July 16, 2021

When Trying Hasn’t Worked: Understanding Fertility Options for Women

By Dylan Snow, SWHR Communications Intern

More than 10 percent of couples in the United States experience infertility – the inability to conceive after trying for at least a year with frequent, unprotected sex – with some estimates as high as 15 percent.

A variety of factors can cause infertility in both men and women. It is estimated that in one-third of cases, there is an issue with the male reproductive system, such as low sperm count or damage to reproductive organs. In another third, there is an issue in the female reproductive system, such as blocked fallopian tubes or endometriosis. In the remaining third, both partners have fertility issues or the cause is undetermined.

One unavoidable factor for women is age, with fertility gradually declining through the mid-30s and decreasing more rapidly in her 40s. Alcohol, tobacco, and marijuana use may also decrease fertility, as well as being over or underweight.

How Can I Diagnose a Fertility Issue?

number of tests can be used to try to determine the cause of infertility in women. Blood tests can assess levels of specific hormones involved in the reproductive process. Ovulation tests can measure luteinizing hormone – high levels of which suggest that a woman is ovulating or near ovulation – and an ovarian reserve test can help determine the number of eggs available for ovulation.

Imaging tests such as an ultrasound can also be performed to look for abnormalities in the uterus or ovaries. A hysterosalpingography (HSG) is a procedure in which a special fluid is injected into the uterus and fallopian tubes while an X-ray is taken to look for blockages. Although HSG is used to determine if the tubes are blocked, many women conceive in the first three to six months after undergoing the procedure. The so called “flushing of the tubes” during the HSG procedure has a beneficial effect on fertility. One theory is that the contrast dislodges mucous plugs that have caused a temporary obstruction.

One of the advantages of tubal flushing is that the benefit continues over time, unlike IVF which only helps for the current cycle. Tubal flushing also helps achieve an otherwise natural conception, and the cost is a fraction of an IVF cycle. IVF can also have a significant negative impact on a women’s emotional well-being, and can cause medical complications. According to a recent study, “the risk of babies being born too small, too early, or with birth defects is higher in babies conceived by IVF.” The study also found there was a higher risk of mortality in the first few weeks of life.

On rare occasions, a doctor might perform a hysteroscopy, in which a device called a hysteroscope is inserted through the cervix into the uterus to search for abnormalities. Alternatively, a doctor may perform a laparoscopy – a minimally invasive surgical procedure that views the uterus, fallopian tubes, and ovaries.

What Are My Options?

For many couples, infertility causes great distress and concern. Fortunately, there are treatment options available that may increase fertility for both women and men, to varying degrees of access, cost, and invasiveness.

Assisted reproductive technology (ART) is any procedure that involves the handling of eggs or sperm, the most common of which is in vitro fertilization (IVF). In IVF, eggs are retrieved, fertilized in a lab, and then implanted in the uterus. This option allows for the donation of either egg or sperm, as well as for the use of a gestational carrier (or surrogate). Success rates for IVF depend on a number of factors, including the reason for infertility, where you’re having the procedure done, and your age.

Women with an ovulation disorder are typically prescribed fertility medications that provide hormones to stimulate the ovaries and trigger ovulation. Drugs such as clomiphene citrate and letrozole have been shown to increase fertility, with live birth rates of around 20%. Intrauterine insemination (IUI) may be used in cases of male infertility or unexplained infertility. This procedure involves placing healthy sperm in the uterus around the time of ovulation and is sometimes used in conjunction with fertility drugs.

If the cause of infertility is another condition, such as diabetes, treatment for the comorbidity is sometimes enough to increase fertility. Some causes of infertility – such as endometriosis, uterine fibroids, or endometrial polyps – can be treated surgically by removing the abnormal tissue or growths. Furthermore, changes in lifestyle can have a huge impact on fertility. Exercise, reducing substance use, and even timing of sexual intercourse can improve success of conceiving.

Access to Fertility Assistance Can Be Challenging

Unfortunately, many health insurance policies in the United States do not cover fertility services, so cost can be a huge barrier for patients. Costs for fertility services can add up quickly, totaling thousands of dollars. The Society for Assisted Reproductive Technology estimates IVF averages $10,000 to $15,000 per cycle in the U.S.

It is critical for patients to first contact their health insurance providers to learn what is covered before undergoing fertility testing and treatment. According to the Kaiser Family Foundation, only 15 states require some private insurers to cover some fertility treatment and only one state Medicaid program covers any fertility treatment at all.

Research shows that there are racial disparities when it comes to addressing infertility. Non-Hispanic white women are more likely to receive fertility treatment than women of other races. Black women are less likely to visit a doctor for help getting pregnant and often wait longer after experiencing infertility to see a doctor.  Increasing awareness about the potential challenges for conception and addressing stigma surrounding infertility are needed so that women feel empowered to seek the necessary care and support.

There remains a large gap in reproductive health research in men, likely in part due to the way that medicine and social norms historically view women as the focus of reproductive health. As a result, there are fewer treatments for male infertility, and even knowledge about the subject is lower among men than women.

Women would greatly benefit from increased access to a broad spectrum of fertility treatment options including cost effective  and less invasive procedures that lead to better outcomes for mother and baby.