CC BY-NC-ND 4.0 · Indian J Radiol Imaging 2023; 33(04): 463-470
DOI: 10.1055/s-0043-1768964
Original Article

Age-Specific Nomograms for Antral Follicle Count in Fertile and Infertile Indian Women: A Comparative Study

1   Department of Radiodiagnosis & Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
1   Department of Radiodiagnosis & Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Madhu Jain
2   Department of Obstetrics & Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Rabindra Nath Mishra
3   Centre of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
› Author Affiliations
Funding None.


Objectives The aim of this study was to develop age-specific nomograms for antral follicle count (AFC) in fertile and infertile Indian women and (2) to compare the influence of age on AFC in both groups.

Setting and Design It is a prospective cross-sectional study in a tertiary-care hospital in north-central India.

Methods and Material One-thousand four-hundred seventy-eight fertile and 1,447 infertile women (primary infertility) of reproductive age (18–49 years) were recruited. One-thousand one-hundred eighty-one fertile and 1,083 infertile women fulfilled the selection criteria for the study. Transvaginal ultrasonography was done on the second or third day of the menstrual cycle.

Statistical Analysis Age-specific nomograms for AFC were built for the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles in both groups. Correlation and regression analysis was done to estimate the relationship between the study variables. Statistical analysis was done by using IBM SPSS Statistics for Windows, version 20.

Results At every age, each percentile value of AFC was lower in infertile than in fertile women. The decline of AFC with increasing age was linear in both fertile (r = − 0.431, p < 0.001) and infertile (r = − 0.520, p < 0.001) women; however, the rate was higher in the latter (0.50 follicle/year) than in former (0.44 follicle/year) group. The variation in AFC explained by age was 16.3% in fertile and 22.7% in infertile women.

Conclusion AFC decreased linearly with advancing age in both fertile and infertile women, but more rapidly in the latter. The age only modestly explained the decline of AFC. The age-specific percentile thresholds for AFC should be used instead of age-independent constant thresholds in infertility counselling.


The authors would like to declare that they have published the manuscript, using part of the data of this paper. However, both studies are not entirely the same.

Publication History

Article published online:
16 May 2023

© 2023. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Bozdag G, Calis P, Zengin D, Tanacan A, Karahan S. Age related normogram for antral follicle count in general population and comparison with previous studies. Eur J Obstet Gynecol Reprod Biol 2016; 206: 120-124
  • 2 Practice Committee of the American Society for Reproductive Medicine. Electronic address:; Practice Committee of the American Society for Reproductive Medicine. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril 2020; 114: 1151-1157
  • 3 Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81: 19-25
  • 4 Broekmans FJ, de Ziegler D, Howles CM, Gougeon A, Trew G, Olivennes F. The antral follicle count: practical recommendations for better standardization. Fertil Steril 2010; 94 (03) 1044-1051
  • 5 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 (02) 663-666
  • 6 Loy SL, Cheung YB, Fortier MV. et al. Age-related nomograms for antral follicle count and anti-Mullerian hormone for subfertile Chinese women in Singapore. PLoS One 2017; 12 (12) e0189830 DOI: 10.1371/journal.pone.0189830.
  • 7 La Marca A, Spada E, Sighinolfi G. et al. Age-specific nomogram for the decline in antral follicle count throughout the reproductive period. Fertil Steril 2011; 95 (02) 684-688
  • 8 Khan HL, Bhatti S, Suhail S. et al. Antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) are the predictors of natural fecundability have similar trends irrespective of fertility status and menstrual characteristics among fertile and infertile women below the age of 40 years. Reprod Biol Endocrinol 2019; 17 (01) 20
  • 9 Murphy MK, Hall JE, Adams JM, Lee H, Welt CK. Polycystic ovarian morphology in normal women does not predict the development of polycystic ovary syndrome. J Clin Endocrinol Metab 2006; 91 (10) 3878-3884
  • 10 Wiser A, Shalom-Paz E, Hyman JH. et al. Age-related normogram for antral follicle count in women with polycystic ovary syndrome. Reprod Biomed Online 2013; 27 (04) 414-418
  • 11 Scheffer GJ, Broekmans FJ, Dorland M, Habbema JD, Looman CW, te Velde ER. Antral follicle counts by transvaginal ultrasonography are related to age in women with proven natural fertility. Fertil Steril 1999; 72 (05) 845-851
  • 12 Broekmans FJ, Faddy MJ, Scheffer G, te Velde ER. Antral follicle counts are related to age at natural fertility loss and age at menopause. Menopause 2004; 11 (6 Pt 1): 607-614
  • 13 Wiweko B, Prawesti DM, Hestiantoro A, Sumapraja K, Natadisastra M, Baziad A. Chronological age vs biological age: an age-related normogram for antral follicle count, FSH and anti-Mullerian hormone. J Assist Reprod Genet 2013; 30 (12) 1563-1567
  • 14 Faddy MJ, Gosden RG, Gougeon A, Richardson SJ, Nelson JF. Accelerated disappearance of ovarian follicles in mid-life: implications for forecasting menopause. Hum Reprod 1992; 7 (10) 1342-1346
  • 15 van Rooij IA, Broekmans FJ, Scheffer GJ. et al. Serum antimullerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: a longitudinal study. Fertil Steril 2005; 83 (04) 979-987
  • 16 Barbakadze L, Kristesashvili J, Khonelidze N, Tsagareishvili G. The correlations of anti-mullerian hormone, follicle-stimulating hormone and antral follicle count in different age groups of infertile women. Int J Fertil Steril 2015; 8 (04) 393-398
  • 17 Göksedef BP, Idiş N, Görgen H, Asma YR, Api M, Cetin A. The correlation of the antral follicle count and serum anti-mullerian hormone. J Turk Ger Gynecol Assoc 2010; 11 (04) 212-215
  • 18 Scheffer JAB, Scheffer B, Scheffer R, Florencio F, Grynberg M, Lozano DM. Are age and anti-Müllerian hormone good predictors of ovarian reserve and response in women undergoing IVF?. JBRA Assist Reprod 2018; 22 (03) 215-220
  • 19 Bentzen JG, Forman JL, Johannsen TH, Pinborg A, Larsen EC, Andersen AN. Ovarian antral follicle subclasses and anti-mullerian hormone during normal reproductive aging. J Clin Endocrinol Metab 2013; 98 (04) 1602-1611
  • 20 Iglesias C, Banker M, Mahajan N, Herrero L, Meseguer M, Garcia-Velasco JA. Ethnicity as a determinant of ovarian reserve: differences in ovarian aging between Spanish and Indian women. Fertil Steril 2014; 102 (01) 244-249
  • 21 Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L. ESHRE working group on Poor Ovarian Response Definition. ESHRE consensus on the definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod 2011; 26 (07) 1616-1624
  • 22 Saxena P, Ghumman S, Prateek S. Ovarian reserve. Fertil Sci Res 2017; 4: 74-80
  • 23 Ruess ML, Kline J, Santos R, Levin B, Timor-Tritsch I. Age and the ovarian follicle pool assessed with transvaginal ultrasonography. Am J Obstet Gynecol 1996; 174 (02) 624-627
  • 24 Haadsma ML, Bukman A, Groen H. et al. The number of small antral follicles (2-6  mm) determines the outcome of endocrine ovarian reserve tests in a subfertile population. Hum Reprod 2007; 22 (07) 1925-1931