Ovarian aging and implications for fertility female health

Ovarian aging is a major detrimental factor of pregnancy achievement and it is related to other issues of women's health. The purpose of this review is to present an update on ovarian aging risk factors followed by contemporary methods of its assessment and an overview of its current management strategies in assisted reproductive technologies (ART). Ovarian aging is a multifactorial trait governed by several factors including medical, lifestyle, genetic, autoimmune and idiopathic. There are several established risk factors and many others that are still being revealed. Heritability has a major influence on ovarian aging. Different genetic strategies and approaches for ovarian aging evaluation have been rapidly expanding; however the mission is far from complete. Genome-wide association studies seems to be the most applicable to advance this research. Although anti-Müllerian hormone and antral follicle count (AFC) biomarkers seems to be the most reliable predictors of ovarian aging, none has demonstrated conclusive evidence to predict pregnancy achievement in an ART setting. The debate continues which of the two predictors is the most suitable in ART as well as non-ART settings. Although multivariate models have been shown to be equally predictive to AFC, latest data support the notion that chronological age and genetic markers inclusion may increase their reliability. Several strategies have been suggested to manage ovarian aging in ART settings. None of the stimulation protocols or ART interventions has been shown to be convincingly beneficial to ovarian aging women and individualization of treatment is still recommended. Ovarian priming by different androgen preparations has been shown to be promising but more randomized controlled studies are required to substantiate these findings. Except for oocyte donation other ART strategies have not shown a persuasive evidence for advanced ovarian aging infertility patients. The new development of oocyte vitrification may well introduce opportunities for fertility preservation to woman at risk. It is concluded that proper assessment and detection of ovarian aging, employing current or developing biomarkers of ovarian reserve, may enable health providers to recommend, at appropriate biological time, early pregnancy achievement or fertility preservation in women at risk.