Understanding DOR, POA, and POI

Diminished Ovarian Reserve (DOR), Premature Ovarian Aging (POA) and Primary Ovarian Insufficiency (POI): What Is the Difference and Why It Matters?

Hello everyone, I am Dr Sonia Gayete-Lafuente, a Fertility Expert and Physician-Scientist at the CHR, and today we’re going to talk about some terms that may be confusing for patients around ovarian function and reserve.

I often hear women say that they’ve been told they have “low ovarian reserve”, “early menopause”, or “ovarian failure, insufficiency or aging”…, as though these terms mean the same thing. They do not… and understanding the differences is important because each condition can have different implications for fertility, long-term health, and treatment.

Let’s look at each one more closely based on questions I received from some of you.

Q1: What is diminished ovarian reserve?

A1: Diminished ovarian reserve is a broad description of reduced egg quantity, in absolute terms. We estimate ovarian reserve using AMH, antral follicle count, and sometimes a patient’s response to ovarian stimulation. According to the conventional international classifications (Bologna / POSEIDON), DOR would be defined as having an AMH <1-1.2 ng/mL, antral follicle count <5-6 on the ultrasound, and obtaining = or <3 eggs retrieved after stimulation.

Q2: Does having DOR imply aging, having early menopause or infertility?

A2: NOT NECESSARILY! A woman with DOR may still have regular periods and may still conceive naturally. It does not automatically mean menopause, infertility, or poor egg quality. It just tells us that only a few eggs may be available per cycle, in absolute terms.

Q3: What is premature ovarian aging?

A3: Premature ovarian aging describes an ovarian reserve that is lower than expected for a patient’s chronological age. So this is a relative term, interpreted in the context of age. à For example, the same AMH level may be relatively expected in a woman in her early forties but relatively low in a woman in her twenties.

Some physicians also call it AMH age-appropriate or NOT age-appropriate…

Q4: What are the implications of having POA?

A4: A young patient with POA may still have regular cycles and normal estrogen levels…. BUT her ovaries may respond more like those of an older woman, and her reproductive window may be shorter than expected.

Q5: What is primary ovarian insufficiency?

A5: In a way, it’s like an extreme POA that end up disrupting ovarian hormonal function before age 40 due to an early depletion of follicles.

So, it is always associated with very extreme DOR that leads to irregular or absent periods, elevated FSH levels (>10), and low estrogen production… often leading to perimenopausal states at young ages.

Q6: Is POI the same as early menopause?

A6: POI is sometimes compared with early menopause, but it is not exactly the same. In POI, ovarian function may fluctuate, and occasional ovulation can still occur. It’s not yet an ovarian failure but an insufficiency.

And if we can still get any eggs… they may be of better quality compared to older menopausal women, due to the younger age.

IN SUMMARY!!! DOR, POA and POI can overlap but are not the same!

Despite they can all have low AMH, they’re different because, again:

• DOR describes reduced egg quantity in absolute terms.
• POA describes ovarian reserve that is lower than expected for age.
• POI describes a substantial loss of ovarian function before age 40, affecting menstrual pattern.

THIS MEANS THAT A LOW AMH is not a diagnosis by itself, and it is not a final verdict. The correct interpretation depends on the patient’s age, menstrual cycles, hormone levels, ultrasound findings, previous treatment response and reproductive goals.

Q7: Why does distinguishing between POI, POA and DOR matter?

A7: Well, because these patients may require very different counseling AND the treatment should be individualized for each patient.

An older woman with DOR may need treatment focused on obtaining the best possible outcome from a limited number of eggs.

A young woman with POA may need to consider fertility preservation or pregnancy sooner than she had planned.

A woman with POI needs not only fertility counseling but also management of estrogen deficiency and long-term bone, cardiovascular, sexual and general health.

The diagnosis should therefore never be based on a single AMH result.