Female Infertility

Female infertility affects millions of women worldwide, making it difficult or impossible to achieve pregnancy even after consistent attempts. Understanding the causes, recognizing the signs, and knowing the available treatments can help women and couples navigate this challenging journey.

Table of contents

• What is Female Infertility?
• How Common is the Problem?
• Signs and Symptoms
• What Causes Female Infertility?
• Risk Factors
• Diagnosis and Testing
• Treatment Options
• Coping with the Emotional Impact

What is Female Infertility?

Infertility is a disease of the reproductive system defined as the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse^[1]. For women, this means being unable to get pregnant despite trying consistently without birth control.

The timeframe for diagnosis varies based on age. Healthcare providers typically recommend an infertility evaluation after 12 months of trying for women younger than 35, but only six months for women 35 or older^[2]. This earlier evaluation for older women reflects the fact that female fertility declines with age, making timing more critical.

Infertility can be classified into two types. Primary infertility means a woman has never been pregnant and cannot conceive after the appropriate timeframe of trying. Secondary infertility occurs when a woman cannot get pregnant again after having at least one successful pregnancy and birth^[1].

The process of getting pregnant involves many steps. A woman’s body must release an egg from one of her ovaries, a man’s sperm must join with the egg to fertilize it, the fertilized egg must travel through a fallopian tube toward the uterus, and the embryo must attach to the inside of the uterus in a process called implantation^[17]. Problems with any of these steps can result in infertility.

How Common is the Problem?

Infertility is very common. In the United States, approximately one in five married women aged 15 to 49 with no prior births are unable to get pregnant after one year of trying^[17]. At least 10% of females deal with infertility of some kind^[1].

Research shows that infertility affects millions of people globally. Estimates suggest that approximately one in every six people of reproductive age worldwide experience infertility in their lifetime^[6]. When examining couples specifically, approximately one in six couples experience fertility difficulties^[8].

It’s important to understand that infertility is not solely a female issue. In 37% of infertile couples, female infertility is the cause; in 35% of couples, both male and female causes are identified; and in 8%, there is male factor infertility^[3]. This means that around one third of fertility problems originate in the woman, one third in the man, and in one third of couples both partners have a fertility problem^[8]. In about one in ten couples investigated for infertility, no cause is found, which is called unexplained or idiopathic infertility^[8].

Signs and Symptoms

The most common sign of infertility is simply being unable to get pregnant despite having regular, unprotected sex for the appropriate length of time^[1]. Beyond this primary indicator, other signs may suggest fertility problems.

Irregular or absent menstrual periods can indicate fertility issues. A menstrual cycle that’s too long (35 days or more), too short (less than 21 days), irregular, or absent can mean that a woman is not ovulating regularly or at all^[2]. Regular, predictable periods that occur every 21 to 35 days likely reflect ovulation, while irregular periods suggest a woman may not be ovulating^[17].

There might be no other obvious signs or symptoms beyond the inability to conceive^[2]. For this reason, many women don’t realize they have fertility problems until they actively try to become pregnant.

What Causes Female Infertility?

Female infertility can result from many different factors. While approximately 85% of infertile couples have an identifiable cause, it can be difficult to pinpoint the exact problem, and the remaining 15% have unexplained infertility^[14].

Ovulatory disorders account for approximately 25% of infertility diagnoses and are the most common identifiable cause^[3]. When a woman doesn’t ovulate regularly or at all, pregnancy becomes difficult or impossible. About 70% of women with irregular or absent ovulation have polycystic ovary syndrome (PCOS)^[3], a condition where the ovaries may not release an egg regularly or may not release a healthy egg.

Problems with ovulation can stem from various conditions. Hormonal imbalances, eating disorders, substance use disorders, thyroid conditions (both overactive and underactive), severe stress, and pituitary tumors are all examples of things that can affect ovulation^[1]. Primary ovarian insufficiency (POI) is a condition in which an extremely low egg supply makes the ovaries stop functioning before the age of 40^[1].

Problems with the fallopian tubes represent another significant cause. The most common cause of “tubal factor” infertility is pelvic inflammatory disease (PID), which is often caused by untreated sexually transmitted infections such as chlamydia and gonorrhea^[1]. Tubal blockage or damage affects 11% of infertile women^[3]. Scarring from pelvic surgery can also damage and block the fallopian tubes, making it impossible for an egg to travel from the ovaries to the uterus^[9].

Endometriosis is a condition where tissue similar to the lining of the womb grows in other places outside the womb. This can damage the ovaries or fallopian tubes and cause fertility problems^[9]. Endometriosis can also cause scarring of the fallopian tubes^[1]. It accounts for 15% of female infertility cases^[3].

Problems with the uterus can prevent pregnancy. This includes uterine polyps, fibroids (non-cancerous growths), or adhesions (scarring) inside the cavity of the uterus. Polyps and fibroids can form on their own at any time, while adhesions can form after surgery^[1]. In some cases, these growths may prevent a fertilized egg from attaching itself in the womb or may block a fallopian tube^[9].

Issues with the cervix can also affect fertility. Problems with cervical mucus can make it harder to conceive. When a woman is ovulating, mucus in the cervix becomes thinner so sperm can swim through it more easily. If there’s a problem with the mucus, conception becomes more difficult^[9]. Cervical surgery can sometimes cause scarring or shorten the neck of the womb^[9].

Problems with egg count and quality become more common with age. Women are born with all the eggs they will ever have, and this supply can run out early, before the natural age of menopause (around 51). In addition, some eggs will have the wrong number of chromosomes and be unable to fertilize and grow into a healthy fetus^[1].

Risk Factors

Age is the most significant factor affecting female fertility. The age of the female partner is the number one determinant of successful fertility for couples^[20]. Female fertility declines steadily with age^[17]. The chance of pregnancy for a woman aged 40 years is only 5% per menstrual cycle, compared to much higher rates in younger women^[8]. Aging eggs are thought to be the primary cause of this decline. Women over 40 also face increased risk of miscarriage and genetic abnormalities in the unborn baby^[8].

Body weight significantly impacts fertility. Weighing too much or too little can not only put overall health at risk but also diminish fertility^[20]. Obesity is a known risk factor that can adversely affect fertility^[1].

Smoking lowers chances for pregnancy and increases the risk of miscarriage. Smokers also tend to go through menopause two years earlier than non-smokers^[20].

Sexually transmitted infections pose serious risks to fertility. The sexually transmitted infection acquired today can affect fertility tomorrow^[20]. Untreated chlamydia and gonorrhea can lead to pelvic inflammatory disease, which can severely damage reproductive organs.

Previous sterilization procedures can cause permanent infertility. Some women choose to be sterilized if they do not want children. Sterilization involves blocking the fallopian tubes to make it impossible for an egg to travel to the womb. It’s rarely reversible, and even if reversed, pregnancy is not guaranteed^[9].

Certain medications can affect fertility. The long-term use or high dosage of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin can make it more difficult to conceive. Chemotherapy medicines can sometimes cause ovarian failure, and certain antipsychotic medicines can cause missed periods or infertility^[9].

Lifestyle factors also play important roles. Stress, excessive exercise (such as consistently running more than 6 to 10 miles a day), and the use of illegal drugs such as marijuana and cocaine can affect fertility and make ovulation more difficult^[20].

Diagnosis and Testing

When couples seek help for infertility, both partners should be evaluated, as the cause can lie with either the woman or the man^[7]. The evaluation begins with a detailed medical history and physical examination.

Ovulation testing helps determine if a woman is releasing eggs regularly. An at-home, over-the-counter ovulation prediction kit can detect the surge in luteinizing hormone (LH) that occurs before ovulation. A blood test for progesterone, a hormone produced after ovulation, can also document that ovulation is occurring. Other hormone levels, such as prolactin, may also be checked^[10].

Hysterosalpingography is a test where X-ray contrast dye is injected into the 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 the fallopian tubes. If any problems are found, further evaluation is needed^[10].

Ovarian reserve 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^[10].

Imaging tests provide visual information about reproductive organs. 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 cannot be seen on a regular ultrasound^[10].

In some cases, more invasive procedures may be necessary. Laparoscopy involves inserting a thin viewing instrument through a small incision near the navel to examine the fallopian tubes, ovaries, and uterus. This procedure can identify problems like endometriosis, scarring, blockages, or irregularities^[10].

Treatment Options

Treatment for female infertility depends on what is causing the problem and what is available locally. There are three main types of fertility treatment: medicines, surgical procedures, and assisted conception^[12].

Common fertility medicines help stimulate ovulation. Clomiphene citrate encourages the monthly release of an egg in women who do not ovulate regularly or cannot ovulate at all. Letrozole, an aromatase inhibitor, is an alternative to clomiphene that may be offered if there are ovulation problems. Metformin is particularly beneficial for women who have polycystic ovary syndrome. Gonadotropins can help stimulate ovulation in women and may also be used for ovarian stimulation during in vitro fertilization cycles^[12].

Some of these medicines may cause side effects such as nausea, vomiting, headaches, and hot flushes. Gonadotropins carry risks of multiple pregnancy (up to 36% of cycles depending on specific therapy) and ovarian hyperstimulation syndrome (1-5% of cycles), which consists of ascites (fluid accumulation), electrolyte imbalance, and hypercoagulability^[14].

Surgical procedures can address specific anatomical problems. If fallopian tubes have become blocked or scarred, surgery can be used to break up scar tissue, making it easier for eggs to pass through. However, the success of surgery depends on the extent of damage, and possible complications include ectopic pregnancy^[12].

Laparoscopic surgery is often used to treat endometriosis by destroying or removing fluid-filled cysts. It may also be used to remove submucosal fibroids, which are small growths in the womb. For women with polycystic ovary syndrome, a minor surgical procedure called laparoscopic ovarian drilling can be used if ovulation medicine has not worked^[12].

Intrauterine insemination (IUI), also known as artificial insemination, involves inserting sperm into the womb via a thin plastic tube passed through the cervix. Sperm is first collected, washed, and the best quality specimens are selected^[12]. For couples with unexplained infertility, endometriosis, or mild male factor infertility, an initial three to four cycles of ovarian stimulation with IUI may be pursued^[14].

In vitro fertilization (IVF) is when an egg is fertilized outside the body. Fertility medicine is taken to encourage the ovaries to produce more eggs than usual. Eggs are removed from the ovaries and fertilized with sperm in a laboratory. A fertilized egg (embryo) is then returned to the womb to grow and develop^[12]. Because female fertility declines with age, this factor should guide decision-making, and immediate IVF may be considered as a first-line treatment for women over 38^[14].

If a woman or her partner has an infertility problem, it may be possible to receive eggs or sperm from a donor to help conceive. Treatment with donor eggs is usually done using IVF^[12].

Many couples treated for infertility are able to have babies^[4], though there is no guarantee of pregnancy even after all the testing and treatment^[16].

Coping with the Emotional Impact

Infertility can cause significant psychological, physical, mental, and spiritual difficulties. The unique quality of this medical condition is that it affects both the patient and the patient’s partner as a couple^[3].

Many women experience profound emotional distress related to infertility. It can feel like an inability to do something they thought they would be able to do, like a dream of being a mother won’t be realized, or like being a failure with a body that is failing them. These feelings are completely normal^[21].

Every month can hurt like a loss when women find out they aren’t pregnant, because every month brings renewed hope. The uncertainty of not knowing when or if pregnancy will occur, combined with the lack of control over the situation, makes infertility particularly difficult to cope with^[21].

Several strategies can help with emotional coping. Preparing close friends and family in advance about the difficult emotions that arise, especially around the time of monthly disappointments, can be helpful. Finding someone to talk honestly with, whether close friends or a therapist familiar with fertility issues, provides necessary emotional support. Therapy offers a safe space where anything can be said without judgment^[21].

Taking the best possible care of oneself during this challenging time is crucial. This includes maintaining physical health and investing in emotional wellbeing. Maintaining the couple relationship separately from the fertility journey is also important, as having a baby does not make a struggling relationship easier or better^[21].