Follicular stalk in woman & stalk of Seminiferois tubules in males.

through toxins produced by MTB or indirectly by adverse immuno-modulatory change in intra- follicular environment. The consequences may be gonadotropin response deficiency, anovulation, endometrial hyperplasia, luteal phase defect, etc.

Physiology of Ovarian Reserve and Endocrine Function

Normal ovarian reserve: Follicular stock:

Ovaries contain a stock of follicles, number of which gradually declines as age advances by a process of physiological apoptosis. Physiological atresia starts from intrauterine life; the process of atresia continues through childhood, puberty, adolescence, child-bearing age till the stock is exhausted by the time when woman reaches menopause. From several millions of follicles appearing in intrauterine life, the number is reduced to two millions at birth and 3,00,000 at puberty.

Thereafter during reproductive years with each menstrual cycle, some 30 to 40 follicles are wasted. It should be noted that better quality follicles (with good quality eggs) are exhausted in the first half of reproductive years followed by relatively inferior quality follicles. During this long journey from puberty to menopause, any trauma or insult (e.g. toxins liberated from MTB, mumps, oophoritis, etc.) to the ovary may lead to qualitative and quantitative loss of follicles— reducing ovarian reserve prematurely. One clinically useful indicator to predict ovarian reserve is to measure the level of baseline follicle-stimulating hormone (dl-d3 FSH and currently AMH). Gradual rise of baseline FSH in consecutive cycles indicates diminishing ovarian reserve.

FSH is a quantitative predictor of oocytes; level of borderline elevated FSH does not indicate the quality of oocytes available. From
that point of view, patient's age and assess­ment of AMH are better qualitative predictors of ovarian reserve than baseline FSH.

As genital tuberculosis affects women of younger age, better quality eggs are still available, although ovarian reserve may be borderline. This fact provides a favorable scope for treating infertility by ART for women with genital tuberculosis.

The Fig. 16.1 demons­trates that though numbers of eggs are less (baseline elevation of FSH), quality of eggs is better because of relatively younger age of the patient affected with genital tuberculosis.

A better qualitative predictor for ovarian reserve namely anti-mtillerian hormone (AMH) has recently been identified AMH is synthesized and released by granulosa cells of the follicle. Unlike other biomarkers for ovarian reserve like FSH, inhibin or E2, estimation of AMH can be done on any day of menstrual cycle. This is because, levels of serum FSH, E2 and inhibin-B depend on individual feedback mechanism, whereas production of AMH depends on health and integrity of granulosa cells and is not dependent on 'feedback' mechanism.