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Causes of Infertility

Diminished Ovarian Reserve

Normal ovarian aging begins while the female fetus is still inside the womb. A female fetus has approximately six to seven million eggs before she is born. Several hundred thousand eggs remain when a young woman enters puberty.

Research has demonstrated that the likelihood of establishing a pregnancy begins to decline when a woman reaches age 25. Between the ages of 35 and 40, fertility rates fall significantly, and further accelerate after the age of 40. 

Worldwide experience with in vitro fertilization (IVF) has shown a similar decline in fertility beginning in the mid 30s, with a more rapid decline in fertility after the age of 40. This reduced fertility appears entirely due to diminishing egg quality and quantity.

Measuring follicle stimulating hormone (FSH) levels on the second, third or fourth day of a woman's menstrual period is highly predictive of future fertility. While elevated FSH levels mostly affect women in their late 30s and early 40s, a young woman with an elevated FSH level also has a reduced likelihood of establishing a pregnancy without the use of donor eggs.

There are some women with a normal day three FSH level who still have diminished ovarian reserve. Such women, typically in their late 30s and early 40s, or with prior ovarian surgery, can be diagnosed with the use of a clomiphene citrate challenge test (CCCT). Clomiphene citrate is taken daily, starting on cycle day five for a total of five days. On cycle day ten, an FSH level is again measured. It appears that a single elevated FSH level represents diminished ovarian reserve and a poor prognosis for pregnancy, even if FSH testing in subsequent months is normal.

Another method to assess ovarian reserve and the chance for pregnancy is by assessing the woman’s antral follicles, which are small follicles that can be measured with ultrasound. An antral follicle count is a good predictor of the number of follicles in the woman's ovaries that may produce a mature egg.

Other tests such as early follicular estradiol gonadotropinreleasing hormone agonist stimulation tests, inhibin levels (a hormone produced in the ovaries), and anti-mullerian hormone levels (secreted by the small follicles on the ovary) are not as thoroughly studied as FSH values for predicting ovarian reserve and, therefore, are not routinely recommended.

The use of donor eggs is the most effective form of therapy for women with elevated FSH testing.  At RMA of Philadelphia, our donor egg program has a 70 percent per cycle pregnancy rate. We have also had successful pregnancies using ovulation induction medications in some women with diminished ovarian reserve.

Other Causes of Infertility:

About Infertility
Diagnosing Infertility
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