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The possible causes of infertility, and what you should know

The possible causes of infertility, and what you should know

7 min read

When you’re trying to conceive and have trouble getting pregnant, it can be a confusing and overwhelming experience. (And it’s certainly not made easier by the fact that many of us have unanswered questions about how our reproductive systems work, given the lack of modern sex ed in school!) But learning about what’s happening in our bodies and what to expect when dealing with infertility can help us feel more prepared for whatever happens.

Dr. Rashmi Kudesia, MD, MSc, a reproductive endocrinologist and infertility specialist (REI) at CCRM Fertility in Houston, advocates for a concept she calls “reproductive empowerment” to underscore the importance of understanding your body and menstrual cycle, and debunking the myths you’ve learned about reproductive health growing up. Familiarizing yourself with female infertility is a key way of taking control of your pregnancy journey, especially when some medical professionals still have yet to do so. In fact, in a study she conducted, Dr. Kudesia found that 1 in 3 gynecologists feels uncomfortable talking about infertility — even more reason for you to take charge.

Recently, we sat down with Dr. Kudesia for a conversation about what to expect during fertility treatment, how to prepare for the road ahead, and what to know about different infertility diagnoses.

When you’re informed about infertility, you can advocate for the treatment and providers you need — whether that’s by sharing your own test results with your healthcare provider using the Modern Fertility Hormone Test (a simple at-home finger-prick blood test) or confidently explaining your goals to an REI so you can decide if you want them on your medical team.

What are possible infertility diagnoses?

For the majority of infertility patients, diagnoses will usually fit into one of the following categories:

  • Low ovarian reserve (egg count)
  • Irregular or absent ovulation, often due to polycystic ovary syndrome (PCOS)
  • Tubal issues, including endometriosis (this can also cause low ovarian reserve)
  • Uterine issues, such as fibroids, adenomyosis, or scarring
  • Sexually transmitted infections (STIs)
  • Male factor infertility
  • Unexplained infertility

Often, related hormonal abnormalities such as thyroid conditions or insulin resistance may affect fertility or the chances of pregnancy complications as well. Fertility testing and physical exams help REIs understand what’s at the root of the problem.

It’s important to note that 15% of couples who seek help for infertility will be diagnosed with unexplained infertility — a frustrating statistic that means test results are normal and both partners appear physically able to conceive without medical intervention, but have thus far been unsuccessful for unknown reasons.

Also, lifestyle factors (like nutrition, physical activity, sleep, stress, alcohol, and/or other substance use) can impact fertility, so talk to your doctor if you have any questions about how your personal medical history may factor in.

Below, we’ll review each of the categories of infertility diagnoses.

1. Ovarian issues

If your infertility diagnosis relates to your ovaries, it’s likely due to a diminished ovarian reserve (DOR) or polycystic ovary syndrome (PCOS) — two very different diagnoses that both involve the ovaries.

Diminished ovarian reserve (DOR) is the term used to describe when a person has fewer remaining eggs than other people their age. “While DOR can happen at any age, it’s often caused by getting older,” Dr. Kudesia says, “because when we enter our 40s, our ovarian reserve is naturally declining anyway.” Testing your levels of follicle-stimulating hormone (FSH), anti-Mullerian hormone (AMH), and the estrogen estradiol (E2), and examining your follicle count in a transvaginal ultrasound can help an REI understand what’s causing the problem.

If the numbers in your results are low, CCRM Fertility explains that a diminished ovarian reserve can be treated by ovarian-stimulating medications so you can get that one egg you need to conceive (it only takes one!). DOR can also be caused by ovarian endometriosis, prior chemotherapy or pelvic radiation therapy, or prior ovarian surgeries.

Polycystic ovary syndrome (PCOS) is a hormonal disorder marked by high levels of androgens (“male” sex hormones) and often AMH, multiple immature ovarian follicles, and irregular ovulation and menstruation. You can’t get pregnant if you don’t ovulate, and it’s much harder to time intercourse to increase chances of conception if you’re not ovulating regularly. But with medications like Clomid and Letrozole and/or treatments like in-vitro fertilization (IVF), it’s possible to get pregnant with PCOS.

2. Endometriosis or tubal diseases

Endometriosis “is a condition where the cells lining the inside of the uterus grow in other parts of the body, and it can create a lot of issues relating to fertility,” explains Dr. Kudesia. “It can block off the fallopian tubes or cause ovarian cysts that speed up the ovarian aging process.” If you receive this infertility diagnosis, you may have surgical treatment options.

Tubal diseases (or disease affecting the fallopian tubes) can also lead to infertility. According to CCRM Fertility, “When [the] fallopian tube(s) are blocked or damaged, [it] prevents the sperm from reaching and fertilizing the egg, or the fertilized egg from reaching the uterus.” Whether it’s caused by endometriosis, pelvic inflammatory disease (PID), or untreated sexually transmitted infections (the most common STIs are chlamydia and gonorrhea), tubal factor infertility results in 25-35% of infertility cases in people with ovaries.

3. Fibroids or adenomyosis

You may be diagnosed with fibroids or adenomyosis via a transvaginal ultrasound.

Fibroids “are benign growths of the uterine muscle,” Dr. Kudesia explains. While CCRM Fertility states that most people with fibroids won’t experience infertility, complications can still arise. These growths can potentially result in fallopian tube blockages, miscarriage, or uterine abnormalities that can “create issues with implantation” (when the fertilized egg tries to embed itself in the uterine lining).

Often, fibroids and any related infertility can be treated with hormone therapies or surgery. However, Dr. Kudesia stresses that surgical options are unique to each patient, so the most important thing is to get the appropriate fertility workups (i.e., fertility hormone testing) and dive into the details with your REI.

Adenomyosis is a condition where tissue from the lining of the uterus actually grows into the uterus’ muscular wall. “Adenomyosis isn’t as well known as fibroids,” Dr. Kudesia explains, “but it's a more generalized bulking up of the uterus.” Its effects on fertility, and subsequent treatments, are also similar to fibroids, but surgery is often less applicable.

4. Thyroid conditions or insulin resistance

Thyroid conditions are hormonal imbalances that can make conceiving more difficult. They can occur when thyroid-stimulating hormone (TSH) (the hormone the pituitary gland in the brain releases to regulate the thyroid) levels are too low or too high. If thyroid conditions like hypo- (underactive thyroid) or hyperthyroidism (overactive thyroid) are left untreated, there’s a risk of infertility or complications in pregnancy. That said, you can increase your chances of conception by working with your doctor to manage the condition.

Insulin resistance is a common symptom of PCOS and can greatly increase your chances of developing gestational diabetes. If your blood sugar levels are high, that may be a sign you have insulin resistance. Medications like Metformin can manage PCOS and insulin resistance to increase your fertility.

5. Male factor infertility

REIs test for male factor infertility via semen analysis. These tests look at someone’s sperm concentration (sperm count in 1 milliliter of ejaculate), volume (how much sperm and semen they have), motility (how their sperm moves), and morphology (how their sperm is shaped). These features of sperm all impact whether or not they’re able to travel through the vagina after ejaculation and get to the egg.

While people with ovaries are often conditioned to believe fertility is their responsibility alone, 40% of opposite-sex couples who visit infertility specialists will be diagnosed with male factor infertility. Depending on what the semen analysis reveals, infertility treatment options can range from hormonal medications to surgery, often combined with intrauterine insemination (IUI) or assisted reproductive technology (ART) like IVF, or even utilization of a sperm donor.

When is it time to speak to a doctor about testing for infertility?

Dr. Kudesia’s general advice is that there’s really no such thing as being “too early” when discussing your anxieties and concerns with an infertility specialist. You deserve to understand how your body works and what it needs (remember reproductive empowerment?). That being said, Dr. Kudesia emphasizes specific symptoms, lifestyle factors, and aspects of your medical history that definitely warrant a visit with a specialist if you’re trying to conceive.

If you’re experiencing symptoms of infertility

If you have ovaries, you’re younger than 35 years old, and you’ve unsuccessfully tried to conceive for one year with a partner who has sperm, the American College of Obstetricians and Gynecologists (ACOG) recommends getting evaluated by an REI and undergoing fertility testing. The recommendation if you’re 35 and older is to make an appointment with an REI after six months of unsuccessfully trying to conceive with a partner who has sperm.

Now, if you’ve already been diagnosed with a hormonal disorder or reproductive health condition like PCOS or endometriosis, then you don’t need to wait before seeing a doctor. In fact, it’s recommended that you make an appointment as soon as possible if you decide to start trying to conceive since, as we discussed earlier, those conditions are known to contribute to fertility struggles.

If there’s anything in your medical history that could impact fertility

There are other parts of your medical history that are worth discussing with an REI, such as any prior pregnancies or gynecological surgeries. “An especially difficult pregnancy or birth can sometimes lead to infertility,” Dr. Kudesia says, whether that’s due to injuries sustained during traumatic labor or due to secondary infertility, which CCRM defines as ”[struggling] with infertility after already having a baby.”

If you’ve had any gynecological surgeries or procedures to treat fibroids, ovarian cysts, polyps, or tubal disorders, surgical scarring can potentially contribute to infertility. (Dr. Kudesia recommends calling the hospital where you underwent those surgeries so you can share your medical records with your REI.)

If you’ve had recurrent miscarriages

It’s important to speak with your REI about any pregnancy losses, too. If you’ve experienced two or more miscarriages, Dr. Kudesia explains there are specific fertility workups that are recommended before trying to conceive again. Results could reveal issues including genetic disorders in either partner, recurring chromosomal abnormalities, autoimmune or hormonal complications, or uterine abnormalities that could potentially be treated with surgery. (You can learn more about fertility after micarriage here.)

If you need a sperm donor

If you’re trying to conceive on your own, you’re in a relationship with someone who has ovaries and want to get pregnant, or you’re in any other situation where you may need access to donor sperm for conception, Dr. Kudesia says that your situation is “part of the infertility rubric.”

Regardless of the reason for infertility, there’s no doubt how stressful it can be. Struggling to conceive can result in depression, anxiety, and even identity crises as your understanding of parenthood shifts. “It’s important to acknowledge that feeling,” Dr. Kudesia says, and to give yourself credit for all the work you’re doing to achieve your reproductive goals. Groups like the Modern Community can help you work through those tough emotions — and Modern Fertility is always here to help you better understand fertility and everything that can have an impact on it.

Watch our full convo with Dr. Rashmi Kudesia below, and stay tuned for more information on reproductive health from this discussion and from all of our experts.

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Rachel Sanoff

Rachel Sanoff is a writer and editor in Los Angeles. She was previously an essays editor at O.school, a digital sex education platform, and the features editor at HelloGiggles.

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