Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel’s back
Diminished ovarian reserve predicts diminished ovarian response to stimulation but does not predict cycle fecundity. It has been recently defined by ESHRE, the Bologna's criteria, according to which at least two of the following three features should be present: (1) Age >40 years/any other risk factor for DOR, (2) abnormal ovarian reserve test, i.e. antral follicle count, AMH, (3) poor ovarian response in a previous stimulated cycle, i.e. less than three follicles after standard gonadotropin stimulation. Poor response to maximal stimulation on two previous occasions also defines DOR. The treatment options are limited. Avoiding the GnRH agonist long protocol and stimulation with microdose flare or antagonist protocol yields better results. Adjuvant therapy with LH, DHEAS and growth hormone shows some benefit in improving the oocyte yield. It is advisable to perform ICSI for all obtained oocytes and some advocate assisted hatching. Pregnancy rates are, however, poor and often these patients require ovum donation. Developing tests that will diagnose DOR in a low-risk population will allow women to plan their reproductive careers early.