Diminished Ovarian Reserve

What is diminished ovarian reserve?

Diminished ovarian reserve is when you have fewer eggs in your ovaries compared to people your age. It’s sometimes called low egg count or low ovarian reserve. Your eggs are the building blocks (along with sperm) for pregnancy. Your egg count will decrease as you age, but this happens sooner than expected for some people. Diminished ovarian reserve makes it harder to get pregnant. Your healthcare provider diagnoses low ovarian reserve with ovarian reserve testing. Just because you have diminished ovarian reserve doesn't mean you can't get pregnant. It means you may find getting pregnant more difficult or need to consider fertility treatment.

How many eggs should I have?

Women or people assigned female at birth (AFAB) are born with all the eggs they’ll ever produce. Your age is the strongest predictor of egg supply. Studies show that the rate of egg loss increases once you turn 35.

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

• 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.

Can I get pregnant with diminished ovarian reserve?

Yes, you can still get pregnant with diminished ovarian reserve. 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.

What are the symptoms of diminished ovarian reserve?

Most people don’t have symptoms other than not getting pregnant after months or years of regular sexual intercourse. Others may notice their menstrual cycle getting consistently shorter.

If you’re experiencing symptoms of primary ovarian insufficiency, you may have symptoms of perimenopause such as:

• Hot flashes.
• Irregular menstrual periods.
• Vaginal dryness.

What causes diminished ovarian reserve?

Aging is one of the biggest causes of low ovarian reserve; however, sometimes, there is no cause. Other times, genetics or medical treatments cause diminished ovarian reserve. These include:

• Genetic disorders that affect the X chromosome.
• Radiation or chemotherapy (cancer treatment).
• Having surgery on your ovaries.
• Losing one or both of your ovaries.
• Autoimmune conditions.

Can stress cause diminished ovarian reserve?

No, stress can't cause diminished ovarian reserve. According to the American Society of Reproductive Medicine, smoking and using tobacco are the only lifestyle factors associated with decreased ovarian reserve.

What are the screening tests for diminished ovarian reserve?

Healthcare providers use ovarian reserve testing to screen for diminished ovarian reserve. Ovarian reserve testing is a way for providers to estimate how many eggs you have left. It can’t tell you for certain how many years of fertility you have left or if you’ll get pregnant. 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.

If you screen positive for diminished ovarian reserve, it doesn’t mean that you can’t conceive naturally. These tests don’t predict your ability to conceive naturally.

Ovarian reserve testing involves:

• Blood tests to measure levels of anti-mullerian hormone (AMH) or follicle-stimulating hormone (FSH) and estradiol. These tests measure how well you may respond to ovarian stimulation or fertility medication.
• Vaginal ultrasound to measure ovarian volume and count the number of follicles in your ovaries. This is called antral follicle count (AFC).
• A test called a clomiphene citrate challenge involves taking oral fertility medication and monitoring your body’s response. This test is uncommon.

People with diminished ovarian reserve have higher FSH levels, lower AMH levels and lower AFC compared to people of the same age. These tests don’t measure your ability to get pregnant without medication. They only predict the likelihood that you will have a good response to ovarian stimulation medication.

How is diminished ovarian reserve treated?

There is no way to reverse diminished ovarian reserve or produce more eggs. Once your healthcare provider suspects that you have low ovarian reserve, they’ll work with you on a treatment plan that helps you reach your pregnancy goals. This treatment plan will be determined by how soon you would like to get pregnant, how many children you would like to have, finances and the strength of your desire to have a child who is genetically related to you. Treatment options may include freezing your eggs for later use, attempting to conceive naturally or undergoing IVF with your own eggs or donor eggs.

Using your eggs

Freezing your eggs is one way to preserve your fertility. If your provider says you are at high risk for low ovarian reserve, they may suggest freezing your eggs before your egg count declines further. Egg freezing involves taking hormones to stimulate your ovaries to make as many eggs as possible. Then, the mature eggs are collected and frozen for future IVF treatment. In some cases, your provider will suggest creating embryos, meaning that they would fertilize the mature eggs with your partner’s sperm or donor sperm before freezing them for future use or transferring them to your uterus to get pregnant.

Using donor eggs

If your egg quality and/or quantity are poor, your provider may suggest using donor eggs. In this case, your partner's sperm fertilizes an egg from a donor. The resulting embryo is then transferred to your uterus. Your baby won't have your genes but can still have the genes from your partner (unless you use donor sperm).

Another option is embryo freezing. This involves fertilizing your eggs (or donor eggs) with sperm, creating an embryo, then freezing the embryo for future use.

Does folic acid improve egg quality?

Prenatal vitamins contain folic acid and are important for maintaining egg quality. Your healthcare provider will recommend starting a prenatal vitamin if you wish to become pregnant. Ideally, you should start a prenatal vitamin at least three months before conception. Diet, exercise and other lifestyle factors play a role in your eggs' health (or quality). However, it doesn’t affect the number of eggs or your egg count.

How can I reduce my risk for diminished ovarian reserve?

There is nothing you can do to prevent diminished ovarian reserve because most causes are out of your control. However, certain factors that may help maintain the quality of your eggs include maintaining a healthy weight and avoiding tobacco products like cigarettes.

How successful is IVF with low ovarian reserve?

Success rates with IVF vary depending on the cause of low ovarian reserve, how many eggs you have and how your body responds to fertility medication. The exact success rates of IVF in people with diminished ovarian reserve are unknown. Researchers know that like natural pregnancies, your success with IVF declines as you age. This includes people with diminished ovarian reserve. If screening tests show that you have a low ovarian reserve, you are less likely to respond well to ovarian stimulation medication, but it still may be the best option. You should discuss this with a fertility specialist.

Does diminished ovarian reserve mean menopause is coming?

It’s hard to put an exact timeline on when menopause will begin. Low ovarian reserve is an indication that your egg quantity is decreasing.

A note from Cleveland Clinic

A diagnosis of diminished ovarian reserve may leave you feeling hopeless or questioning what comes next. Just know that getting pregnant with this condition is possible, and you don't have to feel discouraged. Your healthcare provider can work on a treatment plan that helps you achieve your pregnancy goals with your remaining egg supply. Other options for pregnancy include fertility treatment or using donor eggs. Don’t give up your dreams of having a child based on having diminished ovarian reserve — there are treatments to help you.