Female infertility, male infertility or a combination of the two affects millions of couples in the United States. An estimated 10 to 15 percent of couples are infertile, which means that they’ve been trying to get pregnant for at least a year — or for at least six months if you’re a woman age 35 or older.
Generally, infertility results from female infertility factors about one-third of the time and male infertility factors about one-third of the time. In the rest, the cause is either unknown or a combination of male and female factors.
The cause of female infertility can be difficult to diagnose, but many treatments are available. Treatment isn’t always necessary: Half of all infertile couples will go on to conceive a child spontaneously within the next 24 months.
The main symptom of infertility is the inability of a couple to get pregnant. An abnormal menstrual cycle that’s too long (35 days or more) or too short (less than 21 days) can be a sign of female infertility. There may be no other outward signs or symptoms.
When to see a doctor
If you’re in your early 30s or younger, most doctors recommend trying to get pregnant for at least a year before having any testing or treatment.
If you’re age 35 to 40, discuss your concerns with your doctor after six months of trying.
If you’re over 40 or have a history of irregular or painful periods, pelvic inflammatory disease (PID), repeated miscarriages, prior cancer treatment or endometriosis, your doctor may want to begin testing or treatment right away.
For pregnancy to occur, every part of the complex human reproduction process — from the ovary’s release of a mature egg to the fertilization of the egg to the fertilized egg’s implantation and growth in the uterus — has to take place just right. In women, a number of factors can disrupt this process at any stage. Female infertility is caused by one or more of these factors.
- Ovulation disorders: Ovulation disorders account for infertility in 25 percent of infertile couples. These can be caused by flaws in the regulation of reproductive hormones.
- Abnormal FSH and LH secretion: The two hormones responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are produced by the pituitary gland in a specific pattern during the menstrual cycle.
- Polycystic ovary syndrome (PCOS): In PCOS, complex changes occur in the hypothalamus, pituitary and ovary, resulting in overproduction of male hormones (androgens), which affects ovulation.
- Luteal phase defect: Luteal phase defect happens when your ovary doesn’t produce enough of the hormone progesterone after ovulation. Progesterone is vital in preparing the uterine lining for a fertilized egg.
- Premature ovarian failure: This disorder is usually caused by an autoimmune response, where your body mistakenly attacks ovarian tissues. It results in the loss of the eggs in the ovary, as well as in decreased estrogen production.
Damage to fallopian tubes (tubal infertility)
When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or close off the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include:
- Inflammation of the fallopian tubes (salpingitis) due to chlamydia or gonorrhea
- Previous ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of in the uterus
- Previous surgery in the abdomen or pelvis
Endometriosis occurs when tissue that normally grows in the uterus implants and grows in other locations. This extra tissue growth — and the surgical removal of it — can cause scarring, which impairs fertility. Researchers think that the excess tissue may also produce substances that interfere with conception.
Cervical narrowing or blockageAlso called cervical stenosis, this can be caused by an inherited malformation or damage to the cervix. The result is that the cervix can’t produce the best type of mucus for sperm mobility and fertilization. In addition, the cervical opening may be closed, preventing any sperm from reaching the egg.
Uterine causesBenign polyps or tumors (fibroids or myomas) in the uterus, common in women in their 30s, can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids can become pregnant. Scarring within the uterus also can disrupt implantation, and some women born with uterine abnormalities, such as an abnormally shaped (bicornuate) uterus, can have problems becoming or remaining pregnant.
Unexplained infertilityIn some instances, a cause for infertility is never found. It’s possible that combinations of minor factors in both partners underlie these unexplained fertility problems. The good news is that couples with unexplained infertility have the highest rates of spontaneous pregnancy of all infertile couples.
How your infertility is treated depends on the cause, your age, how long you’ve been infertile and personal preferences. Although some women need just one or two therapies to restore fertility, it’s possible that several different types of treatment may be needed before you’re able to conceive.
Treatments can either attempt to restore fertility — by means of medication or surgery — or assist in reproduction with sophisticated techniques.
Fertility restoration: Stimulating ovulation with fertility drugs
Fertility drugs, which regulate or induce ovulation, are the main treatment for women who are infertile due to ovulation disorders. In general, they work like the natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation.
Using fertility drugs carries some risks:
Becoming pregnant with twins or other multiplesOral medications carry a fairly low risk of multiples (less than 10 percent), but your chances increase to about 15 to 20 percent with injectable medications. Generally, the more fetuses you’re carrying, the greater the risk of premature labor, low birth weight and later developmental problems. Sometimes the amount or timing of the medications will be altered in an attempt to lower the risk of multiples. Treatment cycles may be canceled if your doctor detects the development of too many follicles, which could result in ovulation of more than one egg.
Developing enlarged ovariesOvarian hyperstimulation syndrome (OHSS) is a condition that can result from the use of fertility drugs. In response to the medication, your ovaries become overstimulated. Besides developing enlarged ovaries, you might experience abdominal pain and distention, gastrointestinal problems and shortness of breath. Signs and symptoms can develop while you’re undergoing ovulation induction or during the early stages of pregnancy.
There are several fertility drugs for abnormal LH and FSH production. These drugs include:
Clomiphene citrate (Clomid, Serophene)This drug is taken orally and stimulates ovulation in women who have PCOS or other ovulation disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg. Clomiphene citrate also improves fertility in normally ovulating women, and is often used as an initial treatment for unexplained infertility.
GonadotropinsInstead of stimulating the pituitary gland to release more hormones, these treatments stimulate the ovary directly. Often, gonadotropin medications are used in combination with intrauterine insemination (IUI) — a procedure during which sperm is injected into your uterus via a thin tube (catheter) — to increase the odds of a pregnancy. Gonadotropin medications include:
- Human menopausal gonadotropin, or hMG, (Repronex, Menopur). This injected medication is for women who don’t ovulate on their own due to the failure of the pituitary gland to stimulate ovulation. HMG contains both FSH and LH, and directly stimulates the ovaries to ovulate.
- Follicle-stimulating hormone, or FSH, (Gonal-F, Follistim, Bravelle). FSH works by stimulating the ovaries to produce mature egg follicles.
- Human chorionic gonadotropin, or HCG, (Ovidrel, Pregnyl). Used in combination with clomiphene, hMG or FSH, this drug stimulates the follicle to release its egg (ovulate).
- Metformin (Glucophage). This oral drug is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of PCOS. Metformin improves insulin resistance, normalizing the insulin level and making ovulation more likely to occur.
Letrozole (Femara). Letrozole belongs to a class of drugs known as aromatase inhibitors. Letrozole, also used to treat some breast cancers, may induce ovulation. However, the effect the medication has on early pregnancy isn’t yet known, so this medication isn’t used for ovulation induction as frequently as others.
Fertility restoration: SurgerySeveral surgical procedures can correct problems or otherwise improve female fertility. They include:
- Tissue removal. This surgery removes endometrial tissue or pelvic adhesions with lasers or ablation, which can improve your chances of achieving pregnancy.
- Tubal reversal surgery (microscopic). After a woman has had her tubes tied for permanent contraception (tubal ligation), surgery may be done to reconnect them and restore fertility. Your doctor will determine whether you’re a good candidate for the surgery.
- Tubal surgeries. If your fallopian tubes are blocked or filled with fluid (called hydrosalpinx), tubal surgery may improve your chances of becoming pregnant. Laparoscopic surgery is performed to remove adhesions, dilate a tube or create a new tubal opening. Tubal surgery is more successful when the blocked or narrowed part of the tube is closer to the ovary than to the uterus. Tubal blockage close to your uterus may increase your risk of ectopic pregnancy. In these and other severe cases of blockage or hydrosalpinx, removal of your tubes (salpingectomy) can improve your chances of pregnancy with in vitro fertilization.
Reproductive assistance: In vitro fertilizationThis effective technique involves retrieving mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a laboratory and transferring the embryos in the uterus three to five days after fertilization. In vitro fertilization (IVF) often is recommended when both fallopian tubes are blocked. It’s also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility, male infertility and ovulation disorders. IVF increases your odds of having twins or other multiples if more than one embryo is transferred to your uterus. IVF requires frequent blood tests and daily hormone injections.