Diminished ovarian reserve: what is it, symptoms, testing, treatment

If you’ve been trying to get pregnant but haven’t been able to—and especially if you’re over 35—there are many possible causes, one of which is a condition called diminished ovarian reserve. This means you have fewer eggs, which may be of lower quality, making it harder to get pregnant. But many women with diminished ovarian reserve successfully get pregnant and give birth to healthy babies. 

Read on to learn about this condition, how it’s diagnosed, and what treatments are available.

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Diminished ovarian reserve, also called low egg reserve or low ovarian reserve, is a condition in which a woman has a reduced number of high-quality eggs in her ovaries. At birth, a female baby has about a million follicles (fluid-filled sacs in the ovaries that contain immature eggs). At puberty, that number has dropped to about 300,000 follicles. The number of follicles continues to go down throughout a woman’s life, accelerating in a woman’s mid-thirties (Walker, 2021). 

Over time, that ovarian reserve diminishes. For some women, though, it can happen at an accelerated rate for various reasons. 

Usually, diminished ovarian reserve isn’t a disease or a disorder. It’s part of the normal process of aging. Age is the single most important factor in a woman’s fertility. Women are most fertile in their early 20s. Fertility declines after that, dropping steeply after age 35, when a woman generally has fewer eggs, typically of lower quality (Vollenhoven, 2018). 

Of course, many women over 35 have successful pregnancies that result in healthy babies, and it’s becoming more common for women to have children older in life—in 2016, over 22% of births in the US were to women over 35 (Heazell, 2018). Still, it’s important to be aware of the increased risk of infertility, miscarriage, and congenital abnormalities in women older than 35 trying to get pregnant or become pregnant, which is why these women will often receive more intensive prenatal care (Liu, 2015).

But diminished ovarian reserve isn’t only a consequence of aging. It can also happen due to injury, illness, or other external factors. One well-documented cause of diminished ovarian reserve is smoking. Smoking harms both your chances of getting pregnant and the quality of your eggs. One study found that menopause occurs almost two years earlier in smokers than in nonsmokers (Walker, 2021).

Other causes of diminished ovarian reserve include ovarian surgery, chemotherapy, radiotherapy, genetic disorders (such as Turner’s syndrome and fragile X syndrome), and autoimmune diseases (including Addison’s disease, Hashimoto thyroiditis, and celiac disease) (Walker, 2021).

Diminished ovarian reserve has no symptoms other than a potential difficulty getting pregnant if you are trying to do so. 

If you don’t experience diminished ovarian reserve prematurely due to other causes, the symptoms that will come along with diminished ovarian reserve are the same as those that accompany menopause. As you get older, you might notice changes brought on by alterations in your hormone levels. Your menstrual cycles might get shorter (for instance, going from 27 days to 23 days). As you approach menopause, you might see other signs of dropping estrogen levels, like missed periods, vaginal dryness, hot flashes, and trouble sleeping.

Most women experience natural menopause between the ages of 40 and 58. However, 1% of the population experiences ovarian failure (menopause) earlier than 40 (Torrealday, 2015). This condition is called premature ovarian failure or premature menopause.

There are several different tests for diminished ovarian reserve. The two most common are blood tests (Walker, 2021):

• Cycle day 3 FSH and estradiol—An FSH (follicle stimulating hormone) level greater than 20 IU/mL indicates low ovarian reserve.

• Anti-Mullerian hormone (AMH)—Lower levels of AMH generally reflect reduced numbers of eggs in the body.

If ovarian reserve tests show a diminished ovarian reserve, it means that pregnancy without assistance is less likely. But that doesn’t mean it’s impossible.

Diminished ovarian reserve can be difficult to treat. However, some women with diminished ovarian reserve can conceive with their own eggs after getting individualized treatment (Rasool, 2017). Women can also choose to use donor eggs to conceive.

Once diminished ovarian reserve has been diagnosed, it’s important to start fertility treatment as soon as possible. Any accompanying conditions (such as an autoimmune disease) that may limit fertility should be treated as well. In addition, some of a woman’s remaining eggs may be removed and frozen for future use.

Treatment options include:

• Intrauterine insemination (IUI)—Prepared semen is inserted directly into the uterus.

• In vitro fertilization (IVF)—Mature eggs are removed from the body and mixed with sperm outside the body. One or more fertilized eggs are then transferred directly into the uterus. IVF is usually done together with ovarian stimulation using fertility medications.

• ICSI (intracytoplasmic sperm injection)—ICSI is a form of IVF in which the male partner’s best-quality sperm are selected and injected directly into each egg.

• Dehydroepiandrosterone (DHEA)—This supplement may be taken before IVF is begun to improve the health of the eggs and improve the chances of pregnancy (Qin, 2017).

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Current version

January 26, 2022

Written by

Alison Dalton

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.