When you’re dealing with infertility, it’s normal to feel like other couples get pregnant easily, even automatically.
And while it’s true that some people conceive without much effort, there are always many things that must go right for that pregnancy test to turn positive—the release of hormones, the mechanics of fertilization, the timing.
If you’re one of the 1 in 6 people worldwide who has experienced infertility, or the inability to get pregnant after a year of trying, any hiccup in this process can prevent conception.
That’s why talking to your doctor and pursuing fertility testing is so important—your doctor will examine you and your partner to find out what could be stopping you from getting pregnant, and what you might be able to do to build your family.
We spoke to UNC Health Fertility specialist Anne Steiner, MD, about the steps of a typical fertility evaluation.
Testing for Male Factor Infertility
Infertility is not just a female problem: Roughly a third of cases are due to an issue with the female partner, but another third are due to an issue with the male partner; the final third are attributed to both partners or unexplained.
A man’s sperm has to take a relatively long swim—from the vagina up through the cervix and uterus and into the fallopian tubes to fertilize an egg, and it’s possible that something is preventing it from getting to its final destination.
“We assess the male factor with a semen analysis,” Dr. Steiner says. “The male will provide a semen sample, either at home or in a clinic, and we’ll analyze the volume, concentration and movement of sperm—the factors that determine whether sperm can make the journey from the vagina to the fallopian tubes.”
A variety of issues can affect sperm production and quality, including physical blockages, infections, immune system problems, hormone imbalances, certain medications and exposure to harmful chemicals.
Identifying Ovulation Disorders and Considering Age
Issues with ovulation are the most common cause of female infertility. If you have unpredictable menstrual cycles or don’t have a menstrual cycle, then your body may not be producing an egg for sperm to fertilize. One of the most common ovulation disorders is polycystic ovary syndrome.
A blood test can reveal whether the hormones associated with ovulation are present, Dr. Steiner says. A woman could use an over-the-counter ovulation testing kit to help time intercourse; these urine tests will reveal the presence of luteinizing hormone (LH), which is released a day before ovulation.
The blood test will include a measure of anti-mullerian hormone (AMH), which can give your doctor a sense of your remaining egg supply.
“Over time, the number of eggs remaining in the ovary declines, and there’s nothing that can be done to stop that process—not birth control or stopping ovulation,” Dr. Steiner says. “We used to think that this drop in quantity was the main driver of age-related declines in fertility, but we know now that it’s not because you run out of eggs, but because there’s an age-related drop in egg quality.”
Dr. Steiner says that for most women, egg quality remains stable until the age of 35. By the time a woman is 40, egg quality has slowly declined so that it is about half of what it was five years ago, and quality is considered very low after the age of 43. A woman may continue to menstruate until her early 50s, but a low-quality egg may not have the genetic material necessary for fertilization.
“This is important to recognize, because fertility treatments do not affect the quality of the egg,” Dr. Steiner says. “Treatments improve the likelihood that the sperm and the egg will come together, but there’s no method to reverse quality of eggs.”
In previous years, according to Dr. Steiner, a woman may have been told her AMH level as a general indicator of fertility because of how many eggs she had left. But now it’s considered a marker of how well someone will respond to ovarian stimulation during fertility treatment, when you might be preparing for an egg retrieval prior to in vitro fertilization.
Looking for a Fallopian Tube Blockage
For pregnancy to occur, the egg and sperm have to meet at a very specific rendezvous point: the fallopian tube. Sometimes, the fallopian tubes can be blocked because of birth defects, injuries, past surgeries, or diseases that can cause swelling and scar tissue. A blocked fallopian tube doesn’t cause any symptoms, so a woman may not know of this issue until she’s trying to conceive.
To test if the tubes are open, your doctor will perform a hysterosalpingogram (HSG). The first part of this exam will feel like a standard pelvic exam, as a speculum is inserted and liquid dye is inserted into the uterus. Then, the speculum is removed, and X-ray images are taken to see if the fluid travels from the uterus to the fallopian tubes. The exam typically takes about five minutes, and it’s safe for this fluid to be put into the body; you may experience some cramps or discomfort during and after.
Other Anatomical Factors and Unexplained Infertility
In addition to a semen analysis, blood test and hysterosalpingogram, Dr. Steiner says a fertility evaluation typically includes an ultrasound, which will allow your doctor to examine the uterus, ovaries and endometrium (the uterine lining). This exam can show whether cysts, fibroids or endometriosis may be affecting a woman’s ability to achieve or maintain a pregnancy.
Sometimes, these tests may not reveal an exact cause of infertility, but combined with other factors in your and your partner’s medical history, such as your age, weight or health conditions, your doctor may be able to determine the best route forward.
“Unexplained infertility is not uncommon,” Dr. Steiner says. “Age-related decline is a factor there. We also know that weight plays a role in ovulation and success rates of treatment. When either the male or female partner smokes, there’s a reduced probability of conceiving naturally, and women who use nicotine have lower ovarian reserve and an earlier age of menopause.”
When Should You See a Doctor for Infertility?
If a female partner is younger than age 35, couples are encouraged to try to conceive on their own for a year before consulting a doctor. If the female partner is 35 or older, it’s recommended to talk to a provider after six months of trying, due to concerns about egg quality and age.
There are exceptions, though.
“Women may already know about some of the issues occurring with their bodies, like irregular cycles,” Dr. Steiner says. “If you’ve had a history of surgery or infection that could have affected an ability to conceive, if there’s a known issue, then couples should seek an evaluation and talk to a provider sooner rather than later.”
If you have questions about fertility, talk to your doctor. If you need a doctor, find one near you.