Health 101: Infertility in Women
If you've been struggling to get pregnant, you've probably got lots of questions. Here, find out what causes infertility, how to reduce your risk, when to see a doctor, potential infertility treatments, and more.
What is infertility?
Infertility is a medical condition in which a couple is unable to conceive a baby. Experts don't consider a couple to have fertility problems until they've been actively trying to get pregnant for at least one year, or if the woman is older than 35, for more than six months. Some couples who experience recurrent miscarriages may also be considered infertile and should seek help from their doctor or a fertility expert.
Experiencing infertility, though, doesn't mean you won't ever have a baby. For some couples, it just takes longer; for others, it may require drugs, surgery, or high-tech help. Take heart in the following stats from the Mayo Clinic:
- After 12 months of unprotected sex, about 85 percent of couples will get pregnant.
- Of the remaining 15 percent, about half will get pregnant over the next three years, using methods like medications, surgery, assisted reproductive technology, or even naturally.
According to other research, about two-thirds of all couples who seek treatment for fertility problems are able to have a baby eventually.
Are men or women more likely to experience infertility?
It's pretty much an even split, despite persistent misconceptions that infertility is a "woman's problem." About one-third of cases are due to women's health issues, another third are due to men's health issues, and the rest of the time, it's either a mix of both partners' conditions or unknown causes.
What causes infertility in women?
Making a baby is a complex process that's contingent upon four crucial steps:
- A woman and man each producing eggs and sperm
- Healthy fallopian tubes that allow the sperm to easily get to the egg
- Sperm's ability to fertilize the egg upon reaching it
- A fertilized egg's ability to attach to the uterus and continue developing normally
Infertility may result when there's a hiccup in one or more of these steps. Because conception is so complicated, there are a number of factors that can lead to infertility in women:
Fallopian tube damage is the primary cause of infertility in women, occurring in about 30 percent of cases. If your fallopian tubes are scarred or blocked, sperm may have difficulty reaching your egg, or your fertilized egg may not be able to safely travel to your uterus to develop into a healthy baby. Having very painful periods or a history of pelvic pain are common signs of fallopian tube damage.
Fallopian tubes may become blocked or damaged in a few ways. Often, it's from an infection called pelvic inflammatory disease, which usually results when sexually transmitted diseases like chlamydia and gonorrhea go untreated (they're easily curable with antibiotics).
Another cause is endometriosis, a condition where the tissue that normally lines the uterus starts growing where it shouldn't -- like in the fallopian tubes, ovaries, or other nearby organs. If this tissue blocks openings in the ovaries or fallopian tubes, it can prevent an egg from being released or fertilized.
In rarer cases, fallopian tube damage may be due to having a prior ectopic pregnancy (where the fertilized egg implants outside of the uterus). Ectopic pregnancies are very dangerous for moms-to-be; because they need to be terminated as soon as possible, they don't result in live births.
Ovulation problems occur about 20 percent of the time. If you don't ovulate normally, then you're not releasing healthy eggs for sperm to fertilize. The main symptoms of ovulation roadblocks are irregular or missing periods.
Ovulation problems usually result from hormonal imbalances. The female sex hormones LH, FSH, and estrogen are the big ones needed to launch an egg each menstrual cycle -- if they're released at the wrong time or in the wrong amounts, it can throw off ovulation. Weighing too much or too little can also mess with your hormones and hinder ovulation.
Up to 10 percent of all women experience a condition called polycystic ovarian syndrome (PCOS), where a hormone imbalance triggers the body to produce excess testosterone, which can also hinder ovulation. Women with PCOS may be overweight and have excess body or facial hair and acne, in addition to irregular or missing periods.
Problems with the uterus occur about 20 percent of the time. If your egg can't attach normally to the wall of the uterus, it can't continue developing into a healthy fetus. Unexplained lower-abdominal pain or bloating may be a sign of uterine problems that can affect fertility. This may be due to fibroids or polyps, which are benign tissue growths from the wall of the uterus; they may sometimes affect fertility depending on their size and location. Scar tissue in the uterus from infection, miscarriage, or abortion may also play a role.
The remaining causes of infertility in women may include immune system diseases, kidney disease and diabetes, early menopause, cancer and treatment for it (like chemotherapy and radiation), or taking certain medications (some drugs that treat blood pressure, depression, or asthma, for example, may impact fertility).
What increases my risk of infertility?
More than anything else, age has the biggest impact on your ability to get or stay pregnant. Regardless of how healthy or fit you are, the quality of your eggs and your ability to ovulate normally decreases over time.
For example, less than 10 percent of 20-something couples have fertility problems, but nearly 30 percent of those in their early 40s do, and more than 50 percent of those older than 45 do, according to the American Society for Reproductive Medicine. Of course, women over 40 get pregnant all the time, but it may take longer or require help from a fertility specialist.
Although you can't control your age, the following factors also increase your risk of infertility. Making a lifestyle change may boost your ability to conceive -- and your all-around health.
- Smoking cigarettes. Volumes of research have shown that smoking cigarettes may interfere with ovulation and damages eggs, making them more prone to genetic defects that can lead to miscarriage. One recent study found that couples who smoked were more than three times as likely to take more than six months to get pregnant compared to couples who didn't smoke.
- Excess alcohol and caffeine intake. According to the most recent research on these somewhat controversial areas, an occasional cocktail or daily cup of coffee does not increase your risk of infertility. While heavy drinking is definitely harmful for conception and pregnancy, most well-designed studies have found no solid evidence that moderate drinking (say, a glass of wine a day) has an impact on your ability to get pregnant. The evidence on caffeine is mixed too, although most research shows that having less than two cups of coffee a day won't affect your fertility or a healthy pregnancy.
Bottom line: If you're actively trying to get pregnant, avoid alcohol (most women don't know they're expecting in the earliest stages of pregnancy, so it's better to play it safe anyway) and limit caffeine intake.
- Being significantly overweight or underweight. Women with a body mass index (BMI) below 20 or above 27 are less likely to conceive than woman with BMIs that fall within that range. The main reason: Weighing too little (from excessive exercise or not eating enough) or too much may throw your hormones off-balance and interfere with ovulation.
- Sexually transmitted diseases. STDs like chlamydia and gonorrhea (both easily treatable with antibiotics) may lead to pelvic infections that interfere with conception.
- Extreme stress. While getting regular massages or taking yoga is unlikely to speed up conception, some research shows that extreme stress may impact fertility indirectly. Major life changes -- like a death in the family, job loss, etc. -- may cause hormonal swings that make ovulation less regular. And if you're totally burned out or anxious all the time, you're probably less likely to be in the mood for babymaking.
- Find out what increases men's risk of infertility here
When should I see a doctor for infertility?
That answer depends on your age and certain known health conditions. The following guidelines offer some general rules, but of course it can't hurt to bring up any concerns with your doctor at any time.
Women under 35 who've been unsuccessfully trying to get pregnant for more than one year. If you're still seeing the minus sign on the stick after a few months of trying, you may simply need to give it more time before calling for medical help. For women who spend much of their young-adult lives deliberately trying not to get pregnant, it may come as a surprise to learn how difficult getting in the family way actually is.
In any given month, your babymaking odds are slim -- only about 20 percent during your 20s and 30s -- which is why it sometimes takes completely healthy, fertile couples many months to conceive.
Women 35 and older who've been trying to conceive for more than 6 months.
Women of any age with the following symptoms:
- Irregular periods (a sign you may not be ovulating normally)
- Very painful periods (a sign you may have pelvic inflammatory disease, an infection of the fallopian tubes, or endometriosis, which occurs when uterine lining grows in organs outside the uterus, like the fallopian tubes, making it hard for eggs to become fertilized or make their way to the uterus)
- A history of polycystic ovarian syndrome (a hormonal imbalance where your body makes too many male hormones, which thwarts ovulation)
- A history of miscarriage
Do I need a fertility specialist?
If you're worried about how long it's taking to get pregnant, your first stop may be your ob-gyn or family doctor. He or she can perform basic tests to determine whether you're ovulating normally or may be experiencing problems with your fallopian tubes, ovaries, or uterus. While your regular doctor may be able to prescribe drugs that jump-start ovulation or perform outpatient procedures to treat fibroids or endometriosis, for example, you'll need to see a specialist for more complex procedures like IVF.
A fertility specialist -- officially called a reproductive endocrinologist or RE -- is an ob-gyn who has had an extra three years of training (on top of four years of regular ob-gyn education). After completing these seven years of training, doctors take a series of written and oral tests to become board certified in reproductive endocrinology.
Women 35 or older, or who know they have health conditions that may affect fertility, may choose to bypass their own doctors and head straight to an RE. You usually don't need a referral to visit a reproductive endocrinologist.
How do I find a fertility specialist?
Start by asking your current ob-gyn or family physician, friends, or family members for a referral. Organizations like the Society for Reproductive Endocrinology and Infertility and the American Society for Reproductive Medicine have great Web sites with listings of specialists.
During your first phone call or visit, ask the doctor or office staff about costs, insurance coverage, and payment plans; the types of tests he or she will use; office hours, availability to patients, and willingness to talk with you at length about your situation. Infertility testing and treatment require a big commitment from you and your doctor, and you'll want to make sure you've chosen someone you're comfortable with and trust with important emotional and financial decisions.
A word of caution: Be careful not to choose a specialist based on statistics alone. Of course high success rates are important, but some clinics may have higher ratings than others because they're more selective about the patients they take on. And obviously, larger clinics with more doctors and patients will result in more babies than smaller practices will produce.
The Centers for Disease Control and Prevention (CDC) publishes a national report on fertility clinic success rates, which you may want to check out as part of your research.
How will my doctor test for infertility?
Because there are many potential causes of infertility in women and men, a number of tests may be needed to figure out what's going on, and the process may take many months. Here's a brief overview of the types of tests or procedures you may experience:
- Checking for ovulation: The first thing your doctor will look for is whether you're ovulating normally. You can start this process at home by using an ovulation predictor kit or measuring your basal body temperature every morning, but the only true way to know you're ovulating is through a combination of blood tests (to check for hormone levels) and an ultrasound of your ovaries (this allows your doctor to see whether or not an egg's been released).
- Hysterosalpingogram (HSG): An x-ray that looks at the uterus and fallopian tubes; it can reveal problems like fibroids or polyps in the uterus, which can prevent a fertilized egg from attaching to the uterine wall, or fallopian tube blockage, which can impact ovulation or fertilization.
- Laparoscopy: An outpatient surgery done under general anesthesia; your doctor uses a small tool to examine the ovaries, fallopian tubes, and uterus for endometriosis or pelvic scarring. Sometimes, your doctor may be able to remove cysts from your ovaries or scar tissue during this procedure.
- Hysteroscopy: An outpatient procedure done under general anesthesia; your doctor uses tools to examine the uterus and to possibly remove fibroids, polyps, or scar tissue.
- Ovarian reserve testing: A series of tests that measure the number and health of your eggs; it helps your doctor determine whether you're a good candidate for fertility medications or assisted technology like IVF.
How is infertility treated?
How you're treated for infertility depends on your test results (a woman experiencing ovulation problems would likely be treated differently than one with fibroids, for example), your age, how long you've been trying, and many personal decisions, including financial pros and cons.
According to the American Society for Reproductive Medicine, up to 90 percent of infertility cases are treated with drugs or surgery -- not assisted reproductive technologies like IVF. As a general overview, women are typically treated for infertility in one of the following ways, or often, through a combination of several:
- Drugs that trigger ovulation: Taken orally or injected, fertility drugs deliver different hormones that help boost ovulation. Many of these drugs increase your risk of getting pregnant with multiples.
- Surgery: Fallopian tube blockage, fibroids, or other problems in the uterus may be treated through different surgeries or procedures.
- Intrauterine insemination: Also known as IUI or artificial insemination, sperm are directly inserted into the uterus using a syringe.
- Assisted reproductive technology: This includes several methods (IVF is the main one) where eggs are fertilized with sperm in a lab and then put back into your body to develop into a fetus. ART increases your risk of getting pregnant with multiples.
Sources: 100 Questions and Answers About Infertility, by John D. Gordon, MD, and Michael DiMattina, MD; The Fertility Diet, by Jorge E. Chavarro, MD, and Walter C. Willett, MD; American Society for Reproductive Medicine sections on infertility; National Women's Health Information Center; MayoClinic.com sections on infertility; Intelihealth.com sections on infertility
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