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Oxford Medical Kuwait

Ovarian Reserve
& IVF

A personalised clinical strategy for your consultation

Consultation with Professor Scott Nelson
& Dr Karema Alrashid

The Biological Constant

Lifetime Follicle Depletion

The ovarian follicle pool declines continuously from birth — a steady, log-linear process.

2M 1M 300K 100K 25K 1K Birth 10 20 30 40 50 Woman's Age

Women are born with ~1–2 million oocytes. By puberty ~300,000–400,000 remain. The decline is continuous — by age 40, fewer than 25,000. This depletion is universal and irreversible.

Key distinction: This describes egg quantity decline. Egg quality (aneuploidy) follows a different, sharper trajectory — next slide.

Quantity vs Quality

Reserve Decline vs Aneuploidy

AMH predicts quantity, not quality. Age is the sole reliable predictor of euploidy.

Follicle Depletion (Absolute)

2M 300K 100K 25K 1K Birth Puberty 25 35 Menopause ~85% lost by puberty

Euploidy Rate (Quality)

100% 75% 50% 25% 0% 25 30 35 40 45 Age 35

Ovarian reserve undergoes a massive absolute decline from birth through puberty, continuing steadily through adult life to menopause. In contrast, egg quality (euploidy) remains relatively stable through early adulthood before aneuploidy accelerates sharply after age 35.

The AMH Fallacy: High AMH ≠ high egg quality. AMH reflects follicle count only. Age remains the sole reliable predictor of euploidy.

Nelson et al. (2012)

Your AMH Profile

Anti-Müllerian Hormone mapped against age-expected centiles.

0.1 0.5 1 2 5 10 20 50 80 0.01 0.07 0.14 0.28 0.7 1.4 2.8 7.0 11.2 20 25 30 35 40 45 50 Woman's Age AMH (pmol/L) AMH (ng/mL) 90th Average 25th 10th
Above 25th centile — normal reserve. ~80% chance of 8+ eggs in IVF.
25th–10th centile — reduced reserve. Individualised protocol recommended.
Below 10th centile — very reduced reserve. Expectations discussion essential.

The Treatment Cycle

The Stimulation Timeline

From ovarian priming through to embryo transfer decision.

Day 21 Ovarian priming Preceding cycle ▲ Daily FSH/LH injections Day 2–3 Baseline scan & start stims Day 6 Monitoring scan Day 6+ Antagonist added Day 11 Trigger Day 13 Egg retrieval Day 18 Blastocyst assessment

Fresh transfer

Pregnancy test ~Day 28

PGT-A biopsy + freeze all

Results ~2 wks, FET next cycle

Freeze all (no biopsy)

FET in subsequent cycle

Note: This is a standard antagonist protocol. Your specific timeline will be individualised based on AMH, AFC, and clinical history.

Expectation Management

The Attrition Funnel

Enter antral follicle count to see personalised expectations.

Antral Follicles
15
↓
Eggs Retrieved ~85%
13
↓
Mature (MII) ~75%
10
↓
Fertilised (2PN) ~80%
8
↓
Paternal genome activation — sperm DNA quality influences blastulation
↓
Blastocysts (Day 5) ~45%
4

Clinical Note: Conversion rates matter more than absolute numbers. A DOR patient who retrieves 3 eggs and achieves 1 blastocyst has a ~33% conversion — an excellent outcome. The fertilisation-to-blastocyst drop is heavily influenced by sperm DNA quality.

Male Factor Assessment

Semen Analysis

Your results compared to the population distribution.

Semen Volume Normal: ≥1.4 mL
— mL
1.4 3.0 6.2
Concentration Normal: ≥16 M/mL
— million/mL
16 66 208
Progressive Motility Normal: ≥30%
— %
30 55 77
Normal Morphology Normal: ≥4%
— %
4 14 39

4% is the healthy target — this is normal biology, not a failing grade.

Recommended Pathway

Natural / IUI
All parameters within WHO range. Timed intercourse or intrauterine insemination.
ICSI
Standard for any male factor or as default IVF. Single sperm injected per oocyte.
Surgical + ICSI
Severe oligospermia (<5 M/mL) or azoospermia. TESA/micro-TESE then ICSI.

Optimisation: Zymot, PICSI, sperm mobilisation and oocyte activation may be used to optimise sperm selection and fertilisation.

Embryo Development

The Day 5 Blastocyst

By Day 5, the embryo has differentiated into distinct cell populations.

Inner Cell Mass (becomes the baby) Trophectoderm (becomes placenta) Zona pellucida Blastocoel Biopsy point (PGT-A sampling)

The trophectoderm biopsy (5–8 cells) is taken from the outer layer that forms the placenta — the inner cell mass is left untouched.

Embryo Selection

The Day 5 Advantage

Why extended culture and blastocyst biopsy improve outcomes.

Day 3 (Cleavage)

  • 6–8 cells, limited differentiation
  • Mosaicism common — cells may not represent whole embryo
  • Embryonic genome not yet activated
  • Morphology grading less predictive
  • Biopsy removes 12–25% of embryo mass

Day 5 (Blastocyst)

  • 100–200 cells with clear differentiation
  • Natural selection — weak embryos arrest before Day 5
  • Embryonic genome fully activated
  • ICM + trophectoderm grading highly predictive
  • Biopsy takes <5% of total cells

Impact of Biopsy on Implantation

baseline
−34%
Day 3 Biopsy
No effect
Day 5 Biopsy
Reference
No Biopsy

Day 3 biopsy reduces implantation by ~34%. Day 5 trophectoderm biopsy shows no measurable impact.

Success Probability

Euploidy & Cumulative Live Birth

PGT-A euploidy rates and mature eggs needed for a realistic chance of a baby.

Euploidy Rate by Age (PGT-A)

< 35
~65%
35–37
~50%
38–40
~35%
41–42
~20%
43+
~10%

Mature (MII) Eggs Needed for ~75% CLBR

Based on POSEIDON/Sunkara modelling. This answers: "How many eggs do I need?"

< 35
~10–15 MII eggs
35–37
~15–20 MII eggs
38–40
~20–25 MII eggs
41–42
~30+ MII eggs
43+
Individualised

Multiple cycles: These targets may require more than one stimulation cycle. Cumulative banking is standard for lower reserve patients.

Genetic Screening

The PGT-A Report

What the genetic report looks like and what it tells us.

Normal Male Karyotype (46,XY)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 X Y 22 autosome pairs + X, Y = 46 chromosomes total

Example PGT-A Report

PGT-A Results Summary

Embryos biopsied: 10

Analysed: 22 autosome pairs, X and Y

Embryo Autosomes XY Result
1NormalXXNORMAL
2NormalXXNORMAL
3NormalXYNORMAL
4NormalXYNORMAL
5NormalXXNORMAL
6NormalXXNORMAL
7+22XXTrisomy 22
8NormalXXNORMAL
9+6,+14XXYComplex
10NormalXYNORMAL

Normal XY: #3, #4, #10

Normal XX: #1, #2, #5, #6, #8

Abnormal: #7, #9

8 of 10 euploid (80%)

NGS technology screens all 22 autosome pairs plus X and Y at high resolution. Abnormal embryos (aneuploid) are not transferred — this reduces miscarriage risk and improves implantation rates per transfer. Results are typically available within 2 weeks of biopsy.

Executive Summary

Key Takeaways & Next Steps

AMH & Reserve

Your AMH tells us how many eggs to expect — not their quality. Age determines quality.

The Funnel

Not every egg becomes a blastocyst. Conversion rates matter more than starting numbers.

Day 5 Culture

Extended culture provides natural selection and safer biopsy for genetic testing.

PGT-A Testing

Screening for chromosomal normality reduces miscarriage risk and improves per-transfer success.

Freeze-All Strategy

Supraphysiologic oestrogen disrupts endometrial receptivity. Freeze-all resets the uterine environment, yielding higher implantation rates and eliminating late-onset OHSS risk.

Cumulative Strategy

Banking embryos across cycles builds toward the MII egg target needed for the best chance of live birth.

IVF Consultation Summary

Oxford Medical Kuwait — Professor Scott Nelson

Ovarian Reserve

AMH Level

—

Age

—

at consultation

Classification

—

Nelson AMH Nomogram

Recommended Pathway

Treatment Strategy

—

Key Takeaways

Oxford Medical Kuwait · oxmedkw.app · +965 66202241

This summary is for patient reference only. It does not constitute a prescription or medical directive.