Diminished Ovarian Reserve

Diminished ovarian reserve affects about 10 to 30 percent of women seeking help for infertility, yet many who receive this diagnosis can still achieve pregnancy with proper care and treatment options tailored to their individual circumstances.

Table of contents

• What is Diminished Ovarian Reserve?
• Understanding Your Egg Count
• What Causes Diminished Ovarian Reserve?
• Symptoms of Diminished Ovarian Reserve
• How is Diminished Ovarian Reserve Diagnosed?
• Can You Get Pregnant with Diminished Ovarian Reserve?
• Treatment Options
• Related Conditions

What is Diminished Ovarian Reserve?

Diminished ovarian reserve (DOR) is when you have fewer eggs in your ovaries compared to other people your age^[1]. It’s also called low egg count or low ovarian reserve. The condition can also involve reduced quality of the remaining eggs^[3].

Ovarian reserve refers to the reproductive potential left within your ovaries based on the number and quality of eggs^[3]. Your eggs, along with sperm, are the building blocks for pregnancy. While your egg count naturally decreases as you age, this happens sooner than expected for some people, leading to a diagnosis of diminished ovarian reserve^[1].

Between 10 and 30 percent of people who seek help for infertility are diagnosed with diminished ovarian reserve^[4]. The condition makes it harder to get pregnant, but it does not automatically mean you cannot conceive. It simply means you may find getting pregnant more difficult or may need to consider fertility treatment^[1].

• Ovaries

Understanding Your Egg Count

Women are born with all the eggs they will ever produce^[1]. Your age is the strongest predictor of egg supply, and studies show that the rate of egg loss increases once you turn 35^[1].

Actual numbers vary from person to person, but these are the average number of eggs you have throughout life^[1]:

• Birth: 1 to 2 million eggs
• Puberty: 300,000 to 400,000 eggs
• Age 40: 25,000 eggs
• Menopause: less than 1,000 eggs

Only your healthcare provider can tell you how many eggs they think you have based on ovarian reserve testing results^[1]. The ovarian reserve can be considered part of the biological clock, but this clock can vary from woman to woman. Some women continue to be fertile in their 40s, while others begin to lose their fertility in their 20s^[3].

What Causes Diminished Ovarian Reserve?

Aging is one of the biggest causes of low ovarian reserve. As women age, their natural fertility potential begins to diminish. This is universal and can be seen as early as age 30, becoming more pronounced over the next decade^[4]. However, sometimes there is no identifiable cause for diminished ovarian reserve^[1].

Other factors that can cause diminished ovarian reserve include^[1][3]:

• Genetic disorders that affect the X chromosome, including Fragile X syndrome
• Radiation or chemotherapy used to treat cancer
• Surgery on your ovaries
• Losing one or both of your ovaries
• Autoimmune conditions
• Endometriosis
• Pelvic infections

According to the American Society of Reproductive Medicine, smoking and using tobacco are the only lifestyle factors associated with decreased ovarian reserve^[1]. Stress cannot cause diminished ovarian reserve^[1].

Symptoms of Diminished Ovarian Reserve

Most people don’t have symptoms other than not getting pregnant after months or years of regular sexual intercourse^[1]. Unfortunately, most women show no signs or symptoms of diminished ovarian reserve until they try to conceive^[4].

Some people may notice their menstrual cycle getting consistently shorter. As the condition progresses over time, women may notice a shortening of the menstrual rhythm, such as 28-day cycles reduced to 24 or 25 days^[3][4].

If you’re experiencing symptoms of primary ovarian insufficiency, you may have symptoms similar to perimenopause, such as^[1]:

• Hot flashes
• Irregular menstrual periods
• Vaginal dryness
• Trouble sleeping

How is Diminished Ovarian Reserve Diagnosed?

Healthcare providers use ovarian reserve testing to screen for diminished ovarian reserve. This testing is a way for providers to estimate how many eggs you have left^[1]. Testing is considered for women who are 35 years or older, have had ovarian surgeries, or have responded poorly to treatments such as ovarian stimulation^[8].

If you screen positive for diminished ovarian reserve, it doesn’t mean that you can’t conceive naturally. These tests identify if you’re less likely to respond well to ovarian stimulation medications for in vitro fertilization (IVF) or if you have a lower likelihood of achieving pregnancy without treatment^[1].

Ovarian reserve testing involves^[1][3][8]:

• Blood tests to measure levels of anti-mullerian hormone (AMH) or follicle-stimulating hormone (FSH). FSH levels above 10 to 12 mIU/mL are considered mildly elevated. Levels above 15 mIU/mL are considered abnormal enough to cancel assisted reproduction attempts, since patients in this range will fail to satisfactorily respond to fertility-enhancing medications. A low AMH level (less than 1.0 ng/mL) predicts a lower chance of pregnancy after IVF.
• Estradiol levels measured on day 3 of the menstrual cycle. Estradiol levels of 80 pg/mL or higher on day 3 suggest ovarian reserve is decreased.
• Transvaginal ultrasound to measure the antral follicle count (AFC). This is the total number of follicles that measure 2 to 10 millimeters in both ovaries during the early follicular phase. If AFC is low (3 to 10), pregnancy after IVF is less likely.

The AMH level and AFC appear to be the best tests for diagnosing diminished ovarian reserve^[8]. The AMH level is an early, reliable predictor of declining ovarian function^[8].

Can You Get Pregnant with Diminished Ovarian Reserve?

Yes, you can still get pregnant with diminished ovarian reserve^[1]. Your odds of conceiving may be smaller when your ovarian reserve is low, but you only need one egg to get pregnant. Egg count isn’t the only factor in getting pregnant. Egg quality, sperm quality, and the overall function of your uterus and fallopian tubes also play a large part in getting pregnant^[1].

Women diagnosed with diminished ovarian reserve have the same reduced success of conceiving with in vitro fertilization (IVF) as they do with natural efforts to conceive^[3]. In addition, women with DOR often have a greater risk of miscarriage when conceiving via IVF with their own eggs due to lower egg quality^[3].

However, diminished ovarian reserve does not mean that pregnancy is impossible^[8]. Because pregnancy may still be possible, treatment is individualized based on the woman’s circumstances and age^[8].

Treatment Options

Presently, no treatments exist that can slow down or prevent ovarian aging^[4][8]. Once diminished ovarian reserve is identified, treatments are designed to hasten the time to conception or to preserve eggs or embryos for future use^[4].

Fertility Preservation

If you are interested in extending your fertility, you should consider egg freezing^[4]. This involves freezing eggs or embryos for your future use.

Ovulation Induction

Ovulation induction may be done as treatment for diminished ovarian reserve^[8]. This involves using hormonal medications to trigger the body to produce as many mature eggs as possible each cycle. The treatment is often combined with intrauterine insemination (IUI), where prepared sperm is placed through the cervix with a small catheter at the time of ovulation^[3].

In Vitro Fertilization (IVF)

Patients with diminished ovarian reserve who are undergoing IVF are typically placed on higher doses of ovarian stimulation regimens in an effort to maximize the number of eggs harvested^[4]. However, aggressive IVF protocols can raise costs, reduce efficiency, and put additional cycles out of reach. Some clinics use natural cycle IVF or minimal stimulation IVF, which are precision-driven strategies designed to support patients with DOR or poor response to traditional protocols.

Donor Eggs

If women are over 42 years or if diminished ovarian reserve is diagnosed and the ovary has failed to respond to stimulation, donor eggs may be recommended to restore a woman’s reproductive potential^[4][8].

Related Conditions

Diminished ovarian reserve has to be distinguished from other related conditions:

Premature ovarian failure, also called premature menopause or primary ovarian insufficiency, is related to cessation of ovarian function before the age of 40. It is defined by a triad of signs: amenorrhea for at least 4 months, decreased estradiol serum concentrations, and elevated follicle-stimulating hormone levels^[5]. One percent of the population experiences ovarian failure earlier than age 40^[4].

Poor ovarian responders are patients who fail to respond satisfactorily to fertility-enhancing medications during assisted reproduction attempts^[4].

low egg count, low ovarian reserve, DOR