Diminished Ovarian Reserve

A woman’s ability to reproduce heavily relies upon the state of her the number of eggs present in her ovaries because the more there are the higher the probability of becoming pregnant. This is known is the ovarian reserve. When there is a physiological decrease in the number of eggs then there is an insufficient number of eggs. Majority of the time this is directly impacted by age or ovarian dysfunction. By the time a woman hits puberty, her millions of eggs in utero and birth have decreased to a number around 300,000 – between 250,000 and 500,000 eggs. When a woman reaches the age 37, she will have, maybe a tenth of those eggs left, and only 0.4% of her initial count may remain. There are some disorders which will prematurely decrease a woman’s ovarian reserve, including Turner’s syndrome and other chromosomal abnormalities.

In Turner’s syndrome, a patient has only one X chromosome versus a woman with 2 X chromosomes. Another chromosomal abnormality which may cause premature ovarian reserve decline is Fragile X, a genetic condition involving changes in part of the X chromosome and is the most common form of inherited intellectual disability of boys. Ovarian tissue is also destroyed through:

  • torsion,
  • surgical removal of part of all of the ovary,
  • ovarian cysts caused by endometriosis,
  • benign or malignant ovarian tumors,
  • radiation or chemotherapy,
  • immunological conditions,
  • pelvic adhesions, or
  • obesity (a high body mass index).

The whole process is a part of a woman’s normal physiology regardless of the reason. In a normal menstrual cycle, hundreds of eggs are stimulated and only one is released during ovulation whereas the others are all reabsorbed and not functional.

 

 Figure 1 – As a woman’s age changes, her FSH, generally, increases and this affects the rate of live births.

Figure 1 – As a woman’s age changes, her FSH, generally, increases and this affects the rate of live births.

Treatments have been recognized to increase the number of eggs for women who have low ovarian reserves. These are known as stimulation protocols:

  • OCP/MicroFlare Lupron with high FSH dosing,
  • High FSH/HMG dosing with GnRH antagonist,
  • Combination MicroFlare and Antagonist with high FSH/HMG dosing,
  • Letrozole or Clomiphene and FSH/HMG,
  • Estrogen/progesterone in previous cycle on day 2,
  • Estrogen in luteal phase of previous cycle,
  • Estrogen and Antagonist start in the 2nd part of the luteal phase,
  • Low does FSH/HMG stimulation,
  • And natural or minimally sustained cycle.

In the hypothalamus (brain), GnRH is released in a pulsatile fashion which is best for fertility as well as a normal menstrual cycle. For those who do not have appropriate stimulation or too much stimulation of GnRH, there will be an imbalance in their FSH and LH (pituitary) numbers. Moreover, blood levels of:

  • FSH
  • Estradiol (E2)
  • Inhibin B
  • Anti-Mullerian hormone (AMH)
  • Antral follicle count (AFC),

should be checked for when a woman comes to see a physician for problems of infertility. Additionally, the Clomiphene Citrate Challenge Test (CCCT), exogenous follicle stimulating hormone reserve test (EFFORT), and GAST, which is the ovarian response to GnRH agonist (GnRHa) test may be done.

Furthermore, there are no apparent symptoms of diminished ovarian reserve. The condition advances over time and some women may see that their menstrual cycle has decreased in rhythm. And when menopause is impending, women may notice hot flashes, trouble sleeping, missed menstrual periods and vaginal dryness. Prognosis of the diagnosis of diminished ovarian reserve is solely dependent on when the diagnosis is made. Increased risk of miscarriages is a strong factor in hinting towards the diagnosis. Since this is normal physiology, there is no prevention. If you are a woman living in Denver you can visit the Denver Holistic Center to monitor your blood work and for more information if you feel you have any of the symptoms.