National Infertility Awareness Week

In general, infertility is defined as not being able to get pregnant (conceive) after

one year (or longer) of unprotected sex. Because fertility in women is known to decline steadily with age, some providers evaluate and treat women aged 35 years or older after 6 months of unprotected sex. Women with infertility should consider making an appointment with a reproductive endocrinologist—a doctor who specializes in managing infertility. Reproductive endocrinologists may also be able to help women with recurrent pregnancy loss, defined as having two or more spontaneous miscarriages.

Pregnancy is the result of a process that has many steps. To get pregnant:

A woman’s body must release an egg from one of her ovariesexternal icon.

A man’s sperm must join with the egg along the way (fertilize).

The fertilized egg must go through a fallopianexternal icon toward the uterusexternal icon (womb).

The embryo must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps.

Impaired fecundity is a condition related to infertility and refers to women who have difficulty getting pregnant or carrying a pregnancy to term.

In the United States, among heterosexual women aged 15 to 49 years with no prior births, about 1 in 5 (19%) are unable to get pregnant after one year of trying (infertility). Also, about 1 in 4 (26%) women in this group have difficulty getting pregnant or carrying a pregnancy to term (impaired fecundity).

Infertility and impaired fecundity are less common among women with one or more prior births. In this group, about 6% of married women aged 15 to 49 years are unable to get pregnant after one year of trying and 14% have difficulty getting pregnant or carrying a pregnancy to term.

 

Women need functioning ovariesexternal icon, fallopianexternal icon, and a uterusexternal icon to get pregnant. Conditions affecting any one of these organs can contribute to female infertility. Some of these conditions are listed below and can be evaluated using several different tests.

A woman’s menstrual cycleexternal icon is, on average, 28 days long. Day 1 is defined as the first day of “full flow.” Regular predictable periods that occur every 21 to 35 days likely reflect ovulation. A woman with irregular periods is likely not ovulating.

• Polycystic ovary syndrome (PCOS).external icon PCOS is a condition that causes women to not ovulate, or to ovulate irregularly. Some women with PCOS have elevated levels of testosterone, which can cause acne and excess hair growth. PCOS is the most common cause of female infertility.
• Diminished ovarian reserve (DOR). Women are born with all of the eggs that they will ever have, and the number of eggs declines naturally over time. DOR is a condition in which there are fewer eggs remaining in the ovaries than expected for a given age. It may occur due to congenital (condition present at birth), medical, surgical, or unexplained causes. Women with DOR may be able to conceive naturally, but will produce fewer eggs in response to fertility treatments.
• Functional hypothalamic amenorrhea (FHA). FHA is a condition caused by excessive exercise, weight loss, stress, or often a combination of these factors. It is sometimes associated with eating disorders such as anorexia.
• Improper function of the hypothalamus and pituitary glands. The hypothalamus and pituitary glands in the brain produce hormones that maintain normal ovarian function. Production of too much of the hormone prolactin by the pituitary gland (often as the result of a benign pituitary gland tumor), or improper function of the hypothalamus or pituitary gland, may cause a woman not to ovulate.
• Premature ovarian insufficiencyexternal icon (POI). POI, sometimes referred to as premature menopause, occurs when a woman’s ovaries fail before she is 40 years of age. Although certain exposures, such as chemotherapy or pelvic radiation therapy, and certain medical conditions may cause POI, the cause is often unexplained. About 5% to 10% of women with POI conceive naturally and have a normal pregnancy.
• Menopauseexternal icon. Menopause is a natural decline in ovarian function that usually occurs around age 50. By definition, a woman in menopause has not had a period for at least one year. Many women experience hot flashes, mood changes, difficulty sleeping, and other symptoms as well.

Risk factors for blocked fallopian tubesexternal icon (tubal occlusion) can include a history of pelvic infection, ruptured appendix, gonorrhea, chlamydia, endometriosisexternal icon, or prior abdominal surgery.

• Hysterosalpingogram is an X-ray of the uterus and fallopian tubes. A radiologist injects dye into the uterus through the cervix and simultaneously takes X-ray pictures to see if the dye moves freely through fallopian tubes indicating they are open.
• Chromopertubation is similar to a hysterosalpingogram but is done in the operating room at the time of a laparoscopy. Blue-colored dye is passed through the cervix into the uterus and through the fallopian tubes. This test is used to evaluate if the fallopian tubes are open and to assess if they are dilated.

Depending on a woman’s symptoms, the uterusexternal icon may be evaluated by transvaginal ultrasound to look for fibroidsexternal icon or other problems, including intrauterine adhesions, endometrial polyps, adenomyosis, and congenital anomalies of the uterus. A sonohystogram or hysteroscopy may also be performed to further evaluate the uterine environment.

• About 1 in 5 (22%) couples in which the woman is 30-39 have problems conceiving their first child, compared to about 1 in 8 (13%) couples in which the woman is younger than 30. Fertility declines with age primarily because egg quality declines over time. In addition, older women have fewer eggs left and they are more likely to have health conditions that can cause fertility problems. Aging also increases a woman’s chances of miscarriageexternal iconand of having a child with a genetic abnormality.
• Smoking.
• Excessive alcohol use.
• People with overweight or obesity or underweight.
• Extreme weight gain or loss.
• Excessive physical or emotional stress that results in amenorrhea (absent periods).

Infertility can be treated with medicine, surgery, intrauterine insemination, or assisted reproductive technology.

• The factors contributing to the infertility.
• The duration of the infertility.
• The age of the female.
• The couple’s treatment preference after counseling about success rates, risks, and benefits of each treatment option.

 

• Clomiphene citrate (Clomid®*) is a medicine that causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovary syndrome (PCOS)external icon or other problems with ovulation. It is also used in women with normal ovulation to increase the number of mature eggs produced. This medicine is taken by mouth.
• Letrozole (Femara®*) is a medication that is frequently used off-label to cause ovulation. It works by temporarily lowering a woman’s progesterone level, which causes the brain to naturally make more follicle-stimulating hormone (FSH). It is often used to induce ovulation in woman with PCOS, and in women with normal ovulation to increase the number of mature eggs produced in the ovaries. It is taken by mouth.
• Human menopausal gonadotropin or hMG (Menopur®*; Repronex®*; Pergonal®*) is an injectable medication often used for women who don’t ovulate because of problems with their pituitary gland—hMG acts directly on the ovaries to stimulate development of mature eggs.
• Follicle-stimulating hormone or FSH (Gonal-F®*; Follistim®*) is an injectable medication that works much like hMG. It stimulates development of mature eggs within the ovaries.
• Gonadotropin-releasing hormone (GnRH) analogs and GnRH antagonists are medications that act on the pituitary gland to prevent a woman from ovulating. They are used during in vitro fertilization cycles, or to help prepare a woman’s uterus for an embryo transfer. These medications are usually injected or given with a nasal spray.
• Metformin (Glucophage®*) is a medicine doctors use for women who have insulin resistance or diabetes and PCOSexternal icon. 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 taken by mouth.
• Bromocriptine (Parlodel®*) and Cabergoline (Dostinex®*) are medications used for women with ovulation problems because of high levels of prolactin. These medications are taken by mouth.

Many fertility drugs increase a woman’s chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses may have more problems during pregnancy. Multiple fetuses have a higher risk of being born prematurely (too early). Premature babies are at a higher risk of health and developmental problems.