Ovarian Reserve The Stock of Reproductive Potential

Female fertility is not defined solely by the presence of ovaries or the regularity of the menstrual cycle. One of the most important indicators of reproductive capacity is ovarian reserve — the quantity and quality of eggs a woman still has in her ovaries. It is a physiological parameter that directly affects the chances of conception, both naturally and through assisted reproduction.

What Is Ovarian Reserve?

Ovarian reserve refers to the number of follicles remaining in a woman’s ovaries at any given point in her life. From birth, each woman has a finite number of eggs — about 1 to 2 million. Over the years, this number gradually declines due to natural apoptosis, menstrual cycles, and ovarian aging. By puberty, this number is reduced to about 300,000–500,000 eggs, and around age 40, most women have fewer than 10,000 eggs left — many of which may have chromosomal abnormalities.

The importance of ovarian reserve lies not only in the quantity but also in the quality of the remaining eggs. This quality declines significantly with age, leading to lower fertilization rates and dramatically higher risks of miscarriage. Ovarian reserve assessment is often one of the first and most critical tests performed during a fertility
evaluation. Assessing ovarian reserve can also be important during adolescence when there is suspicion of polycystic ovary syndrome or premature ovarian insufficiency.

When and Why We Evaluate Ovarian Reserve

Ovarian reserve assessment is particularly important in the following cases:

When a woman is approaching or over 35 and wishes to conceive naturally

When a woman has been trying to conceive for a long time without success

When planning to start an IVF cycle or other infertility treatment

In cases of previous failed IVF attempts

When there are signs of early menopause or ovarian insufficiency

Before medical treatments (e.g., chemotherapy) that may affect the ovaries

During adolescence when there is suspicion of PCOS or premature ovarian insufficiency

What Does Ovarian Reserve Assessment Include

Ovarian reserve assessment includes three main pillars:

Anti-Müllerian Hormone (AMH) Test

The anti-Müllerian hormone (AMH) is the most reliable blood test for evaluating ovarian reserve. AMH is a protein produced by the cells of the follicles, and its levels decline with age. A range of 1–3 pg/ml is considered normal. Low AMH values suggest a low egg supply, while high values are associated with polycystic ovaries. However, AMH levels are not related to egg quality, so low AMH alone does not necessarily indicate infertility.

Follicle Stimulating Hormone (FSH) Levels

FSH is a glycoprotein hormone that influences gonadal function. FSH is measured at the beginning of the cycle (day 2–4), with normal values ranging from 3–8 IU/l. Higher levels suggest that the ovaries require more stimulation to function, which is linked to reduced ovarian reserve.

Ultrasound with Antral Follicle Count (AFC)

Through transvaginal ultrasound, the number of visible follicles is counted at the start of the cycle (day 2–4). The Antral Follicle Count (AFC) is indicative of ovarian function — if fewer than 6–10 follicles are detected, ovarian reserve is considered low. The AFC is especially important in IVF cycles and determines the stimulation protocol to be used during fertility treatment. In addition to the basic tests (AMH, FSH, and AFC ultrasound), several supplementary markers can offer additional insights, especially when baseline results are borderline or conflicting:

Estradiol (E2)

Measuring estradiol on days 2–4 of the cycle can reveal possible dysfunctions. Values above 250 pg/ml — even with normal FSH — may suggest reduced ovarian reserve. This is due to the overproduction of estrogens as a compensatory mechanism in response to weakened ovarian function.

Inhibin B

Inhibin B is produced by developing follicles and acts as a regulator of FSH. Values below 45 pg/ml in the early follicular phase are associated with poor response to stimulation protocols and lower chances of successful pregnancy. Although not necessary for all women, these additional tests may be used alongside the main ones when greater diagnostic accuracy is needed, or when there is suspicion of premature ovarian insufficiency.

Factors That Affect Ovarian Reserve

Ovarian reserve is primarily affected by age, but also by a variety of other factors, such as:

Genetics and hereditary factors

Autoimmune diseases

Chemotherapy or radiotherapy

Ovarian surgeries

Endometriosis

Smoking and other environmental stressors

It is important for every woman to be aware of her ovarian reserve status, even if she is not currently trying to conceive. Early assessment allows women to plan their future with knowledge and security.

Low Ovarian Reserve – What It Means and What Options Exist

A low AMH or elevated FSH value does not necessarily mean that a woman cannot get pregnant. On the contrary, many women with low ovarian reserve have conceived either naturally or through IVF.
The strategy followed at FertUlity depends on many factors such as age, the number of previously failed pregnancy attempts, and other fertility indicators, and is always tailored to the individual patient. In many cases, PRP fertility treatment may offer ovarian rejuvenation. In other cases, ovarian stimulation with alternative protocols or egg donation are additional options with high success rates.

Frequently Asked Questions About Ovarian Reserve

What is ovarian reserve and why does it matter?

Ovarian reserve refers to the quantity and quality of eggs remaining in a woman’s ovaries at a given point in time. It is a key fertility indicator, as it affects both natural conception and the response to assisted reproductive treatments like IVF. A low reserve does not make pregnancy impossible but highlights the need for timely action or personalized strategies.

Why is early testing important?

Early evaluation of ovarian reserve provides crucial information about a woman’s fertility. Knowing your fertility status early allows you to make informed decisions about your future. Testing is particularly helpful before trying to conceive, when planning to delay motherhood for personal reasons, in infertility cases, before starting IVF, or before undergoing chemotherapy. This knowledge can lead to proactive measures like egg freezing, helping women protect their fertility.

How is ovarian reserve tested?

Ovarian reserve is evaluated through a combination of hormonal blood tests and ultrasound imaging. The main hormonal markers are AMH (reflecting the number of developing follicles) and FSH (which, when elevated, indicates reduced reserve). Estradiol (E2) and Inhibin B may also be measured. In parallel, an AFC ultrasound counts how many follicles are visible in a cycle.

If I have low ovarian reserve, can I still get pregnant?

Absolutely — although the chance of conception decreases as reserve declines. The outcome depends not only on the number but also on the quality of the eggs. Many women with reduced reserve conceive naturally or through assisted methods, especially
with early diagnosis and the right medical guidance. Treatment is customized, from mild stimulation protocols to alternative options like egg donation or egg freezing at a younger age.

Our Doctors

In an era where fertility requires knowledge, care, and substantial guidance, FertUlity is not an impersonal clinic. It is two people who look you in the eye and accompany you step by step on the journey you dream of.

Dr. Maria Oikonomou Obstetrician – Gynecologist

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Dr. Chrysostomos (Makis) Papadopoulos Obstetrician – Gynecologist, MD, PhDc, MIC I

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