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There are known causes of infertility such as blocked fallopian tubes, ovulation problems, decreased sperm counts and medical conditions such as diabetes, lupus and thyroid problems that contribute to decreased fertility. There are some causes of infertility that are more difficult to explain their association with infertility. However, there are some recommendations you can follow to maintain and/or increase your fertility health:
A woman’s fertility peaks during a specific time each month. The egg lives a short 24 hours during the menstrual cycle. Therefore using an ovulation kit (purchased at any pharmacy), basal body temperature and charting of cervical mucus can help pinpoint the best time for conception. If a woman is <35 years old and had 12 months of unprotected intercourse without conception this is defined as infertility. If a women is >35 years old and had 6 months of unprotected intercourse without conception she should see a fertility specialist sooner due to decreased fertility with age. If a woman is 40 years or older, she should see a fertility specialist after 3-6 months of attempting conception. A very high number of women over age 40 will need medical assistance for conception. Regardless of age, if a woman is known to have conditions that predispose her to infertility such as having irregular menstrual cycles, do not have periods, known to have endometriosis, polycystic ovary syndrome or had a previous tubal pregnancy should see a fertility specialist before attempting conception.
Causes of infertility are determined by performing a basic infertility evaluation. A basic infertility evaluation can usually be completed in one menstrual cycle.
Age plays a role in fertility. Female fertility begins to decline many years prior to the onset of menopause despite continued regular cycles. Optimum fertility occurs when you are about 18 years old and remains constant in the early part of your 20s. The decline of fertility among couples with advancing age has been documented, repeatedly. By the time a woman reaches 35, fertility declines rapidly. A classic report on the effect of female age on fertility found that the percentage of women not using contraception who remained childless rose steadily according to their age at marriage: 6% at age 20-24, 9% at age 25-29, 15% at age 30-34, 30% at age 35-39 and 64% at age 40-44.
In the last 10-15 years prior to menopause, there is an acceleration of follicular loss; therefore the number of eggs is decreased. The loss correlates with subtle but a real increase in follicle-stimulating hormone (FSH). The increased FSH, reflects the reduced quality and capability of the aging follicles. Elevated FSH levels on cycle 3 are associated with poor performance with in vitro fertilization.
The risk of miscarriages increases with female age. The percentage of clinical pregnancies (gestational sac seen on ultrasound) that failed to result in a live birth increased according to the woman’s age: 14% for patients under age 35, 19% at age 35 to 37, 25% at age 38-40 and 40% after age 40.
The age-associated decline in female fertility and increased risk of miscarriage are mainly caused by the abnormalities in the egg. The egg in the older woman will frequently have abnormalities in the number of chromosome alignment causing aneuploidy in preimplanted embryos and ongoing pregnancies. The higher rate of aneuploidy is a major cause of increased miscarriages and decreased live birth rates in women with advanced reproductive age (>35).
Fertility testing in women with advanced reproductive age should include an assessment of ovarian reserve. Ovarian reserve describes a woman’s reproductive potential with respect to ovarian follicle (sac that holds the egg) number and egg quality. Some of the most common tests used to evaluate ovarian reserve are:
1) FSH and estradiol levels on cycle 2 or 3 of a woman’s menstrual cycle,
2) clomid challenge test which is performed by measuring a day 3 FSH, administering clomiphene citrate 100mg on cycle days 5 to 9 and measuring FSH again on cycle 10, and
3) small antral follicle count by ultrasound.
Treatment options for age-related infertility include controlled ovarian hyperstimulation (COH/IUI), IVF and egg (oocyte) donation.
Ovulation occurs when the mature follicle (sac that holds the egg) bursts and the egg is released. The egg begins to travel down the fallopian tubes. The egg is available for fertilization in the fallopian tubes. Then the fertilized egg (embryo) travels over several days into the uterus where implantation takes place.
Failure to ovulate is the major problem in approximately 40% of female infertility. If a woman is not getting a period or her periods are irregular, you are not ovulating. This condition is called anovulation. Many factors can cause anovulation such as stress, emotional factors and medical conditions.
Stress can alter chemical changes in the body, which can affect your reproductive hormonal status and menstrual cycle. Weight loss or gain can cause anovulation
A slight deviation of weight by 15% are higher can cause menstrual irregularities. Excessive exercise can cause anovulation if the fat percentage drops to low.
The infertility specialist will order a number of tests to assess for medical causes of anovulation. However, sometimes eggs will not fertilize and develop for unexplained reasons. After medical causes are determined they are treated according to the findings.
Ovarian failure - this means that eggs will no longer develop, the patient’s body has gone through early menopause, IVF using egg-donation is the best treatment
Polycycstic ovarian syndrome (PCOS) - this is a common condition which is associated with elevated androgen (male hormone) and chronic anovulation, reduced insulin sensitivity and numerous cyst on the ovary, treatment is ovulation induction (controlled ovarian stimulation) with clomiphene citrate and/or gonadotropins (FSH and/or LH), sometimes metformin is used to treat problems with elevated insulin levels
Thyroid problems - low thyroid hormones (hypothyroidism) or abnormally high thyroid hormones (hyperthyroidism) can cause irregular ovulation. Treatment is to correct the thyroid problem
Adrenal problems - Increased androgens (male hormones) are associated the ovulatory problems. Medication is used to lower the male hormones
Pituitary problems - Prolactin is a hormone that is responsible for the production of milk. If the prolactin level is elevated (hyperprolactinemia) this can lead to ovulatory problems. This is usually treated with an oral medication called Bromocriptine
Various conditions such as pelvic adhesions, history of pelvic inflammatory disease, prior tubal ligation and endometriosis with tubal involvement can create barriers to the fallopian tubes ability to adequately transport eggs, sperm and embryos to the uterus. A hysterosalpingogram (HSG)is used to evaluate the uterus and the fallopian tubes. A hysterosalpingogram is a study which is usually done by a radiologist in which dye is injected into the uterine cavity and travels up and through both fallopian tubes in order to examine the shape of the uterine cavity and determine the patency of the fallopian tubes.
Some cases of tubal blockage may be treated surgically depending on the degree and location of tubal damage. The best treatment for tubal factor infertility is in vitro fertilization (IVF). IVF is a process that bypasses the fallopian tube as a means of transportation and has been proven to be very efficient in the production of successful pregnancies.
Egg quantity and quality issues can be inherited, iatrogenic, or consequences of various environmental exposures. The best tests for these issues are a cycle day 3 FSH, an antral follicle count and in some cases a clomid challenge test. If a patient has an elevated FSH, and a decreased antral follicle count, this often implies that there will be a decreased response to fertility medication and therefore a decreased success rate with assisted reproductive technologies. This type of patient may have to try more attempts at becoming pregnant than patients with normal testing. In cases where the FSH is really elevated and the antral follicle count is really low, egg donation may be considered as an alternative therapy, which has very high success rates.
Endometriosis is a disease in which endometrial implants are present outside the uterine cavity, in various areas of the pelvis. These implants are seen as a foreign body and therefore the immune system reacts to their presence which can cause, irritation, pain during intercourse, painful menses, and inability to conceive. Approximately 25% of infertile women have some degree of endometriosis. A laparoscopy is the gold standard for diagnosing this condition. Laparoscopy use to be done on everyone as part of the initial fertility work up, however, given surgical risks and new advances in reproductive technology, laparoscopy is now reserved for women who either have symptoms of endometriosis, have endometriomas present on ultrasound, or who have failed several cycles of either ovulation induction with insemination or in vitro fertilization. A recent study published in Fertility and Sterility by Littman et al, suggests that laparoscopic treatment of endometriosis in women who have previously failed IVF cycles, has resulted in not only increased pregnancy rates in women undergoing further treatment but also increased spontaneous conceptions.
Approximately 25 % of infertility problems are unexplained. This implies that all testing, (hormonal, tubal, immunological, laparoscopic, etc) have produced normal results, however, the couple is still persistently unable to conceive successfully on their own. Interestingly, even though the etiology is unknown, advanced reproductive technology has been shown to increase pregnancy rates in couples who suffer from unexplained infertility.
Similar to egg quality and quantity issues, sperm quantity, quality and motility are all factors which play an important role in the infertility process. Millions of motile sperm are needed to help dissolve the shell around the egg and at least one sperm needs to have the correct shape and forward progression to penetrate the egg and cause fertilization to occur. Once fertilization has occurred issues with sperm DNA fragmentation can contribute to the development of abnormal embryos and early miscarriages. A simple semen analysis is used to examine most of these factors and determine whether the issue of male fertility is present. Male infertility accounts for approximately 30% of fertility issues.
1. Menken, J, Trussell J, Larsen U. Age and infertility. Science 1986; 233:
1389-94.
2. Center for Disease Control and Prevention, American Society for
Reproductive Medicine, Society for Assisted Reproductive Technology,
RESOLVE. 1999 Assisted reproductive technology success rates.
Atlanta, GA: Centers for Disease Control and Prevention, 2001.
Last updated:
November 28, 2006
Reviewed by Dr. Rachel McConnell and her medical staff