What is infertility?
Infertility means not being able to get pregnant. You may have fertility problems if you couldn't get pregnant after trying for at least 1 year (or 6 months if you're over 35). It doesn't mean you'll never get pregnant. Some people conceive without help in their second year of trying. Treatments help many people.
What causes it?
Most cases of infertility are caused by a problem with the female or male reproductive system. This can include a problem with the eggs, with the uterus or fallopian tubes, or with sperm. But sometimes no cause can be found.
What are the symptoms?
The main symptom of infertility is being unable to get pregnant after 6 to 12 months of trying, depending on your age.
How is it diagnosed?
Doctors can do tests and ask you questions about your past health to check for infertility. Tests may check hormone levels, semen quality, or the uterus, fallopian tubes, and ovaries.
How is infertility treated?
A wide range of treatments may be used for infertility. Depending on the cause, they include:
- Medicine that helps with releasing an egg (ovulating).
- A procedure that puts sperm directly inside the uterus (insemination).
- Surgery for a problem caused by endometriosis or blocked fallopian tubes.
- A procedure to concentrate sperm count for insemination.
You may also consider in vitro fertilization (IVF). During IVF, eggs and sperm are mixed in a lab to fertilize the eggs. Then the doctor puts one or more fertilized eggs into the uterus.
Treatment for fertility problems can be stressful and costly. Before you start, think about how far you're willing to go with treatment. You may change your mind later, but it's a good idea to start with a plan.
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Infertility may be caused by:
- Problems with the eggs or releasing an egg (ovulating).
- Problems with the uterus or the fallopian tubes. This may result from things like endometriosis or pelvic inflammatory disease.
- Problems with the sperm. These problems may include how sperm is made, how it functions, or how it moves.
- An unknown issue. Sometimes the cause of infertility is not known.
Rates of infertility and miscarriage increase with age. Female fertility peaks in the late 20s. It slowly starts to decline in the early 30s. A larger drop in fertility and increase in miscarriage risk begins around the mid-30s. This is mainly because of the aging egg supply. Male fertility also decreases with age. But it's a more gradual decline.
What Increases Your Risk
Things that increase your risk for infertility include:
- Age. Eggs and sperm can decrease in number or quality with age.
- Birth defects. Some people were born with problems in their reproductive systems.
- Moderate or severe endometriosis.
- Past exposure to very high levels of environmental toxins, certain drugs, or high doses of radiation. This includes cancer chemotherapy or radiation.
- Past infection with a sexually transmitted infection (STI) that has since damaged the reproductive system. This includes gonorrhea or chlamydia.
- Polycystic ovary syndrome. This is a hormone imbalance that can affect ovulation. This can make it harder to get pregnant.
Sometimes infertility is related to lifestyle or other health conditions. To help protect your fertility:
- Avoid using tobacco (cigarettes) and marijuana.
- Avoid exposure to harmful chemicals.
- Avoid excessive alcohol use.
- Limit sex partners and use condoms to reduce the risk of getting a sexually transmitted infection (STI). Untreated STIs can damage the reproductive system and cause infertility. If you think you may have an STI, get treatment right away to reduce the risk of damage.
- Stay at a body weight that's close to the ideal for your height. It will reduce the chance of hormone imbalances.
If you have been diagnosed with cancer and hope to have children in the future, talk to your doctor about your options to help preserve fertility.
When to Call a Doctor
Consult with your doctor if you:
- Want children but have been unable to become pregnant after 1 year of having sex without using birth control.
- Are older than 35 and have been unable to become pregnant after about 6 months of sex without using birth control.
- Have had two or more miscarriages in a row.
Before seeking medical help with conception, you can increase your chances of becoming pregnant by practicing fertility awareness. This means charting your basal body temperature and using home tests to let you know when you are likely to ovulate and be fertile.
Who to see
For your first fertility questions and testing, you can see:
For complete fertility testing, see an obstetrician/gynecologist with special training and experience in fertility problems. This doctor may be called a reproductive endocrinologist or fertility specialist. When looking for a specialist, ask what percentage of a doctor's practice is fertility treatment. Also ask if the doctor has training in reproductive endocrinology.
Exams and Tests
To check for infertility, a doctor can:
- Do a physical exam.
- Ask questions about your past health. This may help your doctor find clues, such as a history of miscarriages or pelvic inflammatory disease.
- Ask about your lifestyle habits. This includes how often you exercise and whether you drink alcohol or use drugs.
- Do tests that check semen quality. Other tests can measure hormone levels. Hormone imbalances can be a sign of ovulation problems or sperm problems that can be treated.
- Check the uterus, fallopian tubes, and ovaries.
Before you have fertility tests, it may help to try fertility awareness. Chart basal body temperature and use home tests to learn when you are likely to ovulate and be fertile. Some people find that they have been missing the most fertile days when trying to conceive.
A wide range of treatments may be used for infertility. Treatment depends on the cause of fertility problems. They can include:
- Problems with releasing an egg (ovulating).
Treatment may include taking medicine, such as:
- Clomiphene or letrozole. These stimulate your ovaries to release eggs.
- Metformin. It's used to treat polycystic ovary syndrome.
- Blocked or damaged tubes.
If your fallopian tubes are blocked, treatment may include tubal surgery.
If mild to moderate endometriosis seems to be the main reason for your infertility, treatment may include laparoscopic surgery to remove endometrial tissue growth. This treatment may not be an option if you have severe endometriosis.
- Problems with sperm.
Depending on the cause of the problem, treatment may include medicines, surgery, or insemination. If your doctor recommends insemination, the sperm are collected. Then an increased number of healthy sperm are placed inside the uterus.
- Unexplained infertility.
If your doctor can't find out why you haven't been able to get pregnant, treatment may include:
- Hormone injections.
Assisted reproductive technology
Many people who have problems getting pregnant consider assisted reproductive technology (ART). The most common type of ART is in vitro fertilization (IVF). During IVF, eggs are fertilized by sperm in a lab. The fertilized egg or eggs are then placed in the uterus through the cervix. Sometimes a technique called intracytoplasmic sperm injection, or ICSI (say "ICK-see"), is used during IVF. With ICSI, each egg is injected with one sperm in the lab. This can help fertilize the eggs.
Take time to plan
Before you start treatment, talk about how far you want to go with treatment. For example, you may want to try medicine but don't want to have surgery. You may change your mind during your treatment. But it's good to start with an idea of what you want your limits to be.
Treatment for fertility can also cost a lot. And insurance often doesn't cover these expenses. If cost is a concern for you, ask how much the medicines and procedures cost. Then find out if your insurance covers any costs.
- Infertility: Questions to Ask About Assisted Reproductive Technology
- Infertility: Setting Limits on Treatment
- Infertility: Should I Have Treatment?
- Infertility: Thinking About Adoption
- Infertility Treatment for Women With PCOS
- Insemination Procedures
- Intracytoplasmic Sperm Injection (ICSI)
- In Vitro Fertilization (IVF)
- Take a multivitamin with folic acid. This helps to prevent birth defects if you do become pregnant.
- Get regular exercise. But do not overdo it. Excessive exercise can cause eggs to release less often or sperm count to lower.
- Avoid excessive alcohol and caffeine use.
- Avoid smoking, marijuana, and illegal drugs.
- Stay at a healthy weight. This will increase your chances of getting pregnant. Being overweight or weighing too little can affect fertility.
- Talk to your doctor about all medicines you are taking or may take. This includes over-the-counter and prescribed medicines and herbal remedies. Some medicines interfere with pregnancy.
- Write down when your period starts and stops for a few months. Bring that information to your doctor. Your doctor can help you figure out when you ovulate and are most likely to get pregnant if you have sex. Or you may prefer to use a home ovulation test.
- If you know when you will ovulate, try to have sex once a day for the 4 days before ovulation and on the day of ovulation.
- If you don't know when you will ovulate, have sex 2 or 3 times each week.
- Don't use lubricants during sex. They may affect how well sperm can travel to meet an egg.
Protecting sperm count and quality
To decrease the risk of fertility problems and increase the chances of pregnancy, use the following guidelines.
- If you use a vaginal lubricant during sex, select one that doesn't kill or damage sperm.
- Reduce your level of activity, if you exercise strenuously most days of the week.
Very strenuous exercise may be a cause of lower sperm counts in some men.
- Avoid hot tubs and saunas.
High scrotal temperatures may decrease sperm count and quality.
- Try to relieve fever when you are ill.
High fever has been known to have a harmful effect on sperm for 2 to 3 months afterward. (Sperm take this long to grow from germ cells to mature sperm.)
When you have infertility, you may feel alone, confused, or scared. Talking with others about your feelings can help. Here are some places you may find support.
- Family and friends. They can help you cope by giving you comfort and encouragement.
- Counseling. Professional counseling can help you understand and deal with your infertility, and the emotions that may come with it.
- Your doctor. Find a doctor you trust and feel comfortable with. Be open and honest about your fears and concerns.
- Spiritual or religious groups. These groups can provide comfort. And they may be able to help you find counseling or other social support services.
- Support groups. In a support group, you can talk to others who have had similar experiences. Your doctor may be able to tell you about groups in your community. You may also be able to find support in online groups, forums, or discussion boards.
Medicine or hormone treatments are often the first steps in fertility treatment. They're also used for in vitro fertilization (IVF) and other assisted reproductive technologies. Medicines include:
- Clomiphene and letrozole. These stimulate the release of hormones that help with ovulation.
- Gonadotropins. These hormone shots stimulate the ovaries to produce mature eggs.
- Treatment for polycystic ovary syndrome (PCOS). If you're not ovulating because of PCOS, your doctor might recommend a drug such as metformin along with clomiphene.
- Gonadotropin-releasing hormone (GnRH). It increases production of hormones needed to produce eggs and sperm.
- Bromocriptine and cabergoline. These lower prolactin levels. High prolactin levels can prevent ovulation and sperm production.
- GnRH analogue. This is used for IVF.
For some people with fertility problems, a structural problem can be treated with surgery. Treatment can increase the chances of natural conception.
When thinking about surgery, ask your doctor questions about the procedure. For example, how many times has the surgeon done the procedure? What are the chances of treatment success? How long will it take to recover?
Surgery may include:
- Fallopian tube procedures. This includes sterilization reversal.
- Laparoscopic surgery. This may help treat endometriosis.
- Myomectomy. This may help treat uterine fibroids.
- Laparoscopic ovarian drilling. This may be used when weight loss and medicine haven't stimulated ovulation in people who have polycystic ovary syndrome (PCOS).
- Varicocele repair. This is used to cut or bypass an enlarged vein in the scrotum.
- Vasectomy reversal. This reconnects the tubes (vas deferens) that were cut during a vasectomy.
If you have severely blocked fallopian tubes, your doctor may advise you to skip surgery and have in vitro fertilization (IVF). IVF is also often recommended first for women over 34 (regardless of the type of blockage). This is because tubal surgery and natural conception may use up precious time if IVF might be used later.
Complementary medicine may help you stay well and cope with infertility. Complementary medicine for fertility includes:
- Dietary changes.
- Relaxation techniques.
- Mind-body medicine.
Talk with your doctor about any complementary health practice that you would like to try or are already using. Your doctor can help you manage your health better if they know about all of your health practices.
Current as of: August 2, 2022
Author: Healthwise Staff
Kathleen Romito MD - Family Medicine
Adam Husney MD - Family Medicine
Femi Olatunbosun MB, FRCSC - Obstetrics and Gynecology