The medical definition of female infertility is when a woman is unable to conceive a child after 12 months of regular intercourse with her partner without the use of contraception.
Fertility test. Male and female home-use Fertell fertility test kit. At bottom right is the wand used to test female fertility. It measures the amount of follicle stimulating hormone in the woman's urine which is an indicator of ovarian reserve.
Alternative names for female infertility
Subfertility.
What is infertility in women?
The term 'female infertility' is often used as a general term to describe a situation where a woman is unable to conceive a child. The true medical definition of female infertility is when a woman is unable to conceive after 12 months of regular (at least three times in a week), unprotected sexual intercourse. Infertility can be a very distressing and emotional issue for both women and men and it is important that advice and professional counselling is sought. Some causes of infertility in women are treatable; for those that are not, assisted conception, surrogacy or adoption could be considered as alternative ways to start a family.
It is important to mention that difficulty in conceiving may not necessarily be a problem with the woman’s fertility, ie, it could be due to male infertility – due to problems such as low numbers or poor quality of sperm.
What causes infertility in women?
There are a number of different causes of infertility in women and sometimes the cause remains unknown. The most common reasons why a woman may not be able to conceive a child include:
- Infrequent release of eggs from the ovary - this can happen as a result of various physical or medical conditions. These can include general illnesses, disturbances to hormone balance in the body (the most common being polycystic ovary syndrome), too much weight loss or being overweight. Premature ovarian failure or early menopause is when the ovaries stop producing eggs before the age of 40 and will require the woman to undergo some sort of assisted reproductive therapy in order to become pregnant.
- Blockage of one or both fallopian tubes such as through infection - the most common infection leading to blockage of tubes is Chlamydia, which is a sexually transmitted disease. Pelvic adhesions caused through surgery or through non-tubal infection (appendicitis, inflammatory bowel disease) are not uncommon and can lead to blockage of the fallopian tubes.
- Problems in the womb such as fibroids and conditions such as endometriosis - fibroids are lumps that develop from the muscle wall of the womb called the endometrium. Fibroids that sit or project inside the womb cavity are particularly known to cause infertility. Endometriosis can lead to cysts being formed in the ovaries and the pelvis, and can cause the fallopian tubes to become distorted which, in turn, can lead to infertility.
Having a BMI (body mass index) that is too low (underweight) or too high (overweight or obese) can result in difficulties conceiving. For women, BMI (which is calculated as weight in kilograms/height in metres2) should be between 21 and 25. Being overweight or underweight can affect the release of eggs from the ovaries each month leading to irregular periods and problems conceiving.
Women who have had surgery during a previous pregnancy, had repeated uterine scrapes or any type of surgery inside their womb may develop scarring and adhesions inside the womb (Asherman’s syndrome) which can lead to infertility.
There are other reasons, which are not purely gynaecological (ie to do with the female reproductive system) which could also cause infertility:
- Illnesses affecting general physical and mental health
- Lifestyle issues such as being over or underweight, taking part in extreme exercise, smoking or drinking high quantities of alcohol
- Disturbances to the balance of hormones in the body, such as too much production of prolactin,thyroid hormones or adrenal hormones
It is possible, after investigation, that the cause of infertility may remain unexplained.
What are the signs and symptoms of infertility in women?
The signs and symptoms of infertility in women depend on the underlying condition causing the infertility. In women with regular menstrual cycles (periods), 95% of the time one egg is released in each cycle (each month). Women who have problems in releasing eggs are likely to experience infrequent or absent periods (amenorrhea). Polycystic ovary syndrome is the most common hormone disturbance for women with infertility which results in irregular periods. With this condition some women will experience unwanted hair growth on the face and body, patchy hair loss from the scalp (alopecia) and too much weight gain. Women with endometriosis are likely to have painful and heavy periods, lower abdominal pain, painful sexual intercourse or a combination of these symptoms.
How common is infertility in women?
Infertility occurs in around 12% of women in the UK. The older the woman is, the more difficult it can become to conceive. This is because the potential for eggs to become fertilised weakens as the woman ages.
In 35% of cases, infertility is a combination of male and female problems.
Is infertility in women inherited?
Infertility itself is not an inherited condition. However, conditions that can cause infertility, such as polycystic ovary syndrome, endometriosis and premature ovarian failure often occur in a number of female members in the same family.
How is infertility in women diagnosed?
Blood tests are usually carried out within the first three to five days of a woman’s period to assess hormone levels. These tests provide an approximate measure of ovarian reserve – ie the number of eggs a woman has left in her ovaries. In some hospitals, a test to measure anti-Müllerian hormone in the blood can be used as an index of ovarian reserve. An ultrasound scan of the ovaries to count the number of potential eggs during the first few days of a period is also another method of checking the ovarian reserve. This can help to measure the quantity of eggs the body is holding in reserve. A blood test is also taken on day 21 of the menstrual cycle to check that eggs are being released (ovulation).
Tests for current or previous Chlamydial infection are carried out in blood and urine samples and genital swabs. A blood test is also usually taken to ensure the woman has developed protection against rubella infection as part of the initial fertility tests.
The method of testing whether the fallopian tubes are open or blocked can vary depending on the symptoms, personal preference and the risks to the individual patient. These methods include:
- An X-ray of the pelvis which is taken while injecting a dye through the neck of the womb
- An ultrasound scan of the pelvis while injecting the dye
- A ‘keyhole’ surgical operation to allow the specialist to directly see the pelvis and fallopian tubes. This operation is combined with a dye test to check the fallopian tubes. It is called a laparoscopy and dye test.
- An examination of the womb cavity with a camera (hysteroscopy). This helps to identify any problems within the uterus.
Sometimes, after the above tests are carried out, the cause of the infertility remains unknown.
What treatments are available?
The first and most important treatment is to ensure the woman is in the best possible health to conceive. This includes maintaining an ideal body weight (this should be a body mass index of 21-25); taking regular exercise; avoiding smoking; and limiting alcohol intake to two to three units per week.
More specific treatment will depend on the cause of infertility. In certain conditions such as high prolactin levels in the blood, correction of the hormonal imbalance can restore ovulation. In women with polycystic ovary syndrome who are overweight, weight loss is the main treatment; other medication used includes metformin, spironolactone and cyproterone which work by overcoming the hormonal imbalance.
Ovulation is frequently brought on using drugs such as clomiphene citrate, taken in tablet form, or withfollicle stimulating hormone given by injection. During these treatments women have to be carefully monitored to prevent the ovaries becoming too stimulated or a multiple pregnancy taking place (as a result of more than one egg being released). For some selected women, an operation called ovarian diathermy may be helpful. This involves a few tiny punctures being made in the ovary using a laparoscope. This can help to restore ovulation.
Specific treatment of other causes of infertility such as removal or treatment of endometriosis, uterine fibroids, uterine polypsor pelvic adhesions can help to improve fertility.
For women with unexplained causes of infertility or with multiple causes of infertility including a problem in their partner’s sperm, assisted reproduction techniques such as in vitro fertilisation (IVF) can be the best option. IVF involves collecting eggs from a woman (or using donor eggs) and artificially fertilising them in the lab using the partner’s (or donor) sperm. If fertilisation is successful, the embryo is then transferred back into the woman’s uterus where the hope is that it implants into the wall of the uterus and a pregnancy is conceived.
The success of IVF treatment depends heavily on age; younger women have the best success rate. Older women with very poor reserves of eggs and women with premature ovarian failure will need to use donor eggs for assisted reproduction. Further information and advice about assisted reproduction and related treatments can be found at the links below.
Another option, which may be recommended for patients without a uterus, is using a surrogate. In this case, assisted reproduction is carried out using the patient’s own eggs with the embryo then being implanted into the surrogate woman who carries the child until birth.
Are there any side-effects to these treatments?
In assisted reproduction, women are given drugs called gonadotrophins to stimulate the ovaries to produce eggs to be fertilised in the lab. A potential side-effect to this treatment is ovarian hyperstimulation where the ovaries become swollen and the patient experiences pain in the abdomen which may be accompanied by nausea and vomiting. In most cases, treatment for ovarian hyperstimulation is pain relief and bed rest, but in severe cases, surgical intervention may be required; however, this is very rare (less than 1% of patients). Patients should discuss any concerns about the treatment with their doctor.
Women under investigation and treatment for fertility problems find it emotionally stressful. Those in need of IVF may need more than one treatment cycle to achieve a pregnancy and each treatment cycle may stretch between four to eight weeks. In addition, donor egg or surrogacy treatment come with a large number of psychological implications and fertility counselling is considered to be essential prior to such treatments.
What are the longer-term implications of female infertility?
Although infertility in itself has no long-term physical implications besides the inability to conceive a child, there are a number of broader issues that should be considered. For example, there may be longer-term implications that could result if the underlying causes of infertility, such as a hormonal imbalance, remain untreated.
More importantly, it should be recognised that infertility can have significant implications for the mental health of both the woman and her partner, the impact on their relationship and on long-term wellbeing. When infertility is diagnosed, counselling is often suggested to help the woman and the couple better understand the implications of infertility. Other options may also be considered such as adopting or fostering a child.
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