Infertility in women

Conception

New life begins when an egg is fertilised by a sperm. Ovulation is when an egg is released from one of the ovaries and it occurs around 14 days before the start of the menstrual period.

The egg is swept into the nearby fallopian tube and ushered towards the uterus (womb). If the egg is fertilised on its journey, it lodges in the womb lining (endometrium). Pregnancy then begins.

The monthly chance of a young fertile couple conceiving is approximately 25%. If there is no pregnancy after 12 months of trying (6 months if the woman is over the age of 35) there may be a fertility problem.

Fertility difficulties

Approximately one in six couples experience fertility difficulties. In most cases, the couple can be helped with assisted reproductive technologies.

Around one third of couple infertility originates in the woman, one third in the man and in one third of couples both partners have a fertility problem. No cause is found in around one in 10 couples investigated for infertility. This is called ‘unexplained’ or ‘idiopathic’ infertility.

Because people have children later in life than they used to, age-related infertility affects an increasing number of women and men. Read more about Age and reproductive outcomes on Your Fertility website.

Lifestyle factors also affect fertility. Read more on Weight and reproductive outcomes, and Effects of caffeine, alcohol and smoking on reproductive outcomes on Your Fertility website.

Causes of female infertility

Female infertility can be caused by:

• ovulation problems
• polycystic ovary syndrome (PCOS)
• problems with the fallopian tubes
• problems with the uterus
• endometriosis.

Ovulation problems causing female infertility

The menstrual cycle functions by several glands and their hormones working in harmony. For ovulation to occur, a part of the brain called the hypothalamus prompts the nearby pituitary gland to secrete hormones that trigger the ovaries to ripen eggs. Irregular or absent periods indicate that ovulation may be irregular or absent too.

The age of the woman is a significant fertility factor. The chance of pregnancy for a woman aged 40 years is only 5% per menstrual cycle. Ageing eggs are thought to be the cause.

A woman is born with her entire egg supply and, as time passes, these eggs become less viable. Other difficulties for women over 40 include increased risk of miscarriage and genetic abnormalities in the unborn baby.

Polycystic ovary syndrome causing female infertility

Polycystic ovary syndrome (PCOS) is the most common hormonal condition affecting women in their reproductive years. Around one in seven women have PCOS which can cause a range of symptoms including irregular periods (menstruation) and make it difficult for a woman to get pregnant. PCOS is mainly due to a hormonal imbalance rather than a disease of the ovaries.

Problems with the fallopian tubes causing female infertility

The egg is fertilised on its journey down the fallopian tube. A blocked or scarred fallopian tube can prevent the egg from meeting up with sperm.

Problems with the uterus causing female infertility

The fertilised egg lodges (implants) in the lining of the uterus. Some conditions in the uterus can hamper implantation including:

• fibroids – non-malignant tumours inside the womb
• polyps – small protrusions that grows out of lining in the uterus.

Problems with the cervix causing female infertility

At the top of the vagina is the neck or entrance to the uterus, called the cervix. Ejaculated sperm must travel through the cervix to reach the uterus and fallopian tubes.

Cervical mucus around the time of ovulation is normally thin and watery so that sperm can swim through it. However, in some women the cervical mucus is thick and this can hinder the sperm.

Endometriosis causing female infertility

Endometriosis is a condition in which cells from the lining of the uterus (the endometrium) migrate to other parts of the pelvis. It can damage the fallopian tubes and the ovaries and affect the movement of the egg and sperm.

Even if the fallopian tubes and ovaries are not damaged, endometriosis can affect fertilisation, embryo growth and implantation.

Diagnosis of female infertility

Tests for both the man and his partner are done in an infertility investigation. Tests for the woman may include:

• physical examination – including medical history
• blood tests – to check for the presence of ovulation hormones
• laparoscopy – a ‘keyhole’ surgical procedure in which an instrument is inserted through a small incision in the abdomen so that the reproductive organs can be examined
• ultrasound scans – to check for the presence of fibroids and other conditions.

The male partner's semen will also be analysed to make sure that he is fertile.

Treatment for female infertility

Treatment options for female infertility depend on the cause, but may include:

• surgery
• ovulation induction (using hormone treatment)
• assisted reproductive technologies (ART) including in-vitro fertilisation (IVF).

Surgery for female infertility

Female infertility can be caused by obstructions within the reproductive organs. Some of the problems that can be addressed by surgery include:

• fibroids – non-malignant tumours growing inside the uterus
• polyps – small protrusions that grows out of lining in the uterus endometriosis – the growth of endometrial tissue outside the uterus, which can block the fallopian tubes
• abnormalities of the uterus – such as a uterine septum
• ovarian cysts – which can be drained or removed.

These days, most reproductive surgery is performed by keyhole surgery using a laparoscope (through the abdomen) or a hysteroscope (through the cervix and into the uterus). Occasionally, this may not be possible for a variety of reasons and open surgery (a surgical incision in the abdomen) may be necessary.

Ovulation induction for female infertility

Irregular or absent periods usually means that ovulation is also irregular or absent. Ovulation can be induced with a range of medications in tablet or injectable forms. Oral medications such as clomiphene citrate (Clomid, Serophene) can increase in the release of hormones from the brain which stimulate ovulation.

Injectable forms of the hormones that prompt the ovaries to mature and release an egg, can also be used to stimulate ovulation. the response to the hormones is closely monitored with blood tests and ultrasound.

Sometimes, the response to injectable hormones is excessive, and this can cause a condition known as ovarian hyperstimulation syndrome (OHSS). The symptoms include oedema (fluid retention), abdominal pain and bloating. Regular blood tests are used to help fine-tune the dosage and minimise the risk of OHSS.

Assisted reproductive technologies (ART) including in-vitro fertilisation (IVF)

Assisted reproductive technologies (ART) is the term used for procedures that involve retrieval of eggs from the ovaries and handling of eggs and sperm in a laboratory. It includes in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), which is used when there is a male cause of infertility. ART involves hormone stimulation to make the ovaries produce several eggs rather than the one which normally matures every month. When the eggs are ‘ready’ they are retrieved in an ultrasound-guided procedure.

In the case of IVF the eggs are mixed with sperm from the male partner or a donor, and in the case of ICSI each egg is injected with a single sperm. Two to 5 days later an embryo is transferred to the woman’s uterus using a thin tube that is inserted through the cervix. If there is more than one embryo, these can be frozen for future use.
Read more on assisted reproductive technologies (ART).

Risks of assisted reproductive technologies

Health problems associated with the use of assisted reproductive technologies include:

• ovarian hyperstimulation syndrome (OHSS)
• an increased incidence of multiple pregnancies
• an increased risk of premature labour and low birth weight
• an increased risk of caesarean delivery.

Read more on possible health effects of IVF.

Pregnancy isn't always possible

Despite the sophistication of ART, they don’t guarantee pregnancy. Success depends on a range of factors, including the reasons for the woman's infertility, her age and the type of technology used.

This calculator helps you estimate the chance of having a baby with IVF.

Where to get help

• Your GP (doctor)
• A fertility specialist
• Obstetrician or Obstetrician-gynaecologist
• IVF clinic
• Victorian Assisted Reproductive Treatment Authority (VARTA)
• Sexual Health Victoria (SHV). To book an appointment call SHV Melbourne CBD Clinic: (03) 9660 4700 or call SHV Box Hill Clinic: (03) 9257 0100 or (free call): 1800 013 952. These services are youth friendly.
• Public hospital