Struggling to get pregnant and wondering what's wrong? You are not alone. One in six couples is impacted by infertility. But here's the good news.If you can understand the root cause, you can meet your goal sooner. In this article, we are going to break down the top five causes of infertility in women, how they're diagnosed, and how to treat them.
1. Ovulatory Dysfunction
Ovulatory dysfunction can account for about 25 to 30 percent of infertility in women. What is that? It means not ovulating regularly. It most often shows up with irregular and unpredictable menstrual cycles.It is absolutely amazing with all the communication that happens from the pituitary gland to the ovaries and the uterus and back and forth that we have pretty predictable and regular menstrual cycles. Less than 25 percent of people actually have an exact 28-day cycle, but if you are ovulating about once a month, you get a period about once a month.
In the middle of your cycle, the body releases an egg and then the ovaries start making these hormones that help support a pregnancy if you're pregnant, but if you're not pregnant and the ovary drops its production of estragon and progesterone, that signals the shedding of the lining of the uterus and the start of a new period.
So, it is amazing and this is why people call a regular menstrual cycle a vital sign because if you're having a period about once a month, that means that you're ovulating. Not always, and of course you need to talk to your doctor about your personal situation, but typically people with ovulatory dysfunction will not have a monthly cycle. A little bit of variation is okay.Sometimes it could be a 28-day cycle, sometimes it could be a 31-day cycle, but people who are skipping cycles and say, gosh I could maybe not get a period for two or three months or I could have two episodes of bleeding in in a month, if it's not pretty regular, that is a sign of ovulatory dysfunction.
Causes of Ovulatory Dysfunction:
There are many causes of ovulatory dysfunction, so when you're thinking about a diagnosis or kind of how to figure this out, if you are not having a regular period, you probably have ovulatory dysfunction.
· The most common cause of ovulatory dysfunction is polycystic ovarian syndrome or PCOS. It impacts 1 in 10 reproductive age women. It is a metabolic disorder, shows up in many different ways.
· A cause for ovulatory dysfunction that can be kind of scary but you've got to think about it is running low on your egg supply.
· Sometimes getting close to menopause or perimenopause will start to have ovulatory dysfunction.
· And a final cause of ovulatory dysfunction is something that's really hard to nail down. It's not a very specific lab result, but it can be stress, it can be low energy supply, overexercising.
Sometimes this is called hypothalamic hypogonadism. It's sort of a diagnosis of exclusion, but you think about hormonal dysfunction, PCOS, you think about energy levels, stress, you really try to find out why someone is not ovulating regularly. And so, treatment for ovulatory dysfunction is trying to treat the cause issue, the root cause.If that still doesn't work, then sometimes doctors can prescribe medications to help patients ovulate. So, if there is no root cause or you're treating it and there's still ovulatory dysfunction, someone's not ovulating regularly, we can give medications to induce ovulation. You might've heard of Clomid or Clomiphene or Letrozole - These are pills that can help recruit an egg. And then we can trigger ovulation with another medication called a HCG or a trigger shot. It's a little subcutaneous shot.So, there are medical ways that we can induce ovulation and help time trying to improve the chances of getting pregnant and shorten the time to conceiving. Of course, there's lots of fertility treatment options, intrauterine insemination, IVF. So sometimes people will use these treatments with ovulatory dysfunction.
2. Tubal Factor
This means that the egg and sperm cannot meet each other because the tubes are blocked. It's estimated that this can account for 20 to 25% of cases of infertility in women. This can show up without symptoms.So, people might not have pain and they can have perfectly regular menstrual cycles and still have blocked fallopian tubes. So, this can be a silent cause of infertility. The way it's diagnosed is with a test.
There's a test called HSG or hysterosalpingogram, where fluid is flushed into the uterine cavity and under fluoroscopy, we watch the fluid go through the fallopian tubes. The tubes are so small and they're so delicate that you cannot see fallopian tubes on imaging like an ultrasound or an MRI. And even if you could see them, the fallopian tubes are like pipes.You can't tell if they're open or not unless you watch fluid go through the pipes.
So that's much more invasive. That's a surgery where a camera is placed through a hole right near the belly button to look into the pelvis. And you can place a tube in the cervix or the bottom of the uterus and have fluid flush into the uterine cavity and spill through the fallopian tubes.But you can watch it from above from the laparoscopy. So that is a more invasive way. But if you are doing a laparoscopy for other reasons, you could ask your pelvic surgeon, hey, can you flush the fallopian tubes and make sure that they're open? But again, an HSG or a laparoscopy are really the only ways to know that the fallopian tubes are open.
There are some other in-office procedures with saline and ultrasound that can watch fluid flush through the fallopian tubes. But traditionally, the HSG and laparoscopy are the two main ways that have been studied the most.
Treatment for tubal disease
Well, if you know exactly why the tubes are blocked, you would love to be able to fix them. So, laparoscopy might be able to identify some adhesions around the fallopian tubes that if they're lysed, it might allow the tubes to be open and flush. But honestly, fallopian tubes are so delicate that most of the time, surgical interventions do not result in success.
It can often result in more blockage of the tubes. It may be worth a try, but a lot of times people have turned to IVF as a way to treat tubal disease. That is why IVF was invented.
IVF (In Vitro Fertilization)
First baby born in 1978. Her parents had tubal dysfunction and they were unable to fix the fallopian tubes.And IVF at its core is a way for the egg and sperm to meet outside of the body in vitro means in the lab fertilization. So, get the eggs from the body, get a sperm sample, help the eggs and sperm fertilize in the lab. And when the embryo is ready, put the embryo into the uterine cavity by placing it through the cervix and into the uterine cavity.So, people can get without fallopian tubes. So, at its core, IVF was invented for tubal disease.
But, today in the 20th century IVF clinics in Bangalore use it for more than just treating the tubal factors. Dr. Kamini Rao Hospitals built to honour the 4-decade legacy of the Padma Shri Prof. Dr. Kamini A Rao, who herself has dedicated her service of treating childless couples with the blessing of carrying their children into their arms. This hospital is dedicated to IVF and other ART procedures, helping couples with their reproductive health issues. Not just conceiving, but also offering treatment for all reproductive issues one may face from Menarche to Menopause.
3. Endometriosis
Endometriosis is a chronic inflammatory condition in which tissue that looks like the uterine lining is found outside the uterine cavity and throughout the pelvis, through the abdomen, along the fallopian tubes, maybe in the ovaries and other parts of the body where this tissue really should not be. We are still learning so much about endometriosis.It's estimated that 10% of women have endometriosis. And it's estimated that if somebody is diagnosed with endometriosis 40 to 50% of the time, they will have difficulty conceiving. So not everybody with endometriosis will have infertility and not everybody with infertility will have endometriosis.
Diagnosis is tough. The only academic and researched way to definitely diagnose endometriosis is to see it. So, with a laparoscopy, again, the little camera and the belly button looking into the pelvis and finding this tissue that really shouldn't be there.That is a definitive way of diagnosing endometriosis. There are other ways to get a clue that someone may have endometriosis.
Changes in hormone levels often increase symptoms that are associated with endometriosis. And it's something that you have to ask about. It's something that you have to think about.And so many times women have just been taught time and time again to dismiss their symptoms around their period because it should just be awful and maybe that's the way it was in their family. But it doesn't have to be. And it's important to find a provider that is going to listen to you and ask these questions and have endometriosis kind of as a little bit of a red flag and think about it.So, symptoms can diagnose it. Of course, laparoscopy is a definitive way. There are other methods that are still being studied.
There's an endometrial biopsy that you can look for a marker called BCL-6, that if it's found in the luteal phase and an endometrial biopsy at a certain level, it can be associated with endometriosis, but that's not a hundred percent diagnosis either. Treatment for endometriosis. Well, it depends on if you're trying to get pregnant or not.If you are not trying to get pregnant, a lot of medication and medical therapy that will decrease estragon levels and decrease ovulation will really result in decreased symptoms like pain and a lot of the things that I just described. But if you're trying to get pregnant, a lot of the medical therapy for endometriosis is going to make it harder to get pregnant. So that's not going to be helpful.
Some people will do laparoscopy to not only definitively diagnose endometriosis, but also remove the lesions and have symptoms relieved, you know, like pain or like some of the other symptoms that I described, and it can improve fertility. Some people will use fertility treatments to try to conceive faster, like intrauterine inseminations or IVF as a way to bypass some of the reasons that endometriosis causes infertility. Your path is so dependent on your personal situation.
So, you need to talk to your doctor about, hey, do you think I have endometriosis? Do you think this can be a part of my fertility picture? If so, you know, what would you recommend for my personal situation to help me get pregnant sooner and to help me meet my goals?
4. Diminished Ovarian Reserve
Now, this is a tough thing to talk about because there's actually not a universally agreed upon academic definition of diminished ovarian reserve. In general, it's considered having a lower egg supply than you would expect for your age. It is more common in women that are over the age of 35, but people can have diminished ovarian reserve in their twenties or even younger. It's often associated with having a lower-than-expected average of AMH.
AMH is a blood test, anti-malarian hormone that in general can reflect the number of eggs that are up for grabs each month.You can get a diagnosis of diminished ovarian reserve with an ultrasound where the provider is looking at the ovaries and counting the number of resting follicles that are in each ovary. On average, people have 10 to 15 resting follicles on their ovaries anytime in the menstrual cycle. And if it's below average for your age, you could be diagnosed with diminished ovarian reserve.
Some of those people aren't diagnosed with it until after they go through an IVF cycle and they get fewer eggs than you would expect for their age or even their AMH level. So, it is a very general term and not everybody with a low AMH or a low antral follicle count will necessarily have difficulty getting pregnant. So, it is something to consider and think about and talk to your doctor about your test results.
It is so hard to put a label and a box around diminished ovarian reserve and really predict what's going to happen for each individual person, but people with a high FSH or a lower-than-average AMH for their age often can take longer to conceive. Not always, but getting this information kind of early in your fertility journey can help you make long-term decisions. Again, a low AMH and a low FSH does not mean that you cannot get pregnant.
5. Unexplained Infertility
This is one of the most frustrating and difficult discussions to have with a patient, because they're trying to conceive, whether it's six months, whether it's 12 months, it's just not happening. Regular cycles, they are ovulating.Test results look reassuring. Semen analysis, perfect. Anatomy checkup, normal uterus, both fallopian tubes are open.
Unexplained infertility means you have all of the parts to conceive. You're ovulating, sperm exposure, at least one fallopian tube is open and it's still not happening. Of course, there is a reason why you're not getting pregnant, but we are still learning so much about fertility.
This is still a relatively new field of medicine and we are still learning so much about it. So, when we're doing an evaluation, we're really just doing the basics. Are there eggs? Is there sperm? And can they find each other? And unexplained, of course there's a reason why you're not getting pregnant, but we just don't know why.
Sometimes it could be something different happening each cycle. Sometimes you could ovulate a perfect egg and the one sperm that gets in is just not a perfect sperm. Or sometimes you ovulate, but the egg doesn't even get into the fallopian tube.
If you think about all of the things that have to go right for us to conceive, it's amazing that any of us are here. But it does happen 60% of the time in the first three months of trying for most couples, 85% of the time in the first year of trying for most couples. We know it's frustrating, but there are still treatment options available. It could be considered low-tech treatment, like some medications to induce ovulation, help make sure you're ovulating on time with a trigger shot, and doing intrauterine insemination. Or one of the most common reasons people actually do IVF is because it's controlling for so many more variables and you're working with multiple eggs in one cycle.
And then the attrition part of IVF, which is really hard because not every egg and not every sperm is going to turn into a beautiful embryo that's going to turn into a baby. But that attrition, you could get 12 or 15 eggs in one cycle and that could result in three or four embryos. Each time you transfer one of those embryos, it's a much higher chance of success because you really narrowed it down to the embryo that had the highest chance of implantation.
Summary:
In this article, we reviewed five most common causes of infertility in women. We went through how common each cause is, diagnosis, and treatment options.
· Number one, ovulatory dysfunction.
· Number two, tubal disease.
· Number three, endometriosis.
· Number four, diminished ovarian reserve.
· And number five, unexplained infertility.
With advancing ART procedures and demand for better patient outcomes, Medline Academics offers structured online infertility courses in India and Basic Infertility Course designed by leading experts in reproductive medicine for aspiring fertility specialists, gynaecologists, embryologists and medical professionals who wish to upskill in this field. These programs simplify complex topics like ovulatory disorders, ART techniques, endometriosis management, ovarian reserve assessment, IVF protocols and case-based learning, making it easy for clinicians to understand infertility holistically.
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