Infertility

Infertility affects millions of people worldwide, preventing pregnancy despite regular, unprotected sex. While it can be a frustrating and unexpected challenge for couples hoping to become parents, many safe and effective treatments are available that can boost the chances of having a baby.

Table of contents

• What is infertility?
• Types of infertility
• How common is infertility?
• Signs and symptoms
• Causes and risk factors
• Diagnosis and testing
• Treatment options
• Reducing your risk
• Living with infertility

What is infertility?

Infertility is a medical condition where you cannot get pregnant despite having frequent, unprotected sex for at least a year^[1]. For women aged 35 or older, doctors may diagnose infertility after just six months of trying to conceive^[2]. Infertility is a disease of the male or female reproductive system (the organs involved in making babies) that prevents pregnancy from happening^[3].

Getting pregnant involves several complex steps. Your brain must produce reproductive hormones (chemical messengers) that control ovarian function. An egg must mature in your ovary and be released during ovulation (when an egg is released from the ovary). Your fallopian tube must pick up the egg. Sperm must travel up through your vagina and uterus to your fallopian tube. The sperm must fertilize the egg to create an embryo (early stage of pregnancy). Finally, the embryo must travel through your fallopian tube to the uterus where it implants^[1]. A pregnancy cannot occur if anything in this process doesn’t happen.

Types of infertility

There are several types of infertility^[1]:

• Primary infertility: You have never been pregnant and cannot conceive after one year of regular, unprotected sex (or six months if you’re 35 or older)
• Secondary infertility: You cannot get pregnant again after having at least one successful pregnancy
• Unexplained infertility: Fertility testing hasn’t found a reason why you or your partner cannot get pregnant

Infertility can also be primary or secondary. Primary infertility is when a pregnancy has never been achieved by a person, while secondary infertility is when at least one prior pregnancy has been achieved^[3].

How common is infertility?

Infertility is very common and affects both men and women. In the United States, approximately 1 in 5 women between 15 and 49 years old struggle with primary infertility, and about 1 in 20 women struggle with secondary infertility^[1]. Around 1 in 7 couples may have difficulty conceiving^[6].

Approximately 48 million couples live with infertility around the world^[1]. It is estimated that approximately one in every six people of reproductive age worldwide experience infertility in their lifetime^[3].

Signs and symptoms

The main sign of infertility is being unable to get pregnant after six months or one year of regular, unprotected sex^[1]. There may be no other clear symptoms^[2]. However, some women or men may show physical symptoms such as^[1]:

• Pelvic or abdominal pain
• Irregular vaginal bleeding, irregular periods, or no periods
• Penile disorders or issues with ejaculation

Some men may have symptoms of hormonal problems, such as changes in hair growth or sexual function^[2].

Causes and risk factors

There are many causes of infertility, and sometimes there isn’t a simple answer as to why pregnancy isn’t happening. Infertility affects both men and women. Studies show that approximately 33% of infertility involves women, 33% involves men, and 33% involves both partners or is unexplained^[1]. About 25% of infertile couples have more than one factor that contributes to their infertility^[1].

In the female reproductive system, infertility may be caused by^[3]:

• Tubal disorders such as blocked fallopian tubes, which are caused by untreated sexually transmitted infections, complications of unsafe abortion, postpartum sepsis, or abdominal/pelvic surgery
• Uterine disorders which could be inflammatory (such as endometriosis), congenital, or benign (such as fibroids)
• Disorders of the ovaries, such as polycystic ovarian syndrome and other follicular disorders
• Disorders of the endocrine system (the system that produces hormones) causing imbalances of reproductive hormones

In the male reproductive system, infertility is most commonly caused by problems in the ejection of semen, absence or low levels of sperm, or abnormal shape and movement of the sperm^[3].

Several risk factors can affect fertility in both partners^[1]:

• Age, particularly being in your late 30s or 40s. For men, age begins affecting fertility closer to 50
• Eating disorders, including anorexia nervosa and bulimia
• Excessive alcohol consumption
• Exposure to environmental toxins, such as chemicals, lead, and pesticides
• Over-exercising
• Radiation therapy or chemotherapy
• Sexually transmitted infections (STIs)
• Smoking and using tobacco products

Being overweight or obese (having a BMI of 30 or over) reduces fertility. In women, being overweight or severely underweight can affect ovulation^[6].

Diagnosis and testing

If you’re younger than 35, your healthcare provider may diagnose infertility after one year of trying to conceive. If you’re 35 or older, your provider may diagnose infertility after six months of regular, unprotected sex^[1]. Women aged 36 and over, and anyone who’s already aware they may have fertility problems, should see their doctor sooner^[6].

Your healthcare team will work to understand your sexual habits and may make recommendations to improve your chances of getting pregnant. Testing for infertility can involve uncomfortable procedures and can be expensive^[9].

For women, common diagnostic tests include^[9]:

• Blood tests to check hormone levels
• Ovulation testing
• Hysterosalpingography (an X-ray examination of the uterus and fallopian tubes)
• Ultrasound imaging
• Laparoscopy or hysteroscopy (procedures to look inside the reproductive organs)

For men, testing may include^[9]:

• Physical exam including a check of the genitals
• Semen analysis to check sperm count and quality
• Hormone testing
• Genetic testing in some cases

Confirmation of ovulation should be obtained with a serum progesterone level on day 21 of a 28-day cycle or one week before presumed onset of menses^[13].

Treatment options

Many treatment options are available for people with infertility. The treatment offered will depend on what’s causing the fertility problems and what’s available from your healthcare provider^[6]. Some treatments for infertility can cause complications, such as multiple pregnancy or ectopic pregnancy^[6].

Common fertility treatments include^[6][10]:

Medications:

• Clomifene or tamoxifen: encourages the monthly release of an egg in women who do not ovulate regularly
• Metformin: particularly beneficial for women who have polycystic ovary syndrome
• Gonadotrophins: can help stimulate ovulation in women and may also improve fertility in men
• Gonadotrophin-releasing hormone and dopamine agonists: prescribed to encourage ovulation in women

Surgical procedures:

• Surgery for blocked or scarred fallopian tubes
• Laparoscopic surgery to treat endometriosis or remove cysts
• Surgery to remove fibroids
• Laparoscopic ovarian drilling for women with polycystic ovary syndrome
• Surgical extraction of sperm for men with blockages

Assisted conception:

• Intrauterine insemination (IUI): inserting sperm into the womb via a thin plastic tube passed through the cervix
• In vitro fertilization (IVF): fertilizing an egg outside the body in a laboratory, then returning the embryo to the womb
• Egg and sperm donation

More than 8 out of 10 couples where the woman is under 40 will conceive naturally within a year if they have regular unprotected sex^[6]. Many couples who struggle with infertility do end up having children, sometimes with medical help^[4].

Reducing your risk

While not all causes of infertility can be prevented, you can take steps to protect your fertility^[18][19]:

• Maintain a normal body weight. Weighing too much or too little can diminish your fertility
• Exercise regularly to maintain fitness, but be careful not to over-exercise
• Don’t smoke. Smoking lowers your chances for pregnancy and increases the risk of miscarriage
• Avoid or strictly limit alcohol intake
• Limit caffeine intake to below 300mg per day
• Never have unprotected sex. Sexually transmitted infections can affect your fertility
• Reduce stress and maintain good overall health
• Drink plenty of water (about 8-10 cups a day)
• Take a supplement with 400mcg folic acid when trying to conceive

When you’re ready to have children, don’t delay. The age of the female partner is the number one factor in successful fertility. Once you’re actively trying to conceive, don’t delay evaluation, especially if you’re over 35^[18].

Living with infertility

Infertility can cause psychological, physical, mental, and spiritual challenges. The unique quality of this medical condition is that it affects both the patient and the patient’s partner as a couple^[8].

Anxiety over infertility may cause increased stress and decreased libido, further compounding the problem. Formal counseling is encouraged for couples experiencing infertility^[8]. Infertility counseling and support can help you cope with the emotional aspects of trying to conceive^[16].

Some helpful coping strategies include^[16]:

• Connect with support groups where you can find others experiencing similar challenges
• Practice stress reduction techniques such as relaxation and stress management
• Seek professional counseling to help manage the emotional impact
• Stay informed and be actively involved in your healthcare decisions
• Remember that you are not alone—infertility is very common

Try not to worry excessively about becoming pregnant. Many people find that once they release stress, their body reacts to the new peace by creating a new life^[19].