What is decreased ovarian reserve? DOR, fertility & IVF

7 things you need to know about DOR from a fertility specialist

Decreased ovarian reserve (DOR), also referred to as diminished ovarian reserve, is a condition that frequently arises in discussions within the fertility community. It’s an intricate topic that provokes a mix of concerns and hope for those navigating their fertility journey. In this detailed overview, we’ll delve into what DOR entails, its implications for fertility, and the various strategies to maximize success, whether through lifestyle changes, natural conception, or assisted reproductive technologies (ART). This article covers: 

1. What is decreased ovarian reserve (DOR)?
2. Defining DOR: The Bologna Criteria
3. Common misconceptions
4. How to maximize your fertility
5. Treatment options: IVF
6. Family planning
7. Stories of hope 

What Is Decreased Ovarian Reserve?

Eggs are unique among the cells in the human body. Unlike skin or hair cells that regenerate, a woman is born with all the eggs she will ever have. From birth, this finite supply of eggs begins to diminish, both in number and quality. As women age, this decline becomes more pronounced, leading to challenges with conception.

The rate at which ovarian reserve diminishes varies greatly. Some women may face a steep decline early on, potentially leading to menopause before age 40. Others may maintain a robust reserve until the natural age of menopause, typically around 52. Despite this variability, all women experience a drop in both the quality and quantity of eggs over time, which impacts natural conception and the success rates of ART, like in vitro fertilization (IVF).

Defining Decreased Ovarian Reserve: The Bologna Criteria

To provide a standardized framework for diagnosing DOR, the European Society of Human Reproduction and Embryology (ESHRE) developed the Bologna criteria in 2011. This system focuses on three primary features, at least two of which must be present to confirm a diagnosis:

1. Age and Risk Factors:
   
   • Women over 40 are considered at higher risk.
   • Risk factors include ovarian surgery, cancer treatments such as chemotherapy or radiation, and certain genetic conditions linked to reduced ovarian reserve.
     
2. Previous Poor Ovarian Response:
   
   • A history of retrieving three or fewer eggs during a well-stimulated IVF cycle.
     
3. Low Egg Reserve Test Results:
   
   • Antral Follicle Count (AFC): Fewer than 5-7 follicles.
   • Anti-Mullerian Hormone (AMH): Less than 3.6-8 pmol/L.

While this diagnosis provides clarity, it’s important to emphasize that DOR doesn’t mean pregnancy is impossible. Instead, it indicates a reduced number of eggs available for retrieval during a particular IVF cycle.

Addressing Misconceptions About DOR

One of the most common misconceptions about DOR is that it eliminates the possibility of natural conception or successful pregnancy. However, as explained in Episode 33 of My Fertility Podcast, this is not true. While the number of eggs retrieved during IVF cycles may be limited, the quality of these eggs—especially in younger women or those with favorable genetics—can still lead to successful pregnancies.

Moreover, natural conception remains a possibility for many women with DOR. Fertility specialists emphasize that the focus should shift from quantity to quality. Even with fewer eggs, a high-quality egg can lead to a healthy embryo, successful implantation, and a viable pregnancy.

How to Maximize Fertility With DOR

Receiving a diagnosis of DOR can feel daunting, but there are numerous steps women can take to optimize their chances of conception:

1. Lifestyle Adjustments

Lifestyle factors play a crucial role in fertility health. By making proactive changes, women can improve their overall reproductive outcomes.

• Quit Smoking or Vaping: Smoking is detrimental to both the quantity and quality of eggs.
• Limit Alcohol and Cannabis Use: These substances can negatively impact reproductive health.
• Adopt a Healthy Diet and Regular Exercise Routine: A balanced diet and active lifestyle can enhance overall health and potentially improve egg quality.

2. Supplements and Vitamins

Certain supplements have shown promise in improving egg quality and supporting reproductive health:

• Coenzyme Q10 (CoQ10): This powerful antioxidant may help optimize egg quality. Recommended dosage: 600-800 mg daily.
• Vitamin D: Ensures adequate levels for optimal reproductive health.
• Omega-3 Fatty Acids: These promote cellular health and have anti-inflammatory properties.

Read more about prenatal vitamins or listen to the episode below.

Treatment Options: Tailoring IVF Protocols for DOR

For women with DOR, ART offers hope, but it requires specialized approaches to maximize success.

1. Mini or Mild Stimulation IVF

Mild stimulation protocols use lower doses of medications to encourage follicle development. While fewer eggs may be retrieved compared to conventional protocols, the quality of these eggs is often higher.

• Benefits:
  • Lower medication costs.
  • Reduced side effects.
  • Potentially improved embryo quality due to more natural follicular selection.

2. Dual Stimulation IVF (DuoStim)

This innovative approach involves two egg retrievals within a single menstrual cycle—one during the follicular phase and another during the luteal phase.

• Advantages:
  • Maximizes the number of eggs retrieved in a shorter period.
  • May yield higher-quality eggs during the luteal phase.

Studies have shown that dual stimulation can significantly improve cumulative live birth rates and reduce the time to pregnancy compared to traditional protocols.

Adjunct Therapies to Enhance Outcomes

1. Androgen Supplementation

Testosterone, while often considered a male hormone, plays a vital role in female fertility by supporting follicle development and egg maturation.

• Testosterone Gel (Androgel): Applied to the skin for 1-3 months before stimulation.
• Dehydroepiandrosterone (DHEA): An oral supplement often taken for 3+ months before IVF.

Recent evidence suggests that testosterone gel may be more effective than DHEA in improving pregnancy and live birth rates.

2. Growth Hormone Therapy

Growth hormone has been shown to:

• Enhance ovarian sensitivity to stimulation.
• Improve egg and embryo quality.
• Increase cumulative live birth rates.

Although costly, growth hormone is well-tolerated and can be a valuable addition for select patients.

Considering the Bigger Picture: Family Planning With DOR

When planning for a family, it’s essential to consider future goals. For women hoping to have multiple children, early intervention with treatments like IVF can help preserve options. By creating and freezing embryos now, women with DOR can safeguard their chances of building a larger family later, despite the natural decline in ovarian reserve over time.

Exploring Donor Eggs

For some women with DOR, especially those with severely diminished ovarian reserve or repeated unsuccessful IVF cycles, donor eggs can offer a path to parenthood. While this may not align with initial expectations, many women find great joy and fulfillment in carrying and delivering a child through donor egg programs.

Stories of Success: A Reminder of Hope

Countless stories highlight that DOR is not an insurmountable barrier. Women with low AMH levels or poor ovarian reserve often conceive naturally or with minimal intervention. Fertility specialists encourage a mindset that balances hope with realistic planning, underscoring the importance of early consultation and personalized care.

Decreased ovarian reserve is a challenging yet manageable diagnosis. Through tailored IVF protocols, lifestyle changes, and advanced therapies, women with DOR have numerous options to pursue their dreams of parenthood.

If you suspect you have DOR or are navigating a diagnosis, consult with a fertility specialist to explore your options. For more insights and support, listen to Episode 33 of My Fertility Podcast, where experts provide practical advice and real-world examples of overcoming DOR.