“A Poor Ovarian Reserve”- Career Oriented Women’s Fertility Challenge!

India, the nation, with dubious distinction for having high fertility rates in the last century, is experiencing a dramatic drop in birth rates in recent decades, coupled with an increase in cases of infertility, of late more women in the age group of late 20’s and early 30’s planning pregnancy are getting disappointed to discover that their ova count is significantly lower than expected for their age. Infertility is a significant global health issue, affecting millions of people worldwide and posing challenges for individuals, families, and communities. Globally, 15-20% of people experience infertility at some point in their reproductive lives, meaning for many couples, the desire to have a family is not easily realized [1]. Urbanization, modified lifestyles, delayed marriages, shifting career priorities, & rising contraceptive usage are the causes of infertility [2]. Nearly one thirds of patients in private Infertility Clinics in Bengaluru are being diagnosed as “a poor ovarian reserve” reported Fertility specialists recently in an infertility awareness week 2025 recently. This number has been rising exponentially in the last 2 decades [3,4]. This is irreversible and calls for enhancing the current health and reproductive programs, educating people about improving their lifestyle choices and sexual behavior.

Looking around my own contacts, while we were nine siblings for our parents and similarly most of my paternal uncles and aunts had 4-8 children each. In our generation the number came down 2-3 and our next generation has only 1 or 2 children. Counting on our next generations 25 cohorts I see 8 have no children, 8 have one child and 9 have 2 children. Among the childless & single child couples, 12 have primary sterility & 4 secondary sterility. In India, infertility affects an estimated 15-20% of couples, with male infertility contributing to 40-50% of cases. The prevalence of primary infertility ranges from 3.9% to 16.8%. Factors like late marriage, environmental toxins, and lifestyle choices contribute to the high rates of male infertility. Disparities exist across states, with some regions like Goa, Lakshadweep, and Chhattisgarh showing higher burdens [5].

Age at marriage, biological factors, and lifestyle factors are strongly linked to infertility for both sex Women with higher education levels, late marriages, working women delaying first pregnancy are more likely to experience primary infertility. Indiscriminate use of contraceptives, obesity, Diabetes, Endometriosis, Uterine Fibroids, Thyroid problems, Alcohol consumption, and smoking are linked to secondary infertility. This observation has policy implications, and I draw attention of the planners to alarming infertility in India, which is unnoticed due to large population [6].

An average woman is born with all the ova she will ever have from 1-2 million, by her puberty this number falls by about 30% to 20% to about 3 to 4 lakhs and by the age of 30 years to allow a level of just 7-4%, that is around 70,000. From there on the decline is much faster. In the last 2 decades more young women are facing egg depletion faster than expected, due to postponing pregnancy, age being the significant factor. The broader picture indicates that it is a mix of urban lifestyle choices, environmental exposures and delayed first pregnancy. Thus, the biologic clock set which is difficult to reset or slow it [1,6]. This article is in response to an alert raised by gynaecologists in a recent infertility awareness week 2025, reviewing about 25 childless and single child young couples married for at least 5 years in author’s contact and appropriate literature search.

Case reports

Case 1&2: Married for 12-15 years, trying to conceive for 10 years are childless. For one all investigation led to finding our insufficiency of sperms in her husband. The couple could not afford artificial insemination. The second lady’s husband’s work involves 6-8 months’ travel and she herself is professionally occupied and no investigations have been done so far.

Case 3-7: Five young women married for period of 5-10 years are longing for pregnancy with no success. They are all in the age range of 28-35 years. All of them delayed the first pregnancy for the first 3-5 years to pursue career. Two of them have undergone basic fertility investigations in the last year which point to poor ovarian reserve.

Cases 8-11: These are four women in their early thirties age, have one child each in the age group of 5-18 yrs, post which they used contraceptives for 3-5 years and are finding it difficult to conceive 2 years after discontinuing oral contraceptives. One of them is diabetic, the second has put on a lot of weight and suffering from endometriosis and the other three are happy with one child and not keen to go for any investigations for the second child (Sample Reports 1 & 2).

Sample Report 1:Transvaginal follicular monitoring report- secondary infertility case.

Sample Report 2:Transvaginal follicular monitoring report- primary infertility case: October 2022.

Jessica in her own words

My husband and I tried unsuccessfully for four-almost five years to get pregnant. I put my body thru miserable hormonal and fertility treatments. We finally quit trying, and I mean we left the baby idea in the dust. We bought a house on the lake and began looking to live our best life in a different way. Before the ink was dry on the new home, we were pregnant. Nine months later, we had a beautiful baby boy. Our infertility issues were over since it’s so much easier to get pregnant again after you’ve already had one. My baby boy is now a six-year-old boy and doesn’t have any siblings. I assume he never will, but we have tried. I’m not willing to put myself through other treatments though. If it’s meant to happen, it will. Otherwise, my husband and I are fine pouring everything into our little dude [7].

Globally, for about one in six couples, the desire to have a family is not easily realized. An estimated 10-15% of couples in India are having trouble conceiving, and around 27.5 million infertile couples are there nationwide now [2,6]. Infertility differs according to the duration of marriage, for instance, in 2019-2020 it was more common in women who had been married for one year (42.9/1,000) compared those who had been married for four years (20.7/1,000). While primary infertility ranges from 3.9% to 16.8%, much higher in Urban population, secondary infertility is around 30%, in urban population. Roughly 1 in 4 couples in India struggle to conceive a second time after having a child. While national average primary infertility has decreased, secondary infertility rose from 19.5% in 1992-1993 to 28.6% in 2015-2016 and studies show another 5.9% increase in prevalence in the recent decade. While primary infertility is a concern, secondary infertility is becoming almost as prevalent as primary infertility in India. Inter-State Variations indicate Goa, Lakshadweep, and Chhattisgarh show higher burdens [1,2].

NFHS data

The overall infertility rate has risen steadily over the years, increasing from 22.4% in 1992–93 to 25.3% in 2005-2006, climbing to 30.7% in 2015-2016 and The National Family Health Survey 5 (NFHS-5) data for 2019-2021 indicates that India’s Total Fertility Rate (TFR) has declined to 2.0 children per woman. This is below the replacement level of 2.1, meaning each couple is having slightly fewer than two children who will survive to reproductive age. Primary infertility declined steadily from 1992 to 2015, whereas secondary infertility increased from 19.5% in 1992-1993 to 28.6% in 2015-2016. The NFHS 5 findings showed that the prevalence of infertility is 18.7 per 1,000 women among those married for at least five years and currently in union. The prevalence is the highest when the duration of marriage is one year (42.9/1,000) compared to the duration of marriage being more than two years (30.7/1,000), three years (24.1/1,000), and four years (20.7/1,000). This prevalence increases as the duration of marriage decreases [5].

Though mostly the lady is blamed for infertility in a male dominated society, though both partners are equally responsible, as male infertility contributes 40-50% to overall infertility. Beyond the age of 30, women’s fertility starts to diminish, and more quickly beyond the age of 35. This increases the risk of infertility, pregnancy difficulties, and miscarriage. Men’s fertility also falls with age, lower sperm quality, motility, & count begin around 40 years [1,6]. In India, data from a study indicates that 17% of women married between the ages of 31-35. In 2019-2021. For women in the age group 20-49 years, the median age of marriage improved from 16.2 years in 1992-1993 to 19.2 years in the year 2019-2021. A recent government survey suggests that only 52.8% of women in the 25-29 age group having married by age 20, compared to 72.4% in 2005- 06. This indicates a trend of delayed marriage among women, with a growing proportion choosing to marry later in their 20s and 30s.

The rise in male infertility that has been happening globally since the 1970s known as the “male infertility crisis.” Low sperm count, poor sperm motility, and aberrant sperm morphology are some of the reasons that contribute to male infertility. Medical disorders, including diabetes or infections, hormonal abnormalities, Varicocele potentially affect fertility. The other medico-social factors include Azoospermia, Obesity, Genetic disorders, late marriage, Tobacco smoking, Alcoholic beverage, Medication, Defective sperm production, Filarial Hydrocoele, Epididymitis, Environmental factor, Lifestyle factors, Stress, Testicular trauma, Estrogen excess, Anatomical issues, exposure to toxins, Chromosomes, Ejaculatory duct obstruction and Ejaculatory dysfunction. A complete lack of sperm occurs in about 10% to 15% of men who are infertile in recent years. A hormone imbalance or blockage of sperm movement causes a lack of sperm or lack of quality. In some cases of infertility, a condition called varicocele is the causes of man producing less sperm than normal. Oligo-astheno-terato-zoo-spermia a semen abnormality is another common cause [6].

Menstrual disorders, thyroid diseases, obesity, low ovarian reserves in women trying to conceive first pregnancy beyond 30 years are the factors that contribute to female infertility. Infertility prevalence increases as the duration of marriage decreases. Socioeconomic Factors like disadvantaged communities, rural women, and those with lower education levels is more prevalent. Polycystic Ovary Syndrome (PCOS) is the main medical cause of infertility in women, affecting over 10% of reproductive age women. Because of there is inconsistent or absence of ovulation, women with PCOS have trouble becoming pregnant naturally. PCOS is also associated with other disorders, like obesity, affecting fertility. Endometriosis in which tissues that resemble the lining of the uterus develop outside of it, resulting in discomfort and inflammation, ovaries & fallopian tubes get distorted, making it difficult for the egg to be released or fertilized [1,3,7].

Markers of ovarian reserve

Markers of ovarian reserve help assess a woman’s remaining egg supply. The most used markers include blood tests for Anti- Müllerian Hormone (AMH) and Follicle-Stimulating Hormone (FSH), as well as ultrasound measurements of Antral Follicle Count (AFC) & ovarian volume. AMH & AFC are considered the most sensitive & reliable [8].
A. AMH (Anti-Müllerian Hormone): AMH is produced by the granulosa cells within ovarian follicles and is a direct reflection of the number of follicles. The Anti-Mullerian Hormone (AMH) is a key biomarker for egg reserves. Higher AMH levels generally indicate a larger ovarian reserve and better fertility potential, while lower levels suggest diminished reserve and reduced fertility. AMH levels are more sensitive and reliable than FSH levels in assessing ovarian reserve. The healthy range being 2-4ng/mL. Below 1ng/mL is critical level affecting fertility. When AMH drops below 1ng/mL, and AFC shows 2-5 follicles, it is diagnosed as Severely Diminished Reserve (OSDR) [7, 8,3].
B. AFC (Antral Follicle Count): AFC is the number of small follicles (2-9mm) visible on ultrasound in both ovaries during the early follicular phase of the menstrual cycle. A low AFC can indicate reduced ovarian reserve and a poorer response to ovarian stimulation. AFC is a direct reflection of the number of eggs remaining in the ovaries and is a valuable tool for assessing ovarian reserve. Antral Follicle Count (AFC), the number of follicles seen on an ultrasound helps identify problems. Normal AFC being 6-10 follicles per ovary [7,8,9]. For clinical purposes most gynaecologist’s consider AMH drops below 1ng/mL, & AFC count- of 2-5 follicles, to diagnose cases as Severely Diminished Reserve in Bengaluru [3,7,8].
C. FSH (Follicle-Stimulating Hormone): FSH is a hormone released during the menstrual cycle that stimulates follicle growth in the ovaries. High levels of FSH, especially in the early follicular phase of the cycle, are an indicator of diminished ovarian reserve [8]. However, as FSH levels are influenced by other factors, AMH is considered a more reliable marker [7].
D. Ovarian volume: Ovarian volume is the total volume of both ovaries, as measured on ultrasound. While ovarian volume is used to estimate follicle count, it has lower reliability compared to AFC [8].

Other markers

a) Inhibin B: Inhibin B hormone produced by the ovaries & its levels is used as a marker of ovarian reserve.
b) Estradiol: Estradiol, an estrogen hormone, checked in the early follicular phase, and its high levels indicate early follicle development.
c) Clomiphene Citrate Challenge Test (CCCT): This test measures FSH response to ovarian stimulation with clomiphene citrate and is used to assess ovarian reserve.

Poor ovarian reserve influences not only getting pregnant, but also, declining quality of ova increase the risk of miscarriages and chromosomal abnormalities. Only one Ovum ovulated each month and rest die unused in each lady. Age, smoking, surgeries affect the quality, raising endometriosis, ovarian cyst formation which also compromise the egg reserve.

First child after enjoying initial 2-3 years of courtship is normal these days. Once the first child starts going to preschool, s/he starts hankering for a sibling, putting it down as peer pressure. Most couples agree, putting it down as love. In the efforts the couple get stuck for 4-5 years or more after the birth of their first child. On the other hand, in India, we see at least one thirds of the couple having a child struggle for second pregnancy, must go in for lots of investigations costing in hundreds of thousands of Indian Rupees. Even after such efforts and expenditure hardly half of them succeed. The other half accept as their fate or keep unsatisfied and compromise over a long time. Though their reasons range from financial constraints to feeling like their family is already complete, but what many one-and-done-by-choice families have in common is that they feel, in contrast to what society often tells them, that being one and done isn’t just best for them or best for their child [3].

Most of such couples consider maternity leave, family-spacing health recommendations and even potential family holidays, plan to have each of the 2-3 kids they wanted. Soon they realize how naïve they were, and the lady reaches 30+ age. That’s because, just two months after the first child’s birth, couples decide they were ‘one and done’ because of their struggle with sleep deprivation and mental health; a traumatic birth, Postnatal Depression (PND) and Postpartum Anxiety (PPA). But even when life becomes easier, the decision is felt right. It is also a reality that they thought there wasn’t anything “wrong” with not “giving” their child a sibling. They themselves were only children, and they are very happy, “They are so close with their parents [10,11].

After the contraceptive revolution of the mid-20th Century, which gave many women some real control over fertility, the choice of how many children to have has been personal. But there have been clear social and cultural trends, too. In many countries, those trends are shifting towards fewer kids. In the EU, the largest proportion of all families with children-49%-have one child. In Canada, onlychild families make up the largest group, ticking up from 37% in 2001 to 45% in 2021. And looking at mothers near the end of their childbearing years-arguably a better way to measure the popularity of only children, since census data gives only a moment-in-time snapshot-18% of US women in 2015 had one child, up from 10% in 1976 [12].

One thing I realized in my 56 years of experience is that parents can enjoy the childhood of the second child more since they are relatively more experienced in bringing up a child. At times I felt a tinge of sadness for the elder child though, that is because after the birth of the second child she/he is given more responsibility and treated as a grown-up. Having closely followed these 25 couples closely for me it makes sense to go with two children irrespective of the gender because the children grow up to become balanced adults and not privileged spoilt brats. The fact that women are having children later is a significant piece. There are a lot of people who say, no-one wants to have just one kid, but that is all because of delayed fertility following late marriage, postponing first pregnancy for enjoying married life for 2-3 years or focusing on career developments, or some other reasons. For some there are all these other things that are important as well, and they are going to prioritize them, and hoping they will get there, instead of saying ‘those things don’t matter and what comes first is our parenthood’.”

Widespread ideas about the ideal number of children are also changing. For millennia, the preference to have more than one child made sense. Even just fifty years ago, in India more than four in 10 children died before their fifth birthday. Having multiple children helped the family with the many tasks required to survive. And, of course, in the absence of reliable contraception, and with women getting married at far younger ages, having just one child wasn’t just undesirable and often wasn’t feasible. Part of many one-anddone parents’ contentment is the impact their decision has on other parts of their lives, such as careers, hobbies and interests. Such couples think of what it takes to go to the movies, or to go out to dinner, or does it disrupt adult friendships where they get to have an uninterrupted conversation?”. It is also a feeling that it is easier to maintain one’s health and figure and avoid hassles of breast feeding and sagging breasts! Pregnancy, labour and the postpartum period all carry risks, to both partners, particularly for women older than 30. Those giving birth to a second or later child, rather than their first, are at increased risk of pregnancy complications like eclampsia, gestational hypertension and preterm labour. For women in particular, careers, too, take a hit the more children they have. Each child is associated with an average drop in wages of 5%-although this varies from no wage disadvantage countries to a 10% decline per child in India. In the US, one study showed that, even accounting for differences in education or experience, the wage gaps between mothers of one or two children versus childless women are roughly the same, around 13%. But the decline falls to 17.5% for three children [12].

Precautionary measures

Known precautionary measures include balanced diet, maintain healthy body weight, managing stress in Indian context and planning pregnancy before the age of 35, adding limiting alcohol consumption, quitting smoking, in countries where women do smoke or consume alcohol regularly [1,4].

Treatment approaches

Although there are obstacles, access to reproductive therapies in India have been gradually getting better. Advanced fertility clinics offering Assisted Reproductive Technologies (ART), Including Intrauterine Insemination (IUI) and In Vitro Fertilization (IVF), are increasing in major metropolitan centers, making these procedures more accessible to desiring or affluent infertile couples. Current Government Initiatives at Improving Reproductive Health, with an emphasis on family planning, maternal health, and adolescent reproductive education, the Indian government has put in place several initiatives to enhance reproductive health through National Health Mission. Important projects include: i) Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), ii) Janani Suraksha Yojana (JSY), iii) Mission Parivar Vikas

The belief that infertility is only a woman’s problem, is the common misconceptions in India, followed by a feeling that lifestyle habits don’t affect fertility, or realization that stress is the primary cause. Both men & women can experience fertility issues, & factors like diet, exercise, smoking, and alcohol play a major role.

Therefore, in India, addressing increasing infertility requires a combination of raising awareness, promoting healthy lifestyles, improving access to affordable fertility treatments, breaking the stigma surrounding infertility, as increasing infertility is a multifaceted issue influenced by lifestyle factors, delayed marriages, & a lack of awareness & support for reproductive health. While Lifestyle factors like Obesity, poor nutrition, stress, smoking and alcohol consumption significantly impact fertility, delayed marriages and starting families later in life, are increasing the risk of infertility. Infertility is often a taboo topic, leading to delayed diagnosis and treatment-seeking coupled with affordable and accessible fertility diagnosis like Follicular Monitoring and AMH assessment and treatments, like IVF, are not available to everyone, particularly in rural areas.

Actions that need to be popularized are prioritizing preventive measures like safe sexual practices, early detection and treatment of sexually transmitted infections, addressing environmental factors that impact fertility through implementing comprehensive public health campaigns to educate individuals and communities about infertility, its causes, and available treatments. Promote Healthy Lifestyles like healthy eating habits, regular exercise, stress management, and cessation of smoking and alcohol consumption.

Include in the National Family Planning Program interventions to make fertility treatments more affordable and accessible, particularly for low-income individuals. At the society level, communities must create supportive environments where individuals feel comfortable discussing infertility and seeking help. Include reproductive health education in school curricula to empower future generations with knowledge about fertility. Encourage couples to seek professional help if they are unable to conceive after a year of trying, especially for women over 30 years. Providing support and counselling to individuals and couples facing infertility to cope with emotional and psychological challenges. Country needs to enhance the current health and reproductive programs, educating people about improving their lifestyle choices and sexual behavior, and calling attention to a significant shift in fertility dynamics, particularly declining fertility rates, in southern states.

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