FERTILITY

Fertility changes with age. Both males and females become fertile in their teens following puberty.
For girls, the beginning of their reproductive years is marked by the onset of ovulation and
menstruation. It is commonly understood that after menopause women are no longer able to become
pregnant. Generally, reproductive potential decreases as women get older, and fertility can be
expected to end 5 to 10 years before menopause.

Ovulation and the Menstrual Cycle

During their reproductive years, women have regular monthly menstrual periods because they
ovulate regularly each month. Eggs mature inside of fluid-filled spheres called “follicles.” At the
beginning of each menstrual cycle when a woman is having her period, a hormone produced in the
pituitary gland, which is located in the brain, stimulates a group of follicles to grow more rapidly on
both ovaries. The pituitary hormone that stimulates the ovaries is called follicle-stimulating hormone
(FSH). Normally, only one of those follicles will reach maturity and release an egg (ovulate); the
remainder gradually will stop growing and degenerate. Pregnancy results if the egg becomes fertilized
and implants in the lining of the uterus (endometrium). If pregnancy does not occur, the
endometrium is shed as the menstrual flow and the cycle begins again. In their early teens, girls often
have irregular ovulation resulting in irregular menstrual cycles, but by age 16 they should have
established regular ovulation resulting in regular periods. A woman’s cycles will remain regular, 26 to
35 days, until her late 30s to early 40s when she may notice that her cycles become shorter. As time
passes, she will begin to skip ovulation resulting in missed periods. Ultimately, periods become
increasingly infrequent until they cease completely. When a woman has not had a menstrual period
for 1 full year, she is said to be in menopause

Ovulation and the Menstrual Cycle

During their reproductive years, women have regular monthly menstrual periods because they
ovulate regularly each month. Eggs mature inside of fluid-filled spheres called “follicles.” At the
beginning of each menstrual cycle when a woman is having her period, a hormone produced in the
pituitary gland, which is located in the brain, stimulates a group of follicles to grow more rapidly on
both ovaries. The pituitary hormone that stimulates the ovaries is called follicle-stimulating hormone
(FSH). Normally, only one of those follicles will reach maturity and release an egg (ovulate); the
remainder gradually will stop growing and degenerate. Pregnancy results if the egg becomes fertilized
and implants in the lining of the uterus (endometrium). If pregnancy does not occur, the
endometrium is shed as the menstrual flow and the cycle begins again. In their early teens, girls often
have irregular ovulation resulting in irregular menstrual cycles, but by age 16 they should have
established regular ovulation resulting in regular periods. A woman’s cycles will remain regular, 26 to
35 days, until her late 30s to early 40s when she may notice that her cycles become shorter. As time
passes, she will begin to skip ovulation resulting in missed periods. Ultimately, periods become
increasingly infrequent until they cease completely. When a woman has not had a menstrual period
for 1 full year, she is said to be in menopause

Fertility in the Aging Female

A woman’s best reproductive years are in her 20s. Fertility gradually declines in the 30s, particularly
after age 35. Each month that she tries, a healthy, fertile 30-year-old woman has a 20% chance of
getting pregnant. That means that for every 100 fertile 30-year-old women trying to get pregnant in 1
cycle, 20 will be successful and the other 80 will have to try again. By age 40, a woman’s chance is less
than 5% per cycle, so fewer than 5 out of every 100 women are expected to be successful each month.
Women do not remain fertile until menopause. The average age for menopause is 51, but most
women become unable to have a successful pregnancy sometime in their mid-40s. These percentages
are true for natural conception as well as conception using fertility treatment, including in vitro
fertilization (IVF). Although stories in the news media may lead women and their partners to believe
that they will be to able use fertility treatments such as IVF to get pregnant, a woman’s age affects
the success rates of infertility treatments. The age-related loss of female fertility happens because
both the quality and the quantity of eggs gradually decline.
Fertility in the Aging Male
Unlike the early fertility decline seen in women, a man’s decrease in sperm characteristics occurs
much later. Sperm quality deteriorates somewhat as men get older, but it generally does not become
a problem before a man is in his 60s. Though not as abrupt or noticeable as the changes in women,
changes in fertility and sexual functioning do occur in men as they grow older. Despite these changes,
there is no maximum age at which a man cannot father a child, as evidenced by men in their 60s and
70s conceiving with younger partners. As men age, their testes tend to get smaller and softer, and
sperm morphology (shape) and motility (movement) tend to decline. In addition, there is a slightly
higher risk of gene defects in their sperm. Aging men may develop medical illnesses that adversely
affect their sexual and reproductive function. Not all men experience significant changes in
reproductive or sexual functioning as they age, especially men who maintain good health over the
years. If a man does have problems with libido or erections, he should seek treatment through his
primary care provider and/or urologist. Decreased libido may be related to low levels of testosterone.

Treatment Options and Alternatives

Assisted Reproductive Technologies

If a cause for infertility is identified, the clinical care provider may suggest a specific treatment.
However, sometimes no specific problem is found, and the infertility is labeled as “unexplained.” With
unexplained infertility, or when traditional treatments have failed, advanced infertility therapies such
as superovulation with timed intrauterine insemination (SO/IUI) or in vitro fertilization (IVF) may be
suggested. In an SO/IUI cycle, fertility medications are administered to start the growth of multiple
eggs in the ovaries. When these eggs are ready to ovulate, the partner’s washed sperm is placed
directly into a woman’s uterus. This procedure is called intrauterine insemination (IUI) and causes
minimal discomfort. IVF involves removing the eggs and fertilizing them with the male partner’s
sperm in the lab oratory and then transferring the resulting embryos to the uterus. Either procedure,
as well as any infertility treatment, may be used with donor sperm rather than sperm from the
woman’s partner. With any treatment, a woman’s age affects the chance for pregnancy. In women
over 40, the success rate of SO/IUI is generally less than 5% per cycle. This compares to success rates
around 10% for women ages 35 to 40. IVF is more effective but also has relatively low success rates in
women 40 and older, generally less than 20% per cycle. For more information on assisted
reproductive technologies, refer to the ASRM patient information booklet titled Assisted
Reproductive Technologies.

Egg Donation
If you are older, especially if you’re over 42, and have not succeeded with other therapies, or if you
have premature ovarian failure (POF), also known as early menopause, your treatment options are
limited. Egg donation, which involves the use of eggs donated by another woman who is typically in
her 20s or early 30s, is highly successful. The high success rate with egg donation confirms that egg
quality associated with age is the primary barrier to pregnancy in older women. If you are over 40,
your chance of successful pregnancy is much higher in IVF cycles using donor eggs, but many couples
or single women in their early 40s will choose to accept the lower chance of become pregnant and
use their own eggs. By age 43, the chance of becoming pregnant through IVF is less than 5%, and by
age 45, use of donor eggs is the only reasonable alternative.
In an egg donation cycle, the woman receiving the donated eggs is referred to as the “recipient.” The
egg donor receives fertility medications to stimulate the production of multiple eggs in her ovaries. At
the same time, the egg recipient is given hormone therapy to prepare her uterus to receive the
fertilized eggs (embryos). After the eggs are obtained from the donor, they are fertilized in the
laboratory with sperm from the recipient’s partner. Several days after fertilization, the embryos are
transferred to the recipient’s uterus. Any embryos that are not transferred may be frozen
(cryopreserved) for a future cycle.
Donor-egg IVF offers a woman an opportunity to experience pregnancy, birth, and motherhood. The
child, however, will not be genetically related to her but will be genetically related to the father and
the egg donor. Many programs recommend counseling so that all parties in a donor-egg agreement
understand the ethical, legal, psychological, and social issues involved. Because success depends
heavily upon the quality of eggs that are donated, women in their 20s with proven fertility are ideal
donors.
Fertility Preservation
Women who wish to delay childbearing until their late 30s or early 40s may consider methods of
fertility preservation such as freezing of embryos after IVF or retrieving and freezing eggs for later use.
The success of embryo freezing (cryopreservation) is well established, but it requires that the woman
have a male partner or use donor sperm. Egg freezing for preservation of fertility is a new technology
that shows promise for success. Age remains a problem faced by women interested in using elective
egg freezing. As the age of women undergoing egg freezing increases, the outcomes of assisted
reproductive technology cycles utilizing their frozen eggs become less favorable.
Preimplantation Genetic Screening
New technologies that will allow testing of embryos for chromosomal abnormalities are currently
being investigated. This technology applies to embryos created during a cycle of IVF. It may be
particularly useful for older women. With preimplantation genetic diagnosis (PGD), a small number of
cells are removed from each embryo and genetically evaluated. Embryos for transfer to the mother’s
uterus would be selected from the chromosomally normal embryos. The hope is that this procedure
will result in improved successful pregnancy rates and avoidance of transmission of an embryo with a
genetic disorder.

Summary
Fertility naturally declines as women get older. However, the time decline begins and the rate at
which it progresses, vary widely in women, but always begin well before menopause. Generally,
fertility begins to drop in your late 20s or early 30s and falls more rapidly after the age of 35. Women
who decide to delay pregnancy until after age 35 should obtain information on appropriate testing
and treatment while remaining realistic about the chances for success with infertility therapy. By
learning about all of the options and being aware of their own needs and goals, a woman and her
partner will be prepared to make the best decisions.

Age
Female age is the most important factor affecting fertility. Women are born with all the eggs they will
ever have and the number of eggs available decreases each day from birth onwards. In young women
the decline is fairly gradual (only a few eggs are ‘lost’ each day), but as women approach their mid to
late 30s, the decrease gets much steeper (many more eggs are ‘lost’ each day). In addition to this
decrease in the number of eggs available, the quality of the eggs also declines as women get
older. This reduction in both the quantity and quality of available eggs means that older women are
less likely to get pregnant and, if they do get pregnant, they are more likely to have a miscarriage.

Lifestyle Factors

Weight
Overweight women who have irregular periods are less likely to release an egg each month (ovulate)
than women with regular periods. This means the chances of getting pregnant are reduced. Losing
weight, even as little as 5-10% of the total body weight, may restore a regular menstrual cycle thereby
increasing the chance of getting pregnant.

Smoking
Women who smoke are 3 times more likely to experience a delay in getting pregnant than non-
smokers. Even passive smoking can be harmful. Smoking reduces a woman’s ovarian reserve (so her
ovaries will have fewer eggs in them than a woman of the same age who does not smoke) and
damages the cilia inside the fallopian tube (which are important for transporting the egg and/or
embryo along the fallopian tube into the uterus).

Caffeine
There is no clear association between caffeine consumption and infertility

Alcohol
Some studies report that drinking more than 5 units of alcohol a week may reduce female fertility but
others state that low to moderate alcohol consumption may be associated with higher pregnancy
rates than non-drinkers.
Over-the-counter and recreational drugs
Non-steroidal anti-inflammatory drugs such as ibuprofen can interfere with ovulation. Aspirin may
interfere with implantation. Recreational drugs such as marijuana and cocaine may interfere with
ovulation and/or the function of the fallopian tube. The fallopian tube is important for transporting
the egg from the ovary where it is released, to the womb (uterus) where an embryo will hopefully
implant. Fertilisation occurs in the fallopian tube. Anabolic steroids, which are abused by some body-
builders, inhibit the production of sperm and this may be permanent even if the drug is stopped.

Medical Conditions
Some women may have medical conditions that can affect their fertility. These may or may not be
known about when starting to try for a family. Some of these conditions may be more general, for
example thyroid disease and vitamin D deficiency whilst others may be more specific, for example,
polycystic ovary syndrome and endometriosis.

INFERTILITY

In general, infertility is defined as not being able to get pregnant (conceive) after one year (or longer)
of unprotected sex. Because fertility in women is known to decline steadily with age, some providers
evaluate and treat women aged 35 years or older after 6 months of unprotected sex

 Primary infertility is when someone is not able to conceive at all.

 Secondary infertility is when someone has previously conceived but is no longer able to.

Infertility causes
Infertility is defined as the inability to get pregnant after 12 months of trying. Any person of either sex
who fits this definition is experiencing infertility.

Causes in females
Infertility in females can also have a range of causes.

Problems with ovulation

Ovulation disorders make up about 25%Trusted Source of infertility cases in females. Ovulation is the
monthly release of an egg. The eggs may never be released, or they may only be released in some
cycles.

Ovulation disorders can occur due to:

 Hyperprolactinemia: If prolactin levels are high and the female is not pregnant or breastfeeding,
it may affect ovulation and fertility.

 Thyroid problems: An overactive or underactive thyroid gland can lead to a hormonal imbalance
that interferes with ovulation.

 Polycystic ovary syndrome (PCOS): This is a hormonal condition that can cause frequent or
prolonged menstruation and can interfere with ovulation.

Problems in the uterus or fallopian tubes can also prevent the egg from traveling from the ovary to
the uterus, or womb. If the egg does not travel, it can be harder to conceive naturally.

Other causes include:

 Chronic conditions: These include AIDS or cancer.

 Primary ovarian insufficiency (POI): The ovaries stop working normally before the age of 40
years.
 Poor egg quality: The quality of the eggs may interfere with conception. As a female ages, the
number and quality of the eggs declines. Eggs that are damaged or develop genetic
abnormalities may also not be able to sustain a pregnancy. The older a female is, the higher the
risk.

 Surgery: Pelvic surgery can sometimes cause scarring or damage to the fallopian tubes. Cervical
surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the
uterus.

 Submucosal fibroids: Benign or noncancerous tumors occur in the muscular wall of the uterus.
They can interfere with implantation or blockTrusted Source the fallopian tube, preventing
sperm from fertilizing the egg.

 Endometriosis: Cells that normally occur within the lining of the uterus start growing elsewhere
in the body.

 Tubal ligation: In females who have chosen to have their fallopian tubes blocked, the process
can be reversed, but the chances of becoming fertile again are not high.

Infertility tests for females

A female will undergo a general physical examination, and the doctor will ask about medical history,
medications, menstruation cycle, and sexual habits.

They will also undergo a gynecologic examination and a number of tests:

 Blood test: This can assess hormone levels and whether a female is ovulating.

 Hysterosalpingography: A technician injects fluid into the uterus and takes X-rays to determine
whether the fluid travels properly out of the uterus and into the fallopian tubes. If a blockage is
present, surgery may be necessary.

 Laparoscopy: A thin, flexible tube with a camera at the end is inserted into the abdomen and
pelvis, allowing a doctor to look at the fallopian tubes, uterus, and ovaries. This can reveal signs
of endometriosis, scarring, blockages, and some irregularities in the uterus and fallopian tubes.

 Transvaginal ultrasound: Unlike an abdominal ultrasound (where the probe is placed over the
belly), this test is done by inserting an ultrasound wand into the vagina. It allows the healthcare
provider a better view of organs like the uterus and ovaries.

 Saline sonohysterogram (SIS): This test is used to look at the lining of the uterus and assess for
polyps, fibroids or other structural abnormalities. Saline (water) is used to fill the uterus,
allowing the healthcare provider to get a better view of the uterine cavity during a transvaginal
ultrasound.

 Hysteroscopy: In this test, a device called a hysteroscope (a flexible, thin device with a camera
on it) is inserted into the vagina and through the cervix. The healthcare provider moves it into
the uterus to view the inside of the organ.

Other tests can include:

 ovarian reserve testing to count the eggs after ovulation

 pelvic ultrasound to produce an image of the uterus and ovaries
 thyroid function test, as this may affect the hormonal balance
What are some complications of infertility?

If conception does not occur, it can lead to stress and possibly depression. Some physical effects may
also result from treatment for infertility. For example, a female could getTrusted Source ovarian
hyperstimulation syndrome (OHSS) from taking medications to stimulate the ovaries. Another
complication can be an ectopic pregnancy.

Multiple pregnancies may also result from fertility treatment. If there are too many embryos, carrying
all of them to term may causeTrusted Source health problems during the pregnancy.

How is female infertility treated?

Once your healthcare provider has diagnosed female infertility and pinpointed the cause, there are a
variety of treatment options. The cause of the infertility guides the type of treatment. For example,
structural problems may be treated through surgery, while hormonal medications can be used for
other issues (ovulation issues, thyroid conditions).

Many patients will require artificial insemination (injecting washed sperm into the uterus after
ovulation) or in vitro fertilization (fertilizing eggs with sperm in the lab to make embryos, then
transferring the embryo into the uterus).
Adoption and gestational surrogacy may also be options for women with infertility who wish to start a
family.

How is female infertility treated?

Treatments for infertility include:

 Medications: Fertility drugs change hormone levels to stimulate ovulation.
 Surgery: Surgery can open blocked fallopian tubes and remove uterine fibroids and polyps.
Surgical treatment of endometriosis doubles a woman’s chances of pregnancy.

Types of fertility drugs for women

Some fertility drugs try to prompt ovulation in a woman who is not ovulating regularly.
Others are hormones a woman must take before artificial insemination.

Drugs to cause ovulation

Some women ovulate irregularly or not at all. About 1 in 4 women with infertility have issues with
ovulation.

Drugs that can treat ovulation issues include:

 Metformin (Glucophage): This can decrease insulin resistance. Women with polycystic ovary
syndrome (PCOS), especially those with a body mass index over 35, may be insulin resistant,
which can cause problems with ovulation.

 Dopamine agonists: These drugs reduce levels of a hormone called prolactin. In some women,
having too much prolactin causes ovulation issues.

 Clomiphene (Clomid): This drug can trigger ovulation. Many doctors recommend it as the first
treatment option for a woman with ovulation problems.

 Letrozole (Femara): Like clomiphene, letrozole can trigger ovulation. Among women with PCOS,
especially those with obesity, letrozole may work better. A 2014 studyTrusted Source found that
27.5 percent of women with PCOS who took letrozole eventually gave birth, compared to 19.1
percent of those who took clomiphene.
 Gonadotropins: This group of hormones stimulates activity in the ovaries, including ovulation.
When other treatments do not work, a doctor may recommend using a follicle-stimulating
hormone and a luteinizing hormone in the group. People receive this treatment as an injection
or nasal spray.

Hormones before artificial insemination

Drugs cannot treat some causes of infertility.

When this occurs, or when a doctor cannot identify the cause of infertility, they may recommend
artificial insemination.

Intrauterine insemination (IUI) involves inserting sperm directly into the uterus around the time of
ovulation.
It may improve the chances of conceiving when there is an issue with the cervical mucus or the
mobility of the sperm, or when the doctor cannot detect the cause of infertility.

A doctor may recommend taking the following before IUI:

 Ovulation drugs: Clomiphene or letrozole, for example, can induce the body to ovulate and,
possibly, to release extra eggs.

 Ovulation trigger: Because timing the moment of ovulation is essential, many doctors
recommend an ovulation “trigger” shot of the hormone human chorionic gonadotropin (hCG).

 Progesterone: This hormone can help sustain early pregnancy, and a woman usually takes it via
a vaginal suppository.

In vitro fertilization (IVF) involves removing one or more eggs so that a doctor can fertilize them with
sperm in a petri dish. If the eggs grow into embryos, the doctor implants them into the uterus.
IVF requires several drugs, including:

 Ovulation suppression: If a woman ovulates too early, IVF may not work. Many doctors
prescribe gonadotropin antagonist hormones to prevent early ovulation.

 Ovulation drugs: IVF is more likely to succeed, like IUI, if the ovaries to release several eggs. A
doctor will prescribe clomiphene or letrozole to cause this.

 Ovulation trigger shot: IVF also has a better chance of success if the doctor can control the
moment of ovulation using a trigger shot with the hormone hCG.

 Progesterone: A woman receiving IVF will take progesterone to help support early pregnancy.

When treating infertility, a doctor may recommend taking hormonal birth control temporarily to help
regulate the menstrual cycle. It can also help prepare the body for artificial insemination

Side effects

Many women experience side effects of fertility drugs, especially those that contain hormones.
The most common side effects include:

 mood changes, including mood swings, anxiety, and depression

 temporary physical side effects, including nausea, vomiting, headaches, cramps, and breast
tenderness
 ovarian hyperstimulation syndrome
 multiple births
 increased risk of pregnancy loss
Injected Hormones

If Clomid on its own doesn't work, your doctor may recommend hormones to trigger ovulation. Some
of the types are:

 Human chorionic gonadotropin(hCG), such as Novarel, Ovidrel, Pregnyl, and Profasi. This
medication is usually used along with other fertility drugs to trigger your ovaries to release an
egg.

 Follicle-stimulating hormone (FSH), such as Bravelle, Fertinex, Follistim, and Gonal-F. These
drugs trigger the growth of eggs in your ovaries.

 Human menopausal gonadotropin (hMG), such as Menopur, Metrodin, Pergonal, and Repronex.
This drug combines FSH and LH (luteinizing hormone).

 Gonadotropin-releasing hormone (GnRH), such as Factrel and Lutrepulse. This hormone triggers
the release of FSH and LH from your pituitary gland, but it's rarely prescribed in the U.S.

 Gonadotropin-releasing hormone agonist (GnRH agonist), such as Lupron, Synarel, and Zoladex.

 Gonadotropin-releasing hormone antagonist (GnRH antagonist), such as Antagon and Cetrotide.

These drugs aren't pills that you swallow. Instead, you take them as shots. The dose varies, depending
on how they're being used.

Some are given beneath the skin, while others are injected into the muscle. You can get the injections
on your stomach, upper arm, upper thigh, or buttocks.

You usually start taking them during your cycle, the second or third day after you see bright red blood,
and continue taking them for 7 to 12 straight days. Sometimes, you may need to get injections along
with Clomid that you take by mouth.

Side effects: Most are mild and include problems like tenderness, infection, and blood blisters,
swelling, or bruising at the injection site. There's also a risk of a condition called ovarian
hyperstimulation, which makes your ovaries grow and become tender.