Why Can’t I Get Pregnant?

Infertility is a complex but common health issue that impacts millions of individuals and couples. Struggling to have a baby is a deeply emotional and challenging experience. Dr. Sunny H Zhang, MD, discusses what contributes to trouble getting pregnant, signs of infertility and when to see a doctor.

What is Infertility?

Infertile, by definition, is when a couple hasn’t been able to conceive after one year of unprotected intercourse. However, this timeline also depends on age and other factors. Infertility involves four key factors:

1. Ovulation: Irregular (too short or too long) or absent menstrual cycles can mean ovulatory dysfunction (the ability to release an egg normally) and contribute to infertility.
2. Anatomy: Blocked or damaged fallopian tubes, adhesions, inflammation in the pelvis or abnormalities in the uterus can prevent fertilization.
3. Sperm quality: Poor sperm quality and/or quantity impacts fertility.
4. Egg or embryo quality: Ovarian reserve (the number and health of the eggs in a woman’s ovaries) decreases with age. Chances of conception per month also declines with age — accelerating after age 35.

What is Unexplained Infertility?

About 10% of couples are diagnosed with unexplained infertility. It occurs when baseline fertility evaluations don’t reveal obvious issues preventing pregnancy. It doesn’t mean there’s no underlying problem. Instead, further evaluation is needed.

Dr. Zhang says, “In many cases of unexplained infertility, underlying causes like endometriosis, autoimmune conditions or decreased ovarian reserves or egg quality may be the cause but not immediately apparent.”

Your doctor will assess the following things in a baseline fertility workup:

• Ovulation status: A doctor checks to see if, when and how well a woman releases eggs from her ovaries. Blood tests or ultrasounds can determine if ovulation is happening. A woman can track her ovulation with a prediction kit, basal body temperature graph and cervical mucous changes.
• Semen analysis: This test looks at how many sperm are in the semen, how well they move and if they’re shaped normally.
• Hysterosalpingogram (HSG) and TVUS: This checks to see if a woman’s fallopian tubes are open and whether the uterine cavity is normal.

What is Secondary Infertility?

Secondary infertility is when someone didn’t have trouble getting pregnant with their first baby but struggles with their second.

“The outcome for couples or individuals with secondary infertility is more favorable in terms of chances getting pregnant,” Dr. Zhang says.

When to Get Help for Infertility

Dr. Zhang recommends the following guidelines:

• Under 35 years old: Wait a full year before getting evaluated.
• 35-39 years old: Get evaluated after six months of trying to get pregnant.
• Over 40 years old: Option to get evaluated immediately or wait three months.

There are exceptions to these guidelines. If a woman has chronic, irregular periods (more than six months), she doesn’t have to wait an entire year to be evaluated for infertility. Regular menstrual cycles are defined as having a period every 21-35 days.

Additionally, Dr. Zhang says anyone who wants an infertility evaluation has a right to one whenever they choose. “Many times, evaluation depends on the person’s age, size of family they want and other hopes or concerns.”

Signs and Symptoms of Infertility

If you’re having trouble conceiving, knowing the signs and symptoms of infertility can help you and your doctor pinpoint potential causes. These include:

• Decreased sex drive
• Difficulty with penetrative intercourse
• Irregular or absent periods (abnormal amount of bleeding or pattern)
• Low sperm count
• Painful periods
• Pain with intercourse
• Pelvic pain
• Trouble ejaculating

In addition to these symptoms, there may be other reasons you can’t get pregnant. Consider these underlying conditions:

• Congenital abnormalities of the uterus: Such as unicornuate uterus (a person who has one fallopian tube and an abnormally shaped uterine cavity), biconuate uterus (where two chambers of the uterus are joined together) or septate uterus (when the uterus is shaped like a heart and the two sides aren’t fully joined together)
• History of autoimmune disease: Such as Celiac disease, type 1 or 2 diabetes or Hashimoto’s thyroiditis
• Inflammation: Can damage the fallopian tubes, ovaries and uterus due to chlamydia, a ruptured appendix or major abdominal surgeries — such as a bowel resection
• Known reproductive diagnosis: Such as polycystic ovarian syndrome (PCOS) or endometriosis
• Known history of chemotherapy or radiation: Particularly of the pelvic and abdomen
• Obesity: Related to infrequent menstrual cycles

“People with these conditions can start their infertility evaluation early,” Dr. Zhang says.

Causes of Infertility In Women

Is Infertility Genetic?

While infertility isn’t inherited through family members, there are multiple genetic conditions that cause infertility and can be passed down through generations.

“For example, in cystic fibrosis, a genetic disorder, the male is usually infertile due to a bodily obstruction. In females, PCOS, endometriosis and Hashimoto’s can all run in families and contribute to infertility,” Dr. Zhang says.

How Does PCOS Cause Infertility?

A hormonal disorder, PCOS is diagnosed based on two out of three criteria: chronic irregular periods, signs of a high male hormone levels causing things like acne, excessive facial or body hair and elevated lab values as well as ultrasound evidence of polycystic ovaries. While not all women with PCOS have absent menstrual cycles, it’s a symptom in about 60% of those diagnosed with the condition.

Do Ovarian Cysts Cause Infertility?

Most ovarian cysts don’t impact for fertility, but some can interfere with getting pregnant in the following ways:

• Endometrioma: Cysts caused by endometriosis. It presents in an advanced staged endometriosis and causes infertility.
• PCOS: Small, ovarian cysts from PCOS affect ovulation. Medication may be needed to induce a menstrual cycle.
• Functional cysts, cystadenomas, dermoid cysts: These cysts generally don’t affect fertility.

How Does Endometriosis Impact Fertility?

Endometriosis impacts fertility by causing inflammation and bands of scar tissue, known as adhesions, in the pelvis area. This can lead to blocked fallopian tubes or create an unfavorable environment for conception to occur and develop.

Dr. Zhang says reports show about 30-50 percent of infertile women have endometriosis.

“Laparoscopic surgery is the gold standard for diagnosing endometriosis. Although severe cases can be seen on an ultrasound or MRI, negative imaging studies (the condition doesn’t show on imaging) don’t mean endometriosis isn’t present,” she says.

Even mild cases of endometriosis are enough to cause infertility due to inflammation in the pelvis. In fact, it’s the most common cause of unexplained infertility.

Infertility patients with endometriosis are typically treated with medication, intrauterine insemination (a fertility treatment that involves placing sperm directly into the uterus), surgery or In Vitro Fertilization.

Does Birth Control Make You Infertile?

Birth control pills and emergency contraception, like Plan B, don’t cause infertility. They can temporarily affect fertility, especially if used for extended periods without breaks. Fertility returns once birth control is stopped.

Can Sexually Transmitted Diseases (STDs) Cause Infertility?

Yes, STDs such as chlamydia and gonorrhea can cause infertility. Whether you have symptoms or not, they can both lead to blocked fallopian tubes and adhesions in the pelvis. They also increase the risk of an ectopic pregnancy.

Can Diet Cause Infertility?

There’s online chatter about whether foods and drinks, like matcha and some cereals, cause infertility, but Dr. Zhang says both are fine.

 “Drinking green tea is common in Asian cultures, and you don’t see major infertility problems in those countries. I don’t think there’s any good clinical studies that say how much matcha is too much. I would worry more about the amount of caffeine you drink and calories from sweetened teas, because too much isn’t good for anyone.”

She recommends no more than two cups of coffee a day, which should be fine for matcha, too, given it contains less caffeine.

While some reports say Cheerios contain a chemical linked to infertility, Dr. Zhang assures, “The added amount is so small, I wouldn’t think it’s a concern.”

She says there are other lifestyle factors known to adversely impact fertility that deserve more attention, such as smoking.

“In women, smoking eats up your eggs and decreases your chances of ovulation. In men, it decreases sperm count and chances of pregnancy as well. Recreational drug use is also harmful for fertility.”

Dr. Zhang encourages individuals and couples to reduce the number of processed foods they eat as well, as it can negatively impact fertility by disrupting hormones, increasing inflammation and causing excessive weight gain.

“Keeping a normal body weight, positive attitude in achieving your goal, exercising regularly, taking prenatal vitamins and decreasing unnecessary life stressors are all helpful in improving your chances of getting pregnant and delivering a healthy baby,” she says.

Causes of Infertility in Men

About 40% of infertility cases are due to male factors, which is why it’s important for both partners to get checked out. Common signs and symptoms of infertility in men include:

• Erectile dysfunction
• Pain or swelling in the testicles
• Reduced sex drive

Male infertility causes include:

• Chronic conditions, like diabetes
• Heavy alcohol use
• History of sexual trauma or injury
• History of undescended testicles, testicular torsion
• Certain medications
• Smoking
• Taking testosterone supplements
• Varicose in scrotal area

How to Know if You’re Infertile

The best way to know if you’re infertile is to be evaluated by a doctor. Specific tests are recommended based on symptoms and medical history.

How to Test if a Woman is Infertile

To evaluate if a woman is infertile, a doctor may perform the following tests:

• Hormone testing: Assessing hormone levels related ovulation and other hormonal abnormalities.
• Imaging: Looking at the reproductive organs for anything abnormal.
• Physical exam: Checking for abnormalities in the reproductive organs.
• Review medical history: Discussing menstrual cycles, sexual history and previous pregnancies or miscarriages.
• Specialized tests: Using a hysterosalpingogram (HCG) test to check for blocked fallopian tubes, pelvic ultrasound to examine pelvic organs, hysteroscopy to evaluate and treat abnormalities in the uterus or laparoscopy (surgery) to directly visualize and treat abnormalities in the pelvis.

Infertility treatment for women depends on the underlying cause. Oral and injectable medications for ovulation, artificial insemination, surgery and/or In Vitro Fertilization can increase a woman’s chances of getting pregnant. 

How to Test if a Male is Infertile

Sometimes, a man is born infertile due to genetic mutations or chromosome abnormalities. However, a semen analysis is an affordable and easy way to know if a male is infertile. Dr. Zhang says it’s the first thing doctors do to look at the quantity and motility of sperm produced. A hormonal issue usually causes low sperm count, while environmental factors contribute to decreased motility.

A physical exam may also be conducted to look for things like varicocele, a condition where the veins in the scrotum become enlarged, undescended testicles or testicular cancer. Depending on the problem identified, medication, lifestyle modifications, surgery, artificial insemination or In Vitro Fertilization are options for treating male infertility.

When to Talk to Your Doctor About Infertility

If you’re thinking about getting pregnant and are concerned about your fertility, talk to your doctor. Depending on your age and underlying conditions, getting checked out sooner is sometimes recommended. Your doctor can go over what tests make sense for you and a path forward.