Diminished Ovarian Reserve and Infertility

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Most medical research suggests that women are born with all the eggs (oocytes) that they will ever have. Not only is the quantity limited, but it is believed that they ovulate their most fertile eggs first, which explains why miscarriages and chromosomal abnormalities (such as Down syndrome) become more common as women get older.
"Ovarian reserve" is a relative measure of how many eggs a woman has left. Because a woman's reproductive age as reflected by ovarian reserve doesn't always match her biological age ("driver's license age"), it is common to assess ovarian reserve before fertility therapy.

Risk Factors for Diminished Ovarian Reserve

Though a woman's age is one of the most basic components in predicting ovarian reserve, the rate of change in egg quantity and quality varies among women.

Common influences on a woman's ovarian reserve include: 

  • Genetics 
  • Smoking exposure 
  • Surgical history 
  • Autoimmune disease 
  • A history of chemotherapy or radiation exposure 
  • Other conditions
Testing for Diminished Ovarian Reserve
Not all women need to be tested for ovarian reserve - if a woman is under the age of 30, has regular periods, and is generally healthy, it is very likely that she has normal ovarian reserve and a review of her medical history may be the most efficient assessment of her ovarian reserve.
If a woman is 30 or over, and especially if over the age of 35, or there are medical conditions that put her at greater risk for diminished reserve, testing may be necessary. Also, if a woman is younger and about to undergo IVF, her ovarian reserve may be tested to assess optimally how much medication she should receive.
Common tests for ovarian reserve include:
  • Measuring estradiol and follicle stimulating hormone levels
  • Performing an antral follicle count
  • Performing a clomiphene citrate challenge test
Follicle stimulating hormone (FSH) and estradiol (E2, a form of estrogen) levels measure signaling between the brain and ovary, effectively telling us how hard the brain has to work in order to get the ovary to produce eggs. This is usually done on cycle day three, where day one is a patient's first day of heavy menstrual flow.
An antral follicle count measures the number of eggs being developed by the ovary at a particular time - the higher the number, the more likely that a woman has adequate ovarian reserve.
We don't usually order clomiphene citrate challenge tests anymore because they add cost, when usually we have enough information from the previously mentioned tests. However, in certain cases when a patient may be bordering between normal and abnormal ovarian reserve, this test may help clarify things.

Other tests for ovarian reserve include AMH and Inhibin B levels, as well as a few others. Though there are contexts where these might be performed, for most patients in our office, these tests take time and cost money without necessarily changing our assessment or treatment plans, so we rarely perform them.

Treatment for Diminished Ovarian Reserve
With regards to fertility, treating diminished ovarian reserve usually involves relatively assertive therapy, simply because these are usually contexts where there is a narrower window for reproductive opportunities.
This assertiveness for diminished ovarian reserve usually involves in vitro fertilization and generally applies to patients with a cycle day three  FSH between 10 and 15.
When the FSH is over 15, IVF is generally seen as not particularly cost effective, where success rates are comparable to that of intercourse.
Though adoption remains a wonderful alternative for many patients in this situation, women wishing to experience pregnancy for themselves can still conceive through egg donation or embryo adoption.
Generations Fertility Care is working diligently to maximize options for our patients, so contact us about what we can do to help you!