A - Evaluation of the functional reserve of the ovary

Good or bad responder ?
Somtimes a good responder can have an accidental bad response depending on the particular menstrual cycle.
But a patient should be considered "bad responder" when she has repeated an poor or bad response in at least 2 IVF cycles

Measurement of ovarian reserve is an important part of any infertility evaluation. This allows to identify what patient has a good chance or not for success.
Moreover, measurement of ovarian reserve is useful for determining the correct dose of fertility drugs to use in A.R.T treatments (IUI, IVF, ICSI...)..

Today, We use 7 parameters to help assess ovarian-reserve-testing :

- Age of the patient
The patient's age plays a crucial role in the prognosis of an IFV cycle.
Studies show that as age rises cancellation rates increase, the number of oocytes embryos and pregnancy rate decrease, although unchanged fertilisation rates.

- Day 3 FSH
good values : < 15 UI (usual values 2-8)
Basal FSH levels greater than 15 UI/ml are generaly associated with a worth response to stimulation (Martinez F.and All.)

- Day 3 LH
LH levels < 3 mUI / ml can be a bad prognosis for a good response
Moreover a quotient FSH / LH greater than 3 is associated with hight cancellation rates (Mukherjee T. and All)

- Day 3 Estradiol
Normal values : >60 pg/ml.
Patient with E2 levels greater than 80 pg/ml in the early follicular phase generaly have worth response and higher cancellation rates (Buyalos R. and All)

- AMH (anti-Müllerian hormone : it is produced in the granulosa cells of small ovarian follicles and does not change over the course of the menstrual cycle)
A good correlation was found between the number of eggs retrieved and the AMH level.
Normal values : 2,5 - 8,5 pg/ml.
AMH decreases with age
Some studies in IVF patients have shown lower AMH levels (< 1,08) in women who responded poorly to fertility drugs.

- AFC : Antral follicle count, ovarian-volume-assessment
A very poor AFC ( less than follicules) allows to cancel treatment.
Normal AFC (4 to 5 follicules / ovary)
good AFC (5 to 8 follicules / ovary)
High AFC (more than 8 follicules / ovary)

B - OOCYTES RECRUITMENT : See Ovarian stimulation

C - OOCYTES HARVEST

D - CUMULUS OOCYTE COMPLEX

The typical metaphase II oocyte display
- An extruded first polar body (PB), often difficult to see
- An round ooplasm, lightly colored and homogeneous in granularity
- An expanded and radiant corona radiata
- Presence of cumulus cells in a thin acid polysaccharide mass (jelly)
- Presence of membrana granulosa cells

E - OOCYTES QUALITY

Oocytes harvest can give 3 types of oocytes :

Prophase I (BAD) Germinal vesicle	Metaphase I (UNRELIABLE) (Maturation delay :15 -30 h ?)	Metaphase II (GOOD) (Maturation delay : 2-5 h.)

The best oocytes are those which already are in metaphase II at the harvest (preovulatory oocyte).
Insemination : 2-5 hours after the harvest.
Delays greater than 10-12 hours in joining spermatozoa and mature oocytes often produce poor results :
Oocyte posmaturity, abnormal fertilization and reduced conceptus viability.

Degenerative or atretic oocytes.
Degeneration and atresia may occur in an oocyte at any point along the maturational proccess within the follicule, from early immature stages to post mature stages.
These types of oocytes would not be inseminated in IVF procedure because of their obviously non viable state.