DOR Demystified: Why Diminished Ovarian Reserve Isn’t One-Size-Fits-All

Understanding the different types of Diminished Ovarian Reserve and what they mean for your fertility journey

Being told you have Diminished Ovarian Reserve (DOR) can feel overwhelming — but the truth is, it’s not the same diagnosis for everyone. In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols breaks down the “automobile” analogy to explain why DOR is a broad category that can mean very different things depending on the cause.

You’ll learn:

• The four common “models” of DOR and how each affects fertility
• Why age, AMH, AFC, and FSH tell different parts of the story
• How your specific type of DOR shapes your treatment plan
• Real patient stories that prove DOR doesn’t always mean poor outcomes
• The essential questions to ask your doctor if you’re diagnosed with DOR

If you or someone you know has been labeled with DOR, this episode will help you replace fear with clarity — and empower you to make the right next step for your situation.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:01

Today we were talking about a term that can feel emotionally paralyzing and leave you feeling hopeless. But in truth its often overused and misunderstood. Dimined ovarian reserve. Lets break it down so you can drop the stress you dont need. Im Dr. Mark Amols and this is Taco about fertility Tuesday. Have you ever been told you have door dimensia ovarium reserve and felt your stomach drop? Well, here's the truth. DOR is like saying automobile. Sure it was technically correct, but it could mean a truck, a sports car, a van, even a motorcycle with a sidecar. And just like vehicles, the type of DOR you have can be completely different from someone else. And the way you drive or treat it can be totally different too. So what is diminish ovarium reserve? Well, we look at the ASRM criteria. The definition is diminished. Ovarian reserve is a term generally used to indicate a reduced number and or reduced quality of oocytes such that the ability to reproduce is diminished. In medical terms, door means your ovaries may not have as many eggs as expected for your age. Now whether you hear, when you hear re door, you probably think, oh my God, I'm not going to get pregnant. And that is not true. See the problem is door is a graback term. It's not one neat little diagnosis. There are multiple models under the DOR umbrella and they behave very differently. In fact, even the way we determine DOR is different. Some of the more common tests we look at is antiolarin hormone, antral follicle count and cycle day three labs. And each one of those means something different. If you listend to some of my podcasts in the past, we talk about what each of those mean. Cycle Day 3 Labs tells us how well your body is going to respond to the medications, whereas the antral follicle count tells us about how many eggs you have at that current time. Meaning if you have 10 eggs and you respond to the medication, you should be able to get about 10 eggs. Antiolarin hormone is a very useful test that kind of summarizes everything, but it's also more of a marker of your future potential. So as you can see, if one of these tests are bad, someone's going to label you with dimish ovarian reserve. Matter of fact, even if your age is older, they can consider you to have DN ovarian reserve because that meets the diagnosis of lower egg quality. And that's because we know when women get older, they have reduced egg quality, not just quantity, but actual quality. So when someone says your eggs are acting 40, it's not saying the quality is that of a 40 year old because that's based off of DNA of the eggs. They're saying that you may not produce as many egess as someone your age but more like someone who is 40. And this is a very important difference because one says you're not going to make as many eggs and you might not have the same quality of IVF cycle as someone else who was younger where they have better fertilization, better blastulation and better pregnancy rates. But you can still get pregnant. There is no test that can say you can't get pregnant if you're still ovul young every month and have a working uterus because as long as you can release one eggs you can technically get pregnant. This is the idea between the analogy of the automobile. By saying the word automobile you are describing multiple types of vehicle and that's the same thing that goes on with dimnish ovarian reserve. If I told you I was driving an the automobile you would need to say well can you tell me more about it? There is no other way you would be able to determine what type of vehicle I'm driving. Well, the same thing goes on with ditish ovarian reserve. There are different types and the different types are going to affect how you treat it. It's also going to affect the prognosis. So the term door tells you a category but not the specifics. And so you can't sit there and say well my friend has do r and she's having a really hard time. So if I have door I'm going to have a hard time too. Thats not true. The question is what is the reason for your door? When I think of door Im usually thinking of four commonels high fsh, low anto follicle count, age related diminished ovarian reserve and low amh. Dimitish ovarian reserve due to a high FSH doesn't mean you won't do well. It just means that like an older car it needs extra gas. We got to put that pedal to the metal because the ovaries aren't responding well to the stimulation even with high doses. And so there are protocols we can use that can sometimes give a better response than you would have had with a lower fssh level. It's the comment I always make where I say in IVF ovarian reserve is what tells us what to do that help you get there for our first cycle and then we make adjustments so we use that ovarian reserve to make decisions on that protocol. If I know someone has a higher FSH level I may use higher doses of medication. I may use a flare such as a microdosese flare or a femaora flare or even a Clomid flare. But you can be called diminish ovarian reserve. Have a high anteroollicle count but because your FSH is 17 that puts you into the manage ovariant reserve category. If I can get all those eggs to grow then youe probably going to do well. Now in the situation where you have a low antero follicle count but normal antiolarian hormone and normal fsh this would be like having a smaller gas tank but still a brand new engine. You might not make as many eggs per cycle but the quality should be what wed expect for your age. A perfect example of someone who has low AFC but would be called door but really doesn't fit the true door definition would be a patient who had surgery for an ovarian cyst and may have lost a lot of follicles because she lost most of her ovary but the egg she has are very healthy. In this situation it doesn't matter how high I go in the dosage, there's only so many eges I can get per cycle because she's starting with fewer. So yes, she's going to take more cycles to be able to get the same equivalence as someone else her age. And she may get the label of D meas ovarian reserve but she doesn't really have a very concerning version of diminished ovarian reserve. Now financially it's harder because you have to do more cycles. But it's important to know that the labeled dimensional ovarium reserve was only talking about the angralfogle count. Now for the patients who have a low IMH may be younger, that is future risk. Thats like a new car with a slightly smaller gas tank. Its not a problem now but might be a problem in the future. You may be labeled with diminish ovarian reserve but it may not be a big issue right Then this may push you to go on to freeze your eggs because you are not ready to have kids yet. But technically if you have a lower AMH and youre just trying and getting pregnant you really dont have a problem because you only need to make one egg per month and dimish ovarian reserve in this situation doesnt mean you have infertility. Now if you're someone who has infertility and your AMH level is lower. It's unlikely it'going to be only this one parameter. I can't tell you how many times I see young women who had an a.m. m.A. Drawn by their doctor and then started freaking out when they read everything online and thats not the same patient who had infertility with a loumh. Theyre freaking out that theyre not going to be off kids and that is far from the truth. Yes. Do you have diminished ovarian reserve based off a parameter that is usually used in the infertility world? You do. But your dimenishsional ovarian reserve is so much different and your prognosis is very good. The last model of door is the one that most people more worried about. Age related dimens ovarian reserve, normal count, maybe even normal FSH but high andoyed risk. This is the sports car with a great looking engine but when you pop the hood you find out half the parts aren't working. The issue is in quantity. It's a quality issue. At ah aged 43 or 44 you can have a beautiful AFC and a good AMH M but most eggs will be chromosomally abnormal. The solution in this situation is going to be quantity. You want more eggs to be able to get more embryos to eventually get to that normal embryo. PGTA is highly recommended in this situation. So that way you know when you get the normal embryo so you know when you have to stop doing so many cycles. It is very common for women who are more mature to have to undergo multiple cycles. Now it's possible someone could have all four of these models or maybe two of them or three of them and with each one there is some more concern. But as you can see the type of dimensional ovarium reserve and defining it matters because it affects the treatment approach. If I treated every dimensional ovarian reserve patient the same it would be like giving every automobile the same maintenance schedule whether its a semi truck or a scooter and that would be crazy and thats why you shouldnt do it with patients. If I know someone has an antero follicle count of three it might not make sense to use high doses of medications because they're going to waste a lot of money and we may not get any more eggs. If I under stimulate someone with a high FSH then I might miss a few eggs that they could have had to help them get pregnant. And if I rush a younger low AMH patient into IVF without a good reason I could be creating unnecessary Stress. Many cases stick out to me, but there are a few that I think will give you real life examples. One of them, a girl named Sarah, came to my clinic and was told she has dish ovarian Reserve. Her AMH was 0.9 and she was devastated. When she came to the first appointment, she had already looked up everything about ivf. She knew she wanted to freezeer eggs. She was even considering making blastocyst with donor sperm because she wanted to make sure she'll be able to have kids later. One of the first questions I'll sometimes ask patients in the very beginning of the consult, when I see them talking about IVF and I can't figure out why they would want to do ivf, I ask them very nicely, why is it that you're wanting to do IVF today? And I suspected was because of that AMH level. And when she told me, I then explained everything that I explained to you. I said to her, even if it was true, the number, I'm still not worried and I don't even believe the number is correct. And we went in ultrasound that day and I saw multiple antralfocicles. And I said, there, I don't know why the AMH level is low, but I can tell you everything looks good based off the ant TR follicle count. We repeated the AMH and it came back normal. This is why I should never get worried about just one test. I've also had other examples where patients come in with low AMHs and they have a decent anterofocicle count and they only want one kid and they're trying at that time. And I tell him, come back if you haven't got pregnant in six months. Another case I think about, and you probably heard me talk about before on another podcast, was a patient, mine, who was about 43, 44 years of age. Her name was Sharon and her MH was great. It was like four point something. Her antral F count was like over 40. On paper it looked amazing. She got a ton of eggs in the end, weed up getting around 50 something eggs. And of those eggs, 40 of them fertilized. And of those she got 21 embryos. But here's the but unfortunately only one came back genetically normal, meaning euoid. See, in this situation, the egg quality, not the quantity was the main challenge. She did go on to do another cycle and we got one more embryo. Unfortunately that transfer didn't work and unfortunately she's never been back to put the other embryo back. I still reach out to her every year. Just checking on her. there are many, many other stories. The most important thing to understand is if you are given the label of din ovarian reserve door, do not think your journey is over. If anything it gives you a better chance because now the doctors eyes are wide open so they can look at your cycle and customize the plan to you. So if you are re labeled with DOR, the questions you have for your doctor are going to be 1. Which ovarian reserve tests were abnormal for you? 2. Is my DOI related to egg number and quality medication response or combination? Three, how does this affect my timeline? Meaning if you're wanting to have kids, do you need a freeze eggs now? What's the best protocol for your specific door and why? And then the last part is, do I have time to wait or should I act now? If there's anything I ever see is that patients are not told they havedor and don't realize this time they can't wait another year or two. That will make their dor worse. And so you need to ask your doctor, can I wait? I take a lot of things into consideration when I'm defining that if they only want one kid, well then I'd say listen, it's not unreasonable to wait six months. Try if you don't get pregnant then we start stuff. But they tell me they want three kids and I know they have dish ovarian reserve and I know their AMIMH is low and they're not going to have fertility for many, many years and they already have infertility. I'm going to say you need to start now. And that's the point. Just like an automobile doesn't represent every type of vehicle, door doesn't represent everyone. You need to find out which door you are. In summary, door is a category, not a sentence. Just like an automobile could be anything from a sports car to a minivan Door can mean low eg count, poor medication response, age related quality decline, or just a heads up for the future. The key is knowing which model you have so you and your doctor can create the right plan for you. I know when my wife and I went through fertility we were told we had DOR and it was scary. And if this episode was helpful for you or maybe someone else that you know, it was told they have dish ovarian reserve, let them know about this episode. This might help give them some relief of the stress of worrying about the things they read online. As always, if you like this podcast, please tell your friends about us. Give us a five star review on your favorite medium. But most of all, keep coming back. I look forward to talking you again next week on Taco Bell Fertility Tuesday.