. After the age of 35, the rate of fertility decline will accelerate, especially after the age of 40.
2. People who have been pregnant regularly for a period of time but have not been pregnant.
If you are younger than 35 years old, you should be evaluated if you have not been pregnant for 12 months without regular contraception. If you are over 35 years old, you should usually be evaluated if you are not pregnant for 6 months; If you are over 40 years old, you should not continue to wait passively.
3. People whose menstruation begins to shorten, get confused or have obvious changes in menstrual volume.
Shortened cycle and menstrual disorder sometimes suggest changes in ovarian function. It is not necessarily equivalent to premature ovarian failure, but under the premise of only four AFC's, this kind of signal deserves more attention. ASRM also takes abnormal menstruation as an important clue to start the assessment as soon as possible in the opinion of infertility assessment.
4. People with low AMH and high FSH.
A single indicator is not enough, and joint judgment is more valuable. AFC < 5–7 and low AMH are often regarded as one of the important reference ranges of low response or abnormal ovarian reserve in ESHRE evidence table and related research materials.
5. There are other factors affecting pregnancy.
For example, tubal problems, endometriosis, ovulation disorders, abnormal male semen and so on. At this time, even if there are follicles, simply waiting may not improve the success rate, but may miss a more suitable treatment opportunity. ASRM pointed out that infertility evaluation should be bilateral and systematic, rather than just focusing on a certain value of women.
Third, there are 4 basic follicles. What technical indicators do doctors usually look at?
At this stage, what is really valuable is not to repeatedly entangle "whether four are too few", but to fill in the evaluation framework as soon as possible.
1. AFC: Look at "the number of small follicles currently visible"
AFC is helpful to predict ovarian stimulation response. In other words, it is better at answering "how many eggs may be taken during ovulation promotion" than at answering "what is the specific probability of your natural pregnancy" alone.
2. AMH: Look at "the level of ovarian reserve in the near future"
NICE update mentioned that AMH can be used as one of the prognostic indicators of assisted reproductive outcome, and AFC and AMH have similar value in predicting ovarian response. Clinically, the two are often interpreted together.
3. Basic FSH and E2: See whether the endocrine background supports it.
The increase of FSH often indicates that the feedback of ovary to pituitary stimulation is weakened, but a single examination may also be affected by periodic fluctuation, so it is usually not recommended to draw a conclusion only once.
4. Fallopian tube, ovulation and semen: See if there are any other bottlenecks.
Many couples are infertile for a long time, not just the problem of ovarian reserve. ASRM infertility evaluation opinion emphasizes that ovulation, fallopian tube, uterus and male factors should be considered simultaneously.
5. Age: Look at "the speed of egg quality decline"
This is the most easily overlooked but unavoidable variable. The decrease in the number of eggs may be partly dealt with by treatment strategies, but the age-related decrease in egg quality often affects the pregnancy outcome more.
What about key indicators? You can make a short list first.
What limitations can be answered by evaluating the main function of the project?
How is the ovulation induction response of AFC in evaluating the number of ovarian collectable follicles affected by the timing of examination and the operator
AMH Assessing the Trend of Ovarian Reserve How can the recent reserve level not represent the natural fertility alone?
Whether basal FSH/E2 can assist in judging ovarian endocrine status suggests that the fluctuation of reserve decline cycle has great influence.
Tubal examination can not reflect the quality of eggs when judging whether unobstructed pregnancy can occur naturally.
Semen analysis should be combined with review and clinical interpretation to check whether there is male infertility in male factors.
The above judgment logic is consistent with the opinions of ASRM, NICE and ESHRE on infertility evaluation and ovarian response prediction.
Expert tip: AFC low is more like "egg inventory reminder" than "pregnancy verdict". What really determines the next step is the comprehensive conclusion of age +AMH+FSH+ medical history+male examination.
Fourth, if you don't want to wait blindly, how do you go to the follow-up process?
Many people are stuck in "knowing that the value is low, but they don't know how to advance". From the clinical process, it can usually be understood by the following path.
Step 1: Confirm whether the inspection is standard.
AFC is generally recommended to evaluate in the early period of menstruation and try to complete it in a reproductive center with stable experience. If hormonal contraceptives have been used recently or the examination time is not appropriate, the interpretation of the results should be cautious.
Step 2: Complete the basic fertility assessment.
Usually includes:
Female: AMH, basic hormones, ovulation, ultrasound, tubal evaluation when necessary.
Man: Semen routine and further examination when necessary.
The significance of this step is: don't mistake "four basal follicles" for the only problem.
Step 3: Decide whether to continue natural pregnancy according to age and medical history.
Young, regular menstruation, short pregnancy preparation time, normal man and fallopian tube: some people can be observed under the guidance of a doctor for a short time.
Age ≥35 years old or pregnant failure: Long waiting is usually not recommended.
Age > 40 years old or the index continues to decline: more emphasis is placed on making treatment path as soon as possible.
Step 4: Evaluate whether to enter the path of promoting ovulation, artificial insemination or test tube.
When AFC is low, some patients will be discussed earlier, because the time cost and the number of eggs available per cycle may be limited. What needs to be said directly is that there are only four AFC's, which does not automatically mean that test tubes must be made directly; However, if you add older age, lower AMH, longer pregnancy preparation time, male factors or tubal problems, the probability of entering assisted reproduction will increase significantly.
Step 5: Enter the individualized treatment decision.
ESHRE's guidance on IVF/ICSI ovarian stimulation emphasizes that AFC or AMH can be used to predict low response and high response, thus helping to formulate individualized stimulation programs. In other words, the technological path is not fixed, and the key lies in individualization.
Five, the most frequently asked questions of patients
Question 1: 4 basal follicles, can't you get pregnant naturally?
No. Low AFC does not mean that natural pregnancy is completely impossible. ASRM clearly pointed out that ovarian reserve testing has limited predictive power for natural fertility. That is to say, * * it can't say "will you get pregnant naturally" as a simple yes or no. * * But if you are older and have been infertile for a long time, the value of waiting is usually not high.
Question 2: There are 4 basal follicles. Is it necessary to do a test tube immediately?
Not really. Whether to enter the test tube depends on age, AMH, FSH, fallopian tube, semen and previous pregnancy history. If other conditions are better, some people can strive for short-term natural pregnancy under the guidance of doctors or do more basic treatment first; If multiple unfavorable factors are combined, assisted reproduction will enter decision-making earlier.
Question 3: There are 4 basal follicles. Is it certain that ovulation will not respond?
You can't draw such a conclusion. Low AFC usually indicates that the risk of low ovarian response increases, which means that the number of eggs taken may be less, rather than no response at all. Both ESHRE and NICE support the use of AFC or AMH to predict ovarian response, but this kind of prediction mainly serves for making plans, rather than judging absolute results.
Question 4: I'm only 30 years old and have 4 AFC's. Can I wait?
The key to this kind of situation is not just age. The 30-year-old does have a greater quality advantage than the 38-year-old, but if AFC is repeatedly low or AMH synchronization is low, the reasons should be clarified as soon as possible and the observation period should be shortened. * * Being young can increase your choice, but it doesn't mean you can wait indefinitely. * * This judgment logic is consistent with the principle of ASRM that "the evaluation should not be delayed when the known risk factors appear".
Question 5: Can you decide whether to have children in the future just by looking at the number of basal follicles?
I can't. This is the premise error. The number of basal follicles can only provide stage information, and cannot determine the final outcome alone. Age, embryo quality, uterine environment, semen condition, treatment path and time management also affect the outcome. CDC also suggested in the ART national summary data that the outcome of assisted reproduction is influenced by multiple variables such as age.
6. How to answer "Can it wait any longer" more rationally?
From the first-principles point of view, this question is actually asking: Will continuing to wait increase the chances of success, or will it only consume the limited reproductive time window?
A more objective answer is:
People who can be observed for a short time
Relatively young in age
Pregnant time is not long.
Menstruation is more regular
Tuba, ovulation and semen are basically normal.
AMH and FSH were not obviously abnormal.
Under the guidance of specialists, this kind of population can be "short-term, monitored, etc." instead of waiting indefinitely.
People who don't recommend further procrastination
Age ≥35 years old, especially near or over 40 years old.
Pregnancy failure exceeds the corresponding time limit.
Low AFC combined with low AMH or high FSH.
Abnormal menstruation is obvious
Combined with fallopian tube, endometriosis or male factors
This group of people is more suitable to complete the reproductive specialist evaluation as soon as possible and discuss the next step.
VII. Summary
There are only four basal follicles. Can it wait any longer? In most cases, "waiting" is not recommended as the main strategy. More accurately, it can be evaluated and decided whether to observe for a short time, but it is not suitable for further delay under the condition of incomplete information.
Keep in mind three core points:
AFC 4 usually indicates a low ovarian reserve, but it does not mean that there is no chance of natural pregnancy at all.
AFC can better predict the ovarian stimulation response, and it is not enough to judge whether it is pregnant or not.
Age, AMH, FSH, fallopian tube, semen and previous pregnancy history determine whether you can wait and how long you should wait.
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