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Fertility Overview and Treatment Options
Overview
Fertility issues are common and can be very stressful. Depending on the cause, lifestyle changes and various treatments may help.
An individual or couple is considered to have fertility challenges if they’ve been trying to get pregnant for:
- 12 months, if they’re younger than 35
- 6 months, if they’re older than 35 and have ovaries or older than 50 and produce sperm
Talk to your doctor if you have fertility concerns. They’ll check your medical history and may order tests. They may reassure you to keep trying on your own. You may also be referred to our fertility specialists for more evaluation, if needed.
If you’ve been able to get pregnant more than once but haven’t been able to carry a pregnancy to term, talk to your doctor about a condition called recurrent pregnancy loss.
Many types of treatments can help you achieve a successful pregnancy. Your care team will recommend treatments based on your age, health history, how long you’ve been trying to conceive, and your partner's health history, if applicable.
The causes of infertility are different for each person and every couple. Fertility treatment can be time-consuming and stressful. It can also be expensive and may increase the chance that you’ll have a multiple birth (more than one baby). These are all things to consider as you plan for your pregnancy.
Pregnancy Process
Getting pregnant is a complex process. Many elements need to work together to start a pregnancy.
Ovaries must release a healthy egg each month (ovulation). At least one fallopian tube needs to be healthy and unblocked so it can pick up the egg.
Healthy sperm must then be released through ejaculation. The sperm need to have good motility (movement) and survive the journey through the cervix, uterus, and into the fallopian tube(s). Only about 1 in 10 sperm make it through the cervix. A sperm must reach the egg and penetrate its outer layer to fertilize it.
After the egg and sperm have met in the fallopian tube, the fertilized egg (blastocyst) must successfully attach to the lining of the uterus. The uterus must be able to form a healthy lining to support the growth of the embryo.
Many factors can cause fertility issues. Some of them are more likely to happen as you get older. Medical conditions that can cause problems with fertility include:
- Hormone imbalances
- Surgery that creates scarring in the uterus or pelvis
- Cancer or history of treatment for cancer
- Birth defects that involve the reproductive system
- Thyroid problems
- Diabetes
Lifestyle Factors
Lifestyle factors can also impact fertility, including:
- Heavy alcohol use
- Heavy caffeine use
- Marijuana, cocaine, and other drug use
- Tobacco use or secondhand smoke exposure
- Being overweight or underweight
- Extreme levels of exercise
- Frequent exposure to pollutants or toxins
We may recommend some lifestyle changes to improve your chances of getting pregnant. How well this works may depend on your age and how long you’ve been trying to conceive. Sometimes, a lifestyle change is all that’s needed to get pregnant.
Examples of lifestyle changes that can help improve your chances of getting pregnant include:
- Quitting smoking
- Stopping the use of alcohol and drugs
- Monitoring when ovulation occurs and having sex at the right time in your cycle
- Losing weight or maintaining a healthy weight
Causes in the Uterus, Ovaries, or Tubes
The uterus, ovaries, and fallopian tubes all need to be working right to start a pregnancy. Sometimes, problems with these parts may arise. Your doctor can discuss which tests are your best options to diagnose infertility.
Blood tests can help us evaluate your hormone levels, number of eggs, and overall health.
Medical imaging helps us find problems in your reproductive organs. For example, we might order a:
- Vaginal ultrasound
- Pelvic ultrasound
- Special X-ray (called a hysterosalpingogram, or HSG)
Surgery may allow us to look for any issues that can prevent pregnancy, such as scar tissue, blockage, or growths that may cause infertility.
Egg quality and ovulation
As you get older, you have fewer eggs and their quality declines. After age 35, your chances of getting pregnant decrease for this reason.
At any age, your ovaries may not regularly release eggs. This might be caused by:
- Polycystic ovarian syndrome (PCOS), a hormone imbalance that affects ovulation
- Primary ovarian insufficiency, when the ovaries run out of eggs before age 40 (early menopause)
- Weight gain, excessive exercise, high levels of stress, and other factors
Uterine function and structure
Growths in the uterus may prevent the fertilized egg from attaching to the wall of the uterus. These growths are usually polyps and fibroids, which are noncancerous growths in the uterus. The uterus may also have other structural or functional issues that make implantation difficult, such as scarring, a history of radiation to the pelvis, or abnormal development.
Tubal factors
Sometimes a fallopian tube becomes blocked. This prevents fertilization. This might be caused by:
- Pelvic inflammatory disease (PID)
- Endometriosis
- Sexually transmitted infections (STIs) or history of STIs
- Previous surgery
Causes Related to Sperm
Problems with sperm can also contribute to fertility issues. Examples of problems with sperm include:
- Low sperm count
- Poor sperm movement (motility)
- Abnormal sperm shape
Your doctor may not be able to tell what’s causing these issues, but possible causes are:
- Exposure to high temperatures (like hot tubs or saunas)
- Infection or injury
- Spending long hours on a bicycle
- Medical conditions like mumps and cystic fibrosis
- Large veins on the testicles that cause them to overheat
Other reasons for difficulty starting a pregnancy may include:
- Impotence, or the inability to keep an erection long enough to ejaculate during intercourse.
- Retrograde ejaculation, which is when the semen enters the bladder instead of going into the urethra and out the penis. It’s common for those who have diabetes.
- Vasectomy, which isn’t always reversible.
Certain medications might also cause problems with sperm, such as those used to:
- Reduce fluid retention (spironolactone)
- Treat urinary infections (antibiotics)
- Reduce stomach acid (cimetidine)
Your doctor may use several methods to diagnose fertility issues related to sperm.
Semen analysis
Semen analysis is the most common method. You provide a sample of semen by ejaculating into a collection cup. The sample is then evaluated for:
- Sperm count
- Sperm movement
- Sperm shape
- Volume of semen
Blood or urine tests
Blood or urine tests may be ordered to check for:
- Hormone levels, such as testosterone
- Genetic defects that can lead to fertility problems
- Sperm antibodies, which means the immune system is attacking sperm
- Retrograde ejaculation (sperm in the urine)
Medical imaging or biopsy
Your doctor might order:
- An ultrasound if they suspect a blockage in the testicles or tubes that carry semen
- A biopsy to collect a small sample of tissue from the testicles to evaluate the presence of sperm
Treatments for the Eggs, Ovaries, and Uterus
Treatments may include medications to promote egg development and surgeries to correct issues within the uterus or ovaries.
Medications for egg development
Your doctor may prescribe medications that encourage your body to release more eggs. Some are taken in tablet form, and others need to be injected. If injections are prescribed, your care team will give you resources on how to give yourself injections.
Ultrasound exams may be used to monitor your response to medication. For example, a pelvic ultrasound checks egg supply by counting the number of follicles (small sacs in which the eggs develop) in the ovaries.
Medications for egg development include:
- Ovulation induction medications. These drugs increase your body’s hormone levels and stimulate egg development. This medication is usually taken by mouth. Examples include clomiphene citrate (Clomid) and letrozole (Femara).
- Gonadotropins. These medications contain 2 hormones to help stimulate egg development: follicle-stimulating hormone (FSH) and luteinizing hormone (LH). They’re given by injection. You’ll have regular ultrasounds and blood tests to monitor follicle growth.
- Endocrine medications. These drugs treat abnormal prolactin and thyroid levels. They may also treat diabetes and PCOS.
Uterine surgeries
Sometimes, surgery is necessary to correct a problem within the uterus or ovaries. For example, we may surgically remove:
- A large ovarian cyst. An egg is usually fertilized with sperm in the fallopian tube, but a large cyst in an ovary may prevent the egg from reaching the fallopian tube. Removing the cyst may improve your chance of pregnancy. However, some cysts go away without treatment.
- Polyps or fibroids. You may have a polyp or fibroid inside your uterus. Removing this tissue may improve your chance of pregnancy.
Treatments for Sperm
There are several common fertility treatments related to sperm. These include:
- Addressing problems with sexual intercourse such as premature ejaculation and erectile dysfunction.
- Performing surgery to remove a blockage that prevents semen from traveling through the penis, or to redirect blood flow in a vein that’s too large and overheats the scrotum or testes.
- Using antibiotics to treat an infection in the reproductive tract.
- Using hormones and other medications. These drugs adjust the levels of hormones associated with fertility, such as testosterone.
Infertility is often caused by issues with both partners. If sperm issues can’t be resolved, it may be enough to correct the infertility issues in your female partner.
In some instances, male infertility can't be treated, although this is uncommon. If that is the case, we can discuss other options for building a family.
Intrauterine Insemination (IUI)
Intrauterine insemination (IUI) is a procedure to insert sperm directly into the uterus through a small tube (catheter). IUI is a quick procedure done in a clinic while you’re awake and performed around the time of ovulation. It allows the sperm to be placed closer to the egg. IUI is also generally painless, although you may feel some mild discomfort.
Your doctor may recommend IUI in the following situations:
- Problems with sperm
- Unexplained infertility
- Problems with the cervix
- Same-sex couples or singles
To perform the procedure, your care team will:
- Prescribe medications to stimulate ovulation. This increases the chance that an egg is ready for fertilization when the sperm is placed into the uterus. You’ll have regular ultrasounds to check when eggs are mature.
- Prepare the sperm. The sperm must first be washed and concentrated. This ensures they move well and are ready to fertilize an egg.
- Insert the sperm through the cervix and into the uterus using a small catheter.
In Vitro Fertilization (IVF)
In vitro fertilization (IVF) is a more involved process than IUI, and it’s done in several phases. We may recommend IVF for fallopian tube or sperm issues that can’t be corrected or if other treatments haven’t worked.
To start the IVF process, you’ll take medication to stimulate egg production. Your care team will monitor your follicle growth with ultrasounds and blood tests.
The next steps are:
- Removing eggs from the ovaries through a minor surgical procedure.
- Combining the eggs with sperm (a partner’s or a donor’s) in the lab.
- Waiting 5 days for an embryo to develop.
If applicable, your doctor may:
- Biopsy the embryos to test for genetic abnormalities.
- Freeze the embryos and wait for test results.
- Implant the embryo into the uterus.
It may take several attempts to get pregnant using IVF.
Considerations
Unfortunately, fertility treatment isn’t always successful. We can also talk about other ways to build your family.
One option is third-party donation. You may decide to use a sperm or egg donor or consider having another person (surrogate, or gestational carrier) carry the pregnancy. With a gestational carrier, the embryo is usually created from your own sperm and egg but can also be created from donor sperm or eggs.
Counseling
Infertility can be one of the most stressful challenges you and your partner will face. Communication and financial issues can add to these challenges. You’ll have to make difficult treatment decisions together, and you may not always agree.
You may also experience depression, anger, frustration, and sadness when infertility issues arise. Talk to your doctor about getting the support you need. We can offer resources to help manage stress and overall mental health and well-being.
Additional References
Disclaimer
If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.
This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.