Diminished ovarian reserve is a decrease in the ability of the ovaries to respond to hormonal stimulation by follicle growth with a simultaneous deterioration in the quality of eggs. Insufficient reproductive potential causes persistent infertility that cannot be treated. At the initial stage, the shortening of the menstrual cycle may worry. For diagnosis, an analysis for anti-muller hormone (AMH), ultrasound of the follicular reserve of the ovaries is used. There are no specific ways to increase the ovarian reserve. Patients who are planning a pregnancy are offered to resort to modern reproductive technologies.
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Diminished ovarian reserve is a physiological process in women over 35 years of age. According to research, it decreases by 2 times from the age of 37, and in 45-year-olds, the ability to conceive naturally tends to zero. Premature ovarian depletion occurs in 1-3% of the general population and in 4-18% with existing primary amenorrhea. It is not always possible to establish the leading factors, therefore, in half of patients with a reduced reserve, it is considered idiopathic. A high frequency of insufficient number of follicles at a young age is noted in women who were born prematurely.
The decrease in ovarian reserve is a natural process that normally becomes noticeable after 35 years. Under the influence of external and internal factors, it can accelerate, then signs of ovarian insufficiency appear in younger patients. The main reasons for low follicular reserve are:
- Polycystic ovary syndrome. Neuroendocrine disease, in which ovulation does not occur, forms small follicular cysts under a dense capsule covering the ovaries.
- Genital endometriosis. The lesion of the genital glands is accompanied by the formation of endometrioid cysts, the development of immune and inflammatory reactions in the focus. A decrease in the reserve of follicles becomes noticeable with 3-4 degrees of endometriosis.
- Surgical operations. During ovarian resection, the amount of healthy tissue decreases, the blood supply to the remaining area worsens, therefore, the ability to mature follicles decreases by 50-73%. Changes in the ovarian reserve are not observed during coagulation of ovarian endometriosis or opening of the cyst capsule.
- Toxic lesion. Combined treatment of oncological diseases leads to damage to the genital glands. Cytostatics cause destructive processes in granulosa cells, follicle atresia. Smoking more than 10 cigarettes a day has a similar effect.
- Inflammatory diseases. Chronic oophoritis, damage to the cortical layer by opportunistic and pathogenic microorganisms reduces the reserve of oocytes. A small number of primordial follicles capable of maturation remain in ovarian tissues.
By the time of puberty, there are 400-500 thousand immature follicles in a woman’s body. During each ovulation, 1 oocyte is lost, and several hundred die every month under the influence of various factors. By the age of 35, there are about 25 thousand of them, but the process of degradation is accelerating. Normally, there are changes in the menstrual cycle, which serve as harbingers of the approach of menopause.
The mechanism of diminished ovarian reserve depends on the causes of this condition. It has been established that with endometriosis, the number of follicles decreases at all stages of development. In 2007, M. Dolmans and a group of researchers at the Catholic University of Louvain proposed the theory of “burnout”, according to which, with endometriosis, there is an increased maturation of oocytes, so their stock is depleted ahead of time. This is confirmed by dystrophic processes in granulosa cells, changes in the composition of follicular fluid and acceleration of apoptosis.
In girls born at the age of 27-36 weeks, the intrauterine process of maturation of the genitals is not completed, and the nursing of the child does not create normal conditions for its completion. Therefore, they often have developmental abnormalities, decreased reproductive function and a high incidence of polycystic ovaries. With PCOS, hormonal and ovulatory changes occur, leading to rapid depletion of the ovaries and reproductive dysfunction.
Diminished ovarian reserve is manifested by a decrease in AMH synthesis. This hormone is secreted by granulosa cells and maintained in constant concentration throughout the menstrual cycle. When granulosa is destroyed, its amount decreases proportionally. Later, there are changes in the synthesis of estrogens, anovulatory cycles. According to the feedback mechanism, there is an increase in the level of FSH. But there is no response to its stimulating effect, ovarian tissues gradually hypoplasize, menopause occurs.
In the initial period, a decrease in ovarian function does not give symptoms. Later, a woman may notice that the menstrual cycle is shortened to 24-26 days and below. In the running stage, there are failures in the cycle, it loses regularity. Conception in patients with a decrease in the oocyte reserve is impossible naturally, but the use of assistive technologies does not always give the expected result.
With a decrease in the reserve of oocytes, the signs of the underlying pathology come out in the first place. Inflammatory processes are accompanied by aching abdominal pain, abundant whites. Endometriosis is characterized by cycle disorders. PCOS is often accompanied by obesity, hirsutism, acne and amenorrhea. In the later stages, when estrogen deficiency joins the insufficiency of the ovarian reserve, vegetative symptoms become pronounced: hot flashes, sweating, tachycardia. There are sleep disorders, emotional lability and other signs of approaching premenopause.
To confirm the decrease in ovarian reserve, they rely on certain criteria. They include:
- age over 35 years
- cycle duration is less than 26 days
- elevated FSH of more than 10 IU/ml
- the presence of less than 5 follicles with a diameter of up to 10 mm on the 2-3 day of the cycle in the ovary
- reduction of ovarian volume to 8 cm3 or less.
The following methods are used for research:
- Gynecological examination. The reproductive organs are of normal size, but with endometrioid cysts, the ovaries may be enlarged. After the addition of estrogen deficiency, vaginal dryness is noted.
- Blood on AMH. The analysis can be taken on any day of the cycle, with a reduced reserve, its indicator is 0.5-1.1 ng / ml. But with PCOS, the indicator may increase due to the simultaneous maturation of a large number of oocytes.
- Hormonal profile. It is necessary for a comprehensive assessment of the patient’s condition. Includes FSH, LH, estradiol, progesterone, prolactin, testosterone. A decrease in ovarian reserve is accompanied by a decrease in estradiol and an increase in FSH.
- Sonography. Ultrasound assessment of the follicular reserve is carried out at the beginning of the menstrual cycle. There is a lack of antral follicles, ovarian hypoplasia. Sometimes changes characteristic of the underlying pathology are visually noticeable – polycystic, foci of endometriosis.
It is impossible to restore the reduced follicular reserve. Prolonged use of combined oral contraceptives and other hormonal drugs cannot stop this process. Therefore, techniques are used that are aimed at preserving the generative function. These may be the following variants of reproductive technologies:
- Ovulation stimulation. With the help of a combination of gonadotropins, from the beginning of the menstrual cycle, the maturation of several dozen eggs is stimulated in the patient. But the technique cannot be applied if there have already been attempts at simulation with insufficient response.
- The use of donor eggs. With preserved reproductive function, but a significant decrease in ovarian reserve, fertilization is carried out with donor fresh or cryopreserved eggs. In this case, only hormonal support is required to maintain pregnancy.
- The use of own frozen oocytes. Women undergoing chemotherapy are offered to pre-preserve eggs in order to use them later for IVF.
- Surrogate motherhood. Patients with low ovarian function and unsuccessful IVF attempts can resort to this method. The child is being carried by another woman who is not the biological mother.
Prognosis and prevention
With diminished ovarian reserve, the reproductive prognosis is unfavorable. It is impossible to stop the deterioration of ovarian function. Prevention consists in quitting smoking, preventing sexual infection and timely treatment of pelvic inflammatory diseases. In endometriosis or PCOS, preference is given to the destruction of pathological foci, rather than resection.
Women who are going to have chemotherapy or radiation treatment are recommended to carry out the vetrification of eggs. In young women and adolescent girls, cryopreservation of ovarian tissue can be performed for subsequent restoration of reproductive function. After a course of oncology treatment, autotransplantation of the cortical layer of the ovaries is performed, the menstrual cycle and the ability to conceive are restored within a few months.