Diminished ovarian reserve is a decrease in the quantity and/or quality of oocytes, leading to impaired fertility.
(See also Overview of Infertility.)
Ovarian reserve may begin to decrease at age 30 or even earlier and decreases rapidly after age 40. Ovarian lesions or prior ovarian surgery also decreases reserve. Although increasing age is a risk factor for diminished ovarian reserve, age and diminished ovarian reserve are each independent predictors of infertility and thus of a poorer response to fertility treatment. However, diminished ovarian reserve does not mean that pregnancy is impossible.
Diagnosis of Diminished Ovarian Reserve
Follicle-stimulating hormone (FSH) and estradiol levels for screening
Antimüllerian hormone (AMH) level and/or antral follicle count (AFC)
(See also Testing and interpreting measures of ovarian reserve: A committee opinion (2020), from the Practice Committee of the American Society for Reproductive Medicine and the American Society for Reproductive Medicine.)
Testing for diminished ovarian reserve is considered for women who
Are ≥ 35 years
Have had ovarian surgery
Have responded poorly to treatments such as ovarian stimulation with exogenous gonadotropins
Measuring FSH or estradiol levels is useful as a screening test for diminished ovarian reserve. FSH levels > 10 mIU/mL or estradiol levels ≥ 80 pg/mL on day 3 of the menstrual cycle suggest ovarian reserve is decreased. However, the AMH level and AFC appear to be the best tests for diagnosing diminished ovarian reserve.
The AMH level is an early, reliable predictor of declining ovarian function. A low AMH level (< 1.0 ng/mL) predicts a lower chance of pregnancy after in vitro fertilization (IVF); pregnancy is rare when the level is too low to be detected.
The AFC is the total number of follicles that measure 2 to 10 mm (mean diameter) in both ovaries during the early follicular phase; AFC is determined by observation during transvaginal ultrasonography. If AFC is low (3 to 10), pregnancy after IVF is less likely.
Treatment of Diminished Ovarian Reserve
Ovulation induction
Sometimes use of donor oocytes
Because pregnancy may still be possible, treatment of diminished ovarian reserve is individualized based on the woman's circumstances and age. Ovulation induction may be done.
If women are > 42 years or if diminished ovarian reserve is diagnosed, assisted reproduction using donor oocytes, if available, may be necessary.
Key Points
Ovarian reserve may begin to decrease at age 30 or even earlier and decreases rapidly after age 40.
Begin testing for diminished ovarian reserve by measuring FSH or estradiol levels, and measure antimüllerian hormone (AMH) level and/or antral follicle count (AFC) to confirm the diagnosis.
If women are > 42 years or ovarian reserve is decreased, consider assisted reproductive technologies using donor oocytes.
