Female Infertility: Causes, Risk Factors, & Treatment Options

An Overview of Infertility & Fertility

Before we dive deep into the causes of female infertility, it’s important to take a step back and remind ourselves what exactly infertility is and the key component of fertility.

An Overview of Infertility

• Infertility is most often defined as the inability to get pregnant after one year of frequent unprotected intercourse when the female is under 35 and 6 months if the female is over 35. It is less time for those over 35 as it is more critical that they seek care sooner due to age being a significant factor in female infertility (more on that later).
• Infertility could be diagnosed sooner than that by a fertility specialist or there could be other reasons for needing fertility treatments like being single or part of the LGBTQ community.
• Infertility affects roughly 12% percent of couples of reproductive age.
• Female infertility is solely responsible for approximately 1./3 of all cases of infertility.  Male factor infertility similarly accounts for approximately 1/3 of all cases. A combination of male and female factors account for the final third.
• Infertility can be difficult to diagnose with modern testing capabilities. Approximately 1/3 of cases are defined as unexplained infertility.

An Overview of Fertility

To understand how a healthy pregnancy is achieved, it’s important to understand the key components and the steps that must happen.

Key Components:

• Healthy Egg & Ovulate: In order to get pregnant, your ovaries must produce and release an egg.
• Healthy Sperm in Ejaculate: Healthy motile sperm must be present in the ejaculated semen.
• Properly Timed Intercourse: Eggs are only at their height of maturity for a few days and can only be fertilized within this window of time. Intercourse must take place right before or during this time.
• Healthy & Patent Tubes: An egg is usually fertilized in the fallopian tubes. In order for there sperm and egg to travel the tubes and meet, the tubes must be healthy and open.
• Healthy Uterus: The embryo needs a healthy uterus to grow inside of.
• Healthy Mother: Pregnancy requires a great deal of coordination and effort. Though this often “runs” in the background, a woman’s overall health and immune system play a great deal in the ability to carry a pregnancy to term.

Key Steps:

• Eggs and Sperm develop properly without major genetic abnormalities.
• One of the ovaries releases a mature egg.
• The egg is picked up by the fimbria and enter the fallopian tube.
• Sperm swim through the cervix and uterus and into the fallopian tube.
• The sperm and egg meet and fertilize.
• The fertilized egg travels back down the fallopian tube to the uterus.
• The fertilized egg implants and continues to thrive in the uterus.

What Causes Female Infertility?

There are numerous causes of female infertility including egg and ovulatory issues, tubal damage, uterine and cervical abnormalities, endometriosis, genetics, inflammation and immunological issues, and age. If no cause can be determined in either male or female partner, one may be diagnosed with unexplained infertility.

Egg & Ovulatory Causes of Female Infertility:

Female infertility is often caused by something that disrupts the production or ovulation of healthy eggs. Some of the most common disorders involving egg and ovulation issues include:

PCOS

One of the leading causes of infertility in women is PCOS. Approximately 8% of women are affected by PCOS. It causes higher than normal levels of androgens, or “male” hormones, that can result in irregular ovulation or no ovulation at all. Women with PCOS may have enlarged ovaries covered with tiny, fluid-filled cysts.

Fortunately, there are many solutions to getting pregnant with pcos.

Diminished Ovarian Reserve (DOR):

Diminished ovarian reserve is a condition in which the ovary loses its normal reproductive potential, often causing female infertility. The condition may result from disease, injury, or life saving treatments like chemotherapy, but most commonly occurs as a result of normal aging. As women age, their ovarian reserve and egg quality begin to decline, affecting embryo quality and the likelihood of getting and staying pregnant.

Diminshed ovarian reserve is present in approximately 10-30% of cases presenting to a fertility clinic.

Hypothalamic Dysfunction:

Two hormones are largely responsible for stimulating egg development and ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

Excess stress (physical/exercise or emotional), a very high or very low body weight, or a recent substantial weight change can disrupt the production of these hormones.

Thyroid Problems

Hypothyroidism may cause infertility in women through the effects of thyroid hormones on ovulation. In addition, some of the underlying causes of hypothyroidism, autoimmune or pituitary disorders for instance, may impair fertility as well.

Pituitary & Prolactin Levels

High levels of prolactin (hyperprolactinemia) reduce estrogen levels which may cause infertility. Usually caused by pituitary disorders, high levels of prolactin may also be caused by certain medications.

Tubal Factor Infertility

Tubal infertility occurs when a blockage (either fully or partially – often by scar tissue narrowing the tube) in one of both fallopian tubes will not allow the egg and sperm to meet. Tubal infertility causes about 25% of female infertility issues .

There are a number of causes for tubal factor infertility including infections (often from sexually transmitted diseases like Chlamydia and gonorrhea), endometriosis, and abdominal surgeries.

Pelvic Inflammatory Disease (PID) may also cause the inner lining, the opening of the tubes, and the outside of the tubes of the tubes to become permanently scarred.

Uterine & Cervical abnormalities

Congenital Uterine & Cervical Abnormalities

Some women are born with congenital anomalies like a misshapen uterus or cervix. The most common uterine anomalies include a septate uterus, where the uterus is separated into two halves by a band of tissue, a bicornuate uterus, commonly referred to as a heart-shaped uterus, or a unicornuate uterus, where the uterus is horn-shaped and smaller than normal which increases the risk of miscarriage, ectopic pregnancy, and pre-term delivery.  Exposure to certain drugs before birth, such as DES, may also cause deformities of the uterus, resulting in infertility.

Fibroids

Uterine fibroids are tumors that can grow in the uterus usually as a result of excess estrogen. They can change the shape of the uterus and interfere with conception.  Approximately 30-50% of women have uterine fibroids. Fibroids usually develop in adulthood. Depending on the type of fibroid and its location within the uterus, it can lead to miscarriage.  Fibroids that lie closer to the middle of the uterus are also more concerning, as well as those that are larger in diameter.

Polyps

Uterine polyps can cause problems with fertility and/or increase the risk of miscarriage. A “normal” uterine cavity and endometrial lining is needed to conceive and maintain pregnancy.  A polyp is an overgrowth of normal tissue in the lining (endometrium) of the uterus. Most polyps are small (a few millimeters in diameter) and do not negatively affect reproductive capabilities. However, large or multiple polyps can cause infertility or increase the risk of miscarriage.

Cervical stenosis

Cervical stenosis is a narrowing of the cervix that can be caused by genetics or damage to the cervix.

Abnormal Cervical Mucus

This may affect the movement of sperm through the vagina and cervix. Antibodies to sperm present in a woman’s cervical mucus may kill the sperm or affect their ability to move normally.

Endometriosis

Endometriosis is a common condition in which the lining of the uterus begins to invade other organs, including the pelvis, ovaries, and bowels. Endometriosis can obstruct the fallopian tubes and keep egg and sperm from meeting, but it can also affect fertility in less-direct ways, such as damaging the sperm or egg.

Genetics

Some women are unable to conceive and deliver a healthy baby due to genetic factors. Sometimes this is due to an inherited chromosome abnormality. Other times it is because of a single-gene defect passed from parent to child.  Women with Turner Syndrome have trouble conceiving naturally because they are susceptible to early ovarian insufficiency.

Many women are unaware that they have the Fragile X premutation until they are trying to conceive and have difficulties.  Fragile X carriers may find that they have high FSH, low antral follicle count, and other symptoms consistent with a low ovarian reserve which make it difficult to conceive without assistance.

Immunological Problems

A problem with a woman’s immune system can lead to both a failure to conceive and pregnancy loss after conception has occurred.  To work properly, it’s critical that the body’s immune system be able to distinguish “self” from “non-self”. This function is not always failsafe, as fertility doctors have come to learn. Sometimes the immune system mounts an attack against the embryo perceiving it to be an “invader” and thus attempting to stop the growth of these cells.

In other instances, such as with autoimmune disease, the immune system recognizes “self”, but that recognition leads to inflammation, damage, and disease.

Unexplained Infertility

Try as hard as they do, sometimes reproductive endocrinologists cannot find an explanation for a couple’s inability to conceive. After a standard fertility evaluation, test results come back within normal parameters, and there’s no obvious source of trouble. Most of the tests we use are very successful at diagnosing the major causes of infertility, but less so at detecting the more subtle factors such as inadequate egg quality. The lack of answers can be very frustrating. Dr. Kiltz believes that our daily environment, the food we eat, and stress levels all play a role. Diets high in carbohydrates (and low in fat, which is healing and reduces inflammation) have led to obesity and a skyrocketing number of autoimmune disorders. All of this leads to chronic inflammation that is likely a major source of fertility complications.

Even when we don’t have answers to all of the questions, there are steps we can take to optimize a woman’s body and mind for successful pregnancy. Not all of them require surgery or expensive medications.  CNY Fertility is a great resource for information on improving your fertility through diet, supplements, and lifestyle changes that can help increase your odds of conceiving naturally or with assistance. It is also the most affordable fertility center in the nation. If you’re having trouble getting or staying pregnant, contact CNY Fertility to schedule your consultation.

Risk Factors

There are a number of  factors that may put you at higher risk of infertility:

Age

The quality and quantity of a woman’s eggs declines with the increase of age. The rate of decline generally speeds up rapidly in the mid thirties resulting in fewer and poorer quality eggs which result in poorer quality embryos. Poorer quality embryos have lower chances of implantation and higher odds of resulting in miscarriage.

Smoking

Smoking results in cervix and fallopian tube damage increasing the risk of miscarriage and ectopic pregnancy.  Smoking is also thought to contribute to poor egg quality and diminished ovarian reserve.

Weight & Diet

Being significantly over or underweight may affect ovulation. Similarly, a diet high in carbohydrates (the standard American diet) is highly inflammatory and may lead to infertility. Getting to a healthy body mass index (BMI) or reducing the underlying inflammation of a poor diet through a high fat diet may increase the frequency of ovulation and likelihood of pregnancy.

Sexual Transmitted Infections

Infections like chlamydia and gonorrhea can damage the fallopian tubes and lead to infertility.

Alcohol

Excessive alcohol consumption may lead to female infertility.

Treatment Options

There is a vast range of treatments available to help treat infertility including. While there is a general progression of fertility treatments from the less invasive to the more invasive, it’s important to have both male and female fertility testing complete and a consultation with a fertility specialist in order to determine the right treatment for you. Here are some of the most common treatments:

Ovulation Induction

Ovulation induction is an introductory treatment combined with either timed intercourse or intauterine insemination (IUI) that is particularly helpful for those suffering from ovulatory infertility.

IUI

Commonly referred to as artificial insemination, an intrauterine insemination is a simple procedure in which sperm is collected, concentrated, and deposited into a woman’s uterus. It is perhaps the most common starting place for patients entering a fertility clinic.

IVF

In Vitro Fertilization or IVF is the process of removing eggs from a female’s ovaries and fertilizing them with sperm in a petri dish, growing the embryos in a lab, and subsequently transfering the embryos back into the female’s uterus.

IVF is the gold standard of fertility medicine offering the highest odds of success.

Donor Egg IVF

Donor Egg IVF is IVF that uses another woman eggs. Typically it is done by those who have failed multiple IVF cycles, diminished ovarian reserve, or who otherwise can’t use their own eggs.

Reproductive Immunology

Reproductive Immunology is uses a number of immunological medications to treat those with Repetitive IVF Implantation Failures or Recurrent Pregnancy Loss.

Many treatments are being utilized in the field of reproductive medicine to reduce inflammation and suppress the immune system to support successful pregnancy outcomes. CNY Fertility recommends a multi-pronged approach that incorporates dietary changes, nutritional supplements, pharmacological immunology, mind-body and “eastern” therapies, along with surgical interventions.

Surgical Interventions

Surgical interventions like laparoscopy & hysteroscopy can be done to diagnose and correct many of the anatomical issues affecting the tubes and uterus.

Gestational Surrogacy

Surrogacy involves another woman other than the intended parent carry the pregnancy. It is helpful for those who can not carry a pregnancy on their own.