Diminished Ovarian Reserve

Women are born with a fixed number of eggs (oocytes) in their ovaries. This egg supply – known as a woman’s ovarian reserve – decreases with age.

If a woman has diminished ovarian reserve (DOR), it means she has fewer eggs in her ovaries compared to other women her age. This condition is also sometimes referred to as low ovarian reserve or low egg count. 

Most women with diminished ovarian reserve don’t have any symptoms. In many cases, women find out they have diminished ovarian reserve through testing done by one of their physicians or providers. In some cases, some women may find that they are having shorter menstrual periods if they have a diminished ovarian reserve.

In many cases there is not a specific reason that one woman has diminished ovarian reserve compared to another woman. A woman’s ovarian reserve is likely influenced by genetic and environmental conditions, but there are certain additional factors that may contribute to diminished ovarian reserve or make it more likely. These include:

• Genetic disorders
• Cancer treatment, such as radiation or chemotherapy
• Ovarian surgery
• Smoking and tobacco use
• Autoimmune conditions 
• Family history of early menopause 
• Ovarian damage caused by endometriosis, pelvic infection and other diseases 

In many cases, no cause can be identified.

Diagnosis starts with a thorough discussion of your medical history, a physical exam, and typically a pelvic exam.

Additional ovarian reserve testing may include:

• Ultrasound imaging – to examine the reproductive organs for conditions that may be affecting fertility and to determine the number of follicles in the ovaries (antral follicle count, or AFC), for an estimated count. Normally, there are 8-11 follicles growing each menstrual cycle, in each ovary. This number diminishes with age, becoming less than 4 in each ovary in women over 40 years of age. In women with diminished ovarian reserve, the number of antral follicles is typically lower than the expected number by age.
   
• Blood tests to measure hormone levels – The most important hormone for evaluation of diminished ovarian reserve is the anti-Müllerian hormone (AMH). AMH concentration in the blood varies with age, being highest in a woman’s mid-twenties with a value greater than 3.0 ng/ml. In women with diminished ovarian reserve, AMH is typically lower than the value based on their age, and in the severe cases, AMH can be less than 1.0 ng/ml. Other tests include FSH (follicle-stimulating hormone) and estradiol levels, which can indicate whether a woman’s body will need fertility-enhancing medication. 

There is no treatment to increase a woman’s ovarian reserve back to normal but since some patients may find difficulty with becoming pregnant with low egg counts, meeting with a reproductive endocrinology and infertility (REI) specialist, also known as a fertility specialist, can help you determine a treatment plan that best meets your needs and goals. 

Treatment options include:

• Egg (oocyte) freezing – Fertility medication is used to stimulate the ovaries to produce multiple follicles in one given cycle. The eggs are then surgically retrieved and frozen for fertilization with sperm at a later date. Even if your ovarian reserve is low, the quality of each egg (in other words, the likelihood it could become a healthy pregnancy) is mostly determined by your age and not by the number of eggs in your ovaries.
• Ovulation induction with insemination (IUI) – In some cases for couples with a female partner that has diminished ovarian reserve, using fertility tablets can help make your ovary produce 1 to 2 good quality follicles. After using a trigger injection, an intrauterine insemination can be performed to optimize the chance of a successful conception.
• In vitro fertilization (IVF) – Fertility medication is used to stimulate the ovaries to produce eggs, which are then surgically retrieved and mixed with sperm outside the body. If the egg is fertilized, the embryo is then transferred to the woman’s uterus or frozen for later use. IVF is the most effective method for conception in women with diminished ovarian reserve, older than age 37 years.
• IVF using donor eggs – For women unable to produce follicles during ovarian stimulation, a donor’s eggs can be utilized and fertilized in the lab using sperm from the woman’s partner. The fertilized embryo is then implanted in the patient’s uterus or frozen for later use. To some, this method poses some ethical concerns but might be the only possible treatment before undergoing embryo or conventional child adoption.

In general, the guidelines on when to consult a fertility specialist are as follows:

• If you are 35 or older and haven’t gotten pregnant after six months of regular, unprotected sex
• If you are younger than 35 and haven’t gotten pregnant after one year of regular, unprotected sex
• If you are older than 40, an evaluation is recommended even before trying conception 
• If you have been told you have diminished ovarian reserve, we would recommend a consultation to discuss implications or potential options that may fit your desires.

Call 832-826-7272 to make an appointment with a Baylor College of Medicine reproductive endocrinology and infertility (REI) specialist.