Credit...Sophie Le Cuyer

Female Infertility: What to Do and How to Cope

The conception journey can be a long one. Here’s how to determine your risk for infertility, and how to manage if you’re diagnosed.

This guide was originally published on July 26, 2019 in NYT Parenting.

Soon after Jenny DiBenedetto and her husband got married in 2008, they tried to start a family. DiBenedetto was in her early 30s and didn’t want to waste any time — but her body, it seemed, had other plans. Although she took ovulation tests and knew when she was fertile, the pregnancy tests kept coming back negative. After a few months, her ob-gyn put her on hormone supplements but didn’t seem too concerned: Keep having sex, her doctor said, and you’ll eventually get pregnant.

For many women, the journey to conception is a long one. “The chance of getting pregnant, even for a young healthy couple, is not more than 20 percent, or one in five, every month,” said Dr. Alan Copperman, M.D., director of the Division of Reproductive Endocrinology and Infertility at Reproductive Medicine Associates of New York. A number of factors for women — including whether she smokes, is over 35, or is obese or underweight — can nudge these chances down further, and medical conditions such as polycystic ovary syndrome, endometriosis, diabetes and thyroid disease can also make getting pregnant harder.

DiBenedetto and her husband didn’t have any obvious risk factors for infertility, but they continued to struggle to conceive. After more months of frustration, they turned to a reproductive endocrinologist to get answers and help. Reproductive drugs and technologies such as in vitro fertilization can help many women, and 16 states now mandate that health insurance either cover or offer to cover some of these treatments.

For this guide, I spoke with three doctors who specialize in reproductive medicine and two women who have experienced infertility to explain why female infertility happens, how it is diagnosed and how it can be treated.

In a nutshell, you need sperm, eggs, unblocked fallopian tubes and a uterus to get pregnant, said Dr. William Hurd, M.D., a reproductive endocrinologist and chief medical officer at the American Society for Reproductive Medicine.

Of course, the process is a bit more intricate than that: A woman’s ovary needs to release a viable egg that then travels down a fallopian tube into the uterus. At some point along its journey — within 12 to 24 hours after its release — the egg must encounter a sperm that fertilizes it, and the fertilized egg needs to rest in a portion of the tube for 30 hours while the uterus prepares for its arrival. After that, the fertilized egg (or zygote) has to descend into the uterus, successfully implant and begin to grow.

Failure to ovulate or irregular ovulation are responsible for 40 percent of cases of female infertility. “The first thing we ask is, ‘How regular are your periods?’” Dr. Hurd said. If a woman is having periods every month, she’s probably ovulating. But if she misses periods, or if the window between the start of each period is more than 40 days long, then she may not be ovulating regularly.

Often, polycystic ovary syndrome, a health problem caused by an imbalance in reproductive hormones, is to blame. PCOS affects one in 10 women of childbearing age. Women may also have ovulation problems if they have hypothyroidism (an underactive thyroid gland); if their body produces too much prolactin (a hormone that promotes breast milk production); if they exercise strenuously; or if they are either underweight or overweight. Uncontrolled diabetes, kidney disease and liver disease can affect a woman’s ovulation patterns, too.

Having too few viable eggs, or what is called having a low ovarian reserve, can also reduce the chances of conception. Because women lose an estimated average of 1,000 eggs every month starting in puberty, those who are over 35 are at increased risk for having low ovarian reserve. Smoking also reduces ovarian reserve. In a 2008 study, for instance, doctors reported that nonsmokers were nearly three times more likely to get pregnant from I.V.F. than smokers. Women may also have low ovarian reserve if they have a family history of early menopause, if they have a single ovary or have had ovarian surgery, or if they have had chemotherapy or pelvic radiation therapy.

Another important factor that shapes fertility is whether a woman’s fallopian tubes are open so that eggs can travel from the ovaries to the uterus. Women with pelvic inflammatory disease, an infection of the reproductive organs that’s often caused by chlamydia or gonorrhea, are more likely to have damaged tubes than women who don’t have the condition.

Other kinds of uterine problems can affect fertility, too: Uterine fibroids (benign smooth muscle tumors that can develop inside or on the uterus) or uterine polyps (noncancerous growths attached to the uterus’s inner wall) can reduce the chances that a fertilized egg will implant. A woman with an irregularly shaped uterus may also have a harder time getting pregnant.

It’s also important to remember that one-third of fertility problems in heterosexual couples are due to problems with the male partner’s sperm and have nothing to do with the woman. Another one-third are due to problems in the woman alone, and the rest are due to problems in both the man and the woman. For this reason, doctors highly recommend that men have their sperm tested whenever a couple has fertility problems.

[Read our guide about male infertility]

If you’re under 35, you won’t technically be considered infertile until you’ve tried (and failed) to conceive for a year. If you’re over 35, you have to try for six months. But you don’t have to wait that long to see a doctor if you’re concerned. “We recommend that no one get too worried if they don’t get pregnant right away, but we have a lot of younger people who come in after, say, six months of trying,” Dr. Hurd said. (That “period of trying” should be calculated starting from the point at which you stopped using birth control.)

It is also a good idea to see a doctor if you’ve had two or more miscarriages. Recurrent miscarriages aren’t the same thing as infertility, but they can indicate an underlying genetic, anatomical or autoimmune problem that can be treated, Dr. Hurd said.

If you’re concerned about your fertility, you can choose to see your primary care doctor, your ob-gyn or a reproductive endocrinologist, who will probably start by doing a physical exam and asking questions about your menstrual cycle, how long you’ve been with your partner and if you’ve ever conceived with anyone else. The doctor might also order blood tests that can detect hormonal problems that might impair ovulation or indicate a low ovarian reserve.

If you don’t seem to have ovulation problems, or sometimes even if you do, your doctor might also suggest additional tests, which may require seeing a gynecologist or a reproductive endocrinologist. These include a hysterosalpingogram (HSG), an X-ray that checks to see if your fallopian tubes are open and that the shape of your uterus is normal. During this procedure, your doctor will inject a radioactive dye through a tube that’s threaded through your cervix. Your doctor will observe how the dye moves through your uterus and fallopian tubes, to visualize whether there’s a blockage.

A doctor may instead or also perform a sonohysterography (SHG), an ultrasound that can help your doctor visualize whether your uterus has any abnormalities. The procedure involves injecting fluid into the uterus via the cervix through a thin tube. This test is more accurately able to detect uterine abnormalities than the HSG, and does not involve radioactive exposure (which, with HSG, is still quite small).

A transvaginal ultrasound can also be used to estimate ovarian reserve.

Even if your doctor doesn’t identify a specific problem, you can still have trouble getting pregnant; it may be that “things are just a little out of line, even if individual components count as normal,” said Dr. Alan Penzias, M.D., a reproductive endocrinologist at Boston I.V.F. Fertility Clinic and associate professor at Harvard Medical School. This is exactly what happened to DiBenedetto: Although the ovarian reserve tests that her reproductive medicine doctor administered indicated she had fewer eggs than expected for her age, her doctor still wasn’t overly concerned. Other tests came back normal, too — yet she still couldn’t get pregnant.

If your doctors determine that you’re not ovulating regularly, they may prescribe oral drugs to induce ovulation, such as Clomid, which induces ovulation in about 70 to 90 percent of women. These drugs do, however, increase the chance of twin pregnancy to 6 percent (it is half that — 3 percent — without the drugs). In some cases, your doctor may prescribe an injectable drug, though these are usually reserved for women who are undergoing additional fertility treatments such as I.V.F. Some women with ovulation problems may also undergo intrauterine insemination (IUI), when a doctor places sperm directly into the woman’s uterus to maximize the chances of conception. DiBenedetto had three rounds of IUI, although none of them worked.

If both of your fallopian tubes are blocked, or if one tube is blocked and filled with fluid (a condition called hydrosalpinx), your doctor may recommend either laparoscopic surgery to open the tube or I.V.F. Your doctor may also recommend I.V.F. if your fertility issues aren’t clear-cut but other approaches fail. (Read more about I.V.F. here.)

Every health insurance plan is different, but most plans will pay for fertility testing if a woman under 35 has been trying for at least a year or a woman over 35 has been trying for at least six months. Couples who undergo testing before then may have to pay out-of-pocket.

To date, 16 U.S. states have laws that require health insurers to cover or offer coverage for infertility diagnosis and treatment — although in several states, these laws exclude coverage for I.V.F. (This is in part because I.V.F. is expensive: On average, each cycle costs between $12,000 and $17,000, without medication costs. DiBenedetto, who lives in South Carolina, had to pay out-of-pocket.)

Six states also have laws in place to protect or preserve a woman’s ability to have children prior to undergoing medical treatments that could cause infertility, such as for cancer. But coverage does, slowly, seem to be improving, Dr. Copperman said. “Between states actually forcing the issue, and some companies taking the lead on the issue, we’re seeing more insurance coverage than ever before,” he said.

[For more strategies for covering the cost of infertility diagnosis and treatment, see our guide to paying for I.V.F.]

Experiencing infertility can be devastating. Support groups can help. Resolve, an infertility non-profit, describes the pain of infertility as being “similar to the grief over losing a loved one, but it is unique because it is a recurring grief.” Loved ones can support women struggling with infertility by, most importantly, taking their grief and pain seriously.

Debra Kamin, 36, went through three rounds of I.V.F. before getting pregnant with twins in 2015. During the process, she said that well-meaning comments would often backfire. “People sometimes feel compelled, with the best of intentions, to say something to try to make it better — such as ‘Everything happens for a reason,’ or ‘You’ll get pregnant when the time is right,’” she said. But those comments hurt, she noted, because it’s hard to adopt that kind of big-picture perspective when you’re going through such a difficult process. “It really does feel like everything in the world is riding on the next one call from the doctor,” she said. “So really the best thing to do is just say, ‘That must be hard. How can I help you?’”

DiBenedetto agreed. “People often try to make the picture a little rosier for us —especially people who do have kids, who will say things like, ‘My kids were such a pain today, enjoy your freedom while you have it,’ or ‘Take time to travel,’ or ‘At least you get to sleep in,’ when that’s the furthest thing you care about at that moment,” she said.

DiBenedetto’s story does have a happy ending: She ended up receiving I.V.F. and, during her third round, she got pregnant. Her son, Sam, was born in 2013. Then, with one remaining viable frozen embryo, she became pregnant with her daughter, Rosie, born in 2015.

“When your body doesn’t do what it’s supposed to do, it is very frustrating,” DiBenedetto said. But in the end, “it worked out as it feels like it should have.”

Melinda Wenner Moyer is a mom of two and a science journalist who writes for Slate, Mother Jones, Scientific American and O, The Oprah Magazine, among other publications.