What Is Ovarian Reserve? How Is It Measured? Can You Get Pregnant with Low Ovarian Reserve?

One of the most frequently researched topics by women planning pregnancy is ovarian reserve. Especially if the AMH result is low or a small number of follicles are seen on ultrasound, questions such as "Is my ovarian reserve exhausted?", "Can I get pregnant?" or “Should I have in vitro fertilization immediately?” It may bring up questions such as:

ovarian reserve is one of the important parts of fertility, but it does not alone determine the possibility of pregnancy. The woman's age, egg quality, ovulation pattern, openness of the tubes, uterine structure and sperm characteristics are as important for pregnancy as the number of eggs remaining in the ovaries.

For this reason, it is not correct for a woman with a low ovarian reserve result to conclude that she "cannot become a mother" just by looking at a single laboratory value.

The main purpose of clinical evaluation should be to understand the state of the ovarian reserve and to create a personalized pregnancy plan without wasting time.

Short Answer

ovarian reserve refers to the follicle-egg pool in the ovaries that has the potential to develop in the future.

Ovarian reserve naturally decreases with age.

The most commonly used methods in reserve evaluation:

• AMH test
• Antral follicle count (AFC)
• FSH and estradiol evaluation when necessary

.

Low ovarian reserve does not completely prevent natural pregnancy. However, it may require more careful use of time and evaluation of treatment options without delay, especially in women planning pregnancy.

Highlights

• Women are born with a limited pool of eggs.
• ovarian reserve naturally decreases with age.
• ovarian reserve and egg quality are not the same thing.
• AMH and AFC are the most commonly used methods to evaluate ovarian reserve.
• Low AMH does not indicate that natural pregnancy is impossible.
• Low ovarian reserve does not mean the same as menopause.
• A woman who menstruates regularly may also have low reserves.
• Low reserve in in vitro fertilization may suggest that fewer eggs can be obtained in one cycle.
• Age is very important in assessing pregnancy potential, independent of reserve tests.
• When the reserve decreases, the goal is not to increase AMH, but to use the available time and reserve correctly.

What is ovarian reserve?

ovarian reserve, or in medical terms ovarian reserve, refers to the follicle-egg pool in the ovaries that has the potential to develop in the future.

Women's ovaries do not produce an unlimited number of new eggs throughout life. From birth, the available follicle pool decreases over time.

During each menstrual period, many follicles undergo the development process, but usually only one of them reaches the ovulation stage. Most of the other follicles disappear through the natural biological process.

This decrease:

• Adolescence
• Reproductive age
• Advanced reproductive age

Continues throughout.

As menopause approaches, ovarian reserve decreases significantly.

However, the rate of reserve decrease is not the same in every woman. AMH and antral follicle counts of two women of the same age can be quite different.

Why is ovarian reserve Important?

ovarian reserve is especially important in pregnancy planning and assisted reproductive treatments.

Reserve evaluation can give the physician an idea on the following issues:

• Available follicle pool of the ovaries
• Expected response to drugs in in vitro fertilization
• Approximate number of eggs that can be obtained in one cycle
• Egg freezing planning
• Fertility evaluation before endometriosis or ovarian surgery

However, it should not be forgotten that ovarian reserve does not represent the entire fertility.

A woman's chance of pregnancy does not depend solely on her ovarian reserve.

Are ovarian reserve and Egg Quality the Same Thing?

No.

These two concepts are one of the most frequently confused topics.

ovarian reserve is related to the amount of eggs in the ovary.

Egg quality is related to the egg's potential to form a healthy embryo and to be chromosomally suitable.

For example:

Although a 30-year-old woman with low ovarian reserve has a small number of eggs, the likelihood of these eggs being genetically healthy may be higher than a 42-year-old woman.

On the other hand, even if the AMH value of a woman over 40 is good, the effect of age on egg quality continues.

Therefore:

High AMH = high egg quality

or

Low AMH = poor quality eggs

Comments like this are not correct.

When Does ovarian reserve Start to Decrease in Women?

The decrease in ovarian reserve is a natural process that starts from birth.

In reproductive age, this decrease continues for many years.

With the age of 30, the age factor in terms of reserve and fertility becomes more evident. Especially after the age of 35, both the decrease in the number of eggs and the changes in the chromosomal characteristics of the eggs become more important in pregnancy planning.

However, there is no definitive limit such as "ovarian reserve remains constant until the age of 35, and decreases suddenly after 35."

In some women, the reserve may decrease at an earlier age.

How to Measure ovarian reserve?

It is not possible to measure ovarian reserve precisely with a single test.

The most accurate evaluation is made by interpreting more than one data together.

The following methods are mainly used in clinical practice:

• AMH test
• Antral follicle count (AFC)
• FSH
• Estradiol
• Woman's age
• Previous ovarian response
• Medical and surgical history

Especially AMH and AFC can provide valuable information in predicting the response of the ovaries to drug stimulation.

How Does AMH Test Show ovarian reserve?

AMH, that is, Anti-Müllerian Hormone, is secreted by small developing follicles in the ovaries.

As the follicle pool in the ovary decreases, the AMH level generally decreases.

Therefore AMH:

• Evaluating ovarian reserve
• In pre-IVF treatment planning
• Predicting the expected response to ovarian stimulation
• On the egg freezing plan

Available.

But the critical point here is this:

AMH is not a direct "pregnancy probability" test.

A woman with low AMH can become pregnant naturally.

What is the AMH level, is the ovarian reserve considered low?

No single definitive limit applies to all women.

Result:

• Age of the woman
• Depending on the laboratory method used
• AFC value
• Clinical history

It should be interpreted accordingly.

In clinical practice, AMH values ​​below approximately 1 ng/mL may suggest reduced ovarian reserve. However, a diagnosis of infertility, menopause or in vitro fertilization cannot be made by looking at this value alone.

For example, the same AMH value does not have the same clinical meaning in two women aged 27 and 40.

What is Antral Follicle Count?

Antral follicle count, or AFC, is the counting of small follicles seen in the ovaries during transvaginal ultrasound.

These follicles provide information about the potential egg pool of the ovary that can be seen at that time.

During ultrasound:

• Right ovary
• Left ovary
• Small follicles in both ovaries

It is evaluated.

Evaluating AMH and AFC together may be more meaningful than looking at just one blood test.

How Many Antral Follicles Should Be?

There is no single ideal AFC number that applies to everyone.

Result:

• Age
• AMH
• Ovarian volume
• Response to previous treatment

It should be evaluated together.

Low AFC may suggest decreased ovarian reserve.

However, a low follicle count does not mean that the possibility of pregnancy is completely eliminated.

What Happens If AMH and AFC Do Not Match?

In clinical practice, while AMH is sometimes found to be low, more antral follicles may be seen on ultrasound than expected, or vice versa.

In this case, the decision is not made based on only one result.

Assoc. Prof. Dr. In Nurettin Türktekin's clinical approach:

• Age
• AMH
• AFC
• Menstrual pattern
• Response to previous treatment

They are evaluated together.

Especially if in vitro fertilization has been performed before, the actual treatment response of the ovaries may provide more valuable information than laboratory tests.

Does FSH Show ovarian reserve?

FSH, that is, Follicle Stimulating Hormone, is one of the hormones used in the evaluation of ovarian functions.

FSH is usually evaluated early in the menstrual cycle.

As ovarian reserve decreases, FSH levels may increase in some women.

However, since FSH can vary from cycle to cycle, it cannot be used as an adequate reserve test on its own.

In necessary patients:

• AMH
• AFC
• FSH
• Estradiol

They are evaluated together.

What Does Low ovarian reserve Mean?

Low ovarian reserve or decreased ovarian reserve means that the follicle pool in the ovaries is less than expected for age.

In this case, especially in in vitro fertilization treatment:

• Fewer follicles may develop.
• Less eggs can be collected.
• The number of embryos that can be formed may be more limited.

However, low reserve is not a direct diagnosis of infertility.

A woman can have regular ovulation and natural pregnancy potential with a low reserve.

Can You Get Pregnant with Low ovarian reserve?

Yes.

Pregnancy is possible naturally with low ovarian reserve.

It is not necessary to develop a large number of eggs every month for a natural pregnancy to occur. In a cycle in which ovulation occurs, a single egg suitable for fertilization may be sufficient for pregnancy.

For this reason, when evaluating the possibility of natural pregnancy, not only reserve:

• Woman's age
• Ovulation
• Tubes are open
• Uterine health
• Sperm quality

They should be evaluated together.

Does Low ovarian reserve Mean Infertility?

No.

Low ovarian reserve and infertility are not the same thing.

Infertility is the inability to achieve pregnancy despite regular unprotected intercourse for a certain period of time.

Low reserve means that the follicle pool in the ovary has decreased.

While a woman with low reserve can experience a natural pregnancy, a woman with normal reserve:

• Tubal blockage
• Endometriosis
• Intrauterine problem
• Ovulation problem
• Male factor

Due to this reason, it may be difficult to achieve pregnancy.

Does Low ovarian reserve Mean Menopause?

No.

A woman with low reserves:

• Menstruation
• Ovulation
• To get pregnant naturally

may continue.

Menopause is not defined solely by low AMH or low AFC.

Similarly, premature ovarian failure is a different clinical condition from low ovarian reserve and should be evaluated separately.

Does Low ovarian reserve Cause Symptoms?

Most of the time, no.

A woman:

• She may menstruate regularly.
• She can ovulate every month.
• He may not have any complaints.

Despite this, her ovarian reserve may be low compared to her age.

For this reason, the thought "My periods are regular and my reserves are definitely good" is not true.

Menstrual irregularity may occur in severe ovarian function loss, but there is no specific symptom of low reserve.

Why Does ovarian reserve Decrease?

The most important and natural reason for the decrease in ovarian reserve is age.

Apart from this, the following situations may be associated with an earlier decrease in the reserve:

• Genetic predisposition
• Family history of early menopause
• Endometriosis
• Chocolate cyst
• Ovarian surgeries
• Chemotherapy
• Pelvic radiotherapy
• Some genetic diseases
• Some autoimmune diseases

In some women, no obvious cause may be detected.

Does Chocolate Cyst Reduce ovarian reserve?

Endometriosis, and especially endometriomas that develop in the ovaries, can affect the ovarian reserve.

In addition, since there is a risk of damage to healthy ovarian tissue during surgical treatment for chocolate cyst, the decision for surgery should be made carefully, especially in women who want to become pregnant.

In evaluation:

• Patient's age
• Size of the cyst
• Pain complaint
• AMH
• AFC
• Previous surgeries
• Pregnancy plan

They should be considered together.

Not every chocolate cyst should be operated on.

Does Ovarian Surgery Affect the Reserve?

Some ovarian surgeries may cause a decrease in healthy ovarian tissue.

The risk is particularly:

• In endometrioma surgeries
• In bilateral ovarian surgeries
• In repeated operations
• In large cysts

It may gain more importance.

For this reason, reserve evaluation before ovarian surgery may change the treatment strategy in women who plan to have children.

In some patients, fertility-preserving options such as egg or embryo freezing may be considered before surgery.

Does Smoking Affect ovarian reserve?

Smoking may negatively affect women's reproductive health.

It is recommended to quit smoking in women who are planning pregnancy or who are at risk for their ovarian reserve.

However, it is not correct to say that quitting smoking will rebuild the lost ovarian reserve.

The aim is to preserve existing reproductive health as much as possible.

Can ovarian reserve Be Increased?

Today, there is no proven treatment to recreate the egg pool lost in the ovary.

Therefore:

• AMH increasing cure
• Herbal mixture that increases egg count
• Drug that restores reserves

Such claims should be approached with caution.

Some supplements or lifestyle adjustments may be beneficial for overall health but do not produce new eggs.

The purpose of treatment with low reserve is not to increase the AMH number, but to manage the existing reserve correctly.

Can In Vitro Fertilization Be Performed with Low ovarian reserve?

Yes.

Low reserve does not prevent in vitro fertilization treatment.

But during treatment:

• Fewer follicles may develop.
• Less eggs can be obtained.
• Fewer embryos may form.

Therefore, the treatment protocol for the patient:

• Age
• AMH
• AFC
• Response to previous treatment
• Sperm characteristics

It should be taken into account and personalized.

Does Using More Medication at a Low Reserve Provide More Eggs?

Not always.

Using high doses of medication does not create new eggs in the ovary.

The goal is to get the most appropriate response possible from the existing group of follicles.

There may be situations where excessively high drug doses do not always provide additional benefit, especially in patients with low reserves.

The drug dose of the treatment should be determined individually.

How Many Eggs Are Collected in Low ovarian reserve?

It is not possible to give an exact number in advance.

Even two patients with the same AMH value may have different response to treatment.

Factors affecting the number of eggs that can be obtained:

• Age
• AFC
• AMH
• Protocol used
• Response to previous treatment

It can be listed as.

In a patient with low reserve, even 3-4 eggs may be a personally meaningful response.

What is important is not only the number, but also the maturity of the eggs obtained and embryo development.

Can Eggs be Freezed in Low ovarian reserve?

Yes in suitable patients.

But the success of egg freezing is especially:

• Age of the woman
• The number of eggs that can be obtained
• To the maturity of the eggs

It depends.

If the reserve is low, a small number of eggs can be obtained in one cycle.

In some patients, more than one collection cycle may be evaluated.

However, a general approach such as "if there is low AMH, eggs should be frozen" is not correct.

Is Age More Important or AMH?

The answer to this question depends on what is evaluated.

AMH and AFC are very valuable in predicting the response of the ovaries to medications and the number of eggs.

Age is very important in terms of egg quality and pregnancy potential.

For example, it has the same AMH value:

• 28 year old
• 42 years old

The probability of two women's embryos being chromosomally healthy is not the same.

For this reason, age should never be left behind AMH in fertility evaluation.

At What Age Should ovarian reserve Be Checked?

Not every young woman needs to have AMH tests routinely.

However, evaluation may be meaningful in the following cases:

• If pregnancy is planned to be postponed for a long time
• If pregnancy is considered after the age of 35
• If there is a family history of early menopause
• If endometriosis is present
• If you have a chocolate cyst
• If ovarian surgery is planned
• If chemotherapy or radiotherapy is planned
• If there is difficulty in achieving pregnancy

The purpose here is not to cause anxiety in women, but to make future reproductive plans more consciously when necessary.

Assoc. Prof. Dr. What Path Would Nurettin Türktekin Follow in This Situation?

When evaluating ovarian reserve, only "How much AMH is it?" It is not right to focus on the question.

Assoc. Prof. Dr. In Nurettin Türktekin's clinical approach, the following topics are evaluated together:

• Patient's age
• Time of pregnancy plan
• AMH value
• AFC
• Menstrual pattern
• Whether there has been a pregnancy before
• Endometriosis or chocolate cyst
• Ovarian surgery history
• Early menopause in the family
• Treatment response if in vitro fertilization has been performed before
• Sperm characteristics of the male partner

For example, the road map of a 29-year-old woman with a low AMH result, but who has sufficient AFC and is planning a pregnancy soon, and a 39-year-old woman with the same AMH value is not the same.

While a certain period of time can be evaluated for natural pregnancy in the first patient, a faster treatment plan may be required in the second patient due to age.

How does the decision process proceed in patients planning pregnancy?

The following questions are asked for a woman who has low reserves and wants to have a child:

• How long has pregnancy been tried?
• Are the tubes open?
• Is ovulation regular?
• Is there a male factor?
• How old is the woman?
• Has there been a pregnancy before?

If other factors are appropriate, natural pregnancy follow-up can be performed in some patients.

However:

• Advanced age
• Very low reserve
• Long infertility period
• Tube problem
• Male factor

In such cases, in vitro fertilization may come to the fore earlier.

How to decide for women who postpone having children?

For women who plan to postpone pregnancy for a few years, age and reserve are evaluated together.

Especially:

• AMH is low
• AFC low
• Early menopause in the family
• Endometriosis
• Ovarian surgery plan

If available, fertility preservation options can be discussed earlier.

When making the decision to freeze eggs, great importance is given not only to AMH but also to the age at which the eggs are frozen.

Surgery First or In Vitro Fertilization First in Low Reserve?

This question is especially important for women with chocolate cysts.

Not every endometrioma can be operated on.

Before the surgical decision:

• Size of the cyst
• Pain
• Malignant appearance suspicion
• AMH
• AFC
• Age
• Pregnancy plan

They should be evaluated together.

In some patients, in vitro fertilization may be more appropriate, and in some patients, surgery may be more appropriate.

The aim is not to reduce the ovarian reserve unnecessarily while treating the cyst.

Common Mistakes with Low ovarian reserve

“I can't be a mother if I have low reserves.”

Wrong. Low reserve does not completely prevent natural pregnancy.

“If AMH is low, my egg quality is also bad.”

Wrong. AMH is mostly related to the amount of eggs.

“If AMH is low, I will enter menopause immediately.”

Wrong. AMH alone does not accurately indicate the time of menopause.

“If the reserve is low, a very high dose of medication should be used.”

Wrong. Drug dosage should be planned individually.

“If AMH is normal, my fertility is definitely good.”

Wrong. Other factors such as tubes, sperm, uterus and age are also important.

“ovarian reserve come back with herbal products.”

There is no proven method to regenerate the lost follicle pool.

“If I menstruate regularly, my reserve will not decrease.”

Wrong. Women with low reserves may have regular menstrual periods.

What to Do with Low ovarian reserve?

When a low reserve result is obtained, the procedure to be followed may be as follows:

• The result is evaluated with age.
• AMH and AFC are examined together.
• The pregnancy plan is learned.
• Menstrual and ovulation patterns are evaluated.
• Endometriosis and surgery history are questioned.
• If pregnancy is attempted, the tubes and sperm factor are examined.
• It is decided which of the options natural pregnancy, IUI or in vitro fertilization is appropriate.
• If pregnancy is to be postponed, options such as egg freezing are considered.

The main goal is not only to correct the laboratory value; It is to use the available biological time in the most effective way.

When to Consult a Gynecologist and Obstetrician?

Evaluation should not be delayed in the following cases:

• If your AMH result is low
• If AFC is found low
• If you are planning a pregnancy after the age of 35
• If you want to postpone pregnancy for a few years
• If you have a family history of early menopause
• If you have endometriosis or chocolate cyst
• If you have had ovarian surgery
• If ovarian surgery is planned
• If chemotherapy or radiotherapy will be administered
• If you are having difficulty achieving pregnancy

If there is a known risk of low reserve, evaluation can be made earlier than standard infertility waiting periods.

Assoc. Prof. Dr. Nurettin Türktekin's Evaluation

The most common problem in ovarian reserve evaluation is that patients make definitive conclusions about their fertility based on a single AMH result.

AMH and antral follicle count are very valuable in evaluating the ovarian reserve and the expected number of eggs during treatment. However, these tests alone do not indicate egg quality or the possibility of natural pregnancy.

Especially in women planning pregnancy, age, AMH, AFC, ultrasound findings, tubes and sperm characteristics should be evaluated together.

When low reserve is detected, the main purpose is not to scare the patient, but to prevent loss of time. While some women may be given time for natural pregnancy, some patients may need to consider in vitro fertilization or fertility preservation options earlier.

The treatment plan should focus on the patient himself, not the laboratory result.

Conclusion

ovarian reserve refers to the follicle-egg pool in the woman's ovaries that has the potential to develop in the future.

AMH test and antral follicle count are among the most commonly used methods in reserve evaluation. However, low results of these tests do not alone mean that infertility, menopause or natural pregnancy is impossible.

What is really important for women with low ovarian reserve:

• Woman's age
• Egg quality
• Ovulation
• Tubes
• Uterine structure
• Sperm characteristics
• Time of pregnancy plan

To evaluate factors such as these together.

When low reserve is detected, the goal is not to try to increase the AMH figure, but to evaluate the current fertility potential correctly and use time effectively.

A personalized evaluation can help plan treatment and fertility preservation options at the right time, especially for women who are planning pregnancy, postponed having children until later years, or have a history of endometriosis or ovarian surgery.