Infertility

What is infertility?

Infertility is a condition of your reproductive system that causes people to be unable to get pregnant (conceive). Infertility can affect anyone and has many causes. Getting pregnant involves several steps:

1. Your brain must produce reproductive hormones that control ovarian function.
2. An egg must mature in your ovary.
3. Your ovary must release an egg (ovulation).
4. Your fallopian tube must pick up the egg.
5. Sperm must travel up your vagina and through the uterus to your fallopian tube.
6. The sperm fertilizes the egg to create an embryo.
7. The embryo travels through your fallopian tube to the uterus where it implants.

A pregnancy can’t occur if anything in this process doesn’t happen.

If you’re younger than 35, your healthcare provider may diagnose infertility after one year (12 months) of trying to conceive. Trying to conceive is defined as having regular, unprotected sex. If you’re 35 or older, your provider may diagnose infertility after six months of regular, unprotected sex.

Infertility is more common than you might think. Fortunately, there are many treatment options available for people who wish to begin or expand their family.

What are the types of infertility?

Types of infertility include:

• Primary infertility: You’ve never been pregnant and can’t conceive after one year (or six months if you’re 35 or older) of regular, unprotected sexual intercourse.
• Secondary infertility: You can’t get pregnant again after having at least one successful pregnancy.
• Unexplained infertility: Fertility testing hasn’t found a reason that a person or couple is unable to get pregnant.

How common is infertility?

Infertility affects men and people assigned male at birth (AMAB) and women and people assigned female (AFAB) at birth equally. Infertility is very common. In the United States, 1 in 5 women between 15 and 49 years old struggle with primary infertility and about 1 in 20 women struggle with secondary infertility. Approximately 48 million couples live with infertility around the world.

What are signs of infertility?

The main sign of infertility is being unable to get pregnant after six months or one year of regular, unprotected sex. You may not have any other symptoms. But some people may show physical symptoms such as:

• Pelvic or abdominal pain.
• Irregular vaginal bleeding, irregular periods or no periods.
• Penile disorders or issues with ejaculation.

What causes infertility?

There are many causes of infertility, and sometimes, there isn’t a simple answer as to why you’re not getting pregnant. Only a healthcare provider can determine the cause and find the best treatment for you.

While causes of infertility vary, studies show that:

• 33% of infertility involves the partner with a uterus and ovaries.
• 33% of infertility involves the partner with a penis and testicles.
• 33% of infertility involves both partners or is unexplained.

Twenty-five percent of infertile couples have more than one factor that contributes to their infertility.

Infertility causes

Some causes of infertility affect just one partner, while others affect both partners. Risk factors for infertility include:

• Age, particularly being in your late 30s or 40s. For men, age begins affecting fertility closer to 50.
• Eating disorders, including anorexia nervosa and bulimia.
• Excessive alcohol consumption.
• Exposure to environmental toxins, such as chemicals, lead and pesticides.
• Over-exercising.
• Radiation therapy or chemotherapy.
• Sexually transmitted infections (STIs).
• Smoking and using tobacco products. (This behavior plays a role in about 13% to 15% of infertility cases.)
• Substance abuse.
• Having obesity or being underweight.
• Abnormalities of the hormone-producing centers of your brain (hypothalamus or pituitary).
• Chronic conditions and diseases.

Infertility causes for women and people assigned female at birth

Ovulation disorders are the most common cause of infertility in people with ovaries. Ovulation is the process in which your ovary releases an egg to meet sperm for fertilization.

These factors can contribute to female infertility:

• Endometriosis.
• Structural abnormalities of your vagina, uterus or fallopian tubes.
• Autoimmune conditions like celiac disease or lupus.
• Kidney disease.
• Pelvic inflammatory disease (PID).
• Hypothalamic and pituitary gland disorders.
• Polycystic ovary syndrome (PCOS).
• Primary ovarian insufficiency or poor egg quality.
• Sickle cell anemia.
• Uterine fibroids or uterine polyps.
• Thyroid disease.
• Prior surgical sterilization (tubal ligation or salpingectomy).
• Genetic or chromosomal disorders.
• Sexual dysfunction.
• Surgical or congenital absence of your ovaries.
• Infrequent or absent menstrual periods.

Infertility causes for men and people assigned male at birth

The most common cause of male infertility involves problems with the shape, movement (motility) or amount (low sperm count) of sperm.

Other causes of male infertility include:

• Enlarged veins (varicocele) in your scrotum, the sac that holds your testicles.
• Genetic disorders, such as cystic fibrosis.
• Chromosomal disorders, such as Klinefelter syndrome.
• High heat exposure to your testicles from tight clothing, frequent use of hot tubs and saunas, and holding laptops or heating pads on or near your testes.
• Injury to your scrotum or testicles.
• Low testosterone (hypogonadism).
• Misuse of anabolic steroids.
• Sexual dysfunction, such as erectile dysfunction, anejaculation, premature ejaculation or retrograde ejaculation.
• Undescended testicles.
• Previous chemotherapy or radiation therapy.
• Surgical or congenital absence of testes.
• Prior surgical sterilization (vasectomy).

How is female infertility diagnosed?

First, your healthcare provider will get your full medical and sexual history.

Fertility for people with a uterus involves ovulating healthy eggs. This means your brain has to send hormonal signals to your ovary to release an egg to travel from your ovary, through your fallopian tube and to your uterine lining. Fertility testing involves detecting an issue with any of these processes.

These tests can also help diagnose or rule out problems:

• Pelvic exam: Your provider will perform a pelvic exam to check for structural problems or signs of disease.
• Blood test: A blood test can check hormone levels to see if hormonal imbalance is a factor or if you’re ovulating.
• Transvaginal ultrasound: Your provider inserts an ultrasound wand into your vagina to look for issues with your reproductive system.
• Hysteroscopy: Your provider inserts a thin, lighted tube (hysteroscope) into your vagina to examine your uterus.
• Saline sonohysterogram (SIS): Your provider fills your uterus with saline (sterilized salt water) and conducts a transvaginal ultrasound.
• Sono hysterosalpingogram (HSG): Your provider fills your fallopian tubes with saline and air bubbles during an SIS procedure to check for tubal blockages.
• X-ray hysterosalpingogram (HSG): X-rays capture an injectable dye as it travels through your fallopian tubes. This test looks for blockages.
• Laparoscopy: Your provider inserts a laparoscope (thin tube with a camera) into a small abdominal incision. It helps identify problems like endometriosis, uterine fibroids and scar tissue.

How is male infertility diagnosed?

Diagnosing infertility in people with a penis typically involves making sure a person ejaculates healthy sperm. Most fertility tests look for problems with sperm.

These tests can help diagnose or rule out problems:

• Semen analysis: This test checks for low sperm count and poor sperm mobility. Some people need a needle biopsy to remove sperm from their testicles for testing.
• Blood test: A blood test can check thyroid and other hormone levels. Genetic blood tests look for chromosomal abnormalities.
• Scrotal ultrasound: An ultrasound of your scrotum identifies varicoceles or other testicular problems.

How is infertility treated?

Treatment for infertility depends mostly on the cause and your goals. Your age, how long you’ve been trying to conceive and your personal preferences are factors in deciding on a treatment. Sometimes, one person needs treatment, but other times, treatment involves both partners.

In most cases, people and couples with infertility have a high chance of pregnancy. Things like medication, surgery or assisted reproductive technology (ART) can help. Often, lifestyle changes or improving the frequency and timing of intercourse can improve your chances of pregnancy. Treatment can also include a combination of methods.

Infertility treatment for women

Treatments for infertility in women and people assigned female at birth include:

• Lifestyle modification: Gaining or losing weight, stopping smoking or using drugs, and improving other health conditions can improve your chance of pregnancy.
• Medications: Fertility drugs stimulate your ovaries to ovulate more eggs, which increases your chance of getting pregnant.
• Surgery: Surgery can open blocked fallopian tubes and remove polyps, fibroids or scar tissue.

Providers may make suggestions on how you can improve your odds of conceiving. These may include things like:

• Tracking ovulation through basal body temperature, using a fertility tracking app and noting the texture of your cervical mucus.
• Using a home ovulation kit, a kit you can purchase at the drug store or online to help predict ovulation.

Infertility treatment for men

Treatments for infertility if you have a penis or testes include:

• Medications: Medications can raise testosterone or other hormone levels. There are also drugs for erectile dysfunction to help you maintain an erection during sex.
• Surgery: Some men need surgery to open blockages in the tubes that carry sperm or to repair structural problems. Varicocele surgery can make sperm healthier and improve the odds of conception.

What are common fertility treatments?

Some couples need more help conceiving using assisted reproductive technology (ART). ART is any fertility treatment that involves a healthcare provider handling the sperm or egg. To increase pregnancy odds, you can take medications to stimulate ovulation before trying one of these options:

• In vitro fertilization (IVF): IVF involves retrieving eggs from your ovary, then placing them with sperm in a lab dish. The sperm fertilizes the eggs. A provider transfers one to three of the fertilized eggs (embryos) into your uterus.
• Intracytoplasmic sperm injection (ICSI): This procedure may be performed during the IVF process. An embryologist injects a single sperm directly into each egg. Then, a provider transfers one to three of the embryos into your uterus.
• Intrauterine insemination (IUI): A healthcare provider uses a long, thin tube to place sperm directly into your uterus. IUI is sometimes called artificial insemination.
• Assisted hatching: A process that involves opening the outer layer of an embryo to make it easier for it to implant in your uterine lining.
• Third-party ART: Couples may use donor eggs, donor sperm or donor embryos. Some couples need a gestational carrier or surrogate.

What are complications of treatment?

Complications of infertility treatment include:

• Higher chance of multiples (twins, triplets or more): Producing multiple eggs and transferring more than one embryo increases your risk of becoming pregnant with more than one fetus. Complications such as miscarriage, premature birth, low birth weight, neonatal death, and long-term health complications are more common in people pregnant with multiple fetuses.
• Ovarian hyperstimulation syndrome (OHSS): A condition that causes painful and swollen ovaries as a result of fertility medications. It can become serious and require immediate medical attention.
• Ectopic pregnancy: IVF has an increased risk of ectopic pregnancy.
• Failed cycles: A failed cycle is when you go through infertility treatment and it doesn’t end in pregnancy.

Can infertility be cured?

Yes, but it depends on the cause. In 85% to 90% of cases, lifestyle modification, medication, ART or surgery can treat infertility and allow a person to conceive.

How can I prevent infertility?

You can take these steps to protect your fertility, especially while trying to conceive:

• Eat a well-balanced diet and maintain a weight that’s healthy for you.
• Don’t smoke, misuse drugs or drink alcohol.
• Get treated for STIs.
• Limit exposure to environmental toxins.
• Stay physically active, but don’t overdo exercise.
• Don’t delay conception until an advanced age.
• Undergo fertility preservation procedures (freezing eggs or sperm).

What can I expect if I have infertility?

Approximately 9 out of 10 couples get pregnant after undergoing fertility treatments. Success rates vary depending on the cause of infertility, the couple’s ages and other factors.

Infertility has emotional, physical, financial and psychological side effects. Don’t forget to practice self-care and be patient with yourself and your partner throughout the process. Infertility isn’t easy, so surround yourself with supportive people or consider joining an online support group. Sometimes, sharing your feelings with people who understand what you’re going through can be helpful.

Does insurance cover infertility treatment?

Health insurance policies vary, so you should always check with your insurance provider. Most insurers cover medically necessary procedures, such as surgeries to treat endometriosis and uterine fibroids. Some policies cover fertility procedures like IUI, but may not cover ovulation-stimulating medications or IVF.

Certain states have laws that require employers to provide infertility coverage as part of their health insurance policy for employees. As of June 2022, The National Infertility Association (Resolve) states:

• Twenty states have passed fertility insurance coverage laws; 14 of those laws include IVF coverage; and 12 states have fertility preservation laws for iatrogenic (medically induced) infertility.

If you live or work in a state that has an infertility coverage law in place and want to know your coverage details, you should contact your employer.

When should you seek help for infertility?

People who are under the age of 35 and who aren’t pregnant after one year of trying should see a healthcare provider. You should seek help sooner (after six months of trying) if you’re 35 to 39 years old. If you’re 40 or older, you should seek evaluation after fewer than six months of trying. Your chances of getting pregnant decrease with age. For example, a 25-year-old female has a 25% to 30% chance of getting pregnant each menstrual cycle. By the time you reach 40, your chances are less than 5% each cycle.

Regardless of sex, you should seek help early if you have a risk factor or medical condition that affects fertility. Seek prompt evaluation if you have a history of risk factors for premature ovarian failure, severe endometriosis, or known or suspected uterine/tubal disease.

Primary care providers and gynecologists may recommend couples see a fertility specialist, urologist or reproductive endocrinologist for help with infertility diagnosis and treatment.

What questions should I ask my healthcare provider?

You may want to ask your healthcare provider:

• Do I need to see a fertility specialist?
• Should my partner and I both get tested for fertility problems?
• Based on my partner’s age and my age, how soon should we get tested for fertility problems?
• What’s the best treatment for us?
• What’s the treatment success rate?
• What are the treatment side effects or risks?
• Should I look out for signs of complications?

Can chlamydia cause infertility?

Chlamydia causes about 4 million infections each year in the U.S. Untreated chlamydia is a risk factor for infertility because it leads to pelvic inflammatory disease (PID). PID is an infection that can permanently damage your fallopian tubes, uterus or ovaries.

Can birth control cause infertility?

No. Studies show that using birth control doesn’t harm your future fertility.

Is endometriosis a cause of infertility?

Endometriosis is a risk factor for infertility. About 30% to 50% of people with endometriosis will experience infertility.

A note from Cleveland Clinic

Infertility poses many challenges and can feel soul-crushing if you’re wanting to start or expand your family. It can affect your relationships and emotional health. Infertility treatments can also be costly and strain finances. If you’re not getting pregnant despite your best efforts, it may be time to contact a healthcare provider. They can determine if there’s a cause and then discuss possible treatment options with you. Most couples eventually get pregnant, but some turn to reproductive technologies or adoption.