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  1. Germ cells originate from yolk sac
  2. Germ cells are maximum (7 million) at 16-20 weeks of intra-uterine gestation; then they undergo atresia by apoptosis and are 2 million at birth and 3-4 lakhs at puberty
  3. Hypothalamo-Pituitary-Ovarian (HPO) axis is active/functional from 20 weeks of fetal life
  4. Ovulation occurs because of luteinizing hormone (LH) surge
  5. Onset of LH surge to ovulation = 36 hours
  6. Onset to peak = 24 hours
  7. Peak to ovulation = 12 hours

  • Preovulatory estradiol levels should reach 200 pg/mL and should be maintained for 24-48 h. Only when this is achieved there is a positive feedback to pituitary, and then the LH surge starts

Two - Cell Two - Gonadotropin Theory (In the Ovaries)


  • This aromatization also takes place in peripheral tissues like fat/adipose tissue
  • E2 is 10 times more potent then E1, which is 10 times more potent then E3 (estriol)
  • Activin and inhibin are also produced by granulosa cells
  • Sr. FSH and LH estimations are always to be done on day 2 or day 3 of menstrual cycle
  • In polycystic ovarian syndrome (PCOS) ratio is:
  • Follicle-stimulating hormone (FSH) level (done on day 2 or 3) is a marker for ovarian reserve. Rising FSH points to decreasing ovarian reserve, and therefore in menopause Sr. FSH is the highest.
  • In pregnancy, human chorionic gonadotropin (hCG) acts like LH to maintain corpus luteum of pregnancy
  • Luteal phase defect (LPD) causes premenstrual spotting and recurrent first trimester abortions
  • Lag of 48 h or more between the chronological dating and histological dating (by doing endometrial biopsy) in two different samples is used to define LPD
  • Sr. progesterone levels done on day 21 of menstrual cycle less than 5 ng/mL = LPD, more than 8--15 ng/mL = ovulation, and more than 25 ng/mL = pregnancy

Recent Advances: Amh is a Newer Marker for Ovarian Reserve

  • AMH or anti-Mullerian hormone is a substance that is produced by granulosa cells in ovarian follicles. It is first made in primary follicles that advance from the primordial follicle stage. At these stages, follicles are microscopic and cannot be seen by ultrasound. AMH production is highest in pre-antral and small antral stages (<4 mm diameter) of follicle development.
  • AMH test can be done on any day of a woman's cycle unlike FSH level test, which has to be done on day 2 or 3 of the menstrual cycle.
  • Since AMH is produced only in small ovarian follicles, blood levels of this substance have been used to attempt to measure the size of the pool of growing follicles in women.
  • Research shows that the size of the pool of growing follicles is heavily influenced by the size of the pool of remaining primordial follicles (microscopic follicles in 'deep sleep').
  • Therefore, AMH blood levels are thought to reflect the size of the remaining egg supply or 'ovarian reserve'.

With increasing female age, the size of their pool of remaining microscopic follicles decreases. Likewise, their blood AMH levels and the number of ovarian antral follicles visible on ultrasound also decreases. Women who have few remaining follicles (decreased ovarian reserve) and those who are close to menopause have low AMH levels.

AMH levels (ng/mL)


4.0 - 6.8

Optimal fertility

2.2 - 4.0

Satisfactory fertility

0.3 -2.2

Low fertility


Very low fertility


High levels (PCOS and granulosa cell tumor)


NOTE: AMH is always ABSENT in females during embryogenesis.

Methods of Detecting Ovarian Reserve

  1. Baseline hormones
    1. FSH level (Normal 2-4 IU) (On D3)
      >10 IU is suggestive of old ovary / menopause
      >40 IU is diagnostic of menopause
    2. Serum antimiillerian Hormone (AMH): Levels of serum AMH is a good predictor of ovarian stimulation response. Its level also comes with the direct proportion of antral follicle count. Levels of AMH (lng/ mL) declines with age and with poor ovarian reserve. Levels of AMH can be measured any time in the menstrual cycle.
    3. Basal (D3) serum estradiol level > 70-80 pg/ mL, poor ovarian reserve.
    4. Serum inhibin B (DS): Reduced inhibin B levels (less than 40 pg/mL) are observed in woman with advanced age.
  2. Ultrasound parameters
    1. Ovarian volume (Normal 3 x 3.5 x 3.5 cm)
    2. Antral follicle count (4-5 good / young, 1-2 poor / old)
      Antral Follicle Count (AFC) is done by using TVS in early follicular phase in both the ovaries. AFC reflects the primordial follicular pool in the ovary.
      AFC more than 6 (2-10 mm size) reflects adequate ovarian follicular reserve.
      APC, less than 4, indicates poor ovarian reserve and poor response to ovarian stimulation during IVF.
      AFC decreases with age.
  3. Challenge tests:
    1. Clomiphene citrate challenge test (CCCT)
    2. Exogenous FSH ovarian reserve test (EFFORT)
    3. GnRH agonist stimulation test (GAST)


Absence of menstruation


• Before puberty

• After menopause

• During pregnancy

• During lactation





→ True primary amenorrhea


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