Reduced ovarian reserve

What is it?

Reduced ovarian reserve is a condition in which the ovary loses its normal reproductive potential, compromising fertility. This condition embody 10-30% of patients presenting to doctors with infertility and it is a challenge to treat. Etiopathogenesis is complex and only partly understood; however, some of the recognized etiologies include age-related depletion of ovarian follicles, advanced endometriosis, chromosomal and genetic alterations, prior ovarian surgery and pelvic adhesions, metabolic and enzymatic diseases, as well as toxic, autoimmune and infectious diseases. As women age, their natural fertility potential begins to diminish. This phenomenon is universal and can be seen as early as age 30, becoming more pronounced over the next decade. Illness or genetic abnormalities may accelerate this decline. 

Which are the symptoms?

Unfortunately, most women exhibit no signs or symptoms of reduced ovarian reserve. As the condition progresses over time, women may notice a shortening of the menstrual rhythm (e.g. 28 day cycles reduced to 24 days). Once menopause is imminent, women may notice signs of low estrogen such as hot flashes, trouble sleeping, missed menstrual periods and vaginal dryness.

  • Asymptomatic
  • Irregular menses
  • Flashes
  • Trouble spleeping
  • Vaginal dryness

How is it diagnosed?

Non-invasive tests such as hormonal assays and antral follicle count in transvaginal ultrasound are available to evaluate ovarian reserve. The blood measurements of hormones such as FSH and Estradiol should be performed on the second or third day of the menstrual cycle. FSH levels above 12 mIU/mL are considered mildly elevated; levels above 15 mIU/mL are considered abnormal enough to cancel assisted reproduction attempts, since patients in this range will fail to satisfactorily respond to fertility-enhancing medications; however, it has been considered that estradiol levels above 60-80 pg/mL can mask an altered FSH. Fluctuations in the normal baseline expression of these two hormones indicate declining ovarian reserve.
Blood measurements of AMH (anti-Mullerian Hormone) is another blood test which correlates with fertility potential. AMH is a product of the small antral follicles in the ovaries and are widely used to derive prognostic information such as the chance of successful ovarian stimulation.
Transvaginal ultrasound assessment of antral follicular count (AFC) is another tool to assess ovarian reserve. The AFC comprises the number of 2–5 or 2–10 mm diameter follicles measured in the ovaries at the start of the menstrual cycle and is highly correlated to the number of oocytes retrieved at pick up. In young women with familiarity of early monpause, the karyotype study is mandatory to exclude abnormalities linked to the X chromosome (fragile X syndrome, monosomy X, mosaicisms).

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How is it treated?

Presently, no treatments exist that prevent, slow down or reverse ovarian aging or depletion. Once reduced ovarian reserve is identified, treatments are designed to hasten the time to conception or to cryo-preserve (freeze) eggs or embryos for a patient’s future use. Patients with reduced ovarian reserve undergoing IVF are typically placed on higher doses of ovarian stimulation regimens in an effort to maximize the number of eggs retrieved or, in case of AMH level lower than 0.1-0.2 ng/mL, mild stimulation in order to support the patients hormonal spontaneous production. However, because assisted reproduction does not reverse the changes in the eggs responsible for this decrease in fertility, success rates for patients undergoing IVF parallel the normal decline in natural fertility seen in the population at large. Once the ovary has failed to respond to stimulation, or later fails endocrinologically, donor eggs are recommended to restore a woman’s reproductive potential. By using eggs donated by young women, who are typically in their 20s, women with reduced ovarian reserve may conceive and successfully deliver a baby, even long after menopause.

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