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  Zanco J Med Sci:  Apr. 2018; 22 (1):  8-16

Effect of maternal age on the ovarian reserve markers, and pregnancy outcome in a sample of Kurdish women in Erbil city

Manar J. Hussein *, Shahla K. Alalaf **, Namir G. Al-Tawil ***


* Maternity Teaching Hospital, Erbil, Iraq.

** Department of Obstetrics and Gynaecology, College of Medicine, Hawler Medical University, Erbil, Iraq.
*** Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq.


Background and objective: The ovary has a biological age that does not always correspond to the chronological age; this may be of great importance for the evaluation of women reproductive outcome. This study aimed to determine the effect of maternal age on the pregnancy rate, and the ovarian reserve markers (antimullerian hormone, follicular stimulating hormone, and antral follicular count).

Methods:  A cross-sectional study was conducted in the in vitro fertilization center at the Maternity Teaching Hospital located in Erbil city, from January 1, 2015, to January 31, 2016. A convenience sample of 300 infertile women of different age groups was included in the study. Transvaginal ultrasound was conducted to determine antral follicular count, and blood test was done for determination of serum antimullerian hormone and follicular stimulating hormone. The study sample was divided into four age groups. Chi square test, ANOVA test, Pearson correlation, and logistic regression were used to determine the associations.

Results: The biochemical pregnancy rate of the study population was 37% and the clinical pregnancy rate was 32%. The most common type of infertility among the studied sample was primary infertility (74%). Results showed a strong inverse significant correlation between antimullerian hormone and antral follicular count with age, but there was no statistically significant association between maternal age and serum follicular stimulating hormone.

Conclusion: Maternal age is a significant factor that can affect ovarian reserve and causes ovarian aging. The pregnancy rate decreases with advanced maternal age. 

Keywords: Antimullerian hormone; Antralfollicularcount; Female age; Ovarian reserve.



1. Parsanezhad ME, Jahromi BN, Zare N, Keramati P, Khalili, Parsa-Nezhad M .Epidemiology and aetiology of infertility, systematic review and meta-analysis. J Womens Health 2013; 2:6.

2. Hansen KR, Knowlton NS, Thyer AC, Charleston JS, Soules MR, Klein NA. A new model of reproductive aging: the decline in ovarian non growing follicle number from birth to menopause. Hum Repro 2013; 23:699-708.

3. Practice committee of the American society for reproductive Medicine. Definition of infertility and recurrent pregnancy loss: a committee opinion. Fertilsteril 2013;99:63.

4. Younis JS. Ovarian aging: latest thoughts on assessment and management. Curr Opin Obstet Gynecol 2011; 23:427-34.

5. Bukman A, Heineman MJ. Ovarian reserve testing and the use of prognostic models in patients with sub fertility. Hum Reprod Update 2001; 7(6):581-90.

6. Hendriks DJ, Mol BW, Bancsi LF, TeVelde ER, Broekmans FJ .Antral follicle count in the prediction of poor ovarian response and pregnancy after in vitro fertilization: a meta- analysis and comparison with basal follicle stimulating hormone level. Fertil Steril 2005; 83:291-301.

7. Nelson SM. Biomarkers of ovarian response: current and future applications. FertilSteril 2013;99:963-9.

8. Shah DK, Mejia RB, Lebovic D. Effect of surgery for endometrioma on ovarian function. J Minim Invasive Gynecol 2014; 21:203-9.

9. Rigges R, kimble T, Oehninger S, Bocca S, Zhao Y, Leader B, et al . Anti-Mullerian hormone serum levels predict response to controlled ovarian hyperstimulation but not embryo quality or pregnancy outcome in oocyte donation. FertilSteril 2011; 95:410-2.

10. Practice committee of the American Society for Reproductive Medicine. Testing and interpreting measures of ovarian reserve: a committee opinion. FertilSteril 2012; 98:1407-15.

11. Mutlu MF, Erdem M, Yildiz S, Mutlu I, Arisoy O, Oktem M. Antral follicle count determines poor ovarian response better than anti-mullerain hormone but age is the only predictor for live birth in vitro fertilization cycles. J Assist Reprod Genet 2013; 30:657-65.

12. National Collaborating Centre for Women’s and Children’s Health. Fertility: assessment and treatment for people with fertility problems. NICE clinical guideline. 2nded.London:The Royal College of Obstetricians and Gynaecologists; 2013. P. 76.

13. Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, K. Nygren K, et al International committee for monitoring Assisted Reproductive Technology (ICMART) and the WHO revised glossary of ART terminology. FertilSteril 2009; 92(5):1520-4.

14. Paul CA, Karl K, Alexandra HF, Jeffrey DK, Arthur LR, Purnima M. Prevalence and correlates of primary infertility among young women in Mysore, India. Indian J Med Res 2011; 134:440-6.

15. Kalmbach K, LiuL, Keefe D. Female reproductive aging. In: Dubey AK, editor. Infertility: diagnosis, management and IVF. 1sted. New Delhi: Jaypeebrothers medical publishers; 2012. P. 261-2.

16. Samiha M, Hassan AH, Nehad M, Fayek E, Gehan S. Risk factors for primary and secondary female infertility in Alexandria: A hospital based case control study. JMRI 2006; 27(4):255-61.

17. Wilkes S, Chinn DJ, Murdoch A, Rubin G. Epidemiology and management of infertility: a population-based study in UK primary care. Fam Pract 2009; 26:269-74.

18. Omu AE, AL-Qattan F, Ismail AA, Al- Taher SI, Al-Busiri N, Bandar A . Causal factors and management options of infertility in Kuwait. Med Principles Pract 2000; 9:131-8.

19. Abbasali KM, Amir EM, Narges M, Sepideh P, Ayyub B, Nadalu M, et al. Infertility in Mazandaran province-north of Iran: an etiology study. INRM 2011; 9(1):21-4.

20. Paul CA, Karl K, Alexandra HF, Jeffrey DK, Arthur LR, Purnima M. Prevalence and correlates of primary infertility among young women in Mysore, India. Indian J Med Res 2011;134:440-6.

21. Razzak AH, Wais SA. The infertile couple: A cohort study in Duhok, Iraq. East Mediterr Health J 2002; 8:234-8.

22. Serour GI, El Ghar M, Mansour RT. Infertility: A health problem in the Muslim world. Popul Sci 1991; 10:41-5.

23. Cates W, Ferley TM, Rowe PJ. Worldwide patterns of infertility: is Africa different? Lancet 1985; 2(8455):596-8.

24. Bayasgalan G, Naranbat D, Tsedmaa B, Tsogmaa B, Sukhee D, Amarjargal O, et al. Clinical patterns and major causes of infertility in Mongolia. J Obstet Gynaecol Res 2004; 30:386-94.

25. Van Rooij IA, Broekmans FJ, Scheffer GJ, Looman CW, Habbema JD, de Jong FH, et al Serum anti-mullerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: A longitudinal study. Fertil Steril 2005; 83:979-85

26. Mulders AG, Laven JS, Eijkemans MJ, de Jong FH, Themmen AP, Fauser BC. Changes in anti-mullerian hormone serum concentration over time suggest delayed ovarian aging in normogonadotrophicanovulatory infertility. Hum Reprod 2004; 19:2036-42.

27. Broekmans FJ, de Ziegler D, Howles CM, Gougeon A, Trew G, Olivennes E .The antral follicle count: practical recommendation for better standardization. Fertil Steril 2010; 94:1044-51.

28. Elting MW, Korsen TJ, Rekers- Mombarg LT, Schoemaker J. Women with polycystic ovary syndrome gain regular menstrual cycles when aging. Hum Reprod 2000; 5:24-8.

29. Metcalf MG, Livesey JH. Gonadotrophin excretion in fertile women: effect of age and the onset of menopause transition. J Endocrinol 1985; 105:357-62.

30. MacNaughton J, Banah M, McCloud P, Hee J, Burger H. Age related changes in follicle stimulating hormone, LH, estradiol and immunoreactiveinhibin in women of reproductive age. Clin Endocrinol 1992; 36:339-45.

31. Scheffer GJ. The number of antral follicles in normal women with proven fertility is the best reflection of reproductive age. Hum Reprod 2003; 18:700-76.

32. La Marca A, Sighinolfi G, Radi D, Argento C, Baraldi E, Artenisio AC, et al. AMH as a predictive marker in assisted reproductive technology (ART). Hum Reprod Update 2010; 16:113-30.