Infertility in Women
Be in the Know. Female Fertility at a Glance.
- Infertility is the inability to conceive a child or carry a pregnancy to delivery.
- In women, the timing of evaluation is based on age:
- under age 35 – after 12 months of unprotected intercourse.
- 35-40 – after six months of trying.
- over 40 – after three months of unprotected intercourse.
- Women who do not have regular menstrual cycles or have risk factors for infertility (i.e. history of chemotherapy) should seek immediate evaluation.
- The American Society for Reproductive Medicine (ASRM) estimates that 15% of couples will need fertility testing and treatment to conceive. This can be due to female infertility, male infertility, or a combination of both.
- One of our reproductive endocrinologists can help determine any underlying cause of infertility in a woman by first reviewing her reproductive and health history, performing a physical exam, and typically recommending specific diagnostic testing to clarify a diagnosis.
- Common female infertility problems include ovulation disorders, structural issues with a woman’s reproductive organs or unexplained infertility, which means no definitive cause has been found.
- Female infertility is most often treatable, and treatments include medication, intrauterine insemination (IUI), minimally invasive surgery, and/or in vitro fertilization (IVF).
- Single women and LGBTQIA individuals may also have infertility issues, and thus a diagnostic work-up is generally always recommended prior to starting treatment.
- What is infertility in women?
- Causes of infertility in women
- Problems with ovulation
- Structural causes of infertility in women
- Unexplained infertility
- Fertility tests for women
- Female infertility treatment options
What is Infertility in Women?
Female infertility can arise anywhere along the complex pathway that starts in the brain and ends in a successful pregnancy.
For example, the woman’s system must be able to do the following:
- The ovary needs to release a mature egg (ovulation), which is a complex process directed by hormones from the brain and the ovary.
- The egg needs to be picked up by the fimbriae (“fingers”) of the fallopian tube to be brought into the genital tract.
- In the fallopian tube, the egg must be fertilized by sperm within 24 hours to make an embryo.
- The resulting embryo must travel to the uterus and implant for pregnancy to occur.
Any health conditions that prevent the above reproductive processes from occurring result in female infertility.
When to See a Fertility Doctor
ASRM defines infertility as a lack of pregnancy after a specified period of regular, unprotected intercourse and recommends women seek treatment according to their age.
Women under 35 should seek evaluation for infertility after one year of trying to conceive.
Those aged 35-39 should seek an evaluation after trying for six months.
Women age 40 and older should see a specialist after three months of trying to conceive.
A woman should also see a fertility specialist when trying to conceive if she has a known fertility problem, a history of irregular or painful periods, repeated miscarriages, prior cancer treatment, endometriosis, or pelvic inflammatory disease.
Causes of Infertility in Women
ASRM estimates that 15% of couples will need fertility testing and treatment to conceive.
In cases of infertility in a couple, infertility resulting solely from the female partner makes up around one-third of the cases.
Three main categories for the causes of infertility in women are:
- Issues with ovulation (oligo-ovulation or anovulation)
- Structural problems of the reproductive system (fibroids, polyps, Müllerian anomalies, tubal factors)
- Unexplained infertility, which is the diagnosis for 1 in 5 infertile couples (meaning no definitive cause is identified after initial testing)
A woman may be affected by one or more of these issues. And each of these three categories of infertility in women encompasses a variety of specific conditions, from hormonal imbalances affecting ovulation to blocked fallopian tubes preventing sperm from reaching the egg.
Lifestyle issues can also lead to infertility, including being underweight or overweight, smoking, or drug and alcohol use.
Problems with Ovulation
Ovulation problems, also called ovulatory dysfunction, are one of the most common causes of infertility in women.
Ovulation is the release of a mature egg (one that can be fertilized). The ovulated egg is picked up by the fallopian tube where it hopefully encounters sperm. This happens approximately once a month, typically midway through the menstrual cycle.
If a woman’s menstrual cycle is too long (35 days or longer), too short (less than 21 days), absent or irregular, it could indicate an ovulation disorder.
Common Ovulation Disorders
About one-quarter of infertility cases are the result of ovulation disorders. Ovulation disorders can result from issues with a woman’s ovaries, as a result of reproductive hormone dysfunction or for unknown causes.
The following are some of the ovulation disorders we treat.
- Polycystic ovary syndrome (PCOS) is a medical condition that affects ovulation and is one of the most common cause of female infertility. PCOS can be associated with obesity, acne, insulin resistance and abnormal hair growth on the body or face.
- Hypothalamic amenorrhea is a condition in which menstruation stops for several months due to a problem involving the hypothalamus (a region of the brain). This is often due to significant weight loss due to eating disorders or excessive exercise.
- Hormone imbalances occur when the body produces too much or too little of one or more hormones essential for reproduction. This can affect ovulation and/or the success of embryo implantation in the uterus (pregnancy). Common examples would be hypo- or hyperthyroidism and hyperprolactinemia.
- Premature ovarian failure (POF), also called primary ovarian insufficiency, is the ovaries’ loss of normal function before a woman reaches age 40. Not all women with POF/POI will have ovulatory dysfunction.
Structural Causes of Infertility in Women
Structural problems in a woman’s reproductive tract typically affect the fallopian tubes or uterus.
Problems with the fallopian tube can interfere with the egg being picked up by the fallopian tube to enter the genital tract and make contact with sperm. Structural issues can also prevent an embryo from traveling to the uterus for implantation and pregnancy.
Conditions like sexually transmitted diseases, infections, and previous surgeries can damage, scar and block a woman’s fallopian tubes. Scar tissue can also involve the ovaries and other pelvic organs. Endometriosis can also cause structural problems and damage to the fallopian tubes that lead to infertility. It can affect many aspects of reproductive function. This is a condition where the tissue usually found only inside the uterus grows in other places in the woman’s body.
Regarding the uterus, some women are born with structural problems (Müllerian anomalies), such as an abnormally shaped uterus that impacts their fertility. Others may develop fibroids, which are typically benign tumors of the muscular wall of the uterus that can interfere with implantation or blood flow to a growing pregnancy. Polyps, typically benign tumors of the inner lining of the uterus, can also develop and cause difficulties with conception.
This can be one of the most frustrating diagnoses for women struggling with infertility, as it does not provide a clear diagnosis.
According to the national infertility organization Resolve, about 1 in 5 couples who have a thorough infertility evaluation will be diagnosed with unexplained infertility.
Unexplained infertility does not mean that nothing is wrong: it simply means we do not currently have diagnostic testing to identify the patient’s particular problem. Unexplained infertility also does not mean it is an untreatable condition. In most cases, there are steps fertility physicians and patients can take, including:
Fertility Testing for Women
Once a woman has decided to seek evaluation, we will talk to her about her reproductive and health history, as well as any symptoms of conditions that could impact fertility.
We will also perform a physical examination. The most common fertility tests for women include the following.
- Ovarian reserve testing measures the number of eggs a woman has with respect to that of other women her age. Women are born with all the eggs they will ever have, and their supply depletes over time. A woman’s ovarian reserve can be evaluated by a blood test that measures the anti-Müllerian hormone (AMH), which can be drawn at any point in the menstrual cycle or even while on the birth control pill. In addition, an antral follicle count (AFC) may be performed via transvaginal ultrasound by examining the ovaries and assessing the group of eggs that are made hormonally receptive to each cycle. This also serves as a good marker of ovarian reserve.
- Hysterosalpingogram (HSG) is an outpatient imaging test that checks to see if the fallopian tubes are open and anatomically normal in appearance. The HSG is not particularly good at assessing the uterus.
- Transvaginal ultrasonography, performed by inserting an ultrasound probe into the woman’s vagina, allows the fertility specialist to view the uterus and ovaries and examine them for cysts, fibroids or other abnormalities.
- Saline infusion sonohysterography (SHG), is used to detect uterine abnormalities like polyps, fibroids or Müllerian anomalies. It involves filling the uterus with saline (a salt solution) prior to performing a transvaginal ultrasound.
We may perform more advanced fertility tests if necessary.
- Hysteroscopy can be used to diagnose and treat problems inside the uterine cavity.
- Laparoscopy, a minimally invasive surgery, can externally evaluate a woman’s uterus, ovaries and pelvis for endometriosis, scar tissue or other problems with the reproductive organs.
Infertility Treatments for Women
The recommended course of treatment for female infertility will vary for each woman based on individual circumstances, including age, duration of infertility and overall health.
Here are some of the treatments we provide for women.
- Lifestyle changes include managing chronic conditions like diabetes, maintaining a healthy weight and not smoking.
- Ovulation induction uses hormonal medications to stimulate the ovaries to release a mature egg.
- IUI inserts a partner’s or donor’s sperm directly into the uterus.
- Minimally invasive surgery repairs structural issues or damage to a woman’s reproductive organs and can remove ovarian cysts and fibroids that are interfering with reproduction.
- IVF is an advanced assisted reproductive therapy in which a woman’s eggs are fertilized with sperm in our laboratory, embryos are cultured and monitored for appropriate development, and an embryo is implanted into a woman’s uterus.
- Preimplantation genetic testing evaluates embryos during IVF prior to implantation in the uterus for the presence of a specific genetic condition, chromosomal disorders or the improper number of chromosomes.
- Use of donor eggs or embryos for women who are not able to conceive using their own oocytes (eggs).
- Gestational carriers may be used by women who are unable to carry a pregnancy due to health risks or problems with their uterus.