Unfulfilled desire to have children is one of the most common issues seen in gynaecology worldwide. Estimates suggest that about one in six people of reproductive age experience a period of infertility during their lives — regardless of background, sexual orientation or family structure. For many this is a mixture of hope, disappointment, physical strain and an emotional rollercoaster. The good news: diagnosis and treatment are better researched now than ever before. In this article you will learn what female infertility actually means, which symptoms should make you alert, which causes may be involved, how the diagnostic process works and what treatment options you can realistically expect — from cycle optimisation to IVF.
What does infertility mean in women?
The World Health Organization (WHO) defines infertility as a disease of the reproductive system in which a clinical pregnancy does not occur despite regular unprotected sexual intercourse for at least twelve months. Current data indicate that about one in six people of reproductive age worldwide are affected. You can find this classification in the current WHO factsheet on infertility and the report “1 in 6 people globally affected by infertility”.
- Primary infertility: No previous pregnancy has occurred.
- Secondary infertility: One or more pregnancies have occurred previously, but the desire to have a child is currently unmet.
Important is the perspective: infertility does not automatically mean that you will never become pregnant. It initially indicates reduced fertility and that a structured investigation is sensible. At the same time, WHO and professional societies emphasise that infertility should be recognised as a relevant health issue — with fair access to diagnostics and treatment.
Early signs: when should you be alert?
Female infertility is not a single condition but an umbrella term. Some women notice nothing at first, other than that conception is taking longer than expected. Others experience clear early signals.
- very irregular cycles or absent periods
- very heavy, very light or unusually long bleeding
- severe period pain, pain during sex or persistent lower abdominal pain
- signs of hormonal disorders such as excess body hair, hair loss or severe acne
- recurrent miscarriages or very early pregnancy losses
None of these signs is proof of infertility. However, they are reasons to document your cycle and to raise the topic of fertility and family planning with your doctor.
Common causes of female infertility
Professional societies such as ESHRE and ASRM broadly divide causes into hormonal disorders, anatomical changes, reduced ovarian reserve, genetic and immunological factors, as well as environmental and lifestyle influences. Often several factors are present together.
Hormonal disorders and PCOS
Hormone-related cycle problems are among the most common causes worldwide. Polycystic ovary syndrome (PCOS) is particularly prevalent. Typical features include infrequent or absent ovulation, elevated androgen levels and many small follicles on ultrasound.
- Signs of PCOS: irregular cycles, increased body hair, acne, weight gain, insulin resistance.
- Typical treatment components: weight normalisation, exercise, dietary changes, treatment of insulin resistance and medical induction of ovulation.
Ovulation disorders without PCOS
Ovulation can also be absent or infrequent without PCOS. Common causes are thyroid disorders, raised prolactin levels, marked weight changes, eating disorders, intensive competitive sport or pronounced stress.
- Warning signs: very long cycles, absent bleeding, large weight fluctuations.
- Treatment: stabilising hormone balance, for example thyroid medication, treatment of hyperprolactinaemia and gentle cycle regulation.
Endometriosis
In endometriosis, tissue similar to the lining of the uterus grows outside the womb, for example on the ovaries, fallopian tubes or peritoneum. This can cause inflammation, adhesions and pain — and significantly reduce fertility.
- Typical symptoms are severe period pain, pain during sex and chronic lower abdominal pain.
- Treatment: pain management, hormonal therapy and, when trying to conceive, often minimally invasive surgery, complemented by fertility treatments such as IUI or IVF/ICSI.
Tubal factor: problems with the fallopian tubes
Blocked, scarred or damaged fallopian tubes prevent the egg and sperm meeting or stop the embryo reaching the uterus safely. Common causes are previous pelvic infections, surgery or severe endometriosis.
- Diagnosis: contrast studies or specialised ultrasound techniques to assess tubal patency.
- Treatment: depending on severity, surgical reconstruction or direct IVF if the tubes are severely damaged.
Uterine factors and fibroids
Uterine malformations, polyps and certain fibroids can disrupt implantation and increase the risk of miscarriage — especially if they distort the uterine cavity.
- Diagnostics: transvaginal ultrasound, 3D ultrasound and hysteroscopy.
- Treatment: hysteroscopic removal of septa, polyps or submucosal fibroids when they affect the uterine cavity.
Reduced ovarian reserve and age
With increasing age, both the number and quality of eggs decline. Some women experience premature ovarian insufficiency well before the typical age of menopause. Surgery on the ovaries, chemotherapy or radiotherapy can further reduce the reserve.
Useful markers include the AMH level and the antral follicle count on ultrasound. They do not provide a crystal-ball prognosis but help to derive realistic chances and an appropriate treatment strategy.
Genetic and immunological causes
Certain chromosomal abnormalities, clotting disorders or autoimmune diseases can impair implantation or lead to recurrent miscarriages. In the presence of a striking history, genetic and immunological tests are therefore often recommended to avoid missing rare but relevant causes.
Unexplained infertility
In some cases, no clear cause is found despite thorough diagnostics — this is known as unexplained infertility. Current evidence-based guidelines from ESHRE usually recommend a combination of mild hormonal stimulation and insemination initially, before IVF is considered. A clear summary is available in the ESHRE guideline on unexplained infertility and the associated patient leaflet.
Diagnostics: how does the investigation proceed?
The fertility evaluation should give you clarity without subjecting you to unnecessary tests. The American Society for Reproductive Medicine has published a clear framework that is widely used internationally as a guide.
- History and interview: cycle pattern, previous pregnancies, miscarriages, surgeries, infections, medications, underlying conditions, family history, lifestyle.
- Physical and gynaecological examination: weight, blood pressure, thyroid, gynaecological exam with swabs as needed.
- Cycle monitoring: documentation of cycle length, bleeding pattern, pain and possible ovulation signs (cervical mucus, temperature chart, ovulation tests).
- Hormone profile: FSH, LH, estradiol, AMH, prolactin, TSH and, where necessary, androgens at the start of the cycle to assess ovarian reserve and hormonal balance.
- Transvaginal ultrasound: uterus, endometrium, ovaries, antral follicles, cysts or fibroids.
- Tubal assessment: contrast studies or ultrasound techniques to check fallopian tube patency — depending on risk and findings.
- Further imaging and endoscopy: hysteroscopy or laparoscopy if endometriosis, adhesions or structural abnormalities are suspected.
- Genetics and immunology: additional tests for recurrent miscarriages, very early ovarian failure or notable family history.
- Semen analysis: examination of the partner or donor according to the current WHO standard (WHO Laboratory Manual 2021) to assess sperm count, motility and morphology.
The ASRM Committee Opinion “Fertility evaluation of infertile women” summarises these steps concisely and emphasises: in women under 35 years of age, evaluation should begin after about twelve months without pregnancy; in women aged 35 and over, after six months. You can find the summary on the ASRM website.
Treatment options: what really helps?
The appropriate therapy depends on cause, age, duration of trying, health risks and your personal priorities. Modern fertility centres generally follow a stepped approach — from lower-intensity measures to more complex procedures.
Optimising natural fertility
Before invasive or very costly steps are taken, it is worth reviewing basic factors: well-timed intercourse, stress management, habits such as smoking or alcohol. The ASRM statement “Optimizing natural fertility” describes concrete strategies to improve spontaneous chances when trying for a baby.
Medical induction of ovulation
If ovulation is infrequent or absent, medications can stimulate egg maturation. Oral medications and, if necessary, hormonal injections are used to stimulate the pituitary gland or ovaries. The aim is a well-monitored, predictable ovulation with as few, well-controlled follicles as possible.
Intrauterine insemination (IUI)
In IUI, prepared sperm is placed directly into the uterus at the time of ovulation. This is useful for mildly reduced semen quality, cervical problems, certain sexual dysfunctions or unexplained infertility with otherwise favourable conditions. The ESHRE guideline on unexplained infertility often recommends IUI with mild stimulation as the first active treatment step.
In vitro fertilisation (IVF) and ICSI
In IVF, several eggs are retrieved after hormonal stimulation and combined with sperm in the laboratory. In ICSI a single sperm is injected directly into the egg. The resulting embryos are transferred back into the uterus after a few days. These techniques are mainly used for tubal factor, significant male-factor infertility, severe endometriosis or after unsuccessful simpler treatments.
Fertility preservation and donation options
Before treatments that may damage fertility — such as certain chemotherapy or radiotherapy — cryopreservation of eggs, embryos or ovarian tissue is often advisable. An evidence-based overview is provided by the ESHRE guideline “Female fertility preservation”. Depending on the country and legal framework, egg or embryo donation or surrogacy may be options; legal and ethical considerations should be carefully reviewed.
Chances of success and prognosis: how likely am I to conceive?
The most common question from couples or individuals is: “How likely is treatment to work?” There is no exact figure for an individual case, but large registry data show typical ranges. For example, the US health authority CDC publishes annual national ART data (assisted reproductive technology) with success rates by age group.
- Under 35, success rates per IVF embryo transfer in many registries are around 40 to 50 percent.
- Between 35 and 37 they usually fall to about 30 to 40 percent.
- Between 38 and 40 the rates are often in the range of about 20 to 25 percent.
- From the early forties they fall markedly per cycle into the low double-digit or single-digit percentage range.
These figures are averages across many clinics and patient groups — your personal prognosis may be better or worse. A useful view of real-world data is provided by the “National ART Summary” and the state reports in the ART surveillance portal of the CDC.
More important than the outcome of a single attempt is the cumulative chance over several well-planned treatment cycles. Time is a major factor: as age increases, egg quality and embryo stability decline. Early counselling and a realistic, shared strategy with your treatment team are therefore central.
Lifestyle, environment and prevention
You cannot influence every cause — but you can modify some risk factors. International organisations such as WHO, ESHRE and ACOG repeatedly emphasise the importance of lifestyle and environmental factors for fertility and pregnancy outcomes.
Lifestyle and nutrition
- Maintaining a healthy body weight supports hormones, ovulation and egg quality.
- Quitting smoking and moderating alcohol improves fertility and reduces pregnancy risks.
- Regular exercise reduces stress, benefits metabolism and promotes general wellbeing.
- An overall Mediterranean-style diet rich in vegetables, fruit, whole grains, pulses and healthy fats is associated in many studies with better fertility parameters.
- Folic acid is recommended before and in early pregnancy to reduce the risk of neural tube defects.
Environmental factors and endocrine-disrupting substances
Certain chemicals — for example some plasticisers, pesticides and industrial chemicals — can interfere with the hormonal system. Expert groups such as ESHRE have produced concise fact sheets on environmental factors and fertility.
- Avoid heating or storing hot foods and drinks in problematic plastic containers where possible.
- Prefer glass, stainless steel and ceramic, especially for long-term storage.
- Choose minimally processed foods where possible and read labels critically.
Think about fertility preservation early
If you plan to delay childbearing for career, personal or health reasons, or if you are due to undergo treatment that may damage the ovaries, early counselling on fertility preservation is worthwhile. Options such as egg or embryo freezing should be considered individually, with thorough medical and legal counselling.
Emotional impact: you are not alone
Unfulfilled desire to have children is more than a medical diagnosis. Many people experience shame, grief, anger, envy or a sense of failure. Treatments can be physically demanding, appointments and costs hard to plan, and waiting times between cycles exhausting.
This is why WHO and professional societies recommend psychosocial support as an integral part of fertility care. This can include specialist counselling at the fertility centre, psychotherapy, coaching, support groups or a well-moderated online community. It is important that you have a space where your feelings are acknowledged — independent of the medical outcome.
When should you seek medical help?
Guidelines from WHO, ASRM and ESHRE recommend similar timings for a fertility evaluation:
- After about twelve months of regular unprotected intercourse without pregnancy for women under 35 years of age.
- After about six months without pregnancy for women aged 35 and over.
- Independently of duration, seek help immediately if clear risk factors are present, such as very irregular or absent cycles, known endometriosis, previous serious pelvic infections, severely reduced partner semen quality or planned therapies that may harm fertility.
The first point of contact is usually your gynaecology practice. Depending on findings, you may be referred to a specialised fertility centre that offers extended diagnostics and treatments — from cycle monitoring and IUI to IVF and fertility preservation.
Conclusion: make informed decisions, step by step
Female infertility is common worldwide, complex — and more treatable today than ever before. Causes range from hormonal disorders, endometriosis and tubal problems to uterine changes, genetic and immunological factors as well as environmental and lifestyle influences. A wide range of options is available: robust diagnostics, evidence-based treatments, fertility preservation and psychosocial support. The most important step is not to face your questions alone. If your desire to have children remains unfulfilled or you notice warning signs, an early, well-informed evaluation is worthwhile. Together with your treatment team you can develop a plan that balances medical facts, personal values and financial considerations — and so optimises your chances of achieving your desired family.