Diminishing Ovarian Reserve and Infertility

Ovarian reserve is a term that is used to determine the capacity of the ovary to provide egg cells that are capable of fertilization resulting in a healthy and successful pregnancy.The ability of a woman's ovaries to produce high-quality eggs is known as ovarian reserve (OR). As women get older, their OR naturally declines, the number and quality of eggs go down, and it becomes harder to get pregnant. Women attempting pregnancy after age 40 often have difficulty getting pregnant for this reason.

Premature Ovarian Aging and Infertility & Diminished Ovarian Reserve

DOR or POA negatively affects female fertility primarily through sub-optimal number of eggs and poor quality of eggs. Smaller number of lower-quality eggs reduce women’s fertility in two ways: they make it more difficult to get pregnant, and once pregnant, miscarriage are more likely to happen.

The standard goal of all fertility treatments is the improvement in pregnancy rates in patients with infertility problems. Within the past years, ovulation induction has contributed to the success of assisted reproduction techniques, in vitro fertilization (IVF) and embryo-transfer (ET). The efficacy of these techniques depends on a personalized protocol of controlled ovarian hyperstimulation (COH) and an adequate oocyte recruitment.

A woman is born with her entire life supply of eggs, approximately 1-2 million. At the time of her first menstrual period, the number of eggs has diminished to 300,000-400,000. Each cycle, hundreds of eggs undergo stimulation and usually only one is released during ovulation; the others are reabsorbed and are not functional. Peak fertility in women occurs before age 30, with a monthly pregnancy rate of 20-25 percent. This monthly rate starts to decrease around age 32, but rapidly declines beginning in the late 30’s and into the 40’s. Approximately one in three women experience infertility by age 40, mainly due to poor egg quality. Egg quality decreases as a woman ages, resulting in impaired fertilization, reduced implantation, and increased miscarriage along with the increased potential for chromosomal abnormalities of the fetus.

As more women are delaying childbirth and more baby boomers are reaching midlife, the problem of diminished ovarian reserve (DOR) is increasing. This has several major medical consequences including infertility, decreased bone mass with risk of fracture, abnormal uterine bleeding from lack of regular ovulation, and hot flashes. This article will address ovarian reserve testing and its impact on treating infertility.

As a woman, your fertility potential is largely determined by your ovarian reserve. Ovarian reserve refers to the number of eggs you carry in your ovaries, as well as the health and quality of those eggs. Assuming no other reproductive problems exist, ovarian reserve plays a large role in determining whether you will get pregnant or not. Your ovarian reserve depends not only on the quantity and quality of the eggs in your ovaries, but also on the quality of the response of ovarian follicles to hormone signals from the brain.

Ovarian reserve is a biological variable, and egg quantity and quality in an individual woman can be average for her age, better than average, or worse than average. Women with poor egg quality are said to have poor ovarian reserve , poor ovarian function, or occult ovarian failure.

Diminished Ovarian Reserve

Diminished ovarian reserve (DOR) is a condition where the ovary loses normal reproductive potential, which will compromise fertility. DOR can occur from injury or disease, but it is most often the result of normal aging. Around 20% of women diagnosed with infertility have DOR. Diminished Ovarian Reserve (DOR) is a condition meaning a woman's natural reserve of eggs has significantly reduced. This is a process that does normally occur for a woman as she is nearing menopause, but it can occur in a woman of any age. When this occurs, conceiving becomes difficult for a woman as her ability to produce eggs begins to diminish. Diminished ovarian reserve does not eliminate the possibility of pregnancy. However, this problem should encourage a woman to be more aggressive in her quest to become pregnant as time is clearly of the essence.

When a woman is diagnosed with DOR (high baseline FSH, low antral follicle counts and/or low AMH), most often she is told her chances of conceiving a biological child are very slim and that common infertility treatment, such as IVF, may also not be successful. Most of these women are told their only option is to seek out an egg donor to help her successfully achieve a pregnancy.

What are common causes of diminished ovarian reserve?

By the age of 45, few women remain fertile. However, success rates for fertility improve using in vitro fertilization (IVF) and egg donation. Certain things contribute to the diminished ovarian reserve. The common causes include:

• Age of 35 years and older
• Smoking
• Cancer treatments using chemotherapy and radiation
• Genetic abnormalities, such as X chromosome abnormalities
• Surgical removal of a portion or all of an ovary

What signs and symptoms are associated with DOR?

There are no outright symptoms and signs associated with diminished ovarian reserve, other than shortening of the menstrual cycle (going from 30 days to 24 days). Once menopause occurs, women show symptoms and signs of low estrogen, which include vaginal dryness, hot flashes, missed or absent menstrual periods, and trouble sleeping.

How is the ovarian reserve assessed?

To diagnose diminished ovarian reserve, the fertility specialist will perform a thorough physical examination and take blood samples. Testing is done on the second or third day of the menstrual cycle to measure estradiol and follicle-stimulating hormone(FSH) levels. Fluctuations in normal baseline values of these two hormones indicates a decline in the ovarian reserve. Another blood test that checks fertility is the anti-Mullerian hormone (AMH), which reflects the actual number of eggs in the woman’s body. In addition, the doctor will conduct ultrasounds to visualize the number of follicles on the ovaries.

How is DOR treated?

At present, there are no treatments for slowing down or preventing ovary aging. After DOR is diagnosed, a woman can cryopreserve (freeze) eggs or embryos for later use. With ovarian failure, or when ovaries do not respond to ovarian stimulating drugs, donor eggs are recommended by the fertility specialist. Women with DOR can use eggs donated from younger women to conceive long after menopause occurs. Part of the treatment for infertility is injectable gonadotropin (FSH). The response of the ovaries following FSH for stimulation is predictive of egg quantity. In vitro fertilization is a treatment option for women who have poor egg quality, as well as few viable eggs. A natural IVF cycle is used for women who produce 2-3 follicles, and it does not require ovarian stimulation. With natural IVF, the success rate is only 5%. However, with regular IVF, the success rate is 10%.

The option which offers the highest pregnancy rate for women with a poor ovarian response is to use donor eggs. While this is medically straight forward, it can be very hard for a young woman with regular cycles to accept this option. Often, it's worth doing one cycle with your own eggs even if the chances are poor, so that you have peace of mind that you did your best. This also may make it easier to explore the option of donor eggs for the future. When making the choice to move on to donor eggs or adoption be sure that you have explored all available treatment options to your satisfaction.

Many treatment strategies have been developed in order to treat women with poor ovarian reserve. Because time is at a premium for these women, treatment needs to be aggressive, in order to help them conceive before their eggs run out completely. IVF is usually their best option, as it offers the highest success rates. Superovulating these women can be quite tricky, and this is where the experience and the expertise of the doctor makes a critical difference ! Blossom Fertility and IVF Centre and its team of experts take individual interest in each and every patient because the problem of ovarian reserve differs from patient to patient. It is true that a skilled doctor will be able to design an optimal superovulation for women with poor ovarian reserve, it is also true that the results are still likely to be poor. We the doctors at Blossom, provide all the help to patients from blood test, counselling, ultra sonography and all other support till the success of the treatment and the ultimate goal of having a baby.