Definition of Subfertility (Infertility)
If getting pregnant has been a challenge for you and your partner, you’re not alone. Ten to 15 percent of couples in the United States are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most people and six months in certain circumstances.
Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing. Fortunately, there are many safe and effective therapies for overcoming infertility. These treatments significantly improve the chances of becoming pregnant.
Symptoms of Subfertility (Infertility)
Most couples achieve pregnancy within the first six months of trying. Overall, after 12 months of frequent unprotected intercourse, about 90 percent of couples will become pregnant. The majority of couples will eventually conceive, with or without treatment.
The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms.
In some cases, an infertile woman may have irregular or absent menstrual periods. Rarely, an infertile man may have some signs of hormonal problems, such as changes in hair growth or sexual function.
When to see a doctor
In general, don’t be too concerned about infertility unless you and your partner have been trying regularly to conceive for at least one year. Talk with your doctor earlier, however, if you’re a woman and:
- You’re age 35 to 40 and have been trying to conceive for six months or longer
- You’re over age 40, so you should begin testing or treatment right away
- You menstruate irregularly or not at all
- Your periods are very painful
- You have known fertility problems
- You’ve been diagnosed with endometriosis or pelvic inflammatory disease
- You’ve had more than one miscarriage
- You’ve had prior cancer treatment
If you’re a man, talk with your doctor if you have:
- Low sperm count or other problems with sperm
- A history of testicular, prostate or sexual problems
- You’ve had prior cancer treatment
To become pregnant, the complex processes of ovulation and fertilization need to work just right. For some couples, infertility problems can be present from birth (congenital) or something can go wrong along the way that results in infertility.
The reasons for infertility can involve one or both partners. In general:
- In about one-third of cases, the cause of infertility involves only the male.
- In about one-third of cases, the cause of infertility involves only the female.
- In the remaining cases, the cause of infertility involves both the male and female, or no cause can be identified.
Causes of male infertility
Causes of male infertility may include:
- Abnormal sperm production or function due to various problems, such as undescended testicles, genetic defects, health problems such as diabetes, or infections such as mumps. Enlarged veins in the testes (varicocele) can increase blood flow and heat, affecting the number and shape of sperm.
- Problems with the delivery of sperm due to sexual problems, such as premature ejaculation; semen entering the bladder instead of emerging through the penis during orgasm (retrograde ejaculation); certain genetic diseases, such as cystic fibrosis; structural problems, such as blockage of the part of the testicle that contains sperm (epididymis); or damage or injury to the reproductive organs.
- Overexposure to certain environmental factors, such as pesticides and other chemicals, radiation, or to certain medications, such as anabolic steroids, or marijuana. In addition, frequent exposure to heat, such as in saunas or hot tubs, can elevate core body temperature, impairing sperm production.
- Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely. Removal of one testicle due to cancer also may affect male fertility.
Causes of female infertility
Causes of female infertility may include:
- Ovulation disorders, which hinder or prevent the ovaries from releasing eggs. Examples include hormonal disorders such as polycystic ovary syndrome, a condition that might relate to your ovaries producing too much of the male hormone testosterone, and hyperprolactinemia, when you have too much prolactin — the hormone that stimulates breast milk production. Other underlying causes may include excessive exercise, eating disorders, injury or tumors.
- Uterine or cervical abnormalities, including problems with the opening of the cervix or cervical mucus, or abnormalities in the shape or cavity of the uterus. Benign tumors in the wall of the uterus that are common in women (uterine fibroids) may rarely cause infertility by blocking the fallopian tubes. More often, fibroids may distort the uterine cavity interfering with implantation of the fertilized egg.
- Fallopian tube damage or blockage, which usually results from inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, usually caused by sexually transmitted infection, endometriosis or adhesions.
- Endometriosis, which occurs when endometrial tissue implants and grows outside of the uterus — often affecting the function of the ovaries, uterus and fallopian tubes.
- Primary ovarian insufficiency, also called early menopause, when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.
- Pelvic adhesions, bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery.
Other causes in women include:
- Thyroid problems. Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle or cause infertility.
- Cancer and its treatment. Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman’s ability to reproduce.
- Other conditions. Medical conditions associated with delayed puberty or the absence of menstruation (amenorrhea), such as celiac disease, Cushing’s disease, sickle cell disease, kidney disease or diabetes, can affect a woman’s fertility. Also genetic abnormalities can make conception and pregnancy less likely.
- Certain medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
Many of the risk factors for both male and female infertility are the same. They include:
- Age. A woman’s fertility gradually declines with age and this decline becomes more pronounced in her mid-30s. Infertility in older women may be due to the number and quality of eggs as they age or to health problems that may interfere with fertility. Men over age 40 may be less fertile than younger men are.
- Tobacco use. A couple’s chance of achieving a pregnancy is reduced if either partner uses tobacco. Smoking also reduces the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can increase the risk of erectile dysfunction and low sperm count in men.
- Alcohol use. For women, there’s no safe level of alcohol use during conception or pregnancy. Avoid alcohol if you’re planning to become pregnant because you may not realize you’re pregnant for the first few weeks. Alcohol use increases the risk of birth defects, and it may also make it more difficult to become pregnant. For men, heavy alcohol use can decrease sperm count and motility.
- Being overweight. Among American women, an inactive lifestyle and being overweight may increase the risk of infertility. In addition, a man’s sperm count may be affected if he is overweight.
- Being underweight. Women at risk of fertility problems include those with eating disorders, such as anorexia or bulimia, and women who follow a very low calorie or restrictive diet.
- Exercise issues. Lack of or not enough exercise contributes to obesity, which increases the risk of infertility. Less often, ovulation problems may be associated with frequent strenuous, intense exercise in women who are not overweight.
Preparing for your appointment
Depending on your age and personal health history, your doctor may recommend a medical evaluation. A woman’s gynecologist or a man’s urologist or a family doctor can help determine whether there’s a problem that requires a specialist or clinic that treats infertility problems. Both you and your partner will likely have a comprehensive infertility evaluation.
What you can do
To get ready for your first appointment:
- Provide details about your attempts to get pregnant. Your doctor will need information such as when you started trying to conceive and how often you’ve had intercourse, especially around the midpoint of your cycle — the time of ovulation.
- Bring your key medical information. Include any other medical conditions you or your partner has, as well as information about any previous evaluations or treatments for infertility.
- Make a list of any medications, vitamins, herbs or other supplements you take. Include the doses and how often you take them.
- Make a list of questions to ask your doctor. List the most important questions first in case time runs out.
For infertility, some basic questions to ask your doctor include:
- What are the possible reasons we haven’t yet conceived?
- What kinds of tests do we need?
- What treatment do you recommend trying first?
- What side effects are associated with the treatment you’re recommending?
- What is the likelihood of conceiving multiple babies with the treatment you’re recommending?
- For how many cycles will we try this treatment?
- If the first treatment doesn’t work, what will you recommend trying next?
- Are there any long-term complications associated with this or other infertility treatments?
Don’t hesitate to ask your doctor to repeat information or to ask follow-up questions.
What to expect from your doctor
Be ready to answer questions to help your doctor quickly determine next steps in making a diagnosis and starting care.
Questions for the couple
Possible questions for the couple include:
- How long have you been having sex without birth control?
- How long have you been actively trying to get pregnant?
- How frequently do you have intercourse?
- Do you use any lubricants during sex?
- Do either of you smoke?
- Do either of you use alcohol or recreational drugs? How often?
- Are either of you currently taking any medications, dietary supplements or anabolic steroids?
- Have either of you been treated for any other medical conditions, including sexually transmitted infections?
- Are you exposed through your work or lifestyle habits to chemicals, pesticides, radiation or lead?
- How much does stress play a role in your lives?
- How satisfied are you with your relationship?
Questions for the man
If you’re a man, you might be asked:
- At what age did you start puberty?
- Have you had any sexual problems in this relationship, such as difficulty maintaining an erection, ejaculating too soon or not being able to ejaculate?
- Have you conceived a child with any previous partners?
- Do you regularly take hot baths or steam baths?
Questions for the woman
If you’re a woman, you might be asked:
- At what age did you start menstruating?
- What are your cycles typically like? How regular, long and heavy?
- Have you ever been pregnant before?
- Have you been charting your cycles or testing for ovulation? For how many cycles?
- What is your typical daily diet?
- Do you exercise regularly? How much?
- Has your body weight recently changed?
Tests and diagnosis
Before having infertility testing, be aware of the commitment that’s required. Your doctor or clinic will need to determine what your sexual habits are and may make recommendations about changing them. Tests and treatment trial periods may extend over several months. In some infertile couples, no specific cause is found (unexplained infertility).
Evaluation can be expensive and in some cases involves uncomfortable procedures. Many medical plans may not reimburse the cost of fertility treatment. Finally, there’s no guarantee — even after all the testing and counseling — that conception will occur.
Tests for men
For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman’s vagina and be able to travel to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.
You may have a general physical exam. This includes an examination of your genitals. Specific fertility tests may include:
- Semen analysis. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes your semen specimen for the health of sperm and the semen fluid.
- Hormone testing. A blood test to determine the level of testosterone and other male hormones is common.
- Transrectal and scrotal ultrasound. Ultrasound can help your doctor look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstruction.
- Genetic testing. Genetic testing may be done to determine whether there’s a genetic defect causing infertility.
Tests for women
For a woman to be fertile, her ovaries must release healthy eggs. Her reproductive tract must allow an egg to pass into her fallopian tubes and allow the sperm to join the egg for fertilization. The fertilized egg must travel on to the uterus and implant in the lining. Tests for female infertility attempt to determine whether any of these processes are impaired.
You may have a general physical exam. This includes a regular gynecological exam. Specific fertility tests may include:
- Ovulation testing. A blood test is performed to measure hormone levels to determine whether you’re ovulating, if you have not had positive home ovulation tests.
- Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the condition of your uterus and fallopian tubes. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid spills out of your fallopian tubes. Blockage or other problems often can be located.
- Ovarian reserve testing. This testing helps determine the quality and quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.
- Other hormone testing. Other hormone tests check levels of ovulatory hormones, as well as thyroid and pituitary hormones that control reproductive processes.
- Imaging tests. Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) is used to see details inside the uterus that are not seen on a regular ultrasound.
Depending on your situation, rarely your testing may include:
- Other imaging tests. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease.
- Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. Laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
- Genetic testing. Genetic testing helps determine whether there’s a genetic defect causing infertility.
Not everyone needs to have all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.
Treatments and drugs
Treatment of infertility depends on the cause, how long you’ve been infertile, your age and your partner’s age, and many personal preferences. Some causes of infertility can’t be corrected. However, a woman may still become pregnant with assisted reproductive technology. Infertility treatment involves significant financial, physical, psychological and time commitment.
Treatment for men
Approaches that involve the male include treatment for general sexual problems or lack of healthy sperm. Treatment may include:
- Medication or behavioral approaches. Addressing impotence or premature ejaculation with one or both approaches may improve fertility.
- Surgery, hormones or assisted reproductive technology. If a lack of healthy sperm is suspected as the cause of a man’s infertility, surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible.
- Sperm retrieval. These techniques obtain sperm when ejaculation is a problem: surgical sperm aspiration, which allows retrieval of sperm if the ejaculatory duct is blocked, and electric or vibratory stimulation to achieve ejaculation, which can help retrieve sperm in men with spinal cord injury.
Treatment for women
Although a woman may need just one or two therapies to restore fertility, it’s possible that several different types of treatment may be needed before she’s able to conceive.
- Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk with your doctor about fertility drug options — including the benefits and risks of each type.
- Intrauterine insemination (IUI). During IUI, healthy sperm that have been collected and concentrated are placed directly in the uterus around the time the woman’s ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
- Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum or intrauterine scar tissue can be treated with hysteroscopic surgery.
Assisted reproductive technology
Assisted reproductive technology (ART), which leads to the highest chance of pregnancy for most couples, is any fertility treatment in which the egg and sperm are handled. An ART health team includes physicians, psychologists, embryologists, lab technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.
In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a lab, and implanting the embryos in the uterus three to five days after fertilization.
Each year thousands of babies are born in the United States as a result of ART. The success rate of ART is lower after age 35.
Other techniques are sometimes used in an IVF cycle, such as:
- Intracytoplasmic sperm injection (ICSI). In ICSI, a single healthy sperm is injected directly into a mature egg. ICSI is often used when semen quality is a problem, there are few sperm, or if fertilization attempts during prior IVF cycles failed.
- Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).
- Donor eggs or sperm. Most ART is done using the woman’s own eggs and her partner’s sperm. However, if there are severe problems with either the eggs or sperm, you may choose to use eggs, sperm or embryos from a known or anonymous donor.
- Gestational carrier. Women who don’t have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using a gestational carrier. In this case, the couple’s embryo is placed in the uterus of the carrier for pregnancy.
Complications of treatment
Complications of infertility treatment may include:
- Multiple pregnancy. The most common complication of infertility treatment is a multiple pregnancy — twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery. Babies born prematurely are at increased risk of health and developmental problems. The goal of infertility treatment should be a single healthy pregnancy, and preventing multiple pregnancies should be discussed before treatment starts. In some cases, fetal reduction can be used to help a woman deliver fewer babies with lower health risks. Pursuing fetal reduction, however, is a major decision with ethical, emotional and psychological consequences.
- Ovarian hyperstimulation syndrome (OHSS). Use of injectable fertility drugs to induce ovulation can cause OHSS, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
- Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology.
- Premature delivery or low birth weight. The greatest risk factor for low birth weight is a multiple fetus pregnancy. In single live births, there may be a greater chance of preterm delivery or low birth weight associated with IVF.
- Birth defects. Some research suggests that babies conceived using IVF might be at increased risk of certain birth defects, such as heart and digestive problems and cleft lip or cleft palate. However, most studies conclude that this appears to be related to why couples need infertility treatment and not the IVF procedures themselves.
Coping and support
Coping with infertility can be extremely difficult. It’s an issue of the unknown — you can’t predict how long it will last or what the outcome will be. The emotional burden on a couple is considerable. Taking these steps can help you cope:
- Be prepared. The uncertainty of infertility testing and treatments can be difficult and stressful. Ask your doctor to explain the steps he or she is planning to take so that you can prepare yourself for each one.
- Set limits. Try to decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner. Fertility treatments may be expensive and often are not covered by insurance companies, and a successful pregnancy often depends on repeated attempts.
- Consider other options. Determine alternatives — adoption, donor sperm or egg, donor embryo, gestational carrier or adoption, or even having no children — as early as possible in the infertility evaluation. This may reduce anxiety during treatments and feelings of hopelessness if conception doesn’t occur.
- Seek support. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.
Managing emotional stress during treatment
Consider these strategies to help manage emotional stress during treatment:
- Express yourself. Reach out to others rather than repressing guilt or anger.
- Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.
- Reduce stress. Some studies have shown that couples experiencing psychological stress had poorer results with infertility treatment. If you can, find a way to reduce stress in your life before trying to become pregnant.
- Exercise and eat a healthy diet. Keeping up a moderate exercise routine and a healthy diet can improve your outlook and keep you focused on living your life despite fertility problems.
Managing emotional effects of the outcome
Whatever the result of your fertility treatment, you’ll face the possibility of psychological challenges. Seek professional help if the emotional impact of any outcomes becomes too heavy for you or your partner, such as:
- Not achieving pregnancy, or having a miscarriage. The emotional stress of not being able to have a baby can be devastating even on the most loving and affectionate relationships.
- Success. Even if fertility treatment is successful, it’s common to experience stress and fear of failure during pregnancy. If you have a history of depression or anxiety disorder, you’re at increased risk of these problems recurring in the months after your child’s birth.
- Multiple births. A successful pregnancy that results in multiple births introduces new medical complexities and the likelihood of significant emotional stress both during pregnancy and after delivery.
Some types of infertility aren’t preventable. But several strategies may increase your chances of pregnancy.
For couples, having regular intercourse several times around the time of ovulation offers the highest pregnancy rate. Intercourse occurring several days before and until a day after ovulation improves the probability of pregnancy. This is usually at the middle of the cycle halfway between menstrual periods for most women with menstrual cycles 28 days apart. Semen quality is optimized by waiting two to three days between ejaculations.
For men, although most types of infertility aren’t preventable, these strategies may help:
- Avoid drug and tobacco use and excessive alcohol consumption, which may contribute to male infertility.
- Avoid high temperatures as this can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.
- Avoid exposure to industrial or environmental toxins, which can impact sperm production.
- Limit medications that may impact fertility, both prescription and nonprescription drugs. Talk with your doctor about any medications you take regularly, but don’t stop taking prescription medications without medical advice.
For women, a number of strategies may increase the chances of becoming pregnant:
- Exercise moderately. Regular exercise is important, but if you’re exercising so intensely that your periods are infrequent or absent, your fertility may be impaired.
- Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
- Quit smoking. Tobacco has multiple negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
- Avoid alcohol and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don’t drink alcohol or use illegal drugs, such as marijuana or cocaine.
- Limit medications that may impact fertility. The use of some prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly, but don’t stop taking prescription medications without medical advice.
- Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for guidance on safe use of caffeine.