"We do not fear the unknown — we fear what we think we know about the unknown."
More than 7 million women have seen a doctor about infertility, and in about one-third of cases the cause of infertility is attributed to the female partner (1). The important thing to remember about infertility is that it does not necessarily mean a couple can’t get pregnant on their own. It can mean anything from a fertile couple that is simply taking longer to conceive than the 12-month time frame that labels a couple as infertile, to the other extreme, such as being completely sterile.
The many unknowns and fears involved in the process can make it feel out of control. For some couples, the solution may simply come down to timing intercourse correctly, for another it may be losing 10 pounds, and yet another may require a more invasive procedure, such as surgery, to fix a tubal blockage.
In this blog we explore all the causes of female-factor infertility. Later this week, look for our blog on male-factor infertility.
Ovulatory disorders are the most common cause of infertility in women and account for 21-25% of cases of female infertility. Ovulation may fail to occur altogether (anovulation) or, as in most cases, may be irregular. Up to one-third of women with regular menstrual cycles are anovulatory at some point (2).
Causes: Irregular ovulation during the reproductive years is typically due to hormonal imbalances. Once we are in our late 30s or early 40s, irregular ovulation is a natural process that occurs as we age, but can happen prematurely. By age 40, the chances of conceiving without assistance drops to less than 10% per menstrual cycle. Hormonal imbalances related to ovulation may be due to diet, weight (either too much or too little), hypothyroidism, hyperprolactinemia, or low progesterone. Polycystic ovary syndrome (PCOS) is one of the most common ovulatory disorders, and will be discussed below (2).
Symptoms: You will not have a regular period if you do not ovulate, but you may experience some abnormal uterine bleeding that could be mistaken for a period (3). You will typically know if you are irregular if your periods are shorter or longer than average or if you skip periods. If your cycle is in the range of 21-35 days, this indicates that you are probably ovulating regularly, suggests fertility expert Dr. Don Aptekar. The biggest concern he finds with cycle lengths closer to 21 days or 35 days is couples missing their fertile window.
Treatment: If you are diagnosed with an ovulatory disorder, your doctor should work with you to discover the cause behind the anovulation or irregular ovulation.
Some doctors feel that patients with irregular periods are pushed to medication or IVF too early. Someone who ovulates 6 times per year will take longer to conceive than someone who ovulates 12 times per year. If you are ovulating, you may not need to take fertility drugs, which often shorten the process but create risk and the possibility of multiples (4).
Fertility drugs like Clomid encourage the body to mature more eggs, whereas alternatives like aromatase inhibitors may kick-start ovulation while carrying less risk of multiples (4). Dr. Aptekar says, "If you don’t want twins or triplets, then wait to find out if you are ovulating first. If you pinpoint your entire fertile window and when you ovulate, you will increase your chances greatly of getting pregnant naturally." Click here to read Who Needs Fertility Drugs to get Pregnant: Fertility Drugs 101.
If you and your doctor believe your ovulation disorder could be due to too much weight, too little weight, or your weight fluctuates often, you may consider working with a nutritionist that specializes in fertility. For overweight women, weight loss alone may regulate your cycle (5).
Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) may sound like a disease of the ovaries, but it is actually an endocrine disorder with multiple secondary symptoms. PCOS is among the most common causes of female infertility (5) and affects 5-12% of women, although it is thought to be undiagnosed in up to 70% of the women who have it (6). One study found that women saw 3 or more healthcare providers before they were eventually diagnosed with PCOS, and for one-third, it took more than 2 years before they were accurately diagnosed (7).
Causes: Although the precise cause of PCOS is unclear, doctors believe it is related to factors like insulin resistance and an overabundance of male hormones called androgens. Androgens may interfere with or prevent ovulation, which may explain why women with PCOS have irregular periods or no period whatsoever (5).
Symptoms: Common symptoms include an irregular menstrual cycle, weight gain, acne, and excess facial hair (5).The symptoms, however, vary significantly among individuals and are often misdiagnosed or undiagnosed.
It is also the most common cause in women for infertility. Due to hormonal imbalances, many women with PCOS do not ovulate regularly (7), which is why they typically get diagnosed with PCOS when they are trying to get pregnant.
Treatment: Doctors, such as Dr. Kyle Willets, believe that the number one way to treat PCOS is with a healthy diet and exercise (read her personal story on natural healing from PCOS). You don’t necessarily need to lose a lot of weight to improve ovulation and insulin levels. A study of women with high body weight and PCOS found that losing just 5-10% of their body weight restored ovulation in up to 100% of the women within 6 months (4).
Losing weight, however, is more difficult with PCOS due to imbalances in hormones, including leptin and ghrelin, which regulate your appetite (8). If you find that you lead a healthy lifestyle already or have made healthy lifestyle changes and still battle with PCOS, medication may help. Metapharm, for example, is used for insulin resistance and to restart ovulation (4). Often that alone will correct infertility caused by PCOS. There are also other medications to treat the hormonal imbalance such as progesterone and thyroid medication (5).
Progesterone plays a critical role in achieving and sustaining pregnancy. A low progesterone level prevents your uterine lining from thickening, may trigger premature shedding of the lining, and will result in a short luteal phase, which makes it challenging to get pregnant (9).
Causes: Low progesterone may be caused by ovulation problems or miscarriage (10). It may be a symptom of other disorders such as hypothyroidism.
Symptoms: Symptoms of low progesterone include headaches or migraines, little interest in sex, hot flashes, anxiety and other mood changes (10), short luteal phase, and fatigue (11). To diagnose low progesterone, your healthcare provider may suggest measuring your progesterone level by drawing a blood sample about a week before you expect your period (9). You can also track your progesterone at home using Proov. Learn more about Proov here.
Treatment: Certain lifestyle factors may help balance your estrogen/progesterone levels for a healthy menstrual cycle. Start by avoiding products containing bisphenol-A (BPA). Multiple studies show that this endocrine-disrupting chemical greatly reduced the chances of having a baby among women undergoing IVF by harming egg quality and shortening the luteal phase, among other effects (12, 13). Other research found women with infertility had higher levels of BPA in their bloodstream than fertile women (although scientists note that nearly all of us have some BPA in our blood — yikes) (13).
BPA leaches into your food from plastic containers and the linings of cans. So make sure to avoid BPA-containing goods in particular — and processed and packaged foods in general (14, 15). (Read about natural fertility-boosting foods to add to your daily diet.)
Plastic containers touted as “BPA free” may contain other endocrine-disruptors, such bisphenol-S (BPS), which can be just as harmful (14, 15). Drink from glass water bottles whenever possible, opt for homemade or “green” household cleaners, and limit your exposure to bug sprays, air fresheners, harsh detergents, and personal care products made with parabens, another endocrine disruptor (14, 15).
As for medical treatments, your healthcare provider may prescribe progesterone supplements in the form of pills, vaginal suppositories, and/or injections. The goal of these medications is to help thicken the uterine lining to allow an embryo to attach. One small study suggests progesterone treatment during the luteal phase improved pregnancy rates (16).
Endometriosis is a chronic disease that causes the endometrium, or lining of the uterus, to grow on your ovaries, fallopian tubes, and other places outside the uterine cavity. The condition occurs in about 10% of women during the childbearing years. Close to 40% of women with infertility have endometriosis (17), and the average age of diagnosis is 27 (18). The condition can produce growths (called implants), scarring (called adhesions), and inflammatory substances called cytokines that hinder the normal processes of ovulation, fertilization, and implantation (19). Severe cases can block the fallopian tubes (17).
Causes: Endometriosis tends to run in families. Clinicians theorize the condition occurs when endometrial cells are carried outside the uterus during menstruation and implant and grow where they shouldn’t (12).
Having endometriosis does not necessarily mean that you are infertile. It is estimated that 60-70% of women with endometriosis are fertile, and about half who struggle to get pregnant do go on to conceive with or without treatment (20).
Symptoms: Common symptoms include heavy and painful periods or pain during intercourse, however, not all women experience symptoms (17). Research suggests it can take 7 years, on average, for a woman to be diagnosed with endometriosis (20).
Treatment: Endometriosis can only be diagnosed by laparoscopy, a surgical procedure using a lighted tube to check for any visible implants and adhesions. Treatment is based on the severity of the condition and other factors. Medications, such as gonadotropin-releasing hormone agonists, may prevent new growths but don’t remove implants that are already there; surgery is recommended to remove implants and reopen blocked tubes (17).
Tubal Factor Infertility
If you find that your partner's sperm is ok and you are ovulating regularly and still not getting pregnant, your doctor may suggest checking that your tubes are open and that your uterus is healthy. Tubal disease accounts for 25%–35% of female factor infertility, and among those cases, 10-20% are due to tubal blockage (21).
Causes: Tubes can be blocked due to a history of sexually transmitted infections (STIs), endometriosis, or scar tissue that forms after pelvic surgery (19). Two STIs in particular, gonorrhea and chlamydia, are the main causes of pelvic inflammatory disease (PID), which can result in scarring that blocks your fallopian tubes (22). PID leads to infertility in 10% of women with the disease (22).
Symptoms: Trying to get pregnant for months without conceiving may be the only sign your tubes are blocked. However, if you have PID, you may experience various symptoms, including unusual vaginal discharge, pain, irregular periods, fever or chills, or pain during sex (22).
Treatment:To find out if your tubes are blocked, your doctor will perform a hysterosalpingogram, a special type of X-ray procedure in which a dye or contrast material is administered through a thin tube into the vagina and uterus (2). The procedure can show injury and abnormalities of the uterus and fallopian tubes (23). If it shows a blockage, your egg cannot travel from the fallopian tube to the uterus. This can lead to an ectopic pregnancy or prevent the sperm from fertilizing the egg (24). This procedure can also detect if there are any problems in the uterus that would prevent implantation of the fertilized egg (25). If there is a blockage or significant damage, treatment typically involves IVF (21).
Age (or Egg Factor)
While many women are able to conceive naturally without problems into their late 30s, age is the most important factor for women in regards to being able to conceive and have a healthy child. Fertility starts to decline gradually but significantly around age 32 and then more rapidly declines after 37 years of age, and unfortunately, age and egg quality cannot be treated (26).
Causes: Aging affects both the number and quality of eggs (26). A female is born with approximately 1–2 million oocytes, but that figure drops to 25,000 by age 37 (26). Egg loss accelerates with cigarette smoking, radiation, chemotherapy, and autoimmune conditions (19).
While there are tests to check on your ovarian reserve, there is no test for the quality of the eggs (source).
Treatment: You can't stop the continual loss of eggs but you can try to be as healthy as possible. Some examples include losing weight, managing any hormonal or thyroid issues, and taking r-alpha lipoic acid (ALA) and CoQ10, which may reduce egg abnormalities and lower the risk of trisomy (17). (More on a healthy diet below.)
In terms of medical treatments, IVF can be successful even for women in their late 30s to early 40s. The percentage of live births after a single IVF cycle was 31.9% in women aged 35–37, 22.1% among women aged 38–40, and 12.4% in women aged 41–42 (16).
If you have no or little eggs left and the statistical chance of conception is low even using IVF, some women opt to use a donor egg and others opt to adopt (27).
Timing Intercourse Incorrectly
Dr. Aptekar says the number one reason his patients have a difficult time conceiving is that they 1) have not waited long enough and 2) are mistiming intercourse. Charting your menstrual cycle may help you estimate your fertile window, but check out the Priya Personal Fertility System to effortlessly pinpoint your most fertile days.
Causes: You are able to conceive about 6 days per month — the 5 days before ovulation and ovulation day itself (28). The fertile window is influenced by individual factors, including the life cycle of the egg and sperm, and the presence of fertile cervical mucus (CM) (28). Sperm, for example, may live 3-5 days in fertile CM or die within hours in “hostile” CM. The egg has only 12-24 hours to be fertilized before it disintegrates (28).
Having intercourse two days before you ovulate will significantly increase your chances of getting pregnant (29). As you can see in the graph, the day after you ovulate has a 0% chance of getting pregnant (30).
Treatment: Treating this issue is as simple as tracking the fertility cues that help identify your fertile window. There are several techniques to determine your fertile window.
- Use a product to find your fertile days and when you ovulate that uses your own biological clues (such as a temperature sensor, luteinizing hormone (LH) sticks that measure LH levels from urine, or saliva tests that measure your estrogen levels). These kits generally detect a surge of LH that happens 24-48 hours prior to ovulation (31), however, these kits may provide misleading results. Read more about that here.
- Use a calendar or app like Kindara to track your cycle length in conjunction with using other methods. Since timing is everything, keeping track of when your period will start and the length of your cycle will help to get the timing right.
- Learn about your cervical mucus and watch for when it is clear and slippery, which indicates that you are fertile (32).
- If waking up at the same time each morning does not seem too daunting, you may want to track your basal body temperature (BBT) to confirm the day you ovulate retrospectively. A rise in temperature of 0.5–1.0°F indicates that you ovulated (33).
- Tracking continuous core body temperature is the most accurate and effortless way to identify when you ovulate (34). Read more about how Priya uses CCBT to pinpoint your fertile window here.
Other Factors Affecting Female Fertility
Stress: Several studies have suggested that stress is associated with infertility, but no study to date has clearly shown that reducing stress before infertility treatment improves pregnancy rates (35).
Shift work: One large study found shift work didn’t make women less fertile (36). However, another paper found that shift work may lead to menstrual cycles that are shorter, longer, or irregular (37). Shift work can also make capturing BBT difficult, in which case continuous core body temperature may be beneficial.
Alcohol: Although research is mixed on the effects of alcohol on female fertility, most observational studies show that moderate and heavy drinkers take longer to conceive and are more likely to require an infertility evaluation (35).
Caffeine: Research suggests that women can drink one or two 6- to 8-ounce cups of coffee per day without affecting their fertility (35).
Environmental factors: Exposure to pollutants and toxins, such as pesticides, dry cleaning solvents, and heavy metals may affect women’s fertility and the health of their pregnancies (35).
Sleep: Research suggests that sleeping poorly at night is significantly associated with a diminished ovarian reserve (38).
Nutrition: Research has consistently shown that consuming a healthy diet is linked to better fertility and higher live birth rates among couples receiving fertility assistance (39). Furthermore, women who adhered to a Mediterranean diet had higher odds of pregnancy (40). The diet emphasizes vegetables, vegetable oils, fish, and legumes, and includes very few snacks (40). Making healthy changes in your diet and lifestyle also helped prevent infertility caused by ovulatory disorders (41).
If you are under 35 years of age, your doctor will recommend trying for up to a year before extensive fertility testing. If you are over 35 years of age, doctors recommend waiting only 6 months (2). While you are trying, you can learn more about your cycle simply by downloading a free app like Kindara and inputting the start and end dates of your period. You can also make healthy lifestyle changes that will not only help you conceive but also support a healthy pregnancy.
Anytime you have a question or concern, even if it is before the recommended wait time, feel free to talk to your doctor.
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- Kuohung, W., Hornstein, M. (2020). Treatments for female infertility. UpToDate.
- American College of Obstetricians and Gynecologists. (2017). Polycystic Ovary Syndrome (PCOS).
- Katsiki, N., & Hatzitolios, A. I. (2010). Insulin-sensitizing agents in the treatment of polycystic ovary syndrome: an update. Current Opinion in Obstetrics and Gynecology, 22(6), 466-476.
- Barbieri, R., Ehrmann, D. (2018). Diagnosis of polycystic ovary syndrome in adults. UpToDate.
- Houjeghani, S., Gargari, B. P., & Farzadi, L. (2012). Serum leptin and ghrelin levels in women with polycystic ovary syndrome: correlation with anthropometric, metabolic, and endocrine parameters. International journal of fertility & sterility, 6(2), 117.
- van der Linden, M., Buckingham, K., Farquhar, C., Kremer, J. A., & Metwally, M. (2015). Luteal phase support for assisted reproduction cycles. Cochrane Database of Systematic Reviews, (7).
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- Crawford, N. M., Chantala, K., & Steiner, A. (2015). Impact of short luteal phase on natural fertility. Fertility and Sterility, 104(3), e344.
- Bienkowski, B. (2016). Undergoing Fertility Treatment? Watch Your Plastics. Scientific American.
- Ziv-Gal, A., & Flaws, J. A. (2016). Evidence for bisphenol A-induced female infertility: a review (2007–2016). Fertility and sterility, 106(4), 827-856.
- The Fertility Society of Australia. (n.d.). How to avoid chemicals that can reduce fertility.
- Green, M. (2017). The Household Chemicals Affecting Your Fertility. The University of Melbourne, Pursuit.
- Tulandi, T., Al-Fozan, H. (2020). Management of couples with recurrent pregnancy loss. UpToDate.
- American College of Obstetricians and Gynecologists. (2019). Endometriosis.
- Liu, J. (2019). Endometriosis. Merck Manual, Professional Version.
- Kuohung, W., Hornstein, M. (2020). Causes of female infertility. UpToDate.
- Wood, R., Guidone, H., Hummelshoj, L. (n.d.). Myths and misconceptions in endometriosis. Endometriosis.org.
- Practice Committee of the American Society for Reproductive Medicine. (2015). Role of tubal surgery in the era of assisted reproductive technology: a committee opinion.
- American College of Obstetricians and Gynecologists. (2019). Pelvic Inflammatory Disease.
- American Society for Reproductive Medicine. (2015). Hysterosalpingogram (HSG). Reproductive Facts.org.
- Mayo Clinic. (2019). Female infertility, symptoms and causes.
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- No, C. O. (2014). Female age-related fertility decline. Fertility and Sterility, 101(3), 633-634.
- Macmillan, C. (2018). Women, How Good Are Your Eggs? Yale Medicine.
- Mu, Q., Fehring, R. (2014). Efficacy of Achieving Pregnancy with Fertility-Focused Intercourse. Marquette University, College of Nursing Faculty Research and Publications.
- Dunson, D. B., Baird, D. D., Wilcox, A. J., & Weinberg, C. R. (1999). Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation. Human Reproduction, 14(7), 1835-1839.
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- American Pregnancy Association. Ovulation Kits And Fertility Monitors.
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- Su, H. W., Yi, Y. C., Wei, T. Y., Chang, T. C., & Cheng, C. M. (2017). Detection of ovulation, a review of currently available methods. Bioengineering & translational medicine, 2(3), 238-246.
- Papaioannou, S., Aslam, M., Al Wattar, B. H., Milnes, R. C., & Knowles, T. G. (2013). User's acceptability of OvuSense: A novel vaginal temperature sensor for prediction of the fertile period. Journal of Obstetrics and Gynaecology, 33(7), 705-709.
- Hornstein, M., Gibbons, W., Schenken, R. (2019). Optimizing natural fertility in couples planning pregnancy. UpToDate.
- Willis, S. K., Hatch, E. E., Wesselink, A. K., Rothman, K. J., Mikkelsen, E. M., & Wise, L. A. (2019). Female sleep patterns, shift work, and fecundability in a North American preconception cohort study. Fertility and sterility, 111(6), 1201-1210.
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