Infertility means not being able to get pregnant after one year of trying. Or, six months, if a woman is 35 or older. Women who are able to get pregnant but who cannot carry a pregnancy to term (birth) may also be considered infertile.
The term "infertility" is limited to those who are of normal childbearing age, not those who can’t get pregnant because they are near or past menopause.
Infertility is a common problem. About 1 out of 10 of women (10%) in the U.S. ages 15-44 have difficulty getting pregnant or staying pregnant.
About 1/3 of infertility cases are caused by women’s problems. Another 1/3 of fertility problems are due to the man. The other cases are caused by a mixture of male and female problems or by problems that cannot be determined.
What causes infertility?
There are many possible causes of infertility. Having a successful pregnancy involves many steps along a very complex path. Problems with any of these steps can lead to infertility.
Pregnancy involves some of the following steps at which points problems can arise:
- A woman’s ovaries must be able to release a viable egg (i.e. ovum, oocyte)
- The egg must be able to travel down the fallopian tube.
- The man must be able to produce sufficient healthy sperm and be able to ejaculate.
- His sperm must be able to travel to the fallopian tube.
- The sperm and egg must unite at the right time to fertilize the egg.
- The fertilized egg must attach to the inside of a uterus that is prepared for the egg
- The uterus must be able nurture the egg and allow the fetus to develop and grow until it is ready for birth.
The cause of infertility can rest in the woman or the man, or can be result from multiple factors. In some cases, environmental factors can contribute to infertility, such as medications. In other cases, genetic conditions or other chronic health problems are the main cause of infertility.
Common causes for infertility can often be detected with the use of different tests. However, it may not always be possible to determine the cause of infertility.
Most cases of infertility in women result from problems with ovulation. Some conditions affecting ovulation include premature ovarian failure, in which the ovaries stop functioning before natural menopause. Primary ovarian insufficiency (POI) occurs when a woman’s ovaries stop working normally before she is 40. POI is not the same as early menopause.
Polycystic ovary syndrome (PCOS), in which the ovaries may not release an egg regularly or may not release a viable, healthy egg is another cause of infertility. Among women who have PCOS, even when a healthy egg is released and fertilized, the uterus may not be receptive to implantation of a fertilized egg, which results in infertility.
Other causes of infertility might include:
- Blocked fallopian tubes due to endometriosis, pelvic inflammatory disease, or surgery
- Physical problems with the uterine wall
- Uterine fibroids, which are non-cancerous growths of muscle in the walls of the uterus.
A woman’s risk for infertility can also be affected by certain lifestyle and environmental factors, including (but not limited to):
- Cigarette smoking
- Poor diet
- Being overweight or underweight
- Recreational drugs
- Environmental toxins
- Genetic conditions, such as being a carrier of Fragile X syndrome
- Other health problems, such as sexually transmitted diseases
A Woman's Age and Infertility
Many women are waiting until their 30s and 40s to have children. 20% of women in the U.S. now have their first child after age 35. So age is a growing cause of fertility problems. About one-third of couples in which the woman is over 35 have fertility problems.
Aging decreases a woman's chances of having a baby in the following ways:
• Her ovaries become less able to release eggs.
• She has a smaller number of eggs left.
• Her eggs are not as healthy.
• She is more likely to have health conditions that can cause fertility problems.
• She is more likely to have a miscarriage.
The male fertility process involves the production of mature sperm and getting the sperm to reach and fertilize the egg. Although it may seem to be a simpler process than female fertility, male fertility also requires many conditions to be met: the ability to have and sustain an erection, having enough sperm, having enough semen to carry the sperm to the egg, and having sperm of the right shape that move in the right way. A problem meeting any of these conditions contributes to infertility.
Male infertility is most often caused by:
- Exposing the testes to high temperatures, which can affect the number and shape of the sperm, and their ability to move. For instance, cryptorchism is a condition where the testes do not descend into the scrotum. Although it does not usually affect the ability to have and sustain an erection, cryptorchism means that the testes are still inside the body cavity, which has a higher temperature than the external scrotum. There is also problem called a varicocele that happens when the veins on a man’s testicle(s) are too large that results in higher body temperature along the testes. For some men, even wearing tight underwear can increase the temperature around the tests.
- Other factors that cause a man to make too few sperm or none at all. Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. For example, cystic fibrosis often causes infertility in men.
- Movement of the sperm. This may be caused by the shape of the sperm. Sometimes injuries or other damage to the reproductive system block the sperm.
A man's sperm can be changed by his overall health and lifestyle. Some things that may reduce the health or number of sperm include:
- Advanced age
- Heavy alcohol use
- Recreational drugs
- Environmental toxins, including pesticides and lead
- Genetic conditions, such as Klinefelter syndrome
- Other health problems, such as mumps, kidney disease, or hormonal problems
- Radiation treatment and chemotherapy for cancer
How is infertility diagnosed?
Although not getting pregnant is an indication of possible infertility, only a health care provider can provide a diagnosis of infertility.
Doctors will do an infertility checkup. This involves a physical exam. The doctor will also ask for both partners’ health and sexual histories. Sometimes this can find the problem. However, most of the time, the doctor will need to do more tests.
In men, doctors usually begin by testing the semen. They look at the number, shape, and movement of the sperm. Sometimes doctors also suggest testing the level of a man's hormones.
- In women, the first step is to find out if she is ovulating each month. There are a few ways to do this. A woman can track her ovulation at home by:
- Writing down changes in her morning body temperature for several months
- Writing down how her cervical mucus looks for several months
- Using a home ovulation test kit (available at drug or grocery stores)
Doctors can also check ovulation with blood tests. Or they can do an ultrasound of the ovaries.
If ovulation is normal, there are other fertility tests available.
Some common tests of fertility in women include:
Hysterosalpingography: Hysterosalpingography is an x-ray of the uterus and fallopian tubes. Doctors inject a special dye into the uterus through the vagina. This dye shows up in the x-ray. Doctors can then watch to see if the dye moves freely through the uterus and fallopian tubes. This can help them 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. A block could also keep the sperm from reaching the egg.
Laparoscopy: Laparoscopy involves the use of a small tube-like tool with a light at the end called a laparoscope which allows the doctor to see inside the abdomen. The doctor make a small cut in the lower abdomen and inserts the laparoscope. With the laparoscope, the doctor can check the ovaries, fallopian tubes, and uterus for disease and physical problems, such as scarring and endometriosis.
Finding the cause of infertility can be a long and emotional process. It may take time to complete all the needed tests. So don't worry if the problem is not found right away.
How Is Infertility Treated?
Infertility can be treated with medicine, surgery, artificial insemination, or assisted reproductive technology. Many times these treatments are combined. In most cases infertility is treated with drugs or surgery.
Doctors recommend specific treatments for infertility based on:
- Test results
- How long the couple has been trying to get pregnant
- The age of both the man and woman
- The overall health of the partners
- Preference of the partners
Although there are treatment options that can help improve a couple's chances of having a successful pregnancy, some causes may not be treatable.
Treatment for Female infertility
Some common medicines used to treat infertility in women include:
- Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
- Human menopausal gonadotropin or hMG (Repronex, Pergonal): This medicine is often used for women who don't ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
- Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
- Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
- Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
- Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production.
Many fertility drugs increase a woman's chance of having twins, triplets, or other multiples.
Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems.
In women, some physical problems can also be corrected with surgery.
Intrauterine insemination (IUI)
Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.
IUI is often used to treat:
- Mild male factor infertility
- Women who have problems with their cervical mucus
- Couples with unexplained infertility
Assisted Reproductive Technology (ART)
Assisted reproductive technology (ART) is a group of different methods used to help infertile couples. ART works by removing eggs from a woman's body. The eggs are then mixed with sperm to make embryos. The embryos are then put back in the woman's body.
Women with no eggs or unhealthy eggs might also want to consider surrogacy. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child will be genetically related to the surrogate and the male partner. After birth, the surrogate will give up the baby for adoption by the parents.
Women with ovaries but no uterus may be able to use a gestational carrier. This may also be an option for women who shouldn't become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by the man's sperm and the embryo is placed inside the carrier's uterus. The carrier will not be related to the baby and gives him or her to the parents at birth.
Treatment for male infertility
Doctors often treat infertility in men in the following ways:
- Sexual problems: Doctors can help men deal with impotence or premature ejaculation. Behavioral therapy and/or medicines can be used in these cases.
- Too few sperm: Sometimes surgery can correct the cause of the problem. In other cases, doctors surgically remove sperm directly from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.
- Sperm movement: Sometimes semen has no sperm because of a block in the man’s system. In some cases, surgery can correct the problem.
Getting Help for Infertility
Those who suspect they are infertile should see their health care providers, including:
- Couples who have been trying to conceive for a year without getting pregnant
- Women who have experienced menstrual irregularities or who have had endometriosis or uterine fibroids
- Women who have gotten pregnant but who have had more than one miscarriage or stillbirth
- Men and women with certain genetic conditions