Female factor infertility
How age and ovarian reserve, ovulation problems, the fallopian tubes, the uterus and endometriosis can affect fertility, and how each is evaluated.
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Several factors can make it harder for a woman to conceive. Understanding which ones apply to you is the first step toward the right plan.
Age and ovarian reserve
Age is the most important factor affecting fertility. As women get older, both the number and the quality of their eggs decline. The number of eggs in the ovaries falls steadily, from roughly 300,000 at birth to about 1,000 at menopause. By age 35, for example, a woman has about half as many eggs remaining as she did at 25, which is why it’s important to seek a consultation as early as possible.
Egg quality also declines with age. The most important aspect of egg quality is the egg’s chromosomes. An abnormal egg carries an extra chromosome or is missing a chromosome or part of one. For reasons that aren’t fully understood, the proportion of abnormal eggs rises with age.
Having fewer good quality eggs lowers the chance of pregnancy, lengthens the time it takes to conceive, and raises the risk of miscarriage, ectopic pregnancy and other abnormal pregnancy outcomes. Fertility treatment, even IVF, is also less successful as age advances.
Other factors can reduce ovarian reserve too, including lifestyle habits such as smoking, and prior surgery on the ovaries, such as removal of an endometrioma or ovarian cyst. Some genetic factors can also reduce the number and quality of eggs.
How ovarian reserve is tested
- Your history, including risk factors such as age, smoking and prior ovarian surgery.
- A detailed vaginal ultrasound to count the small follicles in the ovaries. A reproductive endocrinologist can learn a great deal about ovarian reserve from this exam.
- Blood work measuring FSH, estradiol and anti-Müllerian hormone (AMH), which reflect ovarian function.
Tests of ovarian reserve reflect the number of eggs remaining, and possibly their quality, but they aren’t accurate enough to decide whether someone should or shouldn’t have treatment. Many women with abnormal markers do get pregnant, on their own or with fertility treatment.
Ovulation problems and PCOS
Women may not ovulate for a variety of reasons.
Polycystic ovary syndrome (PCOS)
PCOS is probably the most common cause of anovulation. Diagnosis requires two of these three criteria:
- Polycystic-appearing ovaries on ultrasound
- Absent ovulation
- High levels of male hormones
Women with PCOS are sensitive to fertility medication and need careful ovulation induction to avoid hyperstimulation and multiple pregnancy. They also need attention to body weight and to other health risks later in life. With careful care, women with PCOS can conceive safely and lead healthy lives. If you’ve been diagnosed with PCOS, we’d be glad to help with your reproductive health.
Hyperprolactinemia
Prolactin is a hormone made by the pituitary gland in the brain. Too much of it interferes with follicle development and ovulation. Levels can rise because of a small tumor in the gland or abnormal thyroid function. Both prolactin and thyroid hormones are measured in the initial fertility workup.
Hypothalamic amenorrhea
This usually develops in athletic women, women who run several miles a day, and women who are very thin and conscious of their weight and body shape. These women need special attention to their general health and to how ovulation is stimulated, both to achieve a good outcome and to protect their general and bone health later in life.
Premature ovarian dysfunction
Markedly reduced ovarian reserve can result from genetic factors, surgery on the ovaries, chemotherapy or radiation for cancer, lupus and other diseases.
The fallopian tubes
The fallopian tubes pick up the egg from the ovary and carry sperm to the egg, where fertilization takes place. They can become blocked because of prior infection, surgery or a congenital abnormality.
Whether the tubes are open is checked with a hysterosalpingogram (HSG). Blocked tubes can be evaluated surgically with laparoscopy, and sometimes the problem can be corrected. When the damage is marked, surgery offers a lower chance of conception than IVF, so a couple may prefer to go directly to IVF.
Hydrosalpinx
A hydrosalpinx is a blocked, fluid-filled fallopian tube. The chance of turning it into a functioning tube is very low, and doing so carries a risk of ectopic pregnancy. A hydrosalpinx can also leak fluid back into the uterus and prevent implantation. For these reasons, most experts recommend removing or disconnecting a hydrosalpinx before IVF.
Tubal ligation reversal
If you’ve had your tubes tied, reversal surgery can be considered, if feasible, after a careful evaluation of your fallopian tubes and of male and female factors. Alternatively, you may choose IVF and avoid reversal surgery altogether.
The uterus and cervix
The uterine cavity should be evaluated for anything that could prevent an embryo from implanting.
- Fibroids and polyps. Submucosal fibroids (just beneath the lining of the uterus) and polyps should be found and removed before fertility treatment. A simple test called saline sonography, in which a small amount of sterile fluid is placed in the uterus, clearly outlines abnormalities of the lining. Most problems inside the uterus can be corrected with minimally invasive hysteroscopy.
- Asherman syndrome. Scarring (adhesions) inside the uterus sometimes develops after a D&C, most often one done during pregnancy, and can make periods infrequent. It can also be corrected with minimally invasive surgery.
- Uterine septum. Some women are born with structural differences in the uterus. The most common is a septum, a vertical wall that divides the uterus into two cavities. It should be removed before fertility treatment, again with minimally invasive surgery.
- Other developmental differences of the uterus should be thoroughly evaluated by a reproductive endocrinologist to plan the best course before treatment.
- The uterine lining. The pattern and thickness of the lining should be monitored and optimized before and during treatment.
The cervix deserves attention too. Before treatment, it should be examined for any deformity. A trial transfer, in which an empty catheter is passed through the cervix, helps anticipate any difficulty placing sperm or embryos in the uterus. Prior surgery on the cervix, such as a cone biopsy, may increase the risk of preterm delivery in pregnancy.
Learn more about reproductive surgery.
Endometriosis
Endometriosis means tissue like the lining of the uterus grows in places it shouldn’t, such as the lining of the pelvis, the ovaries or the intestines. This tissue responds to hormones and grows in response to estrogen.
Endometriosis can affect fertility in many ways. It may cause scarring that blocks the fallopian tubes, reduce the ovaries’ response, prevent sperm from fertilizing the egg, or interfere with implantation. It can also cause chronic pelvic pain and pain during intercourse.
- Women with mild endometriosis may benefit from ovarian stimulation with intrauterine insemination (IUI).
- Women with severe endometriosis that blocks the fallopian tubes may need IVF.
- Laparoscopic surgery can help diagnose endometriosis accurately, remove endometriosis or scar tissue, and remove endometriotic cysts from the ovary.
This article is general information, not medical advice. Every situation is different, so talk with your doctor about yours.
