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Poor Ovarian Reserve

Poor ovarian reserve (POR) is an important limiting factor for the success of pregnancy or any treatment modality for infertility. It indicates a reduction in quality and quantity of oocytes in women of reproductive age group.


Ovarian reserve defines the quality and quantity of ovarian Primodial follicular pool. Poor ovarian reserve (POR) is reduction in the quantity of that pool in women of reproductive age group, which is an important cause of infertility.


Women of certain areas have faster ovarian aging . Indian women are found to be approximately 6 years older than their Spanish counter parts. White European women ,  those from India, Southeast Asia, Middle East, Afro-Caribbean undergoing IVF in UK showed a lower live birth rate indicating a possible causative role of ethnicity. Chinese, Latina , and African women had a lower ovarian reserve compared to Caucasian women of similar age.


Diminished ovarian reserve is a phenomenon often noted in women with their mid to late thirties (35-38), but it may affect the younger women too. However, recent evidence challenges this and POR may be associated with low pregnancy rates irrespective of age and high pregnancy loss. Majority of women with POR needs to undergo IVF and accept lower oocytes yield and lower pregnancy rates than those with normal ovarian reserve.


Various ovarian reserve tests have been in use to assess ovarian and predict response to the ovarian stimulation. Basal FSH is not an ideal test to identify poor responder. Antral follicle count(AFC) and Anti Mullerian hormone(AMH) are the most sensitive markers of ovarian reserve, it help in planning personalized ovarian stimulation protocols.

To overcome the limitations, Bologna criteria has been introduced in 2011.

Bolongna criteria recommend the presence of at least 2 of the following three criterias for diagnosis of poor ovarian reserve.

1)      Advanced maternal Age . (more than 40 years)

2)      Previous poor ovarian reserve (less than or equal to 3 oocytes with conventional stimulation protocol)

3)      An abnormal ovarian reserve tests (AFC,5-7 follicles or AMH,0.5-1.1ng/ml).

Reproductive aging is a continuous process.
women have a finite number of germ cells whose number peaks at 6-7 million by 20 weeks of  gestation. From mid gestation onward and throughout reproductive life, an irreversible attrition progressively diminishes the germ cell pool of gonads.

Fertility decline gradually after the age of 30.
This is due to reducing primordial follicular pool as a result of ovulation and predominantly because of follicullar atresia. There is a slow decay from birth till 38 years of age with an accelerated decline thereafter. In addition to the age related decline in the ovarian reserve, factors that may further deplete the ovarian reserve during the reproductive years are diverse.”  Endometrioma, certain pelvic infections,

.surgical excision  of endometrioma is known to cause poor ovarian reserve.
Mechanical pressure on ovarian cortex, impairment in stroma & impaired vascular network can damage ovarian follicles. Genital Tuberculosis, Chlamydial infection and recently uterine artery embolization for treatment of Fibroid, chemotherapy, Radiotherapy, Obesity, Chronic smoking are another major factors for impaired ovarian follicles.

The overriding concern is that women with poor ovarian reserve have limited reproductive life span. To conceive with their own eggs. Majority of available evidence on efficacy of various therapeutic intervention in women with poor ovarian reserve is in context of IVF.

Avoiding profound and prolonged pituitary suppression, prevention of premature luteinizing hormone surge and controlled ovarian stimulation (with high doses of FSH,300-450 IU/day. Addition of recombinant LH, FSH can also be used)) to maximize oocyte yield and achieve embryos with good implantation potential form the basis of all therapeutic interventions in poor responders.

Pretreatment with OCPs, Progesterone ,or Ethinyl Estradiol is to improve the follicular synchronization,  prevent premature ovulation and scheduling of cycles.

Androgen supplementation in the form of oral DHEA is believed to improve the intrafollicular environment and follicular sensitivity to exogenous FHS.

Growth Hormone supplementation in combination with controlled ovarian stimulation  improve oocyte yield and pregnancy rates in poor responders.

Low dose aspirin has been used in IVF in an attempt to improve pregnancy & live birth rates.

The impact of poor ovarian reserve is most often seen in context with infertility where the time availability is limited. Pregnancy rates are very low with simple form of treatment, IVF in such women offers the highest probability of pregnancy. Diagnosis of POR imposes a high financial and emotional burden on such couples. When repeated attempts at treatment become unsuccessful, the only options that remain are recurse to oocyte donation or adoption.


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