Female Infertility
Evaluation and treatment of factors that may make it difficult to conceive
What is female infertility?
Conception needs an egg released, a route for it to travel that is open and mobile, a cavity prepared to receive an embryo, and sperm in adequate numbers. Infertility is a problem in any one of those, and about a third of the time the finding is on the male side, so both partners are assessed together from the start.
On the female side the common findings group neatly. Ovulation may not be happening. The tubes may be blocked or held out of position by scarring. The cavity may contain something that stops an embryo settling. Or the number of eggs remaining may have fallen with age.
Age is the factor that runs underneath all of it. Both the number and the quality of eggs decline, slowly through the thirties and faster after thirty-five, and that is what sets the pace of the workup as much as any result does.
What you might notice
- Trying for a baby without success
- Irregular or painful periods
How it is diagnosed
The workup is short and follows a set order. Ovulation is confirmed with a blood test in the second half of the cycle. Ovarian reserve is estimated with a hormone level and a count of the resting follicles on a scan early in the cycle. Both are usually done in a single month.
The tubes are then checked with a dye study, which shows whether they are open and where any blockage sits. A scan describes the uterus and the ovaries, and where it raises a question about the cavity, looking inside directly answers it.
A semen analysis is done at the same time and not afterwards. Testing one partner over several months while the other has not been tested at all is the commonest way this workup goes slowly, and time is the resource that is hardest to get back.
Recovery
The investigations themselves ask little of you. The dye study takes a few minutes and gives period-like cramping for an hour or two, and a day off is usually enough. Anything done through the cervix means cramping and spotting for a few days.
Where keyhole surgery has been done in the pelvis, allow two to four weeks. Trying again usually starts within a cycle or two, and where the tubes or the cavity have been corrected, the months immediately afterwards are the most productive ones, so the advice is generally to begin as soon as you are cleared.
The part that is rarely mentioned is how long the whole process feels. A workup takes a month or two, each treatment cycle takes another, and the waiting between them is the hardest part for most couples. Ask at each stage what the plan is if this step does not work, so there is never an empty month.
If it is left untreated
There is no danger in not pursuing this, and some couples conceive without any help after a long wait. Where everything tests normal and the woman is under thirty-five, a further six to twelve months of trying is a reasonable and evidence-based plan.
What is lost by waiting is time, and time is not neutral here. Ovarian reserve falls month by month and the chance of success from every treatment falls with it, so a plan that would have worked at thirty-four can be much harder at thirty-eight. That is the entire argument for starting the workup at a year of trying, or at six months over thirty-five.
Some underlying causes also progress while they are ignored, quietly narrowing the options that remain. A cause found and named is worth having even in a month when nothing is being done about it.
Questions about female infertility
When should we see someone about this?
After a year of regular unprotected intercourse if you are under thirty-five, and after six months if you are thirty-five or over, because ovarian reserve declines faster from that point and time changes the odds. Go earlier, without waiting, if your periods are irregular or absent, if you have known endometriosis or previous pelvic infection or pelvic surgery, if you have had more than one miscarriage, or if your partner has a known problem. Both partners are assessed together from the first visit, since about a third of the findings are on the male side and a semen analysis is the quickest test in the whole workup.
Does surgery improve the chance of conceiving naturally?
It does where there is something specific to correct. Removing a polyp or a fibroid that indents the cavity improves implantation. Excising endometriosis and dividing adhesions restores the anatomy so the tube can pick up an egg, and improves natural conception rates in mild and moderate disease. Clearing a blockage where the tube meets the uterus reopens a route that was closed. What surgery cannot do is change egg quality or reserve, so where the finding is a low reserve or advanced maternal age, an operation is not the answer and IVF is generally the more direct route.
Do I have to go straight to IVF?
No, and most couples do not. Treatment follows what the workup found. Where ovulation is the problem, tablets or injections to induce it are the first step and many conceive on those alone. Where the tubes are open and the count is only mildly reduced, IUI is a reasonable next step. Where a structural problem was found, correcting it and then trying naturally is often the plan. IVF is indicated where both tubes are blocked, where reserve is falling, where the male factor is severe, or where the simpler steps have been given a fair trial without success.
Other fertility & reproductive medicine treatments
Assessment and treatment of male factors that can affect sperm production, quality or delivery
Day CareAssisted reproduction in which eggs and sperm are combined in a laboratory before an embryo is transferred to the uterus
Day CareTalk to a care coordinator about female infertility
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one