What is the ovarian reserve?

Have you ever asked yourself what in the world is the ovarian reserve? Learn everything you need to know about your egg cell reserve!

In this guide you will learn about ovarian reserve and how can you actually obtain information from this little treasure you are carrying around. Once you learn the power of this information, you will be able to better navigate the complex world of women’s health. For even more scientific explanations, see our list of references at the end of the page!

Introduction to ovarian reserve

A woman’s ovarian reserve is basically the pool of egg cells in her ovaries. During every menstrual cycle, a couple of the egg cells in the ovarian reserve start to grow. When one of those eggs reaches dominance, it is ready to be fertilised and the woman can therefore potentially get pregnant [1,2]. Since having sufficient egg cells is an essential prerequisite for getting pregnant, the ovarian reserve plays a crucial part in every woman’s fertility story.

Millions of eggs (ovarian reserve) VS. age

Millions of eggs (ovarian reserve) vs. Age

Every female is born with about 1 to 2 million egg cells. This number has already decreased to 300,000 – 400,000 by the time of her first period. After that, the number of egg cells in the ovaries decreases constantly, with women losing around one thousand egg cells per cycle due to natural cell death. At the time of menopause, the ovarian reserve has decreased to an estimated number of 1,000 egg cells and pregnancy is no longer possible [3,4]

How can you measure ovarian reserve?

The most up-to-date marker for ovarian reserve is the Anti-Müllerian Hormone (AMH). AMH is released by the small, growing egg cells in the ovaries, and it can be used as a metric for the remaining number of ovarian egg cells.

However, a woman’s reproductive lifespan cannot be estimated by just measuring the hormone level in the laboratory. Without correct interpretation, the AMH is of little value in fertility assessment. Its interpretation needs to be age-specific and based on the individual’s medical history: this includes an evaluation of smoking status, weight, diseases influencing fertility, and so on. Additionally, it is important to note that AMH tests only measure the number of egg cells left, but not their quality. Egg cell quality is also important when it comes to estimating pregnancy chances and it decreases significantly with age.

The ivary test measures your AMH and provides you with a comprehensive overview of your fertility, including a prediction of when you will enter menopause. Taking into account several other factors evaluated using a simple questionnaire, ivary can also provide you with personalised resources and recommendations.

Which factors influence ovarian reserve?

Contrary to popular believe, your ovarian reserve is decreasing even while you are taking contraception or when are not menstruating. Pregnancy itself does seem to have the potential to save some egg cells, since women with more children usually enter menopause at a later age [5]. Several therapies, surgeries and cancer treatments such as radiotherapy or chemotherapy can also affect ovarian reserve [3].

Beyond that, there is natural variation in the number of egg cells and the age of entering menopause between women [2]. This means that different women will have a different ovarian reserve even at the same age: this is why testing ovarian reserve can provide important information and empower women in their family planning.

A genetic predisposition for premature ovarian insufficiency may also be a risk factor for early menopause [3].

Premature Ovarian Insufficiency (POI)

Premature ovarian insufficiency (POI) is defined as ‘ovarian insufficiency’ before the age of 40 years. Women are diagnosed when they have stopped having their period for over 4 months and show a high FSH (> 40 IU/L) and low estradiol (< 50 pmol/L) in their lab results [6].

What does this really mean? Put simply, it means that your ovaries are already in menopause mode way too early. About 1-2% of women under 40 have POI, and in women under 30 the percentage is around 0.1% [7].

What are the symptoms of POI?

Usually, the effects of premature ovarian insufficiency are very similar to when women enter menopause. Women with POI often experience night sweats, hot flashes, high heart rates, vaginal dryness, recurrent bladder infections and emotional irritability [8]. Over the long term, the lack of estradiol can be connected to low bone density, a high risk for cardiovascular diseases (high blood pressure, heart disease), and an elevated risk for neurological diseases like dementia or Parkinson’s [6]. These effects can be treated by replacing missing estradiol via hormone replacement therapy.

POI is often connected to autoimmune diseases and genetic patterns and can also be a side effect of chemotherapy. Therefore, it is important to get a detailed check-up, including thyroid function tests as well as autoimmune and genetic screening [6,8].

Premature ovarian insufficiency factors

Luisi [8] Causes of premature ovarian insufficiency

What does POI mean for my fertility?

One of the symptoms of POI are missing menstrual cycles. However, up to 50% of women with POI may still have unpredictable ovarian activity every now and then for several years [8]. Therefore, it may still be possible to get pregnant unexpectedly. That is also why the name was changed from ‘premature ovarian failure’ (POF) to ‘premature ovarian insufficiency’.

For women with POI, the chances of becoming pregnant spontaneously are around 5-15% at sometime after the diagnosis is confirmed. For women who are looking to have a baby, oocyte donation offers the best chances to conceive. Egg freezing is another option to maintain good chances for pregnancy after chemotherapy [6].

Difference between Premature Ovarian Insufficiency (POI) and Diminished Ovarian Reserve (DOR)

We know that some of these terms are really complicated and confusing. But don’t worry, it’s not just you – these terms confuse everybody! In this field, not even medical experts seem to all agree on the definitions.

In an overview article addressing this issue, it is made clear that POI and a very low or so-called ‘diminished’ ovarian reserve (DOR) are not the same [9]. While POI comes with quite specific criteria only for women under 40 and causes several symptoms, DOR also occurs in women over 40 years and can be a normal state of ovarian reserve. For diminished ovarian reserve, criteria can vary from doctor to doctor, but the Federal Register of the American Center for Disease Control and Prevention accepts an AMH value <1.0 ng/mL as definition [10]. This means that DOR is measurable through ovarian reserve tests.

Diminished ovarian reserve is also a valuable predictor for the response to ovarian stimulation in Assisted Reproductive Technology (ART). There, it is used to identify potential poor responders [11].

However, a diminished ovarian reserve does not necessarily have implications on pregnancy rates. Especially in young women under 35, the quality of oocytes is usually so good that a low ovarian reserve does not affect their pregnancy rates [1213].

Women’s health resources

We have compiled a list of resources for you to get started with your fertility journey or dig deeper into the topic. Have a look at our ivary Resources Library, where you will find tons of free and exciting stuff!

  1. Berek, S. (2002). Novak’s Gynecology, 13th edition. Philadelphia, USA: Lippincott Williams & Wilkins.
  2. Vaskivuo, T.E., Tapanainen, J.S. (2003). Apoptosis in the human ovaryReprod Biomed Online,6(1), 24-35.
  3. Stoop, D. (2018). Preventing age related fertility loss. (Dominic Stoop, Ed.) (1st ed.). Switzerland: Springer International Publishing.
  4. Broekmans, F. J., Soules, M. R., & Fauser, B. C. (2009). Ovarian aging: Mechanisms and clinical consequences. Endocrine Reviews.
  5. Te Velde, E. R., & Pearson, P. L. (2002). The variability of female reproductive ageingHuman Reproduction Update8(2), 141–154.
  6. Vujovic, S., Brincat, M., Erel, T., European Menopause and Andropause Society, et al. (2010). EMAS position statement: Managing women with premature ovarian failureMaturitas67(1), 91–93.
  7. Coulam CB, Adamson SC, Annegers JF (1986) Incidence of premature ovarian failure. Obstet Gynecol 67(4):604–606.
  8. Luisi, S., Orlandini, C., Regini, C., Pizzo, A., Vellucci, F., & Petraglia, F. (2015). Premature ovarian insufficiency: From pathogenesis to clinical managementJournal of Endocrinological Investigation38(6), 597–603.
  9. Pastore, L. M., Christianson, M. S., Stelling, J., Kearns, W. G., & Segars, J. H. (2018). Reproductive ovarian testing and the alphabet soup of diagnoses: DOR, POI, POF, POR, and FORJournal of Assisted Reproduction and Genetics35(1), 17–23.
  10. Centers for Disease Control and Prevention (2015). Reporting of Pregnancy Success Rates From Assisted Reproductive Technology (ART) Programs. Department of Health and Human Services21108. Retrieved from federalregister.gov.
  11. La Marca, A., Sighinolfi, G., Radi, D., et al. (2010). Anti-Müllerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART)Human Reproduction Update16(2), 113–130.
  12. Pereira, N., Setton, R., Petrini, A. C., Lekovich, J. P., Elias, R. T., & Spandorfer, S. D. (2016). Is anti-Müllerian hormone associated with IVF outcomes in young patients with diminished ovarian reserve? Women’s Health (London, England)12(2), 185–92.
  13. González-Foruria, I., Peñarrubia, J., Borràs, A., et al. (2016). Age, independent from ovarian reserve status, is the main prognostic factor in natural cycle in vitro fertilizationFertility and Sterility106(2), 342–347.e2.