The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.

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Result(s):We identified 11 studies on AFC and an updated total of 32 studies on basal FSH from the literature on the basis of preset criteria. The estimated summary receiver operating characteristic (ROC) curves showed AFC to perform well in the prediction of poor ovarian response. Also, prediction of poor ovarian response seemed to be more accurate with AFC compared with basal FSH. The estimated summary ROC curves for the prediction of nonpregnancy indicated a poor performance for both AFC and basal FSH. Conclusion(s):Transvaginal ultrasonography is an easy-to-perform and noninvasive method that provides essential predictive information on ovarian responsiveness. The predictive performance of AFC toward poor response is significantly better than that of basal FSH. Therefore, AFC might be considered the test of first choice in the assessment of ovarian reserve prior to IVF. (Fertil Steril 2005;83:291-301 Reproductive aging is associated with a reduction of the primordial follicle pool and loss of oocyte quality (1). The number of follicles leaving the pool of resting follicles to enter the growth phase toward the antral stages of development decreases with increasing age (2).In an IVF program, ovarian aging is characterized by decreased ovarian responsiveness to gonadotropin administration and lowered pregnancy rates. Correct identification of patients at risk of poor ovarian response by assessment of ovarian reserve before entering an IVF program is important.It can help physicians to tailor their advice to individual couples and help patients to decide whether to proceed with a costly and often demanding and disappointing IVF treatment.A recent meta-analysis on the performance of basal FSH level in the prediction of poor ovarian response and failure to become pregnant after IVF showed that a possible clinical application of basal FSH refers to only a minority of patients with extremely high basal FSH levels (3). However, to date basal FSH is still widely used in many fertility centers.Several other endocrine ovarian reserve tests have been proposed as predictors for IVF outcome in the past decade (4). In the field of quantitative ultrasonography, achievements in the development of tests that assess ovarian reserve have also been reported. After the initial reports by Reuss et al. (5) and Scheffer et al. (6) that transvaginal ultrasonography could detect age-related decreases in follicle counts,

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