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Primary Ovarian Insufficiency

Primary ovarian insufficiency can lead to infertility

Primary ovarian insufficiency, or POI, occurs when the ovaries stop functioning normally before age 40. When this happens, your ovaries don’t produce normal amounts of the hormone estrogen or release eggs regularly. This condition was formerly known as “premature ovarian failure”.

In general, early loss of ovarian function is a gradual process. Early on in this process POI may only demonstrate a few symptoms. Ultimately this process results in premature menopause where women stop having periods and cannot become pregnant.

Look for these symptoms

Signs and symptoms of primary ovarian insufficiency are similar to those of menopause or estrogen deficiency. They include:

  • Irregular or skipped periods for three months or more
  • Absent periods for more than a year
  • Hot flashes and/or night sweats
  • Signs of estrogen deficiency, including osteoporosis, decreased libido, and vaginal dryness
  • Irritability, depression or difficulty concentrating

If you’ve missed your period for three months or more, it might be time to see your gynecologist or a reproductive endocrinologist to determine the cause. You can miss your period for a number of reasons — including pregnancy, stress, or a change in diet or exercise habits — but it’s best to get evaluated whenever your menstrual cycle changes. Even if you don’t mind not having periods, it’s advisable to see your doctor to find out what’s causing the change. Low estrogen levels can lead to bone loss and an increased risk of heart disease.

Primary ovarian insufficiency can be caused by many things

  • Chromosomal defects. Some genetic disorders are associated with POI. These include mosaic Turner syndrome — in which a woman has only one normal X chromosome and an altered second X chromosome — and fragile X syndrome — in which the X chromosomes are fragile and break.
  • Toxins. Chemotherapy and radiation therapy used in cancer treatment are common causes of toxin-induced ovarian failure. These therapies can damage genetic material in cells. Other toxins such as cigarette smoke, chemicals, pesticides and viruses might hasten ovarian failure.
  • An immune system response to ovarian tissue (autoimmune disease). In this rare form, your immune system produces antibodies against your ovarian tissue, harming the egg-containing follicles and damaging the egg. What triggers the immune response is unclear, but exposure to a virus is one possibility.
  • Unknown factors. The cause of primary ovarian insufficiency is often unknown. We might recommend further testing to find the cause, but in many cases, the cause remains unclear.

Testing for POI

Women who suspect they have primary ovarian insufficiency can be diagnosed with several lab tests:

  • Anti-Mullerian hormone (AMH) test. AMH normal levels are between 1.5 and 4.0 ng/mL. A very low level suggests decreased ovarian reserve. Reproductive endocrinologists use AMH hormone levels to help predict which women may respond poorly to fertility drugs and generally are less likely to be successful with fertility treatment.
  • Day 3 follicle-stimulating hormone (FSH) test and estradiol. If FSH levels are high (> 20 mIU/mL, but usually > 30 mIU/mL) and estradiol levels are low (usually < 20 pg/mL), ovarian insufficiency is confirmed.
  • Inhibin B. In women, inhibin B is associated with maturation of follicles in the ovaries. If inhibin B level is low, then your fertility potential (ovarian reserve) and your likelihood of conceiving may be reduced.

Treatment for primary ovarian insufficiency

For women with POI who desire pregnancy, one option is in vitro fertilization using donated eggs plus exogenous estrogen and a progestogen, which enable the lining of the uterus to support the transferred embryo. The age of the oocyte donor is more important than the age of the recipient. This technique is fairly successful, but even without this technique, some women with diagnosed primary ovarian insufficiency can become pregnant. No treatment has been proved to increase the ovulation rate or restore fertility in women with primary ovarian insufficiency.