What is Diminished Ovarian Reserve and How Do You Treat It?

If you're worried about egg quantity, it's time to learn more about diminished ovarian reserve—here's what it means and how to treat it.

Your ovaries contain all the follicles they will have for your lifetime. It's your “ovarian primordial follicular pool” and it refers to the number of premature eggs remaining. Every cycle the ovaries (with the help of hormones) recruit a small group of follicles (the sacs that hold your eggs) to step up and try to grow. In a cycle, typically only one egg will mature, while the remaining die off. So, with each passing cycle, females slowly deplete their egg reserves. Diminished ovarian reserve (DOR) means that there are less follicles available in the ovaries to try to recruit. Lower egg quantity doesn’t necessarily mean there is lower egg quality. Although it’s an important variable to consider in your fertility journey, it doesn't mean you can't conceive—in fact, if you aren't undergoing IVF, egg quantity can't tell you how fertile you are. What it does do is let you know if you might be closer to menopause, which can impact your future ability to conceive.

What causes diminished ovarian reserve?

The main reason why you might have a diminished ovarian reserve is your age. But, from a biological perspective, not everyone ages at the same rate. Not all 40-year-olds have a diminished reserve, but all of them have a lower reserve than they did 10 years ago. There’s also the possibility of having a low egg reserve earlier than expected. When there is essentially no more reserve, and the ovaries stop functioning, this is menopause. If menopause happens earlier than expected (before the age of 40), it's you'll likely be diagnosed with premature ovarian failure or premature ovarian insufficiency, which occurs in about one percent of women and can be due to genetic factors, autoimmune conditions or previous damage to the ovaries (often due to surgery, chemotherapy or radiation treatment). Smoking cigarettes can also cause women to go through early menopause, and it is considered the most important modifiable risk factor if you wish to be proactive.

How do you know if you have diminished ovarian reserve?

In cases of DOR, you might notice your period isn't as regular or stops showing up altogether. But there might not be any signs or symptoms until you’ve been trying to conceive unsuccessfully and have a full workup done with a fertility clinic.

There are three main tests that best estimate ovarian reserve:

• Follicle-stimulating hormone (FSH): FSH stimulates the small follicles to that one will be recruited for ovulation. If there are fewer eggs to stimulate, FSH has to work harder and your body produces more of it. When considered in relation to ovarian reserve, the higher the FSH (when tested on day 3 of your cycle), the lower the ovarian reserve. Bird&Be's Ovarian Reserve Screening Test is an accessible way to test FSH at home to flag diminished ovarian reserve. 
• Anti-Mullerian hormone (AMH): AMH made and released by the recruited follicles and can be measured by a blood test. A low AMH indicates lower ovarian reserve (low number of follicles recruited and available) and in general AMH decrease as we age.
• Antral follicle count (AFC): An antral follucle count uses a transvaginal ultrasound to count the number of follicles recruited to grow that cycle. This is traditionally done on days two to five of the menstrual cycle to get the most accurate results. A low AFC indicates that less follicles are being called up—a sign that there are not as many left in the pool.

Fertility, Genetics and Hormones—A Glossary of TTC Tests →

What is the typical treatment for those with DOR who want to conceive?

If you have a low ovarian reserve and want to conceive, you could conceive without intervention, as it’s not considered a measure of egg quality. On any given cycle if a high-quality viable egg comes along and all other factors are reassuring, then it might just do the trick. That said, having diminished ovarian reserve impacts your timeline (you may want to try to conceive sooner if there are fewer eggs left) and chances of success with treatments like IVF (if there are fewer eggs overall, you'll likely to have fewer retrieved to freeze or fertilize). It’s always best to be proactive and get assessed by a fertility clinic to review your specific treatment options.

The most common initial fertility treatment with DOR is controlled ovarian hyperstimulation (COH). The ovaries are stimulated with hormonal treatments to to help the eggs develop and mature, and to hopefully recruit more eggs per cycle. If your partner’s sperm quality is good and having sex isn’t an issue for you, then the COH will be synced with timed intercourse and a trigger shot to initiate ovulation. If sperm quality is an issue, your doctor may suggest pairing COH with intrauterine insemination (IUI), where a washed sperm sample is inserted directly into the uterus using a catheter.

No matter the treatment, you'll also want to focus on egg quality, which can be improved with some lifestyle tweaks and the right supplements.