Female Infertility: Symptoms, Causes & Diagnosis

Female Infertility

The inability to conceive a child can be stressful and frustrating, and although infertility affects almost 6.7 million couples in the United States (a staggering 10-11% of reproductive-aged couples in the United States), it is highly treatable in many cases.^[1][2]

The highly specialized field of female fertility involves a wide range of medical, environmental, and lifestyle causes which also includes many very specific risk factors.^[3] However, now that the genetic causes of female infertility are more commonly diagnosed, and several female infertility treatments are readily available, couples having difficulty conceiving or carrying to term, can often have success with the use of fertility medications.^[4]

Infertility is defined as a couple’s inability to conceive a child even though they’ve had frequent, unprotected sexual intercourse for a year or longer.^[5] According to the Mayo Clinic, infertility results from male infertility factors about one-third of the time, female infertility factors about one-third of the time, and unknown or a combination of male and female factors about one-third of the time.^[4]

Female Infertility Symptoms

As would be expected the main symptom of infertility (male or female) is the inability to conceive. However, if you are a woman aged 30 or older, who has had unprotected intercourse for six months to a year without getting pregnant, you should have an infertility evaluation. Other symptoms may include:^[6]

an absent menstrual cycle indicating lack of ovulation an irregular menstrual cycle that’s too long (35 days or more) or too short (less than 21 days)

• • an absent menstrual cycle indicating lack of ovulation an irregular menstrual cycle that’s too long (35 days or more) or too short (less than 21 days)
  • an abnormal menstrual cycle that’s heavier or lighter than usual
  • history of irregular or painful periods, or pelvic inflammatory disease
  • repeated miscarriages
  • prior cancer treatment
  • endometriosis

Most physicians agree that when you seek medical attention should be age-dependent, and that if you’re:^[7]

• • in your early 30s or younger, try to get pregnant for at least a year
  • between 35 and 40, six months of trying
  • if you’re older than 40, a couple of months

Understanding Female Infertility

Prior to discussing the causes of infertility, let’s examine the complex process of fertility from the female perspective. This process begins with functioning ovaries that produce and release a healthy egg (ovulation), and regular sexual intercourse during your fertile time. Then for pregnancy to occur, every step in the complex human reproduction process has to be just right:^[8]

• • one of the two ovaries releases a mature egg
  • the egg is picked up by the fallopian tube
  • sperm swim up the cervix, through the uterus and into the fallopian tube to reach the egg for fertilization
  • the fertilized egg travels down the fallopian tube to the uterus
  • the fertilized egg implants and grows within the uterus

Female Infertility Causes

As you can imagine a number of female factors can disrupt any step of this process, and female infertility may be caused by one or more disruptive factors. More specifically, infertility causes are traditionally grouped into categories among which are: ovulation disorders; damage to fallopian tubes (tubal infertility); endometriosis; and uterine or cervical causes.^{[9][10][11][12]}

Ovulation disorders represent ovulating that is infrequent or non-existent, and can be caused by flaws in the regulation of reproductive hormones, the hypothalamus, the pituitary gland, or by problems within the ovary itself. Ovulation disorders account for infertility in approximately 25% of infertile couples, and includes:^[13]

• Polycystic ovary syndrome (PCOS) – complex changes occur in the hypothalamus, pituitary gland and ovaries, resulting in a hormone imbalance, which affects ovulation; most common cause of female infertility.
• Hypothalamic dysfunction – disruption in the release of the two pituitary gland produced hormones responsible for stimulating ovulation each month, i.e., follicle-stimulating hormone (FSH) and luteinizing hormone (LH); main sign of this problem is irregular or absent periods.
• Premature ovarian insufficiency – a disorder usually caused by an autoimmune response wherein your body mistakenly attacks ovarian tissues or by the premature loss of eggs from your ovaries due to genetic problems or environmental complications like chemotherapy.
• Excessive prolactin – rarely the pituitary gland (or medication contraindications) can induce the excessive production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility.
• Damage to fallopian tubes (tubal infertility) or blockage, prevents sperm from getting to the uterus and egg for fertilization, causes include:
• Pelvic inflammatory disease – an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea, or other sexually transmitted infections.
• Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy – a fertilized egg becomes implanted and starts to develop within a fallopian tube instead of the uterus.
• Pelvic tuberculosis – a major cause of tubal infertility worldwide, although uncommon in the United States.

Endometriosis – occurs when extra tissue growth occurs within the uterus requiring surgical removal which can cause scarring that may obstruct the tube and can:

• Prevent egg fertilization
• Affect the lining of the uterus, disrupting implantation of the fertilized egg
• Affect fertility indirectly by damaging the sperm or egg

Uterine or cervical causes – can impact fertility by interfering with egg implantation or increasing the likelihood of a miscarriage through:

• Benign polyps or tumors (fibroids or myomas) are common in the uterus.^[14]
• Endometriosis scarring or inflammation.^[15]
• Uterine abnormalities present from birth, such as an abnormally shaped uterus.^[14]
• Cervical stenosis, a cervical narrowing, can be caused by an inherited malformation or damage to the cervix.^[14][16]
• Cervix inability to produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.^[15][17]
• Unexplained infertility – possible combinations of minor factors in both partners underlie unexplained fertility problems. Although it’s frustrating to not get a specific answer, this problem may correct itself with time.^[15]

Proper Diagnosis of Female Infertility

Infertility evaluations are usually scheduled with a reproductive endocrinologist, a specialist in treating conception disorders. In preparation for your appointment you should:^[18]

• Chart your menstrual cycles and associated symptoms for a few months.
• Make a list of any medications, vitamins, herbs or other supplements you take.
• Bring previous medical records.
• Think about what questions you’ll ask. List the most important questions first in case time runs out.
• Note basic information like how long have you been trying to become pregnant; intercourse frequency; gynecological conditions; number of days between menstrual cycle start dates; and types of premenstrual symptoms.

In most cases, both partners are tested and may undergo a number of varied and gender specific tests to determine the cause of infertility. Female fertility tests may include:^[19]

• • Ovulation testing with an at-home OTC ovulation a test detects the surge in luteinizing hormone (LH) that occurs before ovulation. Doctors perform blood tests for prolactin and progesterone (a hormone produced after ovulation).

• • Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) is an interuterine X-ray which looks for abnormalities.

• • Ovarian reserve testing helps determine the quality and quantity of eggs available for ovulation.

• • Other hormone testing checks levels of ovulatory hormones as well as thyroid and pituitary hormones that control reproductive processes.

• • Imaging ultrasound tests look for uterine or fallopian tube disease.

• • Laparoscopy is a minimally invasive, small incision beneath your navel for inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. May identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.

• • Genetic testing for fertility causing genetic disorders.

The Clinical Rational for Treating Female Infertility

The cause, your age, how long you’ve been infertile, and your personal preferences all largely determine how your infertility is treated. The complexities of infertility constitute significant time, psychological, physical, and financial commitments. Although some women need just one or two therapies to restore fertility, it’s possible that several different types of treatment may be needed before you’re able to conceive.

Treatments attempt to restore fertility in three primary ways:^{[20][21][22][23][24][25][26][27]}

• • Although rarely used now due to the overwhelming success rates of other fertility treatments, several surgical procedures can correct problems or otherwise improve female fertility, including laparoscopic or hysteroscopic surgery, tubal ligation reversal surgery (microscopic), and basic tubal surgeries.

• • The most commonly used method is reproductive assistance intrauterine insemination (IUI), and assisted reproductive technology also known as in vitro fertilization (IVF).

• • The primary treatment for women who are infertile due to ovulation disorders is fertility restoration, or stimulating ovulation with fertility drugs which regulate or induce ovulation. In general, they work like the natural hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), to trigger ovulation. They are also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs.