When Fertility Begins to Decline: Signs You Shouldn’t Ignore

Why has ovarian reserve become such an important topic?

As maternal age continues to rise worldwide, fertility has become a major concern for many women. Very often, a single blood test result, especially AMH, is perceived as a verdict on whether pregnancy is possible or not.

In medical reality, ovarian reserve is not a prediction of reproductive destiny. It is mainly a clinical tool used to guide decisions, and it must always be interpreted in a broader medical context.

What does ovarian reserve actually reflect?

Ovarian reserve is an estimation of how many follicles remain in the ovaries.

It mainly reflects:

• the quantity of potentially available eggs

• the expected response to hormonal stimulation, especially in assisted reproduction

It does not directly reflect:

• egg quality

• the true probability of spontaneous pregnancy

• tubal function, uterine health, or sperm quality

It is therefore only one biological parameter, not a complete measure of fertility.

Can you have low AMH and still be fertile?

Yes, and this is extremely important to understand.

Several studies have shown that in women without known infertility, low AMH is not strongly associated with lower chances of natural pregnancy.

In practice:

• a woman with low AMH can conceive naturally

• a woman with normal AMH may still have difficulty conceiving

AMH is mainly useful to predict ovarian response to treatment, not the absolute ability to become pregnant.

So why measure ovarian reserve?

Ovarian reserve testing is useful in several clinical situations.

It helps to:

• guide infertility management

• anticipate poor response to stimulation in IVF

• adjust medication doses

• identify certain hormonal disorders

• support decision-making when pregnancy is postponed

It helps with planning, not with certainty.

Is high AMH always good news?

Not necessarily.

High AMH is often seen in polycystic ovary syndrome (PCOS).

In this situation:

• follicle count is high

• ovulation may be irregular

• fertility can still be impaired despite a “good” reserve

High AMH does not automatically mean optimal fertility.

What signs may suggest reduced ovarian reserve?

Some clinical features may suggest declining hormone production, such as:

• shorter or irregular cycles

• symptoms of low estrogen

• history of ovarian surgery

• family history of early menopause

However, many women with low ovarian reserve have no symptoms at all.

Age remains the most important factor

Even with normal AMH, fertility declines with age because:

• egg quality decreases

• chromosomal abnormalities increase

• miscarriage rates rise

Age remains the strongest biological predictor of fertility, far more than any hormone test.

What can damage ovarian reserve?

Several factors may accelerate ovarian decline:

• ovarian surgery, especially for cysts or endometriosis

• severe endometriosis

• pelvic infections

• chemotherapy or radiotherapy

• smoking

• genetic factors

But in many cases, decline is simply due to natural ovarian aging.

Can ovarian reserve be restored?

Currently:

• no treatment can increase the number of eggs

• no supplement has proven to restore ovarian reserve

General health and hormonal environment may improve with lifestyle measures, but follicle numbers cannot be regenerated.

How can fertility be preserved?

Although aging cannot be stopped, some measures may help protect reproductive potential:

• avoid smoking

• treat gynecological conditions early

• avoid unnecessary ovarian surgery

• consult early if cycles are abnormal

• plan pregnancy realistically

In some cases, egg freezing may be considered, especially:

• when pregnancy will be delayed

• before treatments harmful to the ovaries

• in certain cases of declining reserve

It is not a guarantee of future pregnancy, but a preservation option to discuss individually.

Why fertility assessment must always be global

Fertility depends on many factors:

• ovarian function and ovulation

• fallopian tubes

• uterus

• sperm quality

• hormonal balance

• duration of infertility

Ovarian reserve is only one part of the puzzle. Interpreting AMH alone may cause unnecessary anxiety or false reassurance.

Key message

Ovarian reserve mainly reflects egg quantity. It does not directly predict the chance of pregnancy.Low AMH does not mean sterility.High AMH does not exclude ovulation disorders.Age remains the most important factor.Medical decisions should always be based on full clinical evaluation.

Every situation is unique. A consultation allows all medical factors to be considered in order to propose the most appropriate strategy for each woman and each couple.

Kind regards,

Dr Sandra Yene Amougui