Ovarian Reserve The Stock of Reproductive Potential

What Is Ovarian Reserve?

Female fertility is not determined solely by the presence of menstruation or the regularity of the menstrual cycle. One of the most important indicators of reproductive potential is ovarian reserve that is, the quantity of eggs a woman has in her ovaries at any given time. This is a physiological parameter that directly affects the chances of achieving pregnancy, both naturally and through assisted reproduction.

Ovarian reserve refers to the total number of follicles remaining in a woman’s ovaries at any stage of her life. From birth, every woman has a finite number of eggs, approximately 1 million. Over time, this number gradually declines due to natural cell loss, menstrual cycles, and ovarian aging. By puberty, this number decreases to around 300,000–500,000 eggs, while by the age of 40, most women have fewer than 10,000 eggs remaining, many of which may present chromosomal abnormalities.

The importance of ovarian reserve is not limited to egg quantity but also includes egg quality. Egg quality declines significantly with age, leading to lower fertilization rates and a substantially increased risk of miscarriage. Ovarian reserve testing is often one of the first and most important evaluations performed in assessing a woman’s fertility. It is also particularly relevant in adulthood when there is suspicion of conditions such as polycystic ovary syndrome (PCOS) or premature ovarian insufficiency (POI).

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 adulthood, particularly when there is suspicion of polycystic ovary syndrome (PCOS) or premature ovarian insufficiency (POI).

Evaluation by a gynecologist and the use of high-resolution ultrasound are necessary steps to exclude pathology and select the appropriate management.

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What Does Ovarian Reserve Assessment Include

The evaluation of ovarian reserve is based on three main pillars:

Anti-Müllerian Hormone (AMH) Test

Anti-Müllerian Hormone (AMH) is the most reliable blood test for assessing ovarian reserve. AMH is a protein produced by the cells of ovarian follicles, and its levels naturally decline with age.

An AMH level of 2–3 ng/ml is generally considered normal, while low AMH levels indicate a reduced egg reserve, and high levels are often associated with polycystic ovaries. However, AMH does not reflect egg quality, and therefore a low AMH value does not necessarily indicate infertility.

Follicle Stimulating Hormone (FSH) Levels

Follicle Stimulating Hormone (FSH) is a glycoprotein hormone that plays a key role in ovarian function. It is measured at the beginning of the menstrual cycle (day 2–4).

Normal FSH levels range between 3–10 IU/L, while elevated values suggest that the ovaries require greater stimulation to function, which is associated with reduced ovarian reserve.

Ultrasound with Antral Follicle Count (AFC)

Through a transvaginal ultrasound, the number of visible follicles is measured at the beginning of the cycle (day 2–4).

The Antral Follicle Count (AFC) is indicative of ovarian function. If fewer than 6–10 follicles are detected, this suggests a low ovarian reserve. AFC is particularly important in IVF cycles, as it helps determine the appropriate stimulation protocol used during fertility treatment.

Beyond the main tests (AMH, FSH, and AFC ultrasound), additional markers may provide further insight, especially when results are borderline or conflicting:

Estradiol (E2)

Measuring estradiol (E2) on days 2–4 of the cycle can reveal underlying dysfunction. Elevated estradiol levels early in the cycle, even when FSH is within normal range, may indicate reduced ovarian reserve.

Inhibin B

Inhibin B is produced by developing ovarian follicles and acts as a regulator of FSH (Follicle Stimulating Hormone). Levels below 45 pg/ml during the early phase of the menstrual cycle are associated with a poor response to ovarian stimulation protocols and lower chances of achieving a successful pregnancy.

Although not required in all cases, Inhibin B testing can be used in combination with primary markers when greater diagnostic accuracy is needed, particularly in cases of suspected premature ovarian insufficiency (POI).

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 Are Available

A low AMH level or elevated FSH 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 (in vitro fertilization).

At FertUlity, the treatment strategy is shaped by multiple factors, including age, the number of previous unsuccessful pregnancy attempts, and other fertility parameters. Every approach is fully personalized to the individual patient. In many cases, PRP fertility treatment may help support ovarian rejuvenation. In other cases, ovarian stimulation using alternative protocols or natural / modified natural cycle IVF can provide additional solutions with high success rates.

Frequently Asked Questions About Ovarian Reserve

Can I get pregnant with low ovarian reserve?

Yes, pregnancy is still possible. However, the chances of conception may decrease depending on the extent of the reduced reserve. The outcome depends not only on the number of eggs but also on egg quality.

Many women with diminished ovarian reserve successfully conceive, either naturally or with assisted reproductive techniques, especially when early diagnosis and proper medical guidance are in place. Treatment approaches may range from mild stimulation protocols to alternative options such as egg donation or egg freezing at a younger age.

Why is early testing important?

Early assessment of ovarian reserve provides valuable information about a woman’s fertility. When we are aware of our fertility status in time, we can make more informed decisions about the future. Testing is particularly useful before attempting pregnancy, when there is an intention to delay motherhood for personal reasons, in cases of infertility, before starting IVF, and prior to chemotherapy. This information may lead to preventive actions such as egg freezing, giving a woman the opportunity to protect her future fertility.

How is ovarian reserve tested?

Ovarian reserve assessment includes a combination of hormonal tests and ultrasound imaging. The main hormonal markers measured through blood tests are AMH (Anti-Müllerian Hormone), which reflects the number of developing follicles, and FSH (Follicle Stimulating Hormone), which, when elevated, indicates reduced ovarian reserve. Additionally, estradiol (E2) and in some cases Inhibin B may also be measured. At the same time, an ultrasound for Antral Follicle Count (AFC) is performed, which shows how many follicles are visible in a given cycle.

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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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