ovarian reserve

If you're considering or embarking on the path of egg freezing, you may have come across the term "Antral Follicle Count" (AFC) during your research. AFC is a crucial tool in assessing ovarian reserve and predicting the success of fertility treatments, including egg freezing. In this article, we delve into the world of AFC, exploring its significance, measurement techniques, and its role in optimizing your egg freezing journey.

In this comprehensive guide, we will walk you through the intricacies of AFC. We'll discuss what an antral follicle is, how AFC is measured, and what a normal AFC looks like based on age. Additionally, we'll explore the relationship between AFC and the egg freezing process, shedding light on how this information can guide and optimize your fertility journey.

What is an antral follicle?

Antral follicles are small fluid-filled sacs found within the ovaries that contain immature eggs. These follicles serve as the building blocks of our fertility. Each month, a group of antral follicles starts developing in response to hormonal signals. Among this group, one follicle becomes dominant and eventually releases a mature egg during ovulation.

How do you measure AFC?

There’s only one way to measure the antral follicle count: through a transvaginal ultrasound, which allows for a close examination of the ovaries. During this procedure, a specialized ultrasound probe is inserted into the vagina to visualize the ovaries and count the number of antral follicles present in both ovaries (the definition of antral follicles varies across fertility clinics. Some clinics count follicles that measure 2–10 mm in diameter, while others focus on follicles ranging from 3–8 mm). 

The AFC measurement is typically taken during the early follicular phase of the menstrual cycle when the antral follicles are at their most visible and measurable state. But it can be done anytime of the cycle.

What can an antral follicle count test tell you?

The antral follicle test holds a wealth of valuable information that can shed light on your reproductive health. So, what exactly can an antral follicle test tell you?

Ovarian reserve assessment 

The number of antral follicles detected during the test directly correlates with your ovarian reserve. This information can help your fertility doctor understand the quantity of follicles remaining in your ovaries in relation to your age. As we age, the number of antral follicles typically decreases, reflecting a decline in ovarian reserve. Understanding this relationship can help in making decisions about family planning and fertility preservation options. Learn more about ovarian reserve here.

How your body would respond to egg freezing

Antral follicles are a key determinant of how your ovaries will respond to ovarian stimulation during fertility treatments such as egg freezing. In fact, AFC correlates directly with the number of eggs retrieved at egg collection. By assessing your AFC, your healthcare team can tailor the stimulation protocol to optimize your chances of success.

Best timing for egg freezing 

The antral follicle count can also assist in determining the ideal timing for initiating fertility treatments. By assessing the AFC, your fertility doctor can guide you on the optimal time to start treatments, maximizing your chances of a successful outcome.

Premature ovarian failure (POF)

POF, also known as premature menopause, refers to the loss of ovarian function before the age of 40. Antral follicle testing can help in the diagnosis of POF by revealing a significantly reduced antral follicle count. A diminished AFC can indicate a decline in ovarian reserve, which is a characteristic feature of POF. This information is crucial in understanding the reproductive potential and considering appropriate fertility treatment options for individuals with POF.

Polycystic ovary syndrome (PCOS) 

PCOS is a common hormonal disorder that affects women of reproductive age. It is characterized by hormonal imbalances, irregular menstrual cycles, and the presence of multiple small follicles on the ovaries. Antral follicle testing plays a vital role in assessing PCOS by revealing an increased number of small antral follicles during the scan. This high AFC, along with other diagnostic criteria, helps in confirming the presence of PCOS and guiding appropriate management strategies.

The antral follicle test is a powerful tool in assessing your fertility health, but it is just one piece of the puzzle. It should be considered alongside other diagnostic measures and discussions with your fertility doctor to form a comprehensive understanding of your fertility health.

What is a normal AFC by age?

The normal range of antral follicle count can vary depending on your age. In general, younger women tend to have a higher number of antral follicles, indicating a larger ovarian reserve. As a woman ages, the number of antral follicles naturally declines, reflecting the diminishing ovarian reserve.

While the specific numbers can vary, a typical AFC for a woman in her 20s and early 30s may range between 10-20 follicles, in her late 30s around 8-15 follicles, and by her 40s, it could further decline to under 10 follicles. It's important to remember that these numbers are approximate and can vary based on individual factors such as genetics and overall reproductive health.

One study of infertile women looked at exactly how antral follicle count declines with age, finding the median AFC to be:

• 14 at age 25
• 12 at age 30
• 10 at age 35
• 8 at age 40
• 6 at age 45

AFC and egg freezing

When it comes to assessing ovarian reserve and predicting the number of eggs that can be retrieved during egg freezing, the antral follicle count (AFC) is a very helpful biomarker. It may even be the most important of ovarian reserve measures. A meta-analysis of 11 studies found that the AFC scan was as accurate as using multiple markers to predict ovarian response to stimulation. AFC outshined its counterparts like anti-Mullerian hormone (AMH) and follicle-stimulating hormone (FSH) as the predictor of ovarian response to egg freezing stimulation. 

So, when it comes to determining the potential success of your egg freezing journey, keep an eye on AFC. It can guide you through the uncertainties and help your healthcare team tailor the stimulation protocol to maximize your chances of a fruitful outcome. 

What does low AFC mean?

A low AFC can indicate a lower ovarian reserve and may have implications for fertility. When the AFC is low, it suggests that there are fewer follicles available in the ovaries, which can impact the number of eggs that can be retrieved during fertility treatments such as egg freezing.

But having a low AFC does not necessarily mean that pregnancy is impossible, but it may suggest that the response to ovarian stimulation during fertility treatments could be lower than average. With fewer follicles available, there may be a reduced number of mature eggs that can be retrieved for fertilization. This can affect the overall success rates of fertility treatments, as the quantity and quality of eggs play a crucial role in achieving a successful pregnancy now or down the line.

Remember that AFC is just one piece of the fertility puzzle, and other factors such as age, hormone levels, and overall reproductive health matter. 

What does high AFC mean?

A high AFC typically indicates a greater ovarian reserve and can be a positive indicator of fertility health. When the AFC is high, it suggests that there are a larger number of antral follicles present in the ovaries, which can potentially result in a higher number of eggs available for retrieval during egg freezing.

Having a high AFC is generally associated with a better response to ovarian stimulation during fertility treatments. With more follicles available, there is a greater likelihood of obtaining a larger number of mature eggs for fertilization. This can potentially increase the chances of success in achieving a pregnancy now or down the line.

A high AFC alone does not guarantee pregnancy or fertility success. Other factors such as the quality of the eggs, age, overall health, underlying reproductive conditions – as well as the health of the sperm – can also influence fertility outcomes. 

AFC is just one piece of the puzzle

The antral follicle count is a valuable tool in the realm of fertility assessment. By providing information about your ovarian reserve, it assists in predicting the response to ovarian stimulation and guides decisions regarding fertility preservation options like egg freezing. 

The AFC measurement, combined with other diagnostic tests and a thorough evaluation of an overall reproductive health, helps paint a comprehensive picture of your fertility health. Armed with this knowledge, you can make informed choices about your reproductive journey and take proactive steps towards preserving your fertility and achieving your family planning goals.

You are not a number

With all the nuances involved here, it’s important not to get lost in the weeds. Fertility is impacted by so many factors that you can drive yourself crazy trying to manage all of them. Remember, you are more than any number. This process can be overwhelming, but focusing on the things that you can control can help you feel more grounded during your fertility journey, whatever it may look like.

Cofertility is here to help you every step of the way on that journey.

Our Split program allows qualified people between 21 to 34 years old (with an AMH of 2+) to have the chance to freeze their eggs for free when donating half of the eggs retrieved to a family that can’t otherwise conceive.

Or, if you’re over 34, you can still participate in the Keep program up to age 40. In the Keep program, you’re able to freeze your eggs and keep them all for yourself, on your timeline. In addition, you’ll have access to our online support community, the Nest. This valuable resource lets you engage with other people freezing their eggs at the same time!

Whatever your journey looks like, our team is here to guide you through it and keep your family-building options open.

Sources:

• Antral Follicle. Science Direct. URL
• Verhagen TE, Hendriks DJ, Bancsi LF, et al. The accuracy of multivariate models predicting ovarian reserve and pregnancy after in vitro fertilization: a meta-analysis. Hum Reprod Update 2008;14:95–100. URL
• CAROLE GILLING-SMITH, STEPHEN FRANKS, CHAPTER 28 - Ovarian Function in Assisted Reproduction, The Ovary (Second Edition), Academic Press, 2004, Pages 473-488, ISBN 9780124445628, https://doi.org/10.1016/B978-012444562-8/50029-X. URL‍
• Almog B, Shehata F, Shalom-Paz E, Tan SL, Tulandi T. Age-related normogram for antral follicle count: McGill reference guide. Fertil Steril. 2011;95(2):663-666. doi:10.1016/j.fertnstert.2010.08.047 URL

If you are considering starting a family or have concerns about your fertility, understanding the concept of ovarian reserve is essential. Ovarian reserve refers to the quantity of eggs (oocytes) available for fertilization. It serves as a key indicator of your reproductive potential and can play a crucial role in fertility treatment decisions. 

In this guide, we will delve into the topic of ovarian reserve, exploring its significance, how it is assessed, factors that affect it, available options for optimizing fertility, and emotional considerations related to fertility journey.

First off, what does your ovarian reserve mean?

Simply put, your ovarian reserve is your fertility potential, which is influenced by a variety of factors, including age, genetics, and certain medical conditions.

As we age, our fertility naturally declines. This is totally normal, and due to fewer eggs in the ovaries, a decrease in egg quality, and an increase in chromosomal abnormalities of the remaining eggs. These collective factors contribute to lower pregnancy rates and higher miscarriage rates as we approach age 40.

While the decline in fertility happens to ALL of us, the specific age when we can no longer conceive varies from individual to individual. And in some cases, it may be earlier than we expected.

To assess your fertility potential, including your ovarian reserve, several tests are available that can give us clues to our reproductive capabilities. These tests can also help fertility doctors, like myself, evaluate the likelihood of successful pregnancy, and guide you in making informed decisions regarding family planning and fertility treatments.

How do I know my ovarian reserve?

If you want to know your ovarian reserve, it’s best to set up time for a fertility assessment with a fertility doctor (reach out – we can help with this!). 

There are two ways a doctor can help assess your ovarian reserve, including:

Blood hormone tests

Hormone tests, including follicle-stimulating hormone (FSH), estradiol, luteinizing hormone (LH), anti-Müllerian hormone (AMH), and estradiol, provide valuable information about ovarian function and egg supply. While AMH can be taken any time, FSH and LH are typically performed on specific days of the menstrual cycle to obtain accurate results.

Antral follicle count

Transvaginal ultrasound is used to visualize the ovaries and count the number of antral follicles present. Antral follicles are small, fluid-filled sacs that contain immature eggs. The count of antral follicles serves as an indirect indicator of ovarian reserve.

By combining the results of hormone tests and ultrasound assessments, we can estimate your ovarian reserve and provide insights into fertility potential.

What is a normal ovarian reserve?

Determining what constitutes a “normal” ovarian reserve involves comparing your results to established reference ranges for your age. Age-specific reference ranges serve as benchmarks to evaluate your ovarian reserve relative to peers of the same age group. Keep in mind that ovarian reserve will gradually decline for everyone – it’s the timing and pace of change that differs. 

For example, in younger women, a higher number of antral follicles (small fluid-filled sacs containing immature eggs) and lower levels of certain hormones like FSH may be considered within the normal range. However, as a woman ages, it is expected that the number of antral follicles will decrease and hormone levels, such as FSH, may increase.

While age is a significant factor, other individual factors should also be taken into account when interpreting ovarian reserve results. Factors such as medical history, previous fertility experiences, underlying medical conditions, and fertility goals play a role in assessing the overall fertility potential. These additional factors can influence the interpretation of ovarian reserve results and help guide fertility treatment decisions tailored to the specific needs of the individual.

What causes decreased ovarian reserve?

Decreased ovarian reserve can result from various factors, including:

• Age: As we age, the quantity and quality of eggs naturally decline. The aging process gradually reduces the quality of eggs and ovarian reserve, making it more challenging to conceive.
• Smoking: Cigarette smoking has been linked to a higher rate of diminished ovarian reserve. Chemicals in tobacco smoke can accelerate the depletion of eggs and negatively impact ovarian function.
• Cancer treatment: Some cancer treatments, such as chemotherapy and radiation therapy, can have damaging effects on the ovaries. These treatments may cause a decrease in ovarian reserve and compromise fertility.
• Pelvic Surgery: Surgical procedures involving the ovaries or other pelvic organs can inadvertently damage or remove ovarian tissue. This can lead to a decrease in ovarian reserve and potentially affect fertility.
• Autoimmune diseases: Certain autoimmune conditions, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis, can impact ovarian function and diminish ovarian reserve.
• Genetic conditions: Certain genetic disorders, such Fragile X syndrome, and other chromosomal abnormalities, can be associated with decreased ovarian reserve. These conditions may affect the development and function of the ovaries.

While these factors are known to contribute to diminished ovarian reserve, individual experiences vary. You may have none of the above conditions, and still face premature ovarian failure (POF). Or you may have one of the above factors, and have no problems at all getting pregnant. Sometimes, it just comes down to luck.

What does it mean if I have a high ovarian reserve?

A high ovarian reserve refers to a situation where there is an abundant number of eggs in the ovaries. While ovarian reserve naturally declines with age, certain factors can contribute to a higher ovarian reserve in some people.

One factor associated with a high ovarian reserve is younger age. Those in their 20s and early 30s generally have a higher number of eggs compared to those in their 40s, resulting in a larger ovarian reserve. Additionally, genetic factors can influence ovarian reserve, and some may have a naturally higher number of follicles and eggs in their ovaries.

Another factor that can contribute to a higher ovarian reserve is polycystic ovary syndrome (PCOS). PCOS is a hormonal disorder that can lead to the development of multiple small follicles on the ovaries. Those diagnosed with PCOS often have a higher number of immature follicles in their ovaries, which can translate into a higher ovarian reserve.

While a high ovarian reserve can be advantageous for fertility, it does not guarantee successful conception or a higher chance of pregnancy. Other factors, such as egg quality and hormonal balance, also play significant roles in achieving pregnancy.

At-home ovarian reserve tests

There are at-home options for ovarian reserve testing. However, keep in mind that most fertility doctors will want to re-do these tests. So taking a test at home, may mean paying for a test twice.

Here are some options:

• Natalist Women’s Fertility Test ($149) measures 5 hormones: estradiol, LH, FSH, TSH, and total testosterone. You can save 20% with code COFERTILITY20
• LetsGetChecked Ovarian Reserve Test ($139) measures 1 hormone, AMH. You can save 25% with code COFERTILITY25

Ovarian reserve and egg freezing

Ovarian reserve plays a significant role in the process of egg freezing, also known as oocyte cryopreservation. Egg freezing involves the retrieval and freezing of your eggs for future use, preserving your fertility potential at a younger age. 

Assessing ovarian reserve before undergoing egg freezing is crucial for determining the quantity of eggs available for freezing. Those with a higher ovarian reserve generally have a greater number of eggs suitable for freezing, increasing their chances of successful future pregnancy. 

On the other hand, those with diminished ovarian reserve may have fewer eggs available for freezing, necessitating careful consideration of the potential outcomes and options. Understanding your ovarian reserve provides valuable information to help guide the egg freezing process and optimize the chances of achieving successful future pregnancies when the frozen eggs are thawed and used in assisted reproductive techniques.

Freeze your eggs with Cofertility

We’d love the opportunity to support you on your egg freezing journey.

Cofertility is a human-first, tech-enabled fertility ecosystem that provides people agency over if, how, and when they have babies — today or someday. We have two programs for egg freezers:

1. The Split program, which offers women a chance to both freeze their own eggs and donate half the eggs to a family who cannot conceive otherwise. If you qualify for the program and decide to donate half of your retrieved eggs, every expense associated with the egg freezing procedure —  medications, supplements, travel if necessary, insurance, and 10 years of storage — are completely free of charge. We don’t even need a payment or credit card up front, as the family you match with covers all the expenses.
2. Our self-pay Keep program allows women to freeze their eggs and keep them all for their future use. Through Keep, we offer our members partnerships and discounts to lighten the financial load of egg freezing, as well as access to our member community.

The benefits for of working with Cofertility include:

• Power of choice: Freeze your eggs more affordably or, if you qualify, freeze for free when you give half to a family who can’t otherwise conceive.
• Community: Our inclusive online spaces allow you to connect with others going through the process in our private online community.
• Compassion: We’ll always treat you with care, and our Split program gives you the opportunity to make someone’s family building dreams a reality.
• Data-driven: We provide you with trustworthy guidance and evidence-based research so you can make informed decisions about your fertility.
• Free egg freezing: Freeze and store your eggs for 10 years, entirely for free if you qualify for our Split program.

Ready to learn about more affordable (even free!) egg freezing with Cofertility? Fill out this quick quiz to learn about our accessible egg freezing options and see if you qualify for our programs — it only takes one minute.

Anti-Mullerian hormone (AMH) is a hormone produced by ovarian follicles. It is commonly used as a marker of ovarian reserve and can be measured in the blood. A high AMH level is often associated with polycystic ovary syndrome (PCOS), but it can also have other causes. In this article, we will explore what a high AMH result means and answer some common questions about AMH testing.

First off, what is AMH?

AMH is a hormone that is produced by the granulosa cells in the ovarian follicles. It plays a role in the growth and maturation of ovarian follicles in females. AMH levels are relatively stable throughout the menstrual cycle and can be measured in the blood.

AMH is commonly used as a marker of ovarian reserve, which is a rough number of eggs that a female has remaining in her ovaries. Since females are born with a fixed number of eggs, this number naturally declines over time. 

What are normal AMH numbers?

What is considered a “normal” AMH level depends on your age, as well as the lab where you take the test. Since there is no international standard, it’s best to use the reference ranges included on the test results (your doctor can share those with you if you did a test through a clinic). 

In general, however, an AMH between 1.0 and 3.5 ng/mL suggests a “normal” range that is likely to have a good response to egg freezing.

If you are looking to donate your eggs, however, minimum AMH requirements may be slightly higher. For example, with Cofertility’s Split program, we require a minimum AMH of 2.0, though clinics may have their own unique requirements. This is to increase the chances of retrieving enough eggs to actually split, to ensure positive outcomes for both parties involved.

What AMH level is considered high?

In healthy females of reproductive age, higher levels of AMH mean that the ovaries have a larger supply of eggs. This means one would be expected to have better than average outcomes for egg freezing. 

Remember, there is no universal standard for AMH, so it can vary depending on the lab where the test is run. Your test results will include if your range is “normal”, “low”, or “high” and the cut-off can differ. For example, Atlanta Fertility considers over 4.5 ng/mL high. Advanced Fertility considers anything over 4.0 ng/ml high. While RMA would consider an AMH over  3.0 ng/ml as “very high”.

With high levels of AMH, you may be at higher risk for ovarian hyperstimulation syndrome (OHSS). This means your doctor may choose a specific protocol and/or do extra monitoring to decrease the risk of complications during egg freezing.

What AMH level is considered too high?

Again, this question depends on the lab. Your test results will come with a reference range, and will indicate if your number is high for your age. If your doctor considers your levels abnormally high and has concerns, they will discuss the results with you. 

Common reasons for high AMH

The most common reason for high AMH is that you are very fertile and likely to retrieve more eggs in an egg freezing cycle.  

But a high AMH level may also indicate PCOS, which is a hormonal disorder that affects 8–13% of females of reproductive age. Those with PCOS typically have high levels of androgens (male hormones) and may have irregular periods, acne, and excess hair growth. Patients with an average AMH level ≥ 4.45 ng/ml have a 9.35 times higher likelihood of developing PCOS, but not all patients with a high AMH have PCOS.

In rare cases, abnormally high AMH could be a sign of an ovarian tumor. Certain types of ovarian tumors, such as granulosa cell tumors, can produce high levels of AMH. 

Does high AMH always mean PCOS?

While an increase in AMH levels has been reported to be associated with PCOS, high AMH alone is not enough to diagnose PCOS. 

Not all patients with PCOS have high AMH levels, and not all patients with high AMH levels have PCOS. Diagnosis of PCOS requires a combination of symptoms, hormone levels, and imaging studies, such as ultrasound.

Does high AMH mean good egg quality?

Not necessarily. While a high AMH level is often associated with a larger number of ovarian follicles and eggs, it does not necessarily mean that the eggs are of good quality. Egg quality is determined by factors such as your age, genetics, and environmental factors, and cannot be measured directly by AMH levels.

Am I ovulating if my AMH is high?

AMH levels do not indicate if you’re ovulating or not. Ovulation is the release of a mature egg from the ovary and can be confirmed by monitoring the menstrual cycle and/or performing ultrasound studies.

Will I get a lot of eggs if I have a high AMH?

The success of egg freezing outcomes largely depends on the number and quality of eggs retrieved. Studies have shown that AMH levels can be used as a predictor of egg quantity, and can thus help to predict the potential success of egg freezing. Those with higher AMH levels tend to have better outcomes with egg freezing, as they are likely to have more eggs retrieved and a higher chance of success in future fertility treatments. 

But by no means does a high AMH level guarantee a lot of eggs during an egg retrieval procedure for fertility treatments. The number of eggs retrieved during an egg freezing cycle depends on several factors, including your age, ovarian response to stimulation medications, any other underlying medication conditions, and the skill of the doctor performing the procedure.

What is a good AMH level for egg freezing?

Research has found that AMH is a good predictor of the response to ovarian stimulation and the number of eggs retrieved. Because of this, fertility doctors typically use your AMH levels (along with other biomarkers) to determine the drugs and dosages you will need to maximize your response to ovarian stimulation. 

Now, what about a correlation between AMH and actual babies born (live birth rate)? Well, while AMH does seem to have some association with live birth rates after IVF, its ability to actually predict a live birth is not that great. This is especially true for younger people. A 2021 study found that AMH is a good predictor of live birth in older (>39 years old), but not younger, people. They found that younger participants (≤38 years old) could get pregnant even with low AMH levels as long as they had frequent egg retrievals. 

Freeze your eggs with Cofertility

One option to make egg freezing better is working with Cofertility. Through our Split program, qualified freezers can freeze their eggs for free when donating half of the eggs retrieved to a family who can’t otherwise conceive. 

Through our Keep program — where you keep 100% of eggs retrieved for your own future use — we offer exclusive discounts on expenses, such as frozen egg storage. Keep members also still gain free access to our Freeze by Co Community, a safe space for those engaging in the egg freezing process (or gearing up for it) to connect and lean on each other. It also enables access to exclusive guidance, free expertise, and community events. 

By making egg freezing easier and more accessible, our programs further strengthen the American Society of Reproductive Medicine (ASRM)’s Committee Opinion that egg freezing can help promote social justice and strengthen gender equality.

Summing it up

A high AMH level is generally a good sign for your ability to successfully freeze your eggs. But for some, it can also be one indicator of PCOS. While a high AMH level is often associated with a larger number of ovarian follicles and eggs, it does not necessarily mean that the eggs are of good quality (egg quality is more dependent on age). 

AMH levels are commonly used as a marker of ovarian reserve and can be helpful, in conjunction with other measures, in predicting the number of eggs that can be retrieved during an egg freezing cycle. However, it is important to keep in mind that egg quality is determined by several factors and cannot be measured directly by AMH levels. If you have concerns about your fertility or AMH levels, it is important to speak with a fertility doctor for personalized advice and treatment options.

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Read more:

• Which Matters More for Fertility: AMH or Age?
• What AMH Level Do I Need to Freeze My Eggs?
• Do’s and Don’ts During Egg Freezing: Alcohol, Baths, Exercise, and More

The human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States. In fact, according to the Centers for Disease Control and Prevention (CDC), HPV is so common that “nearly all sexually active men and women get the virus at some point in their lives.” With at least 150 types of HPVs that we know of, it’s no wonder that 79 million Americans have at least one type. But fear not! 

While it’s true that some STIs can lead to infertility, there’s no need to freak out in the case of HPV. HPV on its own shouldn’t affect your ability to conceive. However, because HPV is often asymptomatic (meaning there aren’t any obvious signs or symptoms), it’s also one of the least treated STIs. Most of the time, that isn’t a big deal. But depending on the type of HPV someone has, there can be an increased risk of developing cancer or precancerous cells on the cervix, which do require treatment. The treatments to remove these abnormal cervical cells can, in turn, affect fertility—this is when discussing fertility if you have HPV becomes really important so let’s talk about it.  

What is HPV and what causes it?

We’re gonna back up for a second here and explain the basics of HPV. HPV is actually an umbrella term for a group of over 200 related viral infections that affect the outer skin layers of the genitals, mouth, hands and feet. So, while transmission can happen without sexual intercourse, the vast majority of HPV infections are the result of unprotected sex.

In these cases, you can get HPV by having vaginal, anal, or oral sex with someone who has the virus but it’s most commonly spread during vaginal or anal sex. It also spreads through close skin-to-skin touching during sex. A person with HPV can pass the infection to someone even when they have no signs or symptoms.

Because of this, if you’re sexually active at all, you can get HPV—even if you’ve had sex with only one person. You can also develop symptoms years after having sex with someone who has the infection. This is why doctors usually can’t tell you when you might have gotten it.

Types of HPV and treatments

Of the many types of HPV, only some are of actual concern and could therefore affect fertility, either due to the virus itself or the treatments used to manage it. Low-risk HPVs mostly cause no disease and typically go away on their own within 2-3 years. However, a few low-risk HPV types can cause warts on or around the genitals, anus, mouth, or throat. High-risk HPVs can cause several types of cancer. There are about 14 high-risk HPV types including HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68. Two of these, HPV16 and HPV18, are responsible for most HPV-related cancers.

As mentioned earlier, most HPV infections don’t cause cancer. Your immune system is usually able to control HPV infections so they don’t progress to cancer. However, high-risk HPV infections are more likely to persist and can eventually cause cervical cancer. In these cases, the immune system is not able to control the HPV infection and as the high-risk HPV infection lingers for many years, it can lead to abnormal cell changes that, if untreated, may worsen over time and become cancer.

If your doctor decides that they need to remove abnormal cells, they’ll use one of the following treatments:

• cryotherapy, or freezing and eliminating the abnormal tissue
• a cone biopsy (conization) to remove part of the cervix
• a loop electrosurgical excision procedure (LEEP), which involves removing cells with a wire loop that has an electrical charge

We’ll talk more about how these procedures can affect your fertility later on.

How does HPV impact fertility?

While most HPV infections clear up on their own (and rarely make themselves known through noticeable symptoms), the infections that persist can have a negative impact on fertility for all genders—either due to the infection itself or the treatments used.

Fertility risks associated with HPV include:

• Damage to the cervix via HPV itself or the treatment used to remove affected tissue from the cervix
• Decreased ovarian reserve
• Damage to sperm or parts of the male reproductive system

HPV and cervical function

First and foremost, HPV can damage the cervix directly over time if left untreated. This is why it’s so important to get those annual exams and routine pap smears with HPV testing! Most of the time, testing is the only way to know for certain whether a person has HPV or not. Once HPV has persisted for a long time or is getting more severe, it’s time to remove abnormal cells with one of the procedures mentioned earlier–cryotherapy, cone biopsy, or a LEEP. These procedures can most notably affect your ability to reach full term in a future pregnancy but this depends on several factors including how large and deep the area to be treated is.

In all cases, cell removal can change your body’s cervical mucus production. The procedures may also cause stenosis, or a narrowing of the opening of the cervix. This can slow down sperm and make it harder for an egg to get fertilized. Cones and LEEPs can also cause the cervix to weaken. While this won’t cause infertility or difficulty getting pregnant, it can lead to cervical insufficiency, which can cause your cervix to painlessly open and thin before your pregnancy has made it to term, and lead to a preterm delivery.

HPV and ovarian reserve

There have been several interesting studies about HPV and ovarian function but overall the literature is a bit of a mixed bag. Overall, research has suggested that HPV infection may be associated with a higher rate of spontaneous loss or underdevelopment when undergoing IVF. One study that compared HPV positive and HPV negative people found that a decreased ovarian reserve was more common in the HPV positive over the HPV negative group. Another study looked at HPV positive and HPV negative people undergoing IVF and their response to stimulation. No significant difference was seen in the responsiveness to controlled ovarian stimulation in terms of the number and maturity of retrieved eggs or in terms of fertilization rates. Finally, a recent study published this year showed no effect on live birth rates when comparing people with and without HPV.

HPV and its effects on male partners

Several studies have shown a link between HPV and decreased fertility for male partners. In particular, sperm containing HPV has been shown to negatively contribute to both male and couple infertility. One study done in 2011 found that men who had HPV were more likely to have an impairment of certain sperm parameters, like motility. This was confirmed in another study done in 2015. On top of that, if sperm containing HPV fertilizes an egg, there may be an increased risk of early miscarriage.

Can I freeze my eggs if I have HPV?

The good news with all of this is that an HPV diagnosis alone should not affect your ability to get pregnant or to freeze your eggs. Most fertility specialists will require an up to date pap smear and HPV test as part of their evaluation and you’ll usually be allowed to continue with the freezing process as long as the HPV is low-risk, since those cases are expected to clear on their own.

If you do have a high-risk HPV, you’ll need to discuss those results with both your OB/GYN and your fertility doctor to figure out what next step is right for you. Depending on the specific HPV strain, if there are any lesions and how advanced they are, your doctor will recommend continuing with egg freezing or delaying until after treatment. 

If there are precancerous cells in the cervix, minor treatment through cryosurgery or LEEP will be necessary and this is almost always recommended before trying to get pregnant or undergoing any other fertility treatments, including egg freezing or IVF. For the most part, these procedures don’t affect reproductive potential though and most people go on to have healthy pregnancies once they’ve recovered.

Risks and benefits of egg freezing with HPV

The main risk of freezing with HPV is the concern for a lower yield and the quality of eggs retrieved. As mentioned before, some studies have shown that HPV does have an effect on ovarian reserve but others have shown little to no differences in IVF outcomes. There are also so many additional factors that affect a person’s fertility. Your provider is going to be the best person to tell you whether your case warrants clearing the HPV before moving ahead with egg freezing. The benefit of egg freezing with HPV is that you’re taking a proactive step to preserve your future fertility. Whether your HPV is low- or high-risk, whether you require treatment or not,  you’ll know you’ve safeguarded your options.

Can I donate eggs if I have HPV?

The donor egg screening process will vary somewhat from clinic to clinic but here at Cofertility, our goal is to be as clear as possible about what this involves. All potential donors will be assessed in terms of their age, AMH levels, medical and family history, psychological and physical health. Making sure your pap smear and HPV testing are up to date is included in this process. 

HPV won’t automatically disqualify you from becoming an egg donor since it’s not transmittable through your eggs. However, as mentioned before, this will depend on which HPV type, whether it’s low or high-risk, and whether there are any precancerous or cancerous lesions found during the screening process. For a full list of disqualifications for egg donation through Cofertility, click here. 

Conclusion

The takeaway from all of this at the end of the day is that preventive care is king! Protecting yourself from HPV by getting vaccinated and making sure to get your pap smears on time can not only decrease your cervical cancer risk (which is a pretty good reason all on its own) but it can also lower your risk for preventable pregnancy or fertility concerns down the road. 

While there’s still more research to be done on the effects of HPV on fertility in all genders, it can safely be said that discussing HPV and fertility with your healthcare providers should be at the top of your list. This is especially true if you have HPV and end up requiring more invasive management—your providers can help you make a plan about your fertility future before any treatments begin.

Egg freezing and HPV can be confusing individually so you’re not alone when it comes to questions and concerns around both topics and how they affect each other. Freeze by Co is here to help you every step of the way. With our Split program, people between 21 to 33 years old have the chance to freeze their eggs for free! After a “Split” cycle, you would donate half of the eggs retrieved to a family that’s trying to conceive and freeze the remaining half for yourself. 

If you’re over 34 or not interested in donating half the eggs retrieved, you can still participate in the Keep program up to age 40. You would be able to freeze your eggs and keep them all for yourself, on your timeline while having access to an additional valuable resource in our support community. Our private, online community allows you to engage with other people freezing their eggs at the exact same time! 

Regardless of which path you choose, our Freeze by Co team and medical experts will be there to guide you through the process as we work to keep your family-building options on the table.