If you've been unable to conceive within a reasonable period of time, seek help from your doctor for evaluation and treatment of infertility.
Fertility tests may include:
- Ovulation testing. An at-home, over-the-counter ovulation prediction kit detects the surge in luteinizing hormone (LH) that occurs before ovulation. A blood test for progesterone — a hormone produced after ovulation — can also document that you're ovulating. Other hormone levels, such as prolactin, also may be checked.
- Hysterosalpingography. During hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee), X-ray contrast is injected into your uterus and an X-ray is taken to detect abnormalities in the uterine cavity. The test also determines whether the fluid passes out of the uterus and spills out of your fallopian tubes. If abnormalities are found, you'll likely need further evaluation. In a few women, the test itself can improve fertility, possibly by flushing out and opening the fallopian tubes.
- Ovarian reserve testing. This testing helps determine the quality and quantity of eggs available for ovulation. Women at risk of a depleted egg supply — including women older than 35 — may have this series of blood and imaging tests.
- Other hormone testing. Other hormone tests check levels of ovulatory hormones as well as thyroid and pituitary hormones that control reproductive processes.
- Imaging tests. A pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a sonohysterogram, also called a saline infusion sonogram, is used to see details inside the uterus that can't be seen on a regular ultrasound.
Depending on your situation, rarely your testing may include:
- Other imaging tests. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease.
- Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
- Genetic testing. Genetic testing helps determine whether there's a genetic defect causing infertility.
Infertility treatment depends on the cause, your age, how long you've been infertile and personal preferences. Because infertility is a complex disorder, treatment involves significant financial, physical, psychological and time commitments.
Although some women need just one or two therapies to restore fertility, it's possible that several different types of treatment may be needed.
Treatments can either attempt to restore fertility through medication or surgery, or help you get pregnant with sophisticated techniques.
Fertility restoration: Stimulating ovulation with fertility drugs
Fertility drugs regulate or stimulate ovulation. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders.
Fertility drugs generally work like the natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They're also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs. Fertility drugs may include:
- Clomiphene citrate. Clomiphene citrate is taken by mouth and stimulates ovulation by causing the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
- Gonadotropins. Instead of stimulating the pituitary gland to release more hormones, these injected treatments stimulate the ovary directly to produce multiple eggs. Gonadotropin medications include human menopausal gonadotropin or hMG (Menopur) and FSH (Gonal-F, Follistim AQ, Bravelle). Another gonadotropin, human chorionic gonadotropin (Ovidrel, Pregnyl), is used to mature the eggs and trigger their release at the time of ovulation. Concerns exist that there's a higher risk of conceiving multiples and having a premature delivery with gonadotropin use.
- Metformin. Metformin is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of PCOS. Metformin helps improve insulin resistance, which can improve the likelihood of ovulation.
- Letrozole. Letrozole (Femara) belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion to clomiphene. Letrozole may induce ovulation. However, the effect this medication has on early pregnancy isn't yet known, so it isn't used for ovulation induction as frequently as others.
- Bromocriptine. Bromocriptine (Cycloset), a dopamine agonist, may be used when ovulation problems are caused by excess production of prolactin (hyperprolactinemia) by the pituitary gland.
Risks of fertility drugs
Using fertility drugs carries some risks, such as:
Pregnancy with multiples. Oral medications carry a fairly low risk of multiples (less than 10 percent) and mostly a risk of twins. Your chances increase up to 30 percent with injectable medications. Injectable fertility medications also carry the major risk of triplets or more (higher order multiple pregnancy).
Generally, the more fetuses you're carrying, the greater the risk of premature labor, low birth weight and later developmental problems. Sometimes adjusting medications can lower the risk of multiples, if too many follicles develop.
Ovarian hyperstimulation syndrome (OHSS). Injecting fertility drugs to induce ovulation can cause OHSS, which causes swollen and painful ovaries. Signs and symptoms usually go away without treatment, and include mild abdominal pain, bloating, nausea, vomiting and diarrhea.
If you become pregnant, however, your symptoms might last several weeks. Rarely, it's possible to develop a more-severe form of OHSS that can also cause rapid weight gain, enlarged painful ovaries, fluid in the abdomen and shortness of breath.
Long-term risks of ovarian tumors. Most studies of women using fertility drugs suggest that there are few if any long-term risks. However, a few studies suggest that women taking fertility drugs for 12 or more months without a successful pregnancy may be at increased risk of borderline ovarian tumors later in life.
Women who never have pregnancies have an increased risk of ovarian tumors, so it may be related to the underlying problem rather than the treatment. Since success rates are typically higher in the first few treatment cycles, re-evaluating medication use every few months and concentrating on the treatments that have the most success appear to be appropriate.
Fertility restoration: Surgery
Several surgical procedures can correct problems or otherwise improve female fertility. However, surgical treatments for fertility are rare these days due to the success of other treatments. They include:
- Laparoscopic or hysteroscopic surgery. These surgeries can remove or correct abnormalities to help improve your chances of getting pregnant. Surgery might involve correcting an abnormal uterine shape, removing endometrial polyps and some types of fibroids that misshape the uterine cavity, or removing pelvic or uterine adhesions.
- Tubal surgeries. If your fallopian tubes are blocked or filled with fluid (hydrosalpinx), your doctor may recommend laparoscopic surgery to remove adhesions, dilate a tube or create a new tubal opening. This surgery is rare, as pregnancy rates are usually better with IVF. For hydrosalpinx, removal of your tubes (salpingectomy) or blocking the tubes close to the uterus can improve your chances of pregnancy with IVF.
The most commonly used methods of reproductive assistance include:
- Intrauterine insemination (IUI). During IUI, millions of healthy sperm are placed inside the uterus close to the time of ovulation.
- Assisted reproductive technology. This involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a lab, then transferring the embryos into the uterus after fertilization. IVF is the most effective assisted reproductive technology. An IVF cycle takes several weeks and requires frequent blood tests and daily hormone injections.
Coping and support
Dealing with female infertility can be physically and emotionally exhausting. To cope with the ups and downs of infertility testing and treatment, consider these strategies:
- Be prepared. The uncertainty of infertility testing and treatments can be difficult and stressful. Ask your doctor to explain the steps for your therapy to help you and your partner prepare. Understanding the process may help reduce your anxiety.
- Seek support. Although infertility can be a deeply personal issue, reach out to your partner, close family members or friends, or a professional for support. Many online support groups allow you to maintain your anonymity while you discuss issues related to infertility.
- Exercise and eat a healthy diet. Keeping up a moderate exercise routine and eating healthy foods can improve your outlook and keep you focused on living your life despite fertility problems.
- Consider other options. Determine alternatives — adoption, donor sperm or egg, or even having no children — as early as possible in the infertility treatment process. This can reduce anxiety during treatments and disappointment if conception doesn't occur.
Preparing for your appointment
For an infertility evaluation, you'll likely see a reproductive endocrinologist — a doctor who specializes in treating disorders that prevent couples from conceiving. Your doctor will likely want to evaluate both you and your partner to identify potential causes and treatments for infertility.
What you can do
To prepare for your appointment:
- Chart your menstrual cycles and associated symptoms for a few months. On a calendar or an electronic device, record when your period starts and stops and how your cervical mucus looks. Make note of days when you and your partner have intercourse.
- Make a list of any medications, vitamins, herbs or other supplements you take. Include the doses and how often you take them.
- Bring previous medical records. Your doctor will want to know what tests you've had and what treatments you've already tried.
- Bring a notebook or electronic device with you. You may receive a lot of information at your visit, and it can be difficult to remember everything.
- Think about what questions you'll ask. List the most important questions first to be sure that they get answered.
Some basic questions to ask include:
- When and how often should we have intercourse if we hope to conceive?
- Are there any lifestyle changes we can make to improve the chances of getting pregnant?
- Do you recommend any testing? If so, what kind?
- Are medications available that might improve the ability to conceive?
- What side effects can the medications cause?
- Would you explain our treatment options in detail?
- What treatment do you recommend in our situation?
- What's your success rate for assisting couples in achieving pregnancy?
- Do you have any brochures or other printed materials that we can have?
- What websites do you recommend visiting?
Don't hesitate to ask your doctor to repeat information or to ask follow-up questions.
What to expect from your doctor
Some potential questions your doctor or other health care provider might ask include:
- How long have you been trying to become pregnant?
- How often do you have intercourse?
- Have you ever been pregnant? If so, what was the outcome of that pregnancy?
- Have you had any pelvic or abdominal surgeries?
- Have you been treated for any gynecological conditions?
- At what age did you first start having periods?
- On average, how many days pass between the beginning of one menstrual cycle and the beginning of your next menstrual cycle?
- Do you experience premenstrual symptoms, such as breast tenderness, abdominal bloating or cramping?