Infertility: Symptoms, Causes, and Treatment Options

The basics

Infertility is a medical term that describes when you’re unable to get pregnant despite having unprotected sex for 12 months. The term infertility brings up a lot of emotions and reactions. But it’s important to remember that infertility, like many things, exists on a spectrum. Some people have subfertility — meaning they’re less likely to have a baby than others. Other people might be unable to conceive even with medical help. One term simply can’t describe a vast array of experiences, that’s why we only use the term as needed to describe medical situations. 

Dealing with this issue can be overwhelming. Alongside emotional effects, you need to navigate a complex and specialized medical world. This comes with its own language and a dizzying array of abbreviations, which can make you feel lost and confused. So learning these medical terms will help you actively engage with your treatment team and let you speak the same language.

What’s more, there’s so much information and misinformation around fertility that it can be hard to tell what’s true. In this guide we’ll cover the basics — including symptoms, causes, and treatment options — so you can start your journey with facts in hand. 

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When to worry about fertility

For many people, the journey starts with a simple question: “Should I be worried?” Some people get pregnant right away, but for others it takes several months. Both are “normal,” but each month brings that nagging worry that something could be wrong. Knowing when to seek help is important. You don’t want to wait too long, but you also don’t want to start down a potentially difficult path before you need to. 

Studies from male-female couples show that:

• Among people trying to get pregnant, 80% to 90% will get pregnant within 1 year.

• Another 5% to 15% who don’t get pregnant within 1 year go on to get pregnant within the next 12 months without any treatment.

Based on this information, most experts suggest that females should see a specialist if they haven’t been able to get pregnant: 

• After 12 months if the female is younger than 35 years old

• After 6 months if the female is 35 years old or older

Currently, there’s no recommendation that’s similar to this for males.

What causes infertility?

In medical terms, there are four main categories or causes:

1) Female factor infertility: This is infertility caused by issues with eggs, menstruation, and female sex organs. Age and hormones can contribute to female factor infertility. 

2) Male factor infertility: This is infertility caused by issues with sperm and male sex organs. Age and hormones can contribute to male factor infertility. 

3) Combination infertility: This is infertility caused by a combination of male and female factors. 

4) Unexplained infertility: In 15% to 28% of people, the cause of infertility is never found. 

Let’s take a look at female and male factor infertility more closely. 

Female factor infertility

To help understand how each issue can affect fertility, it’s helpful to review a few facts about human reproduction. In order for a person to become pregnant, a sperm cell has to reach an egg cell. 

Typically, a female produces a mature egg every month as part of the menstrual cycle. Hormones control this process. The mature egg is released from the ovary and passes through the fallopian tube. The sperm fertilizes the egg, and the resulting embryo implants into the uterus. In female factor infertility, something interferes with the process at one or more of these steps.

Let’s review each possibility, and remember that it’s possible for someone to have more than one of these conditions. 

• Ovulatory dysfunction: This is when a mature egg isn’t produced during a menstrual cycle. One sign of ovulatory dysfunction is irregular periods. People with medical conditions like polycystic ovarian syndrome (PCOS), hypothyroidism, pituitary dysfunction, and obesity can have ovulatory dysfunction. It’s one of the major causes of female factor infertility. 

• Diminished ovarian reserve: This can be considered a type of ovulatory dysfunction. It’s a medical term that describes the fact that it’s harder to get pregnant as you get older. With age, the number of eggs stored in the ovaries decreases. Females are born with millions of eggs but only have 300,000 left by the time they’re 30 years old. The number of eggs drops very fast each year after that. The quality of the eggs also decreases. This makes it more likely that a mature egg won’t be released during each menstrual cycle.

• Tubal damage: The fallopian tubes carry the egg from the ovary and deliver the early embryo to the uterus. If the tubes are blocked or damaged, then fertility is affected. The most common reason for fallopian tubes to have a blockage is pelvic inflammatory disease (PID). Endometriosis or internal scarring (adhesions) from prior surgeries can also cause blockages. Some people are born without fully developed fallopian tubes — though this isn’t as common as the other causes. 

• Uterine and cervical factors: Things like endometriosis and uterine fibroids can affect fertility. Some people are born with different shapes of the uterus and cervix, which can also affect fertility. Uterine and cervical issues are the least common causes of female factor infertility. 

Male factor infertility 

A lot of attention is often focused on female factor infertility. But male factor infertility affects 40% to 50% of male-female couples seeking fertility treatment.

To understand the causes of male factor infertility, it’ll help to review a few more reproductive facts. New sperm is made constantly in the testicles and matures in the epididymis. This process is controlled by hormones. When it’s time to ejaculate, millions of sperm cells travel through the vas deferens and out of the urethra. On the way, the seminal vesicles add fluid to make semen. Sperm then moves through the female’s sex organs to reach an egg.

Male factor infertility usually comes from an issue with: 

• Making sperm: Some people do not produce the hormones necessary for sperm production. Others may not be able to produce sperm because their testicles don’t make sperm — this can happen with certain medical conditions or after exposure to certain medications or toxins.

• Sperm count and quality: The most common cause of male factor infertility is problems with sperm function. Some people are able to make sperm, but they might make less sperm than usual — this is called low sperm count. Some people make sperm that doesn’t move or function properly — this is called low sperm quality. All of these things make it less likely that sperm will successfully reach an egg. Low sperm count and low sperm quality are found in most cases of male factor infertility. 

• Sperm transport: A blockage in the epididymis, vas deferens, or ejaculatory ducts can cause male factor infertility because the sperm can’t leave the body. 

How common is infertility?

Difficulty getting pregnant is actually very common. Here are some facts:

• Among male-female couples, 10% to 15% have trouble conceiving.

• Among males, 10% to 15% have problems with fertility.

• Among females between 35 to 39 years old, 25% have problems with fertility. That number increases to 30% for females between 40 to 44 years old.

If you’re having trouble with fertility, you’re not alone. It can be hard to reach out at first, but you might discover that many people you know have been on this journey. Having a support system can help you through the highs and lows of treatment.

How is infertility diagnosed?

Infertility is diagnosed using several kinds of tests. Some OB-GYNs can start an evaluation, but often you’ll need to see a reproductive endocrinologist or a reproductive urologist — doctors who specialize in fertility treatments. 

The doctor will also ask you some basic questions and do a physical exam and then order specific tests.

Tests for females often include:

• Blood work to look at hormone levels

• Ultrasound of the ovaries

• Hysterosalpingogram — an imaging test that shows the basic shape of the uterus and cervix and looks at the fallopian tubes to make sure they aren’t blocked

Tests for males usually include:

• Semen analysis

• Blood work to look at hormone levels

Depending on the results of these initial tests, more specialized tests may be needed. 

An important thing to keep in mind is that this process takes time. Many of these tests need to be done on specific days during your menstrual cycle. Males may need to give more than one sample of sperm for analysis. The samples usually have to be given at least a week apart. The time spent on the diagnosis process can start to add up quickly, and time is important when it comes to fertility. If you’re worried about your fertility, don’t wait to see a healthcare provider.

How do I access care?

The first step in treatment is to find a fertility center that’s right for you. Centers will have all the healthcare specialists you’ll need during your journey. They’ll also have resources like mental health specialists and support groups. Many centers even have their own acupuncturists, fertility nutritionists, and coaches. 

You want to find a center with experience that is specific to your situation. It’s also important to look at success rates while picking a center — usually this is reported as in vitro fertilization (IVF) success rates. The Society for Assisted Reproductive Technology clinic finder is a great resource. Not only do they provide up-to-date information, but the centers they include have passed rigorous safety and quality checks. The centers also have to keep all their certifications current in order to be included. 

You may have heard that treatment comes with a hefty price tag. Treatment is expensive — especially if you need more advanced techniques like IVF. Some commercial insurances cover treatment — though deductibles and out-of-pocket maximums will still apply. The Resolve Toolkit can help you tackle what your insurance coverage includes. You can use funds from a health savings account (HSA) and flexible spending account (FSA) to cover many costs related to treatment. 

If you don’t have insurance coverage, or if you’re underinsured, many centers offer cost-savings programs. These programs are usually based on your income and may include more than one cycle. Most fertility centers have people whose job is to handle insurance claims and affordability concerns. These individuals are a great resource in navigating treatment costs.  

How is infertility treated?

Once you’ve found a fertility center and had your initial evaluation, you and your team will come up with a treatment plan. 

There’s no one-size-fits-all approach to treatment. Your treatment will depend on many things, including what’s affecting your fertility and what you think the best approach is. Some people aren’t comfortable with all the options available through assisted reproductive technology (ART) — and that’s OK. 

Types of assisted reproductive technology

Before going into ART options — let’s take a look at what each type means:

• Intrauterine insemination (IUI): During IUI, a small tube, called a catheter, is inserted into the vagina, past the cervix and into the uterus. Sperm is then injected through the tube and into the uterus. The sperm will swim up the uterus into the fallopian tubes and hopefully fertilize an egg.

• In vitro fertilization (IVF): IVF describes the entire IVF cycle. But originally the term described just the laboratory process of mixing sperm with eggs. In IVF, the female’s egg is placed into a container with sperm. The sperm are allowed to enter the eggs on their own — hopefully forming an embryo.

• Intracytoplasmic sperm injection (ICSI): ICSI is a newer ART that’s used in cases of severe male factor infertility. With ICSI the female’s eggs are retrieved, just like in IVF, but a sperm cell is injected directly into each egg. This is helpful in cases where sperm may not move well and can’t make it into the egg on their own. 

Treatment for female factor infertility

Treatment is highly personalized and based on data from national trials. Fertility centers have data to guide the types of treatments and how to start, change, and adjust medication doses. Treatment can also be adjusted based on your body’s response. While it’s not possible to go over every type of treatment, here is a basic treatment overview:

• Ovulatory dysfunction and diminished ovarian reserve: Treatment for these conditions involves medications to help the ovaries produce mature eggs — this is called ovulation induction. These medications might be given by mouth or by injection. Often ovulation induction is enough for many females to get pregnant. Some females may need ovulation induction along with IUI or as part of IVF. People who don’t make eggs or don’t respond to ovulation induction may need to consider egg donation. 

• Tubal damage: IVF with ovulation induction is the recommended treatment for females with tubal damage. Females with tubal damage on just one side may be offered IUI, with or without ovulation induction. In very specific situations, surgery can be done to try and open the tubes, but success rates are low and complication rates can be high. 

• Uterine and cervical factors: Treatment for most uterine and cervical issues includes ovulation induction with IUI or IVF. Surgery is sometimes recommended to remove endometriosis, uterine polyps, and fibroids. 

Treatment for male factor infertility

In general, the treatment for male factor infertility is sperm retrieval using special types of surgery that remove sperm from the tesicles. Once the sperm is removed, it’s added to an egg using IVF or ICSI.

In very specific cases, males can be treated with hormone therapy or surgery. But even in these cases IVF is often needed. 

Males who do not make sperm and males who do not have successful sperm retrievals may need to consider sperm donation. 

Unexplained infertility

Most centers treat unexplained infertility using the same principle — try the simplest methods first and go from there. The step-wise approach most centers use is:

• Timed intercourse using an ovulation tracker

• Timed intercourse using ovulation induction medications

• Ovulation induction medications and IUI

• Ovulation induction medications and IVF

Typically, you’ll be asked to try each step for 3 to 4 cycles before moving on to the next step.

Can lifestyle changes improve fertility?

Going through treatment comes with a lot of uncertainty. There is data that can help determine your chances of getting pregnant. But in the end, no calculator can tell you for sure if your cycle will be successful or not. It’s natural to want to do everything you can to improve your chances of conceiving. There are some things you can do to help improve your fertility, but keep in mind that the evidence for some of these things is only moderate at best.

Weight modification

There is evidence that a body mass index (BMI) of less than 17 leads to ovulation dysfunction. Gaining weight can help restore normal ovulation patterns — but it’s important to discuss this with a healthcare provider to develop a healthy approach.

For females with a BMI higher than 27, there’s some evidence that losing weight can restore normal ovulation patterns. In one small study, some females with obesity and PCOS who lost 5% to 10% of their body weight had a return of normal ovulation patterns within 6 months. Many studies are small, so it’s hard to make generalized recommendations regarding weight loss.

Smoking

Smoking decreases both female and male fertility. It also can cause erectile dysfunction and pregnancy complications. Fertility specialists recommend that anyone trying to get pregnant stop smoking.  

Caffeine intake

There’s some evidence that excessive caffeine intake can affect female fertility. Some studies recommend that females stick to 250 mg of caffeine per day — which is about 2 cups of coffee. 

Alcohol intake

Studies also show that heavy alcohol use in males can decrease sperm counts and quality. Studies are less clear about the effects of moderate to heavy alcohol on female fertility. 

Alcohol use in moderation does not appear to affect IVF success rates. Some studies recommend that females keep alcohol intake to 4 drinks per week during the early parts of fertility treatment.

Diet

Small studies also show a diet low in trans fat and high in fruits and vegetables can help increase fertility. There are also some studies showing that Mediterranean diets help increase success rates of IVF. 

Removing gluten from the diet increases fertility only in cases where people have celiac disease.

Supplements

Combination supplements that are sold as fertility enhancers do not have any data to show that they actually increase male or female fertility. 

Fish oil is a popular supplement to increase male fertility, but data on effectiveness is mixed. Some small studies show co-enzyme Q10, L-carnitine, zinc, and folate may increase male and female fertility. 

Stress

Stress does not cause infertility. But infertility causes stress. 

It’s important to take care of your mental health. It’s common to go through periods of sadness, anger, and anxiety. This experience can make you feel isolated from your friends, family, and even your partner. Taking care of your mental health is one of the most important things you can do during this time. 

Keep in mind

This journey is different for everyone. It’s impossible to cover every unique situation in a short article. Your specific situation may not be covered here, but there are resources available to help. Connecting with an experienced fertility center is the best first step in your journey.

Why trust our experts?

Written by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

Reviewed by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. An experienced and dedicated pulmonologist and hospitalist, she spent a decade practicing and teaching clinical medicine at academic hospitals throughout London before transitioning to a career in health education and health technology.

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