Fertility Facts: Women's Fertility Issues Explained
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on April 13, 2022.
What Is Infertility?
Have you been trying to get pregnant but keep coming up short? Here, review a few of the reasons why.
Infertility refers to an inability to conceive after 12 months of having regular sex without the use of contraception.
Getting pregnant is really a multi-step process. To conceive:
- A woman's body must release an egg from one of her ovaries (ovulation).
- The egg must go through a fallopian tube toward the uterus (womb).
- A man's sperm must join with (fertilize) the egg along the way.
- The fertilized egg must attach to the inside of the uterus (implantation).
Risk Factors Affecting Fertility
There are many risk factors that can affect fertility, including:
- Overweight or severely underweight
- History of sexually transmitted diseases, such as chlamydia or gonorrhea
- Eating disorders in women
- Excess alcohol consumption
- Exposure to toxins, such as lead or certain pesticides
- Certain medical conditions, such as endometriosis
What Causes Infertility in Women?
The reason a woman can't get pregnant is usually no fault of her own. Factors leading to infertility include:
- Ovaries not ovulating (releasing eggs)
- Blocked fallopian tubes so sperm can’t meet the egg
- Eggs are not viable
- Shape of the uterus makes it hard for a fertilized egg to implant
- Reproductive cancers
- Conditions (celiac disease, Cushing's disease, sickle cell disease, diabetes) that can lead to lack of menstruation, called amenorrhea
In some cases, there is no known reason for a woman's infertility.
Learn more: Overview of Amenorrhea
What to Do if You Suspect a Fertility Problem
If you've been having regular unprotected sex for more than 12 months and are still not pregnant you should see your doctor.
Women 35 years or older should see their doctors after six months of trying because the chances of pregnancy decrease every year after the age of 30.
If you have a medical problem which increases the risk of infertility you should talk to your doctor before trying to get pregnant.
High risk health problems include: irregular or no periods, very painful periods, endometriosis, pelvic inflammatory disease and multiple miscarriages.
About one-third of infertility cases are the result of male conditions. Abnormal semen and male tube blockages are common causes.
How is Infertility Diagnosed in Women?
The diagnosis of infertility is not always straightforward. Your doctor will begin with a general physical and gynecologic exam, and ask about medical history, medications, menstruation cycle, and sexual habits.
Your doctor may ask you to track your ovulation each month by recording your morning body temperature and testing with a home ovulation test kit.
Other ways to establish ovulation include ultrasound images and blood tests. If ovulation is normal, other tests may be needed to determine the cause of infertility.
Other Infertility Tests for Women
Additional tests to diagnose the cause of infertility include:
- Ovarian reserve testing: to determine how effective the eggs are after ovulation.
- Genetic testing: to evaluate whether a genetic abnormality is interfering with the woman's fertility.
- Pelvic ultrasound: high-frequency sound waves create an image of the woman's uterus, fallopian tubes, and ovaries.
- Thyroid function test: up to 5% of infertile women have an abnormal thyroid.
Procedures to Diagnosis Infertility
Hysterosalpingography is an x-ray of the uterus and fallopian tubes using a special dye. Doctors can then watch to see if the dye moves freely to find physical blocks that may be causing infertility. Blocks in the system can keep the egg from moving from the fallopian tube to the uterus or could keep the sperm from reaching the egg.
Laparoscopy is a minor surgery to see inside the abdomen. A small incision is made in the lower abdomen and a laparoscope - a tool to visual the reproductive organs - allows the surgeon to view the ovaries, fallopian tubes, and uterus for disease and structural problems. Doctors can usually find scarring and endometriosis by laparoscopy.
Causes of Infertility: Fallopian Tube Damage
After ovulation the egg must travel through a fallopian tube toward the uterus in the hope that it will get fertilized along the way. If the fallopian tubes are damaged, inflamed, scarred or blocked, infertility may result.
The main causes of tubal damage are:
- Abdominal diseases, like appendicitis and colitis
- Previous surgeries can cause adhesions that alter the fallopian tubes
- Ectopic pregnancy is a potentially life-threatening pregnancy in the tube itself and can cause tubal damage
- Congenital defects - in rare cases, women may be born with tubal abnormalities, usually associated with uterus irregularities
Causes of Infertility: Endometriosis
Endometriosis is responsible for about 1 in 20 cases of infertility and is a condition in which tissue that normally lines the uterus is found outside the uterus or other pelvic areas.
This tissue becomes trapped and in moderate to severe cases can block the fallopian tubes or damage the ovaries as well as affect the lining of the uterus and nearby structures.
Surgical removal of the extra tissue growth can cause scarring, too. Endometriosis often causes lower abdominal pain, severe cramping, and painful periods.
Causes of Infertility: Uterus or Cervix Disorders
Problems relating to the structure and functioning of the cervix and uterus can also have an effect on fertility. Abnormalities that may have an effect on female fertility incude:
- Fibroids: Non-cancerous tumors found in the uterus in about 30% of women of childbearing age. Fibroids may interfere with implantation. They can also block the fallopian tube, preventing sperm from fertilizing the egg.
- An abnormally shaped uterus.
- A narrow cervix (cervical stenosis) makes it more difficult for sperm to reach the uterus.
- Problems with cervical mucous can prevent successful implantation.
Causes of Infertility: Drug Side Effects
Certain types of medicines may result in infertility in women. Examples of these medicines include:
- Long term, excessive use of NSAIDs (non-steroidal anti-inflammatory drugs)
- Chemotherapy can result in ovarian failure, sometimes permanent
- Radiotherapy near the reproductive organs
- Illegal drugs
- Smoking and nicotine increases the risk of miscarriage, premature birth, and low-birth-weight babies for women. Smoking by either partner reduces the chance of conceiving.
Causes of Infertility: Ovulation Disorders
Ovulation is the release of an egg from the ovaries. For a women to become pregnant she must ovulate. Without ovulation, there are no eggs to be fertilized and pregnancy cannot occur. Irregular or absent menstrual periods may be a sign of an ovulation disorder.
The most common cause of female infertility is an ovulation disorder called polycystic ovarian syndrome (PCOS). PCOS is a hormone imbalance problem which can interfere with normal ovulation and causes abnormally high levels of the male hormone testosterone.
Typical symptoms of PCOS include menstrual problems, excessive hair growth, and acne and is associated with being overweight.
Causes of Infertility: More Ovulation Disorders
There are a number of other disorders which can lead to abnormal ovulation and infertility. These include:
- Premature ovarian failure: the ovaries stop working before menopause and the natural supply of eggs have been depleted. Tends to occur in highly athletic women of low body weight, or may be genetic.
- Gland disorder, such as the thyroid or pituitary glands. These glands control ovulation.
- Long-term conditions, such as diabetes or epilepsy.
- Other underlying causes such as excessive exercise, eating disorders, injury or tumors.
How is Infertility Treated?
This will depend on many factors. The cause of infertility will determine the most appropriate treatment but also the age of the patient, the length of infertility, personal preferences and their general state of health.
There are three main types of fertility treatment:
- Medicines to assist fertility
- Surgical procedures
- Assisted reproductive technology (ART)
In many cases the treatments are combined.
Fertility Drugs: What Is Available?
If the woman has an ovulation disorder she will probably be prescribed fertility drugs which regulate or induce ovulation. Some medicines may be used "off-label", meaning when a doctor prescribes a drug for a different purpose than those formally approved by the FDA and found in the package labeling of the drug. Speak with your doctor about these medical options.
- Metformin: off-label
- Menotropins (Menopur)
- Follicle-stimulating hormone (Follistim AQ, Gonal-F)
- Human chorionic gonadotropin (HCG) (Ovidrel, Pregnyl, Novarel)
- Gn-RH (gonadotropin-releasing hormone) analogs
- Bromocriptine (Parlodel)
- Letrozole (Femara): off-label
- Leuprolide: off-label
- Milprosa Vaginal Ring (progesterone)
- Urofollitropin (Bravelle, Fertinex)
Part 1 - Fertility Drugs: More Info
- Clomiphene: helps to stimulate ovulation in females with low ovulation possibly because of polycystic ovary syndrome (PCOS) or some other disorder. Clomiphene acts on the pituitary gland to release more FSH (follicle-stimulating hormone) and LH (luteinizing hormone).
- Metformin: if there is no response to clomiphene, metformin may be effective for women with PCOS, especially when linked to insulin resistance.
- Menotropins: often used for women who don't ovulate due to problems with their pituitary gland. Menotropins acts directly on the ovaries to stimulate ovulation.
- Follicle-stimulating hormone (Gonal-F) is a pituitary gland hormone that controls estrogen production by the ovaries. It stimulates the ovaries to ovulate.
Part 2 - Fertility Drugs: More Info
- Human chorionic gonadotropin (Ovidrel, Pregnyl, Novarel) is used together with clomiphene, hMG and FSH. It stimulates the follicle to ovulate.
- Gn-RH (gonadotropin-releasing hormone) analogs are often used for women who ovulate early or don't ovulate regularly each month. Gn-RH analogs act on the pituitary gland to change when the body ovulates.
- Bromocriptine (Parlodel) inhibits prolactin production. Prolactin stimulates milk production in breastfeeding mothers. High levels of prolactin in non-pregnant, non-breastfeeding women may lead to irregular ovulation cycles.
Risks of Fertility Drug Treatment
Many fertility drugs increase a woman's chances of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy, and their babies have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems, as well.
The use of injectable fertility drugs can cause ovarian hyperstimulation syndrome in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
Female Surgical Procedures for Infertility
Disorders related to the structure of the cervix and abnormalities in the uterus or fallopian tubes may need to be treated with surgery. Your doctor will be able to discuss options with you if surgery is recommended.
Pelvic problems, primarily endometriosis and adhesions, may also be treated with laparoscopic surgery. Medications are also effective in endometriosis, too.
Assisted Reproductive Techniques (ART) For Women
Assisted reproductive technology (ART) is a group of different methods used to help infertile couples.
In vitro fertilization (IVF) is the most common and most effective ART technique. IVF involves stimulating and retrieving mature eggs from a woman, fertilizing them with sperm in a lab, then implanting the embryos in the uterus 3 to 5 days after fertilization. IVF requires treatment with hormones beforehand.
In April 2020, the FDA approved Milprosa (progesterone) Vaginal Ring to support embryo implantation and early pregnancy as part of an Assisted Reproductive Technology (ART) treatment program for infertile women up to and including 34 years of age.
However, IVF does not guarantee pregnancy. The success rate for a cycle of IVF is about 32% for women under 35 years of age.
Other ART Techniques for Women
IVF is not always successful, but there are other ART options:
- Intracytoplasmic sperm injection (ICSI): a single healthy sperm is injected directly into a mature egg; may be used with low sperm count or low-quality sperm.
- An alternative to ICSI is “conventional” fertilization. The egg and many sperm are placed in a petri dish and the sperm fertilizes an egg on its own.
- Donor eggs or sperm: eggs, sperm or embryos can be used from a known or anonymous donor.
- Gestational carrier (surrogacy): the couple's embryo is placed in the uterus of the carrier for pregnancy; used in cases nonfunctional uterus or when pregnancy poses a serious health risk.
- Zygote intrafallopian transfer (ZIFT): sperm fertilization of egg in lab and embryo transferred to the fallopian tube instead of the uterus (rarely used in US today).
Join Forces to Gain Strength
Trying to conceive can be a stressful and trying time. But rest assured that other women are going through the same concerns and treatments that you are.
Your doctor should always be your first and last stop for your medical plan, but gain strength in numbers by reaching out.
Finished: Fertility Facts: Women's Fertility Issues Explained
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- Centers for Disease Control and Prevention (CDC). Infertility FAQs. March 1, 2022. Accessed April 13, 2022 at https://www.cdc.gov/reproductivehealth/infertility/index.htm
- Infertility Fact Sheet. Womenshealth.gov. Office on Women’s Health; U.S. Department of Health and Human Services. April 1, 2019. Accessed April 13, 2022 at https://www.womenshealth.gov/publications/our-publications/fact-sheet/infertility.html
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