Low Ovarian Reserve

Low Ovarian Reserve

Low ovarian reserve is an important limiting factor for the success of any infertility treatment. It shows that women of reproductive age are producing fewer and lower-quality oocytes. (1)

What is a Low (Decreased) Ovarian Reserve?

The quantity and quality of the ovarian primordial follicular pool are defined by ovarian reserve. Low ovarian reserve in women of reproductive age indicates a decrease in the number of the ovarian follicular pool. Low ovarian reserve, however, is a significant contributor to infertility in many couples. 

In vitro fertilization (IVF) is becoming more widely accepted as a therapeutic option for infertility, which has led to the emergence of low ovarian reserve. It’s estimated that 10% or so of IVF patients will not respond well to gonadotropin stimulation. The incidence may be far higher among the infertile population, though, as many may never receive a thorough assessment or IVF. (2)

At what age is Low Ovarian Reserve common?

Ovarian reserve may begin to decrease at age 30 or earlier and decline rapidly after age 40. The reserve is also decreased by ovarian lesions or prior ovarian surgery. Age and decreasing ovarian reserve are both independent predictors of infertility and, thus, a poorer response to reproductive treatment, even while increasing age is a risk factor for decreased ovarian reserve. However, low ovarian reserve does not mean that pregnancy is impossible. (3)

How to diagnose Low Ovarian Reserve?

  • Follicle-stimulating hormone (FSH) and estradiol levels for screening
  • Antral follicle count (AFC) and/or antimüllerian hormone (AMH) level

Testing for decreased ovarian reserve in women is considered for those who are;

  • over 35 years old,
  • have had ovarian surgery
  • poor response to treatments such as ovarian stimulation with exogenous gonadotropins

Measuring FSH or estradiol levels is useful as a screening test for low ovarian reserve. On day 3 of the menstrual cycle, FSH levels > 10 mIU/mL or estradiol levels 80 pg/mL indicate low ovarian reserve. However, AMH level and AFC are currently the most effective tests to diagnose decreased ovarian reserve. (4)

What does the AMH level indicate?

AMH level is an early and reliable indicator of decreased 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 detect. (5)

What does the AFC level indicate?

AFC is the total number of follicles in both ovaries during the early follicular phase that ranges in size from 2 to 10 mm (mean diameter). AFC is calculated by observation during transvaginal ultrasonography. After IVF, pregnancy is less likely if the AFC is low (3 to 10). (6)

What should women with low ovarian reserve do?

Overriding concern that women with low ovarian reserve have a limited reproductive life cycle at which they can conceive with their own eggs governs all aspects of treatment. In the context of IVF, the majority of the data that are currently available on the efficacy of various treatment procedures in women with low ovarian reserve indicate low pregnancy and live birth rates regardless of age. 

Controlled ovarian stimulation (COS) is the cornerstone of all therapeutic interventions in nonresponsive patients to avoid deep and protracted pituitary suppression, prevent premature luteinizing hormone (LH) surge, maximize oocyte yield, and obtain embryos with good implantation potential. (7)

Treatment of low ovarian reserve is individualized based on the woman’s health and age because conception may still be possible. Ovarian induction can be done. 

If donor oocytes are available, assisted reproduction utilizing them may be required for women who are older than 42 or who have been given a diagnosis of low ovarian reserve. (8)

Treatment Options for Low Ovarian Reserve

For women grappling with the challenge of low ovarian reserve, a variety of treatment pathways exist to navigate the complex journey towards conception. Initially, natural conception remains a possibility despite the odds. With proactive early intervention and carefully timed intercourse, the chances of spontaneous pregnancy marginally increase. Furthermore, fertility medications offer a ray of hope by stimulating the development of eggs. Although these drugs yield lower success rates in comparison to those with a normal reserve, they represent a significant step towards achieving pregnancy.

  • Natural conception: A viable yet less probable route, enhanced by strategic timing.
  • Fertility medications: Drugs aimed at inducing ovulation, albeit with modest success.

In vitro fertilization stands out as the premier choice for those facing this condition. IVF circumvents the hurdles of ovulation, facilitating fertilization externally. Nonetheless, due to concerns regarding egg quality, the utilization of preimplantation genetic testing on one’s embryos might be advisable. Additionally, egg freezing emerges as a forward-thinking strategy for individuals not immediately seeking to conceive. This process secures eggs for future use, with outcomes contingent on the eggs’ quantity and quality.

  • In vitro fertilization: A leading solution, potentially augmented by genetic testing.
  • Egg freezing: A preparatory measure preserving eggs for subsequent IVF attempts.


Coccia, M. E., & Rizzello, F. (2008). Ovarian reserve. Annals of the New York Academy of Sciences, 1127(1), 27-30.

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