A diagnosis of diminished ovarian reserve does not automatically mean infertility, but it can shorten the window for success with a patient’s own eggs, making individualised planning essential, as outlined by Dr Kristýna Frühaufová, PhD, Head Physician at GYNEM Fertility Clinic in Prague.
Diminished ovarian reserve means that the ovaries contain fewer oocytes, or eggs, than expected for a person’s age, or that the ovaries respond less predictably to fertility medication. The condition describes egg quantity rather than egg quality. On its own, it is not a diagnosis of infertility.
Age is the most common reason ovarian reserve declines. As the ovaries age, both the number and quality of eggs decrease. Other possible contributors include ovarian surgery, removal of part or all of an ovary because of endometriosis or tumours, previous chemotherapy or radiotherapy, genetic factors and autoimmune conditions.
A low ovarian reserve can also occur in younger patients. In those cases, testing for Fragile X, including the full mutation or the premutation, may be appropriate. The wider medical history matters as well. For example, autoimmune disease may be relevant to infertility, but testing should be directed by the patient’s history rather than performed indiscriminately.
The diagnosis is therefore more than a single laboratory result. It is a picture assembled from ovarian reserve testing, age, previous treatment response and the goal of IVF.
The most commonly used test is AMH, a blood test that can be taken at any point in the menstrual cycle. AMH helps estimate how many follicles may respond to ovarian stimulation, but it is not the strongest predictor of whether IVF will result in a healthy birth.
An antral follicle count, or AFC, is used alongside AMH. During an ultrasound, the clinician counts the small follicles visible on the ovaries. The count is ideally performed during the early follicular phase of the cycle.
Additional baseline hormone testing commonly includes:
These results help determine how much medication may be useful and which protocol is most appropriate. They also have to be interpreted in the context of the treatment goal. A plan designed to collect eggs for future banking may differ from one intended to create several embryos for genetic testing.
AMH can indicate that only a small number of follicles are likely to respond, but age remains the stronger predictor of outcome. A low AMH does not provide a complete forecast, and a reassuring AMH cannot cancel out the effect of ovarian ageing.
Fertility tends to decline after age 35, and age is a stronger predictor of IVF success than AMH. The reason is that ovarian ageing affects not only the number of eggs available, but also the likelihood that an egg will produce a healthy embryo.
The numbers illustrate why doctors may recommend different strategies at different ages. At age 25, around 8 mature eggs are usually sufficient to guarantee a live birth of a healthy child. At age 40, around 25 to 30 eggs may be needed. At age 45, more than 30 eggs may be required to have one blastocyst.
Those figures are not a promise for an individual patient. They show why one egg does not equal one embryo, and one embryo does not equal one healthy child. With increasing age, obtaining enough eggs may require more than one stimulation cycle, and even repeated treatment does not guarantee success.
For someone in the early 40s who produces only a few eggs per cycle, mild stimulation may be considered because the initial response can be better and treatment may be less demanding on the body. Very high doses are not automatically more effective. Steady follicle growth is preferred, since an overly rapid response may be associated with poorer egg quality.
The most commonly used approach is the antagonist protocol. It usually begins on day 2 of the cycle, with daily injections of FSH or a combination of FSH and LH, known as gonadotropins. The dose can be adjusted during stimulation if the ovaries are responding differently than expected.
For patients with very low ovarian reserve or a previous low response, a flare protocol may be used. This begins with a short course of an agonist before gonadotropin stimulation is added.
Another option is mini IVF, also called mild stimulation. It uses lower doses of gonadotropins, typically alongside oral medication. This approach may suit patients with lower ovarian capacity who are focusing on obtaining the best possible outcome from a small number of eggs rather than maximising the number collected.
When only one or two follicles are visible, additional hormonal stimulation may not add much benefit. A natural or modified natural cycle may then be considered, using little or no stimulation and ovulation induction to help time egg retrieval.
Treatment decisions should be based on what happened in previous cycles, not simply on the amount of medication used. If few or no eggs were retrieved, the clinician may reassess the medication, the timing of the trigger and the interval between the trigger and egg collection. Empty follicles can occur with ovarian ageing because a follicle may contain no egg, or the egg may not have had enough support to mature properly. Adjusting the trigger strategy may help in some cases.
The aim is not to use the highest possible dose. In general, doses above 300 units are not used unless the patient has previously responded well to higher doses. Body weight and the individual treatment history are also considered.
Patients with diminished ovarian reserve are often offered supplements or procedures promoted as ways to improve ovarian function. The evidence described here does not support the idea that supplements improve egg quantity or egg quality. Age-related DNA damage cannot be reversed with medication.
CoQ10 may support egg quality when there is no prior DNA damage and may help maintain mitochondrial function. It is considered low risk, but large studies have not established whether it improves pregnancy rates across large groups of patients.
Growth hormone is more complicated. It can have potential side effects and is costly, so it is not a risk-free solution for diminished ovarian reserve.
PRP, or platelet-rich plasma, may appear to increase the number of follicles recruited in the cycle after treatment. That effect does not mean the eggs are healthier. If egg quality is poor because of ovarian ageing, a larger number of follicles may still produce a larger number of low-quality eggs. No improvement in pregnancy or delivery rates has been seen after ovarian PRP.
There are also procedural concerns. Injecting PRP into the ovaries may cause complications such as bleeding inside the abdomen. PRP may be used for the endometrium in some patients with a nonresponsive uterine lining, but that is a different application from injecting it into the ovaries.
The practical lesson is to separate an increase in follicle numbers from an improvement in the outcome that matters most: pregnancy and delivery.
PGT-A may be useful when several blastocysts are available, and the goal is to select an embryo for transfer. It may reduce the time to pregnancy by helping identify the best-quality embryo among multiple options.
PGT-A does not improve embryo quality. It also remains uncertain whether it improves outcomes when only a few eggs or embryos are available. Embryo testing carries potential risks, particularly for embryos of lower quality that may have difficulty surviving the process. Blastocysts should ideally be at least BB quality before testing.
For some patients, the number of embryos available makes testing a reasonable part of the plan. For others, testing may reduce the number of embryos available without offering a clear benefit. The decision depends on the number and quality of embryos, the patient’s age and the reason genetic testing is being considered.
Other genetic questions may require a different approach. If a partner has a structural abnormality such as a balanced translocation, the chance of obtaining a euploid embryo may be reduced, and the risk of miscarriage may increase. In that situation, embryo genetic testing may be advised. A report of mosaicism, however, needs to be interpreted in detail because its significance depends on the type and level of mosaicism.
If IVF using a patient’s own genetic material does not work, donor eggs are an alternative. Donor eggs offer higher chances because of the donor’s age, rather than because they reverse the recipient’s diminished ovarian reserve.
The possibility of egg donation can be difficult to discuss, particularly after multiple attempts with a patient’s own eggs. Yet waiting for a response that is unlikely to improve may also carry a cost, because ovarian response can decline from month to month. In some situations, several stimulations may be possible within a year, but producing only two or three eggs per cycle may still fall far short of the number needed to obtain a healthy blastocyst.
Embryo donation is another option, although the legal framework differs between countries. In some countries, it may involve an embryo that was created for another infertile couple but was not used. In the Czech Republic, embryo donation means using an egg donor and a sperm donor to create a donated embryo.
These choices should be discussed without judgment. They are not simply technical alternatives; they affect how patients think about genetic connection, family building, and the time they are willing to spend pursuing treatment with their own eggs.
Egg or embryo banking can provide an option for people who want to preserve fertility at an earlier age. The value of preservation depends heavily on when it is undertaken, because both egg number and egg quality are affected by age.
Fertility counselling should not be limited to people already in treatment. The limits imposed by age and ovarian ageing are relevant to the general public as well. People who are not ready to start a family may still benefit from understanding that postponing treatment can reduce the number of eggs available and increase the number needed to obtain a healthy embryo.
For younger patients diagnosed with diminished ovarian reserve, freezing eggs may be considered, particularly if they do not have a partner. Delaying family planning for too long can also reduce the range of available options.
A treatment plan should answer more than “How much medication will I take?” Patients may want to clarify:
The answers should also reflect the emotional and financial demands of treatment. Pregnancy may take time, and success with a patient’s own eggs cannot be guaranteed, especially as age increases.
Diminished ovarian reserve is a measure of egg supply, not a final verdict on fertility. AMH, ultrasound and hormone testing can help shape an IVF plan, but age remains the most influential factor in the likelihood of obtaining a healthy embryo.
The most useful strategy is neither automatically aggressive stimulation nor an uncritical pursuit of supplements and rejuvenation procedures. It is a clear assessment of the likely response, a protocol matched to the patient’s history and an early, open discussion of alternatives. Egg or embryo banking, donor eggs and embryo donation may all have a place, depending on the patient’s goals and the results of treatment.
Testing should be tailored to the specific case and medical history. It is important to establish whether there has been implantation failure or repeated miscarriage, as different investigations may be needed for each condition. Autoimmune disease, such as autoimmune arthritis, may also be relevant to infertility.
For a 46-year-old patient with AMH 0.62, a poor response to stimulation, several cycles using Menopur 300 and 150, and two egg retrievals (OPU) that produced only one follicle and no eggs, mini IVF makes sense. Empty follicles are seen quite often with ovarian ageing. A follicle may be empty by default, or there may not be enough support for the egg inside to grow well.
Double triggering is usually advised to help ensure that an egg, if present, matures. Adjusting the timing of the trigger may also help. Otherwise, the protocol involving Femara tablets and Gonal-F 150 is reasonable.
The recommendation depends on the patient’s parameters, but mild stimulation is often used after age 40 because the initial response may be better and the treatment is less demanding on the body. It may also reduce side effects. Steady follicle growth is preferred, as very high stimulation doses can produce a very fast response and may result in poor egg quality.
The dose usually does not exceed 300 units unless the medical history shows a good response to higher doses. Body weight is also taken into account. If the egg yield is too low, changing medication or adjusting the interval between triggering and egg retrieval may help.
Age is the main factor. The low AMH suggests that only a few follicles would be expected to respond to IVF stimulation. Statistically, around 25 to 30 eggs would be needed to obtain a euploid blastocyst result, which usually cannot be achieved in one stimulated cycle.
Multiple stimulations may be needed, but success is not guaranteed. Because ovarian response may decline each month, repeated stimulation in every cycle is not ideal. Theoretically, six to a maximum of eight cycles per year can be performed, but even an expected yield of two or three eggs per cycle would still likely not reach the target number.
When a patient has already undergone several treatments, including failed IVF and IUI, endometriosis surgery, microbiome testing, and partner DNA fragmentation testing, the testing completed so far may be sufficient. With ageing, the time to pregnancy becomes longer because of egg quality and because the egg needs a supportive follicular environment for growth and maturation.
The issue is not only the egg itself. Supporting structures also wear out over time, and mitochondrial DNA damage and insufficient cell lines within follicles may contribute. If ovarian capacity is good and enough eggs can be obtained in one cycle, IVF is the way forward. If only one egg is retrieved, the chances are reduced. The same applies to IUI.
Given the history of endometriosis, testing for adenomyosis may be useful. Otherwise, no further testing was recommended, and egg donation is a reasonable option.
If partner mosaicism involves a structural abnormality such as a balanced translocation, the chance of obtaining a euploid embryo is reduced, and the risk of miscarriage increases. In that situation, embryo genetic testing would be advised. Low-level mosaicism related to age can be normal in both male and female blood DNA testing.
With a low egg yield and transfers at age 45, the embryos transferred are statistically likely to have been aneuploid. More attempts would be needed to reach statistical significance. Around nine blastocysts would be needed for one to be euploid.
Abdominal tuberculosis is rare, but it may be a reason for diminished ovarian reserve. The uterine lining should also be checked because tuberculosis can affect the tubes, endometrium, and ovaries. In some cases, the endometrium becomes nonresponsive to stimulation.
Ultrasound and hysteroscopy can be used to check for adhesions or an abnormal uterine cavity. A response involving seven follicles was considered quite good for an AMH of 1.07 pmol and an AFC of 4, so the same Menopur, Cetrotide, and double Ovitrelle stimulation would be continued.
When only one or two embryos are available and genetic testing is not being performed, transferring a day 3 embryo can be a good strategy. Staying longer in the laboratory does not improve embryo quality, and embryos may develop better in the womb.
A less aggressive approach is not only for patients of advanced maternal age. Steady stimulation may improve egg quality and egg yield. The dose usually does not exceed 300 units unless the patient has previously responded well to higher doses. Body weight is also considered, and a heavier patient may receive a higher dose.
Medication used for ovarian stimulation can pass directly through breast milk to the baby. The rise in estrogens during stimulation is also not compatible with breastfeeding. For safety, no medication, especially estrogens, should be used during breastfeeding, particularly if the baby is a boy.
PRP affects the ovaries and seems to speed up follicle recruitment in the following cycle. It may therefore have a short-term effect on the number of follicles observed and collected. However, it does not improve egg quality. If egg quality is poor, more follicles would still mean more low-quality eggs.
There is no improvement in pregnancy or delivery rates after ovarian PRP. The clinic does not offer ovarian PRP and remains cautious because of possible complications such as intra-abdominal bleeding. PRP is used for the endometrium, with promising results, especially in patients with a nonresponsive endometrium, by injecting it into the endometrium rather than flushing the uterus.
Prepare emotionally and financially, as treatment can be demanding and pregnancy may take time. In younger women without a partner, freezing eggs can provide a backup. Family planning should not be delayed for too long, because age is the most important factor in IVF success and spontaneous conception.
Remain open and realistic about expectations, and be willing to discuss all alternatives without judgment.
