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Fertility Problems

Topic Overview

What are fertility problems?

You may have fertility problems if you haven't been able to get pregnant after trying for at least 1 year. It doesn't necessarily mean you will never get pregnant. Often, couples conceive without help in their second year of trying. Some don't succeed. But medical treatments do help many couples.

Age is an important factor if you are trying to decide whether to get testing and treatment for fertility problems. A woman is most fertile in her late 20s. After age 35, fertility decreases and the risk of miscarriage goes up.

  • If you are younger than 35, you may want to give yourself more time to get pregnant.
  • If you are 35 or older, you may want to get help soon.

What causes fertility problems?

In cases of fertility problems:footnote 1

  • About 50 out of 100 are caused by a problem with the woman's reproductive system. These may be problems with her fallopian tubes or uterus or her ability to ovulate (release an egg).
  • About 35 out of 100 are caused by a problem with the man's reproductive system. The most common is low sperm count.
  • In about 10 out of 100, no cause can be found in spite of testing.
  • About 5 out of 100 are caused by an uncommon problem.

Should you be tested for fertility problems?

Before you have fertility tests, try fertility awareness. A woman can learn when she is likely to ovulate and be fertile by charting her basal body temperature and using home tests. Some couples find that they simply have been missing their most fertile days when trying to conceive.

If you aren't sure when you ovulate, try this Interactive Tool: When Are You Most Fertile?

If these methods don't help, the first step is for both partners to have some simple tests. A doctor can:

  • Do a physical exam of both of you.
  • Ask questions about your past health to look for clues, such as a history of miscarriages or pelvic inflammatory disease.
  • Ask about your lifestyle habits, such as how often you exercise and whether you drink alcohol or use drugs.
  • Do tests that check semen quality and both partners' hormone levels in the blood. Hormone imbalances can be a sign of ovulation problems or sperm problems that can be treated.

Your family doctor can do these tests. For more complete testing, you may need to see a fertility specialist.

How are fertility problems treated?

A wide range of treatments is available. Depending on what is causing the problem, a couple may be able to:

  • Take a medicine that helps the woman ovulate.
  • Have a procedure that puts sperm directly inside the woman (insemination).
  • Have a surgery that corrects a problem caused by endometriosis or blocked fallopian tubes.
  • Have a procedure that might increase the man's sperm count.

If these options aren't possible or don't work for you, you may want to think about in vitro fertilization (IVF). During an IVF, eggs and sperm are mixed in a lab so the sperm can fertilize the eggs. Then the doctor puts one or more fertilized eggs into the woman's uterus. Many couples try IVF more than once.

Treatment for fertility problems can be stressful, costly, and hard on your body. Before you start testing, make some decisions about how far you are willing to go with treatment. You may change your mind later, but it's a good idea to start with a plan.

  • Learn all you can about the tests and treatments. Then decide which you want to try. For example, some couples agree to try medicines but don't want surgery or other treatments.
  • Find out how much treatments cost and whether your insurance will cover them. If you don't have insurance, decide what you can afford.

Treatments for fertility problems can increase your chances of getting pregnant. But they also increase your chance of having twins, triplets, or more. Be sure to discuss the risks with your doctor.

Fertility problems can put a lot of strain on a couple. It may help to see a counselor with experience in fertility problems. Think about joining a support group. Talking with other people who are going through the same thing can help you feel less alone.

Health Tools

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Decision Points focus on key medical care decisions that are important to many health problems.
Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.

Cause

Fertility problems have many causes that involve either the woman's, the man's, or both partners' reproductive systems. Some causes include:

Rates of infertility and miscarriage increase with age. A woman's fertility peaks in her late 20s. It gradually begins to decline in her early 30s. A more pronounced drop in fertility and increase in miscarriage risk begins around her mid-30s. This is primarily due to the aging egg supply. Male fertility also decreases with age. But it is a more gradual decline than in women.

Symptoms

Fertility problems don't cause physical symptoms.

What Happens

Most healthy young couples trying to have a child are successful after 1 year of trying. But about 10 to 15 out of every 100 couples have trouble getting pregnant.footnote 1

Just because you haven't been able to get pregnant after 1 year doesn't mean you can't get pregnant. Many couples later go on to get pregnant, even without treatment.

But your doctor may suggest testing and treatment if you haven't been able to get pregnant after 1 year of having sex 2 or 3 times a week without using birth control. For women over 35, some doctors will offer testing and treatment after 6 months of trying to become pregnant.

If a clear cause can be found and if there is a promising treatment for that cause, pregnancy is more likely. When a cause can't be found and fertility tests are normal, treatment is less likely to work.

A couple's chances of getting pregnant are greatest within their first 3 years of trying. After 3 years of sex without birth control, pregnancy is considered unlikely without treatment.footnote 1

Some couples who have tried treatment without success become pregnant later without more treatment.

Personal concerns

Before deciding to move forward with testing and treatment, be sure to think about these issues:

What Increases Your Risk

Things that increase your risk of having fertility problems include:

  • The woman's age. The older a woman is, the more likely she is to have problems getting pregnant:footnote 2
    • Age 20 to 24: 7 out of 100 women have fertility problems.
    • Age 25 to 29: 9 out of 100 have fertility problems.
    • Age 30 to 34: 15 out of 100.
    • Age 35 to 39: 22 out of 100.
    • Age 40 to 44: 29 out of 100.
  • Birth defects. Some men and women 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, such as gonorrhea or chlamydia, that has since damaged the reproductive system.
  • Polycystic ovary syndrome .

When should you call your 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.

Watchful waiting

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.

Exams and Tests

Testing for fertility problems usually starts with simple tests for both partners. In addition to an interview and physical exams, these first tests will:

  • Check semen quality.
  • Check both partners' hormone levels in the blood. Hormone imbalances can be a sign of ovulation problems or sperm production problems that can be treated.

If your test results show no cause of infertility, your doctor may recommend checking fallopian tube function. Depending on your age and other risk factors, you may then be offered further testing. Or you may begin treatment with superovulation (to produce more eggs), intrauterine insemination (which puts sperm into the uterus with a tube), or both.

For more information, see the topic Infertility Tests.

Testing can be stressful, costly, and sometimes painful. You may need only a few tests. Or you may need many tests over months and years.

Treatment Overview

Some fertility problems are more easily treated than others. In general, as a woman ages, especially after age 35, her chances of getting pregnant go down. But her risk of miscarriage goes up.

If you are 35 or older, your doctor may recommend that you skip some of the steps younger couples usually take. That's because your chances of having a baby decrease with each passing year.

It's important to understand that even if you are able to get pregnant, no treatment can guarantee a healthy baby. On the other hand, scientists in this field have made many advances that have helped millions of couples have babies.

Take time to plan

Before you and your partner 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. Talk with your partner about what you can afford.

Thinking about this ahead of time may help keep you from becoming emotionally and financially drained from trying a series of treatments you hadn't planned for.

Initial treatment

Treatment for the woman

Treatments for fertility problems in women depend on what may be keeping the woman from getting pregnant. Sometimes the cause isn't known.

  • Problems with ovulating. Treatment may include taking medicine, such as:
  • Unexplained infertility. If your doctor can't find out why you and your partner haven't been able to get pregnant, treatment may include:
  • Blocked or damaged tubes. If your fallopian tubes are blocked, treatment may include tubal surgery.
  • Endometriosis . 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. For more information, see the topic Endometriosis.

Treatment for the man

Your doctor might recommend that you try insemination first. The sperm are collected and then concentrated to increase the number of healthy sperm for insemination.

When initial treatments don't work

Many couples who have problems getting pregnant arrive at a common point: They must decide whether they want to try assisted reproductive technology (ART).

  • In vitro fertilization (IVF) is the most common type of ART. In this treatment, a fertilized egg or eggs are placed in the woman's uterus through the cervix.
  • Intracytoplasmic sperm injection, or ICSI (say "ICK-see"). In a lab, your doctor injects one sperm into one egg. If fertilization occurs, the doctor puts the embryo into the woman's uterus.

To learn more, see Other Treatment.

If you haven't already thought about adoption, this might be a time to think about it. Some couples decide at this point to spend their resources on adoption instead of IVF. Other couples see IVF as the best option.

Fertility treatment clinics

Fertility treatment clinics aren't widely available in some parts of the country, especially in rural areas. You may need to travel for treatment.

When you review clinic success rates, be aware that clinics treating more severe fertility problems may have lower success rates. So it's possible for a clinic with a lower success rate to have greater overall expertise than clinics with higher success rates.

The success rate of a clinic is influenced by many things, including the doctors' skills and experience and the cause or causes of your fertility problem.

When you review treatment success rates, remember that live birth rates are always lower than ovulation and pregnancy rates. Miscarriages are common among all women. But they are more likely in women with risk factors such as older age or a poorly controlled chronic health condition.

Prevention

Some fertility problems are related to lifestyle or other health conditions. To help protect your fertility:

  • Avoid using tobacco (cigarettes) and marijuana. They reduce fertility, especially by reducing sperm counts.
  • Avoid exposure to harmful chemicals.
  • Avoid excessive alcohol use. It may damage eggs or sperm.
  • 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 promptly to reduce the risk of damage to your reproductive system.
  • Stay at a body weight that is close to the ideal for your height. It will reduce the possibility of hormone imbalances. This is very important for men as well as for women.

If you have been diagnosed with cancer and hope to have children in the future, talk to your doctor about preventing cancer treatment–related infertility.

Home Treatment

To decrease your risk of fertility problems and increase your chances of becoming pregnant, use the following guidelines.

Track ovulation at home

  • Estimate when you are ovulating by practicing fertility awareness. This means:
    • Tracking your cervical mucus changes.
    • Tracking your basal body temperature on a monthly Fahrenheit temperature chart or Celsius temperature chart.
    • Tracking your luteinizing hormone (LH) levels with a home ovulation predictor test. Many doctors now recommend these home tests as the best way to track ovulation at home.
  • Try having sex every day or every other day during a woman's fertile period. This can improve the chance of pregnancy.
  • If you exercise strenuously most days of the week, reduce your level of activity. Very strenuous exercise can cause women to ovulate less often.

Protect sperm count and quality

  • If you use a vaginal lubricant during sex, select one that doesn't kill or damage sperm.
  • If you exercise strenuously most days of the week, reduce your level of activity. 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.)

General measures

Women who are trying to get pregnant should avoid using alcohol and medicines, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin.

Medications

Medicine or hormone treatments are often the first steps in fertility treatment. They are also used for in vitro fertilization and other assisted reproductive technologies.

If you have irregular or no ovulation, using medicine or hormones to stimulate ovulation will increase your chances of pregnancy. But these treatments increase your risk of multiple pregnancy. And that poses health risks to both you and your fetuses. When thinking about a fertility treatment:

  • Ask your doctor about your risk for having a multiple pregnancy. Find out how to lower the chance of conceiving more than one fetus.
  • Think about how a high-risk multiple pregnancy, and the possibility of having multiple disabled children, might affect your life.

Other rare complications—such as ovarian hyperstimulation syndrome—can be caused by hormone shots used to stimulate ovulation. These shots may be used in assisted reproductive technology such as IVF.

In very rare cases, male fertility problems are caused by hormonal imbalances. Men are then treated with medicine or hormones that help the hypothalamus and pituitary gland start normal sperm production.

Ask your doctor questions about medicines you are considering. For example, are there long-term effects? How long will the treatment last? How often you must be tested while taking the medicine? Are there any side effects that will affect your daily life?

Medicine choices

For men

  • Gonadotropin-releasing hormone (GnRH). It increases the body's production of hormones needed for sperm production.
  • Bromocriptine and cabergoline lower prolactin levels. High levels of prolactin can prevent the release of testosterone and production of sperm.

For women

  • Clomiphene and letrozole stimulate the release of hormones that trigger ovulation.
  • Gonadotropins. These hormone shots stimulate the ovaries to produce mature eggs.
  • Medicines for polycystic ovary syndrome (PCOS). If you're not ovulating because of PCOS, your doctor might suggest that you take a drug such as metformin along with clomiphene. Learn more about treatment of women who have polycystic ovary syndrome (PCOS).
  • Gonadotropin-releasing hormone (GnRH). It increases the body's production of hormones needed for egg production.
  • Bromocriptine and cabergoline lower prolactin levels. High levels of prolactin can prevent ovulation.
  • Gonadotropin-releasing hormone (GnRH) analogue. This is used for in vitro fertilization.
  • Aromatase inhibitors are sometimes used to stimulate ovulation.

Surgery

For some people, a structural problem can be treated surgically. Treatment can increase the chances of natural conception.

When considering surgery, ask your doctor questions about the procedure. For example, how many times has the surgeon done the procedure? What are your chances of treatment success? How long will it take to recover?

In cases of 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 in vitro fertilization might be used later.

Surgery choices

For men

For women

Other Treatment

Insemination and assisted reproductive technology (ART) can improve the odds of pregnancy. They introduce the sperm to the egg in the woman's reproductive tract (insemination) or in the lab (ART).

Insemination

Insemination flushes the sperm through a thin, flexible tube directly into a woman's vagina, cervix, uterus, or fallopian tube. This puts sperm closer to the egg. And it can overcome fertility barriers such as low sperm count and cervical mucus.

Insemination can be used with donor sperm. It can be combined with other fertility treatments, such as clomiphene or hormone shots.

Assisted reproductive technology (ART)

ART is used to remove eggs from a woman's ovaries (or use donor eggs) and fertilize them with the man's sperm (or donor sperm) outside the body. One or more fertilized eggs are then transferred to the woman's uterus or fallopian tubes.

ART procedures are expensive and complex. Most of the time they are used only after other treatment has failed.

Before deciding on ART treatment, consider the possible emotional and social, financial, religious, and ethical and legal questions that may come up for you and your partner.

In vitro fertilization

In vitro fertilization (IVF) is the most common form of ART.

Usually, more than one embryo is put in the uterus. This increases your chances that one will develop into a baby. Because of this, IVF increases your chance of having more than one baby at a time.

  • Out of 100 women who become pregnant with IVF, about 30 will have twins.footnote 3
  • The chance of having triplets or more is higher than normal but much less than the chance of having twins. The chances of multiple births depend on how many embryos are placed in the uterus at one time.

Side effects of IVF can include bloating, weight gain, and nausea. And you risk having serious side effects such as liver and kidney problems. The embryos may not grow into babies, so the IVF may need to be repeated.

If you have several miscarriages or unsuccessful IVF attempts, talk to your doctor about genetic testing.

Other types of ART

When insemination doesn't work, your doctor may recommend ICSI (say "ICK-see"). In a lab, the doctor injects one sperm into an egg. If fertilization occurs, the doctor puts the embryo into the woman's uterus, just as in vitro fertilization (IVF).

Your doctor may also recommend ICSI when the man has had a vasectomy or has retrograde ejaculation. In retrograde ejaculation, the semen is ejaculated into the bladder instead of out through the penis. In these cases, sperm can be taken from the testicles so that they can be injected into an egg.

Another less common treatment is gamete or zygote intrafallopian transfer (GIFT or ZIFT).

  • GIFT is the transfer of eggs and sperm into a fallopian tube through a small incision in the belly.
  • ZIFT is the in vitro fertilization of an egg. The egg is then transferred to a fallopian tube through a small incision in the belly.

Success rates with IVF are as good as with GIFT and ZIFT or better. And IVF is less expensive. It is also less risky, because it isn't a surgical procedure.

Complementary medicine

Complementary medicine for fertility includes:

  • Acupuncture, which may be effective for enhancing IVF success rates.footnote 4
  • 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 he or she knows about all of your health practices.

References

Citations

  1. Fritz MA, Speroff L (2011). Female infertility. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1137–1190. Philadelphia: Lippincott Williams and Wilkins.
  2. Lobo RA (2012). Infertility: Etiology, diagnostic evaluation, management, prognosis. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 869–895. Philadelphia: Mosby.
  3. Fritz MA, Speroff L (2011). Assisted reproductive technologies. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1331–1382. Philadelphia: Lippincott Williams and Wilkins.
  4. Manheimer E, et al. (2008). Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: Systematic review and meta-analysis. BMJ, 336(7643): 545–549.

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2008, reaffirmed 2012). Medical management of ectopic pregnancy. ACOG Practice Bulletin No. 94. Obstetrics and Gynecology, 111(6): 1479–1485.
  • El-Chaar D, et al. (2009). Risk of birth defects increased in pregnancies conceived by assisted human reproduction. Fertility and Sterility, 92(5): 1557–1561.
  • Ghadir S, et al. (2013). Infertility. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics & Gynecology, 11th ed., pp. 879–888. New York: McGraw-Hill.
  • Practice Committee of the American Society for Reproductive Medicine (2012). Multiple gestation associated with infertility therapy: An American Society for Reproductive Medicine practice committee opinion. Fertility and Sterility, 97(4): 825–34.

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