Journal of Assisted Reproduction and Genetics

, Volume 32, Issue 12, pp 1709–1712 | Cite as

Diminished ovarian reserve, premature ovarian failure, poor ovarian responder—a plea for universal definitions

  • J. Cohen
  • N. Chabbert-Buffet
  • E. Darai



Diminished ovarian reserve (DOR) is characterized by poor fertility outcomes, and it represents a major challenge in reproductive medicine. Although consensus exists on the concept of DOR, its definition remains blurry. DOR has to be distinguished from premature ovarian failure (POF) and poor ovarian responders (POR), who are clearly defined.


We performed a PubMed search with the terms “diminished ovarian reserve” and “in vitro fertilization (IVF)” to assess the homogeneity of the definition of DOR.


Out of 121 articles, 14 gave a definition for DOR. Only one definition was used by two different teams (basal follicle-stimulating hormone (FSH) value >10 IU/l) and eight teams used 11 different definitions. Among those, four definitions did not include antral follicular count (AFC) and seven studies did. Two definitions included the results from a previous cycle.


The heterogeneity in the definition of DOR used in these studies contributes to confusing results. Hence, there is a need for a clear definition of DOR. It appears that AFC and anti-Müllerian hormone (AMH) serum levels are the most relevant criteria. One option could be the use of the following definition: (i) woman with any of the risk factors for POR and/or (ii) an abnormal ovarian reserve test (i.e., antral follicular count (AFC) <5–7 follicles or AMH <0.5–1.1 ng/ml). This hypothesis requires validation.


Diminished ovarian reserve IVF AMH AFC 


  1. 1.
    De Vos M, Devroey P, Fauser BCJM. Primary ovarian insufficiency. Lancet Lond Engl. 2010;376(9744):911–21.CrossRefGoogle Scholar
  2. 2.
    Goswami D, Conway GS. Premature ovarian failure. Hum Reprod Update. 2005;11(4):391–410.CrossRefPubMedGoogle Scholar
  3. 3.
    Ferraretti AP, La Marca A, Fauser BCJM, Tarlatzis B, Nargund G, Gianaroli L, et al. ESHRE consensus on the definition of “poor response” to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod Oxf Engl. 2011;26(7):1616–24.CrossRefGoogle Scholar
  4. 4.
    Goldman MB, Thornton KL, Ryley D, Alper MM, Fung JL, Hornstein MD, et al. A randomized clinical trial to determine optimal infertility treatment in older couples: the Forty and Over Treatment Trial (FORT-T). Fertil Steril. 2014;101(6):1574.e1–2–81.e1–2.Google Scholar
  5. 5.
    Wiser A, Shalom-Paz E, Reinblatt SL, Son W-Y, Das M, Tulandi T, et al. Ovarian stimulation and intrauterine insemination in women aged 40 years or more. Reprod Biomed Online. 2012;24(2):170–3.CrossRefPubMedGoogle Scholar
  6. 6.
    Harris ID, Missmer SA, Hornstein MD. Poor success of gonadotropin-induced controlled ovarian hyperstimulation and intrauterine insemination for older women. Fertil Steril. 2010;94(1):144–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Merhi Z, Zapantis A, Berger DS, Jindal SK. Determining an anti-Mullerian hormone cutoff level to predict clinical pregnancy following in vitro fertilization in women with severely diminished ovarian reserve. J Assist Reprod Genet. 2013;30(10):1361–5.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Buyuk E, Seifer DB, Illions E, Grazi RV, Lieman H. Elevated body mass index is associated with lower serum anti-mullerian hormone levels in infertile women with diminished ovarian reserve but not with normal ovarian reserve. Fertil Steril. 2011;95(7):2364–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Gleicher N, Weghofer A, Barad DH. Improvement in diminished ovarian reserve after dehydroepiandrosterone supplementation. Reprod Biomed Online. 2010;21(3):360–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Gleicher N, Ryan E, Weghofer A, Blanco-Mejia S, Barad DH. Miscarriage rates after dehydroepiandrosterone (DHEA) supplementation in women with diminished ovarian reserve: a case control study. Reprod Biol Endocrinol RBE. 2009;7:108.CrossRefGoogle Scholar
  11. 11.
    Lu Q, Shen H, Li Y, Zhang C, Wang C, Chen X, et al. Low testosterone levels in women with diminished ovarian reserve impair embryo implantation rate: a retrospective case-control study. J Assist Reprod Genet. 2014;31(4):485–91.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Gleicher N, Kim A, Weghofer A, Shohat-Tal A, Lazzaroni E, Lee H-J, et al. Starting and resulting testosterone levels after androgen supplementation determine at all ages in vitro fertilization (IVF) pregnancy rates in women with diminished ovarian reserve (DOR). J Assist Reprod Genet. 2013;30(1):49–62.PubMedCentralCrossRefPubMedGoogle Scholar
  13. 13.
    Gleicher N, Barad D. “Ovarian age-based” stimulation of young women with diminished ovarian reserve results in excellent pregnancy rates with in vitro fertilization. Fertil Steril. 2006;86(6):1621–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Kara M, Aydin T, Aran T, Turktekin N, Ozdemir B. Does dehydroepiandrosterone supplementation really affect IVF-ICSI outcome in women with poor ovarian reserve? Eur J Obstet Gynecol Reprod Biol. 2014;173:63–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Yilmaz N, Uygur D, Inal H, Gorkem U, Cicek N, Mollamahmutoglu L. Dehydroepiandrosterone supplementation improves predictive markers for diminished ovarian reserve: serum AMH, inhibin B and antral follicle count. Eur J Obstet Gynecol Reprod Biol. 2013;169(2):257–60.CrossRefPubMedGoogle Scholar
  16. 16.
    Check JH, Summers-Chase D, Yuan W, Horwath D, Wilson C. Effect of embryo quality on pregnancy outcome following single embryo transfer in women with a diminished egg reserve. Fertil Steril. 2007;87(4):749–56.CrossRefPubMedGoogle Scholar
  17. 17.
    Kumbak B, Oral E, Kahraman S, Karlikaya G, Karagozoglu H. Young patients with diminished ovarian reserve undergoing assisted reproductive treatments: a preliminary report. Reprod Biomed Online. 2005;11(3):294–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Zhang HH, Xu PY, Wu J, Zou WW, Xu XM, Cao XY, et al. Dehydroepiandrosterone improves follicular fluid bone morphogenetic protein-15 and accumulated embryo score of infertility patients with diminished ovarian reserve undergoing in vitro fertilization: a randomized controlled trial. J Ovarian Res. 2014;7:93.PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Check JH, Amui J, Choe JK, Cohen R. The effect of a rise or fall of serum estradiol the day before oocyte retrieval in women aged 40–42 with diminished egg reserve. Clin Exp Obstet Gynecol. 2015;42(3):282–4.PubMedGoogle Scholar
  20. 20.
    Jayaprakasan K, Narkwichean A, Maalouf WE, Campbell BK. Efficacy of dehydroepiandrosterone to overcome the effect of ovarian ageing (DITTO): a proof of principle randomised controlled trial protocol. BMJ Open. 2014;4(10):e005767.PubMedCentralCrossRefPubMedGoogle Scholar
  21. 21.
    Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update. 2006;12(6):685–718.CrossRefPubMedGoogle Scholar
  22. 22.
    La Marca A, Sighinolfi G, Radi D, Argento C, Baraldi E, Artenisio AC, et al. Anti-Mullerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum Reprod Update. 2010;16(2):113–30.CrossRefPubMedGoogle Scholar
  23. 23.
    Broer SL, Mol BWJ, Hendriks D, Broekmans FJM. The role of antimullerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. Fertil Steril. 2009;91(3):705–14.CrossRefPubMedGoogle Scholar
  24. 24.
    Iliodromiti S, Kelsey TW, Wu O, Anderson RA, Nelson SM. The predictive accuracy of anti-Müllerian hormone for live birth after assisted conception: a systematic review and meta-analysis of the literature. Hum Reprod Update. 2014;20(4):560–70.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Service de Gynécologie-Obstétrique, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC 6-UPMC Centre Expert en Endométriose (C3E)Université Pierre et Marie Curie Paris 6ParisFrance
  2. 2.Inserm UMRS938Université Pierre et Marie CurieParisFrance

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