Female Infertility

Overview

Infertility is defined as trying to get pregnant with frequent, unprotected sex for at least a year with no success.

Infertility results from female factors about one-third of the time and both female and male factors about one-third of the time. The cause is either unknown or a combination of male and female factors in the remaining cases.

Female infertility causes can be difficult to diagnose. There are many treatments, depending on the infertility cause. Many infertile couples will go on to conceive a child without treatment.

Symptoms

The main symptom of infertility is the inability to get pregnant. A menstrual cycle that's too long (35 days or more), too short (less than 21 days), irregular or absent can mean that you're not ovulating. There might be no other signs or symptoms.

When to see a doctor

When to seek help can depend on your age:

• Up to age 35, most doctors recommend trying to get pregnant for at least a year before testing or treatment.
• If you're between 35 and 40, discuss your concerns with your doctor after six months of trying.
• If you're older than 40, your doctor might suggest testing or treatment right away.

Your doctor might also want to begin testing or treatment right away if you or your partner has known fertility problems, or if you have a history of irregular or painful periods, pelvic inflammatory disease, repeated miscarriages, cancer treatment, or endometriosis.

Causes

For pregnancy to occur, every step of the human reproduction process has to happen correctly. The steps in this process are:

• One of the two ovaries releases a mature egg.
• The egg is picked up by the fallopian tube.
• Sperm swim up the cervix, through the uterus and into the fallopian tube to reach the egg for fertilization.
• The fertilized egg travels down the fallopian tube to the uterus.
• The fertilized egg attaches (implants) to the inside of the uterus and grows.

Female reproductive system

The ovaries, fallopian tubes, uterus, cervix and vagina, also called the vaginal canal, make up the female reproductive system.

Fertilization and implantation

During fertilization, the sperm and egg unite in one of the fallopian tubes to form a zygote. Then the zygote travels down the fallopian tube, where it becomes a morula. Once it reaches the uterus, the morula becomes a blastocyst. The blastocyst then burrows into the uterine lining a process called implantation.

In women, a number of factors can disrupt this process at any step. Female infertility is caused by one or more of the factors below.

Ovulation disorders

Ovulating infrequently or not at all accounts for most cases of infertility. Problems with the regulation of reproductive hormones by the hypothalamus or the pituitary gland or problems in the ovary can cause ovulation disorders.

• Polycystic ovary syndrome (PCOS). polycystic ovary syndrome (PCOS) causes a hormone imbalance, which affects ovulation. PCOS is associated with insulin resistance and obesity, abnormal hair growth on the face or body, and acne. It's the most common cause of female infertility.
• Hypothalamic dysfunction. Two hormones produced by the pituitary gland are responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt production of these hormones and affect ovulation. Irregular or absent periods are the most common signs.
• Primary ovarian insufficiency. Also called premature ovarian failure, this is usually caused by an autoimmune response or by premature loss of eggs from your ovary, possibly as a result of genetics or chemotherapy. The ovary no longer produces eggs, and it lowers estrogen production in women under age 40.
• Too much prolactin. The pituitary gland can cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and can cause infertility. This can also be caused by medications you're taking for another condition.

Damage to fallopian tubes (tubal infertility)

Damaged or blocked fallopian tubes keep sperm from getting to the egg or block the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include:

• Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea or other sexually transmitted infections
• Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy, in which a fertilized egg implants and develops somewhere other than the uterus, usually in a fallopian tube

Endometriosis

Endometriosis occurs when tissue that typically grows in the uterus implants and grows in other places. This extra tissue growth — and the surgical removal of it — can cause scarring, which can block fallopian tubes and keep an egg and sperm from uniting.

Endometriosis can also disrupt implantation of the fertilized egg. The condition also seems to affect fertility in less-direct ways, such as damage to the sperm or egg.

Uterine or cervical causes

Several uterine or cervical causes can interfere with the egg implanting or increase the risk of miscarriage:

• Benign polyps or tumors (fibroids or myomas) are common in the uterus. Some can block fallopian tubes or interfere with implantation, affecting fertility. However, many women who have fibroids or polyps do become pregnant.
• Problems with the uterus present from birth, such as an unusually shaped uterus, can cause problems becoming or remaining pregnant.
• Cervical stenosis, a narrowing of the cervix, can be caused by an inherited malformation or damage to the cervix.
• Sometimes the cervix can't produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.

Unexplained infertility

In some cases, the cause of infertility is never found. A combination of several minor factors in both partners could cause unexplained fertility problems. Although it's frustrating to get no specific answer, this problem can correct itself with time. But you shouldn't delay treatment for infertility.

Risk factors

Certain factors may put you at higher risk of infertility, including:

• Age. The quality and quantity of a woman's eggs begin to decline with age. In the mid-30s, the rate of follicle loss speeds, resulting in fewer and poorer quality eggs. This makes conception more difficult, and increases the risk of miscarriage.
• Smoking. Besides damaging your cervix and fallopian tubes, smoking increases your risk of miscarriage and ectopic pregnancy. It's also thought to age your ovaries and deplete your eggs prematurely. Stop smoking before beginning fertility treatment.
• Weight. Being overweight or significantly underweight may affect ovulation. Getting to a healthy body mass index (BMI) might increase the frequency of ovulation and likelihood of pregnancy.
• Sexual history. Sexually transmitted infections such as chlamydia and gonorrhea can damage the fallopian tubes. Having unprotected sex with multiple partners increases your risk of a sexually transmitted infection that may cause fertility problems later.
• Alcohol. Excess alcohol consumption can reduce fertility.

Prevention

For women thinking about getting pregnant soon or in the future, these tips might help:

• Maintain a healthy weight. Overweight and underweight women are at increased risk of ovulation disorders. If you need to lose weight, exercise moderately. Strenuous, intense exercise of more than five hours a week has been associated with decreased ovulation.
• Quit smoking. Tobacco has multiple negative effects on fertility, as well as your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
• Avoid alcohol. Heavy alcohol use may lead to decreased fertility. And any alcohol use can affect the health of a developing fetus. If you're planning to become pregnant, avoid alcohol, and don't drink alcohol while pregnant.
• Reduce stress. Some studies have shown that stress can cause couples to have poorer results with infertility treatment. Try to reduce stress in your life before trying to become pregnant.

Diagnosis

If you've been unable to conceive within a reasonable period of time, seek help from your doctor for evaluation and treatment of infertility. You and your partner should be evaluated. Your doctor will take a detailed medical history and conduct a physical exam.

Fertility tests might include:

• Ovulation testing. An at-home, over-the-counter ovulation prediction kit detects the surge in luteinizing hormone (LH) that occurs before ovulation. A blood test for progesterone — a hormone produced after ovulation — can also document that you're ovulating. Other hormone levels, such as prolactin, also might be checked.
• Hysterosalpingography. During hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee), X-ray contrast is injected into your uterus and an X-ray is taken to check for problems inside the uterus. The test also shows whether the fluid passes out of the uterus and spills out of your fallopian tubes. If any problems are found, you'll likely need further evaluation.
• Ovarian reserve testing. This testing helps determine the quality and quantity of eggs available for ovulation. Women at risk of a depleted egg supply — including women older than 35 — might have this series of blood and imaging tests.
• Other hormone testing. Other hormone tests check levels of ovulatory hormones as well as thyroid and pituitary hormones that control reproductive processes.
• Imaging tests. A pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a sonohysterogram, also called a saline infusion sonogram, or a hysteroscopy is used to see details inside the uterus that can't be seen on a regular ultrasound.

Hysterosalpingography

A doctor or technician places a slender catheter inside your cervix. It releases a liquid contrast material that flows into your uterus. The dye traces the shape of your uterine cavity and fallopian tubes and makes them visible on X-ray images.

Depending on your situation, rarely your testing might include:

• Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy can identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
• Genetic testing. Genetic testing helps determine whether there any changes to your genes that may be causing infertility.

Treatment

Infertility treatment depends on the cause, your age, how long you've been infertile and personal preferences. Because infertility is a complex disorder, treatment involves significant financial, physical, psychological and time commitments.

Treatments can either attempt to restore fertility through medication or surgery, or help you get pregnant with sophisticated techniques.

Medications to restore fertility

Medications that regulate or stimulate ovulation are known as fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders.

Fertility drugs generally work like natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They're also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs.

Fertility drugs include:

• Clomiphene citrate. Taken by mouth, this drug stimulates ovulation by causing the pituitary gland to release more follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate the growth of an ovarian follicle containing an egg. This is generally the first line treatment for women younger than 39 who don't have polycystic ovary syndrome (PCOS).

• Gonadotropins. These injected treatments stimulate the ovary to produce multiple eggs. Gonadotropin medications include human menopausal gonadotropin or hMG (Menopur) and FSH (Gonal-F, Follistim AQ, Bravelle).

  Another gonadotropin, human chorionic gonadotropin (Ovidrel, Pregnyl), is used to mature the eggs and trigger their release at the time of ovulation. Concerns exist that there's a higher risk of conceiving multiples and having a premature delivery with gonadotropin use.

• Metformin. This drug is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of PCOS. Metformin (Fortamet) helps improve insulin resistance, which can improve the likelihood of ovulation.
• Letrozole. Letrozole (Femara) belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion to clomiphene. Letrozole is usually used for woman younger than 39 who have PCOS.
• Bromocriptine. Bromocriptine (Cycloset, Parlodel), a dopamine agonist, might be used when ovulation problems are caused by excess production of prolactin (hyperprolactinemia) by the pituitary gland.

Risks of fertility drugs

Using fertility drugs carries some risks, such as:

• Pregnancy with multiples. Oral medications carry a fairly low risk of multiples (less than 10%) and mostly a risk of twins. Your chances increase up to 30% with injectable medications. Injectable fertility medications also carry the major risk of triplets or more.

  Generally, the more fetuses you're carrying, the greater the risk of premature labor, low birth weight and later developmental problems. Sometimes, if too many follicles develop, adjusting medications can lower the risk of multiples.

• Ovarian hyperstimulation syndrome (OHSS). Injecting fertility drugs to induce ovulation can cause ovarian hyperstimulation syndrome (OHSS), which is rare. Signs and symptoms, which include swollen and painful ovaries, usually go away without treatment, and include mild abdominal pain, bloating, nausea, vomiting and diarrhea.

  It's possible to develop a more severe form of OHSS that can also cause rapid weight gain, enlarged painful ovaries, fluid in the abdomen and shortness of breath.

• Long-term risks of ovarian tumors. Most studies of women using fertility drugs suggest that there are few if any long-term risks. However, a few studies suggest that women taking fertility drugs for 12 or more months without a successful pregnancy might be at increased risk of borderline ovarian tumors later in life.

  Women who never have pregnancies have an increased risk of ovarian tumors, so it might be related to the underlying problem rather than the treatment. Since success rates are typically higher in the first few treatment cycles, reevaluating medication use every few months and concentrating on the treatments that have the most success appear to be appropriate.

Surgery to restore fertility

Several surgical procedures can correct problems or otherwise improve female fertility. However, surgical treatments for fertility are rare these days due to the success of other treatments. They include:

• Laparoscopic or hysteroscopic surgery. Surgery might involve correcting problems with the uterine anatomy, removing endometrial polyps and some types of fibroids that misshape the uterine cavity, or removing pelvic or uterine adhesions.
• Tubal surgeries. If your fallopian tubes are blocked or filled with fluid, your doctor might recommend laparoscopic surgery to remove adhesions, dilate a tube or create a new tubal opening. This surgery is rare, as pregnancy rates are usually better with in vitro fertilization (IVF). For this surgery, removal of your tubes or blocking the tubes close to the uterus can improve your chances of pregnancy with in vitro fertilization (IVF).

Reproductive assistance

The most commonly used methods of reproductive assistance include:

• Intrauterine insemination (IUI). During intrauterine insemination (IUI), millions of healthy sperm are placed inside the uterus around the time of ovulation.
• Assisted reproductive technology. This involves retrieving mature eggs, fertilizing them with sperm in a dish in a lab, then transferring the embryos into the uterus after fertilization. IVF is the most effective assisted reproductive technology. An IVF cycle takes several weeks and requires frequent blood tests and daily hormone injections.

Coping and support

Dealing with infertility can be physically and emotionally exhausting. To cope with the ups and downs of infertility testing and treatment, consider these strategies:

• Learn all you can. Ask your doctor to explain the steps for your therapy to help you and your partner prepare. Understanding the process might help reduce your anxiety.
• Seek support. Although infertility can be a deeply personal issue, reach out to your partner, close family members or friends, or a professional for support. Many online support groups allow you to discuss issues related to infertility without identifying yourself.
• Exercise and eat a healthy diet. Keeping up a moderate exercise routine and eating healthy foods can improve your outlook and keep you focused on living your life despite fertility problems.
• Consider other options. Determine alternatives — adoption, donor sperm or egg, or even having no children — as early as possible in the infertility treatment process. This can reduce anxiety during treatments and disappointment if conception doesn't occur.

Preparing for your appointment

For an infertility evaluation, you'll likely see a doctor who specializes in treating disorders that prevent couples from conceiving (reproductive endocrinologist). Your doctor will likely want to evaluate both you and your partner.

What you can do

To prepare for your appointment:

• Chart menstrual cycles and associated symptoms for a few months. On a calendar or an electronic device, record when your period starts and stops and how your cervical mucus looks. Make note of days when you and your partner have sex.
• Make a list of all medications, vitamins, herbs or other supplements you take. Include the doses and how often you take them.
• Bring previous medical records. Your doctor will want to know what tests you've had and what treatments you've tried.
• Bring a notebook or electronic device with you. You may receive a lot of information at your visit, and it can be difficult to remember everything.
• Think about what questions you'll ask. List the most important questions first to be sure that they get answered.

Some basic questions to ask include:

• When and how often should we have sex if we hope to conceive?
• Are there lifestyle changes we can make to improve the chances of getting pregnant?
• Do you recommend testing? If so, what kind?
• Are medications available that might improve the ability to conceive?
• What side effects can the medications cause?
• Would you explain our treatment options in detail?
• What treatment do you recommend in our situation?
• What's your success rate for assisting couples in achieving pregnancy?
• Do you have brochures or other printed materials we can have?
• What websites do you recommend?

Don't hesitate to ask other questions you have.

What to expect from your doctor

Some potential questions your doctor or other health care provider might ask include:

• How long have you been trying to become pregnant?
• How often do you have sex?
• Have you ever been pregnant? If so, what was the outcome of that pregnancy?
• Have you had pelvic or abdominal surgeries?
• Have you been treated for gynecological conditions?
• At what age did you start having periods?
• On average, how many days pass between the beginning of one menstrual cycle and the beginning of your next menstrual cycle?
• Do you have premenstrual symptoms, such as breast tenderness, abdominal bloating or cramping?