What Does It Mean to Have a Diminished Ovarian Reserve?
Trying to conceive is one of those weird things that’s incredibly easy for some people and frustratingly difficult for others. If you fall into the latter camp, at some point you may decide to undergo medical testing in an attempt to figure out where you and your partner stand fertility-wise.
Reproductive science has evolved to the point where there’s a wide range of exams to test fertility, some of which can gauge the status of your ovaries. If, after testing, your doctor reaches out with the news that you have a diminished ovarian reserve, you might feel confused and worried about how it could change your odds of conceiving. Here’s what you need to know.
Your ovarian reserve is essentially the number and quality of your eggs at any given time.
You’re born with a set number of eggs in your ovaries, according to the American College of Obstetricians and Gynecologists (ACOG). This is your ovarian reserve.
If a doctor says your ovarian reserve is low or diminished, this means that your eggs are lower in number or quality than expected for your age, says Deidre Gunn, M.D., a reproductive endocrinologist at University of Alabama at Birmingham. (This is different from premature ovarian failure, which is a loss of the normal function of your ovaries before you turn 40, the Mayo Clinic says. With this phenomenon, your eggs don’t produce normal amounts of the hormone estrogen or release eggs regularly, making it tough to get pregnant without reproductive assistance.)
To give you some background, if you have ovaries, your prime reproductive years are typically between your late teens and late 20s, according to ACOG. As you move past that window, the number of eggs you have in your reserve naturally goes down. So does their quality since the eggs you have left are more likely to have abnormal chromosomes that make conception harder, ACOG explains. As a result, your ability to get pregnant will start to decrease steadily after age 30, declining more by the time you reach your mid-30s. (This is a steady decline, not a fertility “cliff” that suddenly changes your chances of conceiving drastically at any one point, Dr. Gunn says. But it does happen.) By age 45, it’s unlikely that most women will get pregnant without some form of medical intervention like IVF.
Putting all of this into context, having a diminished ovarian reserve can mean that at age 30, the quality and quantity of your eggs is more typical of someone who’s 45, for instance. This can happen due to factors such as chemotherapy, radiation, ovarian surgery (for an ovarian cyst or ovarian cancer, for instance), mutations in genes that are related to ovarian function, and endometriomas, or cysts that form due to the health condition endometriosis. Some experts believe pelvic inflammatory disease, when bacteria from an untreated sexually transmitted infection spread to the reproductive organs, can cause a diminished ovarian reserve. But sometimes doctors can't pinpoint the cause of someone's diminished ovarian reserve at all.
If you have a diminished ovarian reserve or are hoping to get pregnant but are concerned about your age, those last few paragraphs might have been really hard to get through. None of this means that you’re destined for infertility as you get older or that you can’t get pregnant if you don’t have the normal amount or quality of eggs for your age. But it’s important to know these facts so you can make the most informed choices when it comes to your fertility and any medical care you decide to pursue.
The amount of time you should wait to see a doctor when trying to conceive rests largely on your age.
If you’re not yet 35, the recommendation is usually to try to get pregnant for at least a year before you see a doctor with concerns about fertility, according to the Mayo Clinic. If you’re between 35 and 40, that goes down to six months. And if you’re over 40 and hoping to get pregnant, bring that up to your doctor ASAP in case they want to start testing immediately. (To be clear, you should always tell your doctor you want to try to get pregnant no matter your age, but if you’re under 40, the recommendation is generally to wait a certain time before going back if conceiving seems to be taking too long.)
It can also be smart to ask about testing if you’re under 40 with a history of certain health issues, like irregular or painful periods, repeated miscarriages, or endometriosis, the Mayo Clinic says. And you can see a doctor at any time, no matter your age, if you just need some reassurance that things are OK with your fertility or other aspects of your health. That’s what they’re there for.
There are a few tests your doctor can perform to figure out if you have a diminished ovarian reserve.
If your doctor shares concerns about your fertility, they’ll decide to test aspects of it based on factors like your age, time spent trying to conceive, and past medical history.
If they’re going to look into your ovarian reserve, they might perform a transvaginal ultrasound, which involves your doctor or an ultrasound technician inserting a device into your vagina to get a better look at your ovaries (and other reproductive organs). This sounds dreadful but actually shouldn’t be too uncomfortable physically, at the very least. Learning all about what to expect before, during, and after a transvaginal ultrasound may cut down on emotional discomfort, too.
A transvaginal ultrasound can help a doctor examine your ovarian antral follicle count, which tells them how many follicles you have on each ovary, says Alan B. Copperman, M.D., director of the Division of Reproductive Endocrinology at the Icahn School of Medicine at Mount Sinai. At the beginning of your menstrual cycle, these follicles, each of which contains an egg, begin to mature in preparation for ovulation. “[The ovarian antral follicle count] can add information about ovarian reserve and can even help predict how many eggs a woman will produce if she undergoes egg freezing or IVF,” Dr. Copperman says.
Your doctor can also order two different blood tests to look into your ovarian reserve, Dr. Gunn says. One checks the level of follicle stimulating hormone (FSH) in your blood. At the start of your menstrual cycle, the pituitary gland in your brain produces this hormone to make your ovaries to create those egg-containing follicles for ovulation. This test is usually done by day four of your menstrual cycle, says Tarun Jain, M.D., a reproductive endocrinology and infertility specialist at Northwestern Medicine.
The other blood test looks for anti-Müllerian hormone (AMH), a protein made by the cells that surround each egg, and can be done at any point in your cycle. There are standard AMH levels for different age groups, and like your number of eggs, your amount of this protein will also decline as you age. That makes it a pretty good indicator of fertility when considered along with the other tests, Dr. Gunn says. “The important thing is there is no one single test that perfectly measures your ovarian reserve,” she says.
If you have a diminished ovarian reserve, there’s only so much your doctor can do to help—but that doesn’t mean you can’t get pregnant.
“There is presently no known method to reduce the rate of egg loss,” Dr. Jain says. Similarly, there’s no magic pill you can take to create new eggs.
That said, your doctor will likely recommend that you meet with a fertility specialist who can suggest next steps depending on the severity of your situation. In many cases, they’ll have you take a fertility medication like clomiphene, which stimulates ovulation, Dr. Gunn says, adding that the medication can be used together with intrauterine insemination (IUI), where sperm is placed inside your uterus to try to increase the odds that you’ll get pregnant in a particular cycle.
If that doesn’t work, or if your ovarian reserve is low enough that IUI doesn’t have a good chance of succeeding, your doctor may recommend going straight to in vitro fertilization, which involves implanting already fertilized eggs in your uterus.
It might be possible to make IVF work with your own eggs. If not, your doctor may recommend that you consider using donor eggs. “The uterus, fortunately, does not age,” Dr. Jain says. “These donor eggs can be fertilized with the partner's sperm, and the resulting embryo can be placed in the woman's uterus, with a very high chance of a successful pregnancy.”
Again, it’s completely possible to have a diminished ovarian reserve and still conceive—even without reproductive assistance. “Achieving a pregnancy is still possible,” Dr. Copperman says. “The key is to not delay getting a formal evaluation from a specialist and taking action.”