Infertility

Infertility is diagnosed when a couple cannot become pregnant after a year of trying to conceive with condomless sex. About 15% of couples are unable to become pregnant after trying for one year. Infertility may also refer to a person who can become pregnant but has a history of miscarriages or stillbirths. 

Studies show that in about one-third of couples, there is a medical reason why a woman cannot become pregnant. In another third, there is a medical reason for a man contributing to infertility. In the last third, the cause is either unknown or involves both partners. 

This article provides an overview of infertility, including common causes, symptoms, and treatment options. 

Symptoms of Infertility

Infertility symptoms vary depending on the underlying cause. The classic sign is the inability to either become pregnant or carry a pregnancy to term.

In women, an absent (amenorrhea) or irregular period may signify a problem leading to infertility. This is because a woman without regular periods is likely not ovulating each month. 

Causes of Infertility

There are several possible causes of infertility that affect both women and men. 

Female Infertility 

To understand female causes of infertility, knowing how a woman’s body becomes pregnant is helpful. To conceive, a woman’s body must release an egg from one of the ovaries. From there, a man’s sperm must join with the egg to fertilize it. A fertilized egg must travel through the fallopian tube to the uterus, where the embryo attaches or implants to the uterine wall.

Possible causes of female infertility include:

• Age: It’s estimated that about 22% of couples with a woman between the ages of 30 to 39 have problems conceiving their first child—in couples with a woman under age 30, about 13% report problems with conception. 
• Polycystic ovary syndrome (PCOS): A hormonal imbalance that interferes with ovulation. Women with PCOS may have high levels of testosterone. This is the most common cause of female infertility. 
• Premature ovarian insufficiency (POI): A condition similar to premature menopause when the ovaries fail before age 40.
• Diminished ovarian reserve (DOR): A condition that causes a woman to have fewer eggs than is typical for her age. The number of eggs naturally declines with age.
• Functional hypothalamic amenorrhea (FHA): A condition caused by excessive exercise, weight loss, stress, or a combination. It leads to anovulation (when a person does not ovulate).
• Improper function of the hypothalamus and pituitary glands: When these structures don’t function properly, the pituitary gland produces too much prolactin (a hormone), which may lead to anovulation. 
• Blocked fallopian tubes: Risk factors for a blocked fallopian tube include endometriosis, a history of pelvic infection, a ruptured appendix, a history of sexually transmitted infections (STIs), and a history of abdominal surgery. 
• Uterine conditions: Uterine fibroids, intrauterine adhesions, and endometrial polyps are associated with infertility in women.
• Menopause: Ovarian function naturally declines with age. Menopause usually occurs around age 50, and symptoms include irregular or absent periods, hot flashes, and more.
• Substance use: Smoking and excessive alcohol use raise the risk of infertility. 
• Weight changes: A woman is more likely to experience infertility if her body is categorized as underweight, overweight, or obese.
• Stress: Women undergoing significant emotional or physical stress are at higher risk of amenorrhea. 

Male Infertility 

Possible causes of male infertility include:

• Age: Research shows that men older than 40 are more likely to experience infertility than younger men. 
• Varicocele: An enlarged testicle vein may affect the number or shape of the sperm.
• Trauma: Injury to the testes may impact sperm production.
• Hormonal disorders: When the hypothalamus or pituitary glands are not functioning normally, the body may produce too much prolactin, leading to a lower sperm count.
• Genetic disorders: Conditions like Klinefelter’s syndrome, Y-chromosome microdeletion, germ cell aplasia, and myotonic dystrophy may cause low sperm production.
• Medical conditions: Chronic conditions like diabetes, cystic fibrosis, autoimmune disorders, and certain infections may affect sperm production.
• Alcohol or drug abuse: Smoking and illicit drug use are associated with male infertility. 
• Testosterone: Exposure to too much testosterone in the form of injections, implants, topical gel, or steroids may contribute to infertility. 
• Environmental exposures: High temperatures can affect sperm function. Spending time in a sauna, hot tub, or wheelchair may affect male fertility. Other factors that lower a man’s fertility include pesticides, lead, cadmium, and mercury. 
• Cancer treatments: Chemotherapy, radiation therapy, and surgery for testicular cancer increase a man’s risk of infertility. 

What Medications Can Cause Infertility?

The following medications are known to affect male fertility:

• Eulexin (flutamide)
• Androcur (cyproterone)
• Casodex (bicalutamide)
• Aldactone (spironolactone)
• Nizoral (ketoconazole)
• Tagamet (cimetidine)

How to Treat Infertility

The treatment of infertility is highly dependent on the cause. Other factors include the couple’s ages, preferences, and duration of time trying to conceive. 

In couples with mild male infertility or an unknown cause, intrauterine insemination (IUI) may be recommended. The man’s sperm is prepared and inserted into the woman’s uterus during this procedure. IUI may be used in combination with medications as well. 

Medications

Oral medications that may be used to treat infertility include:

• Clomid (clomiphene citrate) causes the pituitary gland to trigger ovulation. This medication can be used to treat PCOS.
• Femara (letrozole) causes ovulation by temporarily lowering a woman’s progesterone level. This causes the brain to naturally make more follicle-stimulating hormone (FSH), which induces ovulation in women with PCOS. 
• Glucophage (metformin) lowers the levels of male hormones in a woman’s body and stimulates ovulation in women with PCOS. 
• Parlodel (bromocriptine) and Dostinex (cabergoline) can reduce the prolactin level in a woman’s body and boost fertility. 

Injectable medications that may be used to treat infertility include:

• Menopur and Repronex (human menopausal gonadotropin or hMG) are used in women who don’t ovulate because their pituitary glands are not functioning. These medications stimulate the development of mature eggs in the ovaries.
• Follistim and Gonal-F stimulate the development of mature eggs much like hMG. 
• Gonadotropin-releasing hormone (GnRH) analogs and GnRH antagonists are used during in vitro fertilization (IVF) treatment to prevent a woman from ovulating in preparation for embryo transfer. 

Assisted Reproductive Technology

Assisted reproductive technology (ART) refers to any fertility treatment that involves handling the eggs or embryos outside the body. The most common options include:

• In vitro fertilization (IVF): The eggs and sperm are combined in a lab to create embryos. Those embryos are transferred into the woman’s uterus after three to five days. The embryos can also be frozen and used for future transfer.
• Intracytoplasmic sperm injection (ICSI): A single sperm is injected into a mature egg in a lab and then transferred into a woman’s uterus. This type of IVF may be used to treat male infertility. 

IVF may use eggs and sperm from the couple to create embryos. It is also possible to use donor eggs, donor sperm, or donor embryos for couples who need them. A woman without a uterus may be able to use a gestational carrier to carry a baby to term.

Complications and Risk Factors

The complications and risk factors associated with infertility depend on the underlying cause. 

The most common complication of ART is a multiple pregnancy (pregnant with more than one baby). The risk of a multiple pregnancy can be minimized by limiting the number of embryos transferred to the woman’s uterus. 

Another possible complication of infertility is anxiety. A review found that women undergoing ART were at higher risk of anxiety, especially if the treatment failed or required multiple rounds. Women who have become pregnant using ART are at increased risk of depression later in life. 

Are There Tests to Diagnose the Cause of Infertility?

There are several tests used to determine the cause of infertility. Your healthcare provider will likely start with a physical exam and medical history from both partners. Initial tests often include a semen analysis, tubal evaluation, and ovarian reserve testing. 

Tests to diagnose infertility in women include:

• Transvaginal ultrasound: Ultrasound to evaluate the health of the uterus
• Hysterosalpingogram: X-ray of the uterus and fallopian tubes to assess the function of the fallopian tubes
• Chromopertubation: Procedure performed during laparoscopy to evaluate the fallopian tubes by injecting dye through the cervix into the uterus and fallopian tubes

A semen analysis is used to diagnose infertility in men. It's a test to check the number of sperm, their movement, and their shape.

When to See a Healthcare Provider

For most couples, it is time to see a healthcare provider to be evaluated for infertility after a year of trying to become pregnant with condomless sex. For couples with a woman who is 35 or older, it is recommended to see a healthcare provider after trying for six months. A reproductive endocrinologist is a physician who specializes in treating individuals with infertility. 

If you or your partner have any infertility risk factors, talk with your healthcare provider when you start trying to conceive. Infertility risk factors for women include:

• Irregular or absent menstrual periods
• Endometriosis
• Pelvic inflammatory disease (PID)
• Uterine disease
• History of miscarriage 
• History of chemotherapy or radiation therapy 

Infertility risk factors for men include: 

• History of testicular trauma
• History of hernia surgery
• History of chemotherapy
• History of infertility with another partner
• Sexual dysfunction

Summary 

Infertility is diagnosed when a couple cannot become pregnant after a year of trying to conceive with condomless sex. There are several possible causes of infertility in both women and men. Infertility is treated with medications, assisted reproductive technology, or a combination. Couples who have been trying to conceive for one year should see their healthcare provider. Women 35 or older are recommended to see their healthcare provider after trying for six months. 

A Word From Verywell 

Infertility is a heartwrenching condition that affects individuals and couples around the world. The diagnostic process can be lengthy and may feel frustrating. Know that your emotions are normal and common. Talk with your partner and healthcare provider about your frustrations and needs. If you feel comfortable, reach out to family and friends for support.