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.
Frequently Asked Questions
Learning about fertility problems: | |
Being diagnosed: | |
Getting treatment: | |
Personal considerations: | |
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 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 a woman older than 35 who has been unable to become pregnant
after about 6 months of sex without using birth control.
- Have had
three 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. For more information, see Home Treatment.
Who to see
For
initial 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 he or she has training in reproductive
endocrinology.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
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:
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.
- Fertility Problems: Should I Be Tested?
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.
- Infertility: Should I Have Treatment?
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:
- Try this interactive tool to
calculate your peak fertility.
- 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.
- Multiple Pregnancy: Should I Consider a Multifetal Pregnancy Reduction?
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 (such as Clomid) stimulates
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.
- Fertility Problems: Should I Have a Tubal Procedure or In Vitro Fertilization?
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.
Other Places To Get Help
Organizations
American Society for Reproductive
Medicine
www.asrm.org
Centers for Disease Control and Prevention: Assisted Reproductive Technology (ART) (U.S.)
www.cdc.gov/ART/index.htm
References
Citations
- Fritz MA, Speroff L (2011). Female infertility. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1137-1190. Philadelphia: Lippincott Williams and Wilkins.
- Lobo RA (2012). Infertility: Etiology, diagnostic evaluation, management, prognosis. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 869-895. Philadelphia: Mosby.
- Fritz MA, Speroff L (2011). Assisted reproductive technologies. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1331-1382. Philadelphia: Lippincott Williams and Wilkins.
- 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.
Credits
ByHealthwise Staff
Primary Medical ReviewerKathleen Romito, MD - Family Medicine
Adam Husney, MD - Family Medicine
Specialist Medical ReviewerFemi Olatunbosun, MB, FRCSC - Obstetrics and Gynecology
Current as ofMarch 16, 2017