What is infertility? Common signs and causes of fertility problems

If you're concerned about your ability to have children, or struggling with infertility, you're not alone.

"Infertility is a lot more common than you think," says Layan Alrahmani, M.D., a board-certified ob-gyn, maternal-fetal medicine specialist, and member of the BabyCenter Medical Advisory Board.

What is infertility?

Most experts define infertility as the inability to get pregnant after one year or longer of having unprotected sex. For women 35 or older, doctors often recommend getting medical help after six months of trying. That's because fertility in women declines with age, so it's best to address problems sooner rather than later.

According to the Centers for Disease Control and PreventionOpens a new window (CDC), 1 in 5 women ages 15 to 49 are unable to get pregnant after trying for one year. About 1 in 4 have trouble getting pregnant or carrying a pregnancy to term.

"Dealing with infertility is a journey and does take time. Our journey lasted 3.5 years before we got our rainbow baby," says BabyCenter Community member RainbowmomSarah.

About one-third of infertility is attributed to females, one-third to males, and one-third to a combination of partners or unexplained.

The types of infertility

Primary infertility

Primary infertility means you're having difficulty getting pregnant with your first baby. According to CDC data from 2015 to 2019, 19.4% of married women ages 15 to 49 have primary infertility.

Secondary infertility

Secondary infertility means you've been unable to get pregnant or carry a pregnancy to term after having one or more children without needing fertility treatments. The reasons for secondary infertility are similar to those for primary infertility.

According to the CDC, from 2015 to 2019, 6% of married women ages 15 to 49 had secondary infertility.

Signs of infertility

The most obvious sign of infertility is that you're not getting pregnant after having unprotected sex during your fertile period. According to the American College of Obstetricians and GynecologistsOpens a new window (ACOG), one in four healthy women in their 20s or 30s will get pregnant in any single menstrual cycle. For women age 40 or so, around 1 in 10 will get pregnant in one menstrual cycle.

Other signs of infertility in women may include:

• Irregular, painful, or absent menstrual periods: This may mean that you're not ovulating regularly or at all.
• Weight gain, increased acne, changes in sex drive, growth of facial hair and/or loss of hair: These issues may signal a hormonal problem.

Signs of infertility in men may include:

• Difficulty with erection and ejaculation
• Problems with the testicles (pain or swelling, or small, firm testicles)
• Changes in sexual desire
• Thinning hair
   

There are many options for the treatment of infertility, and your doctor will be able to tailor a plan specific for you.

- Layan Alrahmani, M.D., board-certified ob-gyn and maternal-fetal medicine specialist

What are the common causes of infertility in women?

Common causes of infertility in women are problems that relate to the ovaries, fallopian tubes, or uterus. Each of these needs to function well for a successful pregnancy. Here's how:

Ovaries

One of your ovaries needs to release a healthy egg to be fertilized. Conditions that might cause a problem with the function of your ovaries include:

• Polycystic ovarian syndrome (PCOS), which means the small follicles in the ovaries don't develop into mature follicles that release eggs. PCOS can also cause hormone imbalances and unpredictable menstrual patterns.
• Diminished ovarian reserve (DOR), which means you have fewer eggs than expected for your age
• Hormonal problems
• Functional hypothalamic amenorrhea (FHA), which means you've stopped having a period because of problems with your hypothalamus gland.
• Primary ovarian insufficiency (POI), which is when the ovaries stop releasing mature eggs before age 40.
• Autoimmune or genetic conditions

Fallopian tubes

The fallopian tubes need to be open, because they're the route your fertilized egg travels to your uterus, where it implants and grows. Conditions that might cause the fallopian tubes to be blocked include:

• Endometriosis, a condition that occurs when tissue normally found in the lining of the uterus (endometrial tissue) grows outside the uterus, usually in the abdomen or pelvis, and in this case in the fallopian tubes
• History of pelvic infection or pelvic inflammatory disease (PID), an infection of the fallopian tubes (and sometimes the uterus or ovaries) that can result in damage
• Ruptured appendix
• Previous sterilization

Uterus

The uterus is where the fertilized egg will implant, grow, and develop. Conditions that may affect the ability of the uterus to support a pregnancy include:

• Fibroids, polyps, or structural problems
• Endometriosis (if the tissue is growing in the uterus)
• Adenomyosis, which is when tissue lining the uterus grows into the uterine wall
• Genetic conditions
• History of uterine infection, adhesions, or scarring (from a previous pregnancy or surgery, for example)

Sometimes lifestyle factors play a role, and occasionally doctors can't identify an obvious cause of infertility. Undiagnosed infertility can still be treated, however.

What are the common causes of infertility in men?

Infertility in men is most often caused by a problem with sperm cells, which can include low sperm count, problems with the sperm's ability to move, or abnormally shaped sperm.

Factors that might affect sperm include:

• Blocked sperm ducts
• Problems with the testicles or ability to ejaculate
• Medical conditions such as anemia, diabetes, thyroid disease, Cushing's syndrome, infection, cancer, surgery, or cystic fibrosis
• Undescended testicles or a varicocele (enlarged veins in the scrotum, which can affect the amount or shape of sperm and may raise the temperature in the testes, affecting sperm production)
• Trauma to the testes or vasectomy
• Hormonal or genetic disorders such as Klinefelter's syndrome, Y-chromosome microdeletion, myotonic dystrophy, adrenal hyperplasia or hypospadias
• Certain types of chemotherapy or radiation therapy
• Medications such as anabolic steroids, sulfasalazine, and chemotherapy drugs

Your doctor may diagnose you with "unexplained infertility" if tests can't pinpoint the reason you're having trouble conceiving. Some experts think there may be various contributing factors, such as exposure to environmental toxins, subtle differences in sperm function or the fertilization process, being at the lower end of the normal range of sperm count and motility, or a combination of factors.

Infertility risk factors

Certain lifestyle choices as well as your medical history can affect your reproductive system and fertility.

Infertility risk factors for women are:

• Older age: According to ACOG, fertility starts to decline by age 30 and accelerates once you reach your mid-30s. By 45, they say, getting pregnant naturally is unlikely.
• Very high or very low body fat
• Certain chronic diseases, such as arthritis, diabetes, or thyroidism
• Having a mother who took diethylstilbestrol (DES, a drug prescribed to pregnant women between 1940 and 1971).
• Having had multiple miscarriages
• Hormonal imbalances, such as problems with the thyroid gland or pituitary gland
• Lifestyle and environmental factors such as smoking, alcohol consumption, and exposure to toxins. According to ACOG, smoking and drinking alcohol at moderate or heavy levels may reduce fertility in women.
• Having had sexually transmitted infections, which can cause pelvic inflammatory disease and other complications.
• Having had fallopian tube disease
• Having had endometriosis
• Prior abdominal surgery

Infertility risk factors for men are:

• Environmental factors, such as exposure to toxic substances (such as lead or pesticides). According to ACOG, smoking, heavy drinking, and using marijuana can reduce sperm count and movement.
• Frequent exposure of the genitals to hot temperatures (in steam rooms, hot tubs, or whirlpools, for example)
• Having a mother who took DES
• Certain prescription drugs (such as anabolic steroids, sulfasalazine, and chemotherapy drugs)
• Medical conditions, such as having had mumps after puberty, having had prostatitis or a genital infection, having undescended testicles, or having had a hernia repair
• Sexually transmitted diseases
• Age. According to the CDC, couples in which the male partner is 40 or older are more likely to have trouble getting pregnant.
• Obesity or excess weight

If you have any risk factors, talk with your doctor about what you can do to improve your chances of having a healthy pregnancy.

How to test for infertility

A reproductive endocrinologist – a doctor who specializes in managing infertility – can help determine the cause of your infertility. They'll take your medical history and do a thorough physical examination.

Laboratory tests

Blood tests and urine tests can be used to evaluate your egg supply and ovulation. These might include:

• Ovarian reserve test to evaluate your egg supply. This will involve lab work to measure follicle-stimulating hormone (FSH) as well as a transvaginal ultrasound (see below).
• Ovulation tests measuring levels of progesterone, prolactin, luteinizing hormone (LH), anti-mullerian hormone (AMH), and antral follicle count (AFC)
• Thyroid function to check for hormones indicating an overactive or underactive thyroid

Your doctor may also have you track your basal body temperature at home to help determine if you're ovulating.

Imaging tests

Imaging tests are used to look at the reproductive organs and how they're functioning:

• An ultrasound – a hand-held transducer placed on your abdomen transmits sound waves to produce a picture of your reproductive organs. A transvaginal ultrasound (the transducer is placed in your vagina) is often used for better images.
• A sonohysterography (a special ultrasound to look at the uterus)
• A hysterosalpinography (an X-ray to look at the uterus and fallopian tubes)
• A hysteroscopy (a lighted camera inserted through the cervix)
• A laparoscopy (a lighted camera inserted through the abdomen to look at the fallopian tubes, ovaries, and outside of the uterus)

Tests the doctor may run for men include:

• Blood test for hormone levels, including testosterone
• Semen analysis to determine how many quality sperm the body is producing
• An ultrasound to check for obstructions or other problems with the reproductive organs
• STD test for chlamydia, which can affect fertility

If a semen analysis isn't normal, or if anything in your medical or reproductive history indicates you need a more thorough evaluation, you may be referred to a urologist or other male reproduction specialist.

Sometimes, there's a genetic reason for male infertility that could be passed down to children. To rule out this possibility, your doctor may order blood tests and refer you to a genetic counselor to help you understand the results.

Treatment options for infertility

Happily, there are many safe and effective fertility treatments.

"There are many options for the treatment of infertility, and your doctor will be able to tailor a plan specific for you," says Dr. Alrahmani.

Your doctor may recommend:

Medications

Fertility drugs can help with ovulation. Clomiphene and gonadotropins are the most often used medications for infertility.

Surgery

Surgery may be necessary to treat some conditions, such as PCOS, endometriosis, blocked fallopian tubes, or fibroids. Surgery can also help correct genetic defects that may be contributing to infertility.

Assisted reproductive technology

According to the CDC, about 2.3% of all infants born in the United States are conceived with assisted reproductive technology. This includes intrauterine insemination (IUI), in which sperm is deposited directly into your uterus, and in vitro fertilization (IVF), in which eggs are removed from your ovaries and combined with sperm in a laboratory. The resulting embryo is then transferred to your uterus.

A process called intracytoplasmic sperm injection (ICSI) is usually added to IVF. This involves injecting a single sperm into a single egg and transferring the resulting embryo to your uterus.

When to call a doctor about fertility concerns

Talk with your doctor if you have any concerns about your fertility. If you've been trying to get pregnant for a year without success (or six months if you're 35 years old or older), ask for a referral to a reproductive endocrinologist who can help you evaluate your infertility and provide options.