Fertility Challenges

Common causes of difficulty conceiving, and the tests and treatments involved, with sources cited.

When to see a doctor

  • ASRM's committee opinion states that for couples with regular, unprotected intercourse and no known cause of impaired fertility, evaluation should be initiated at 12 months when the female partner is under 35 years of age, and at 6 months when the female partner is 35 years of age or older.Source: ASRM
  • ACOG's patient FAQ states that experts recommend an infertility evaluation if pregnancy has not occurred after 1 year of regular intercourse without birth control; if a woman is older than 35, evaluation is recommended after 6 months of trying; and if she is older than 40, ACOG advises talking with an ob-gyn now about an evaluation, rather than waiting.Source: ACOG
  • ASRM's 2021 committee opinion on fertility evaluation of infertile women notes that in women over 40, more immediate evaluation and treatment may be warranted, rather than waiting the standard 6-month threshold used for women 35 and older.Source: ASRM
  • ASRM's 2021 committee opinion states that diagnostic testing for infertility should be initiated without delay, regardless of how long a couple has been trying, when a person presents with a condition already known to cause infertility - including irregular menstrual cycles, cycle length under 25 days, intermenstrual bleeding, oligomenorrhea, or amenorrhea; known or suspected uterine, tubal, or peritoneal disease including endometriosis; or known or suspected male subfertility.Source: ASRM
  • ASRM's 2021 committee opinion notes that a fertility evaluation may also be appropriate for some women who do not otherwise meet the definition of infertility, for example to inform care around recurrent pregnancy loss or to plan assisted reproductive technology treatment.Source: ASRM
  • The NHS advises seeing a GP if you haven't conceived after a year of regular unprotected sex, but recommends seeing a GP sooner - women aged 36 and over, or anyone already aware they may have a fertility problem, should not wait the full year before seeking advice.Source: NHS

IVF & IUI overview

  • In IUI, sperm is 'washed' in the lab to concentrate it and remove seminal fluid, then a thin catheter is passed through the cervix to slowly inject the prepared sperm directly into the uterus around the time of ovulation, bypassing the cervix.Source: ASRM
  • IUI is a brief, usually painless in-office procedure (some mild cramping possible) and is commonly used for unexplained infertility, cervical scarring that blocks sperm passage, certain male-factor issues, or alongside ovulation-inducing medication.Source: ASRM
  • IVF involves several stages: ovarian stimulation with fertility medication over roughly 8-14 days (monitored by ultrasound and blood tests), egg retrieval via a needle about 36 hours after a trigger injection, fertilization of eggs with sperm in a lab dish (sometimes using ICSI), embryo culture for a few days, and embryo transfer into the uterus via catheter; extra embryos can be frozen.Source: ASRM
  • IVF is used for a wide range of situations, including blocked or damaged fallopian tubes, male-factor infertility, endometriosis, unexplained infertility, use of donor eggs or a gestational carrier, and family-building for LGBTQIA+ or single people.Source: ASRM
  • According to ASRM's clinical guideline, IUI is generally considered first-line treatment for unexplained or mild male-factor infertility because it is less invasive and less costly than IVF, while IVF is 'the most effective form of treatment for nearly all causes of infertility, but is substantially more invasive and more costly than other methods of treatment.'Source: ASRM
  • For couples with unexplained infertility, ASRM's guideline notes that in women under about 35-38, studies found no significant difference in pregnancy rates between ovulation stimulation with IUI and IVF, but for women 38 and older, immediate treatment with IVF produced higher live-birth rates than IUI-based approaches.Source: ASRM
  • A typical treatment strategy in this guideline is to first try about 3-4 cycles of ovulation stimulation combined with IUI using oral fertility medication, and to move to IVF if that is unsuccessful, rather than escalating to IUI with injectable gonadotropins.Source: ASRM
  • The most invasive step of IVF is egg retrieval, done with a thin needle guided by transvaginal ultrasound; documented risks include mild medication side effects (nausea, breast tenderness), ovarian hyperstimulation syndrome (OHSS) in under 1% of cases, and rare procedural complications such as infection or organ injury.Source: ASRM
  • In the NHS's description of the IVF process, a full IVF cycle typically takes about 3 to 6 weeks: ovulation suppression (2-3 weeks), egg stimulation (2 weeks), egg collection (about 20 minutes under sedation), lab fertilization, and embryo transfer, with a pregnancy test roughly 16 days after transfer.Source: NHS

Secondary infertility

  • Secondary infertility is defined as having had one or more pregnancies in the past, but now having difficulty conceiving again.Source: NHS
  • ASRM's clinical glossary formally defines secondary female infertility as "a condition in which a woman is diagnosed as infertile following a previously confirmed clinical pregnancy" (distinguished from primary infertility, where no prior pregnancy has occurred).Source: ASRM
  • ASRM's patient fact sheet on defining infertility states that a fertility evaluation should generally begin after 12 months of trying to conceive for those under 35, or after 6 months for those 35 or older — the same timelines used for a first pregnancy, with no separate rule for those trying again after a prior pregnancy.Source: ASRM
  • NHS guidance similarly advises seeing a doctor after a year of trying without success, but sooner — for those 36 or older, or anyone already aware of a possible fertility problem — which applies equally to people who have conceived before.Source: NHS
  • NHS lists declining fertility with age as a general risk factor for infertility, which is relevant to secondary infertility since time has passed since a prior pregnancy even when no problems existed before.Source: NHS
  • MedlinePlus defines infertility broadly as not being able to become pregnant after a year of trying (or repeated pregnancy loss), a definition that does not depend on whether a person has previously carried a pregnancy.Source: MedlinePlus (NIH)
  • ASRM's patient fact sheet on infertility counseling notes that infertility "touches all aspects of your life" and can bring persistent sadness, guilt, anxiety, mood swings, and social withdrawal, and recommends that people experiencing these reactions seek support from family, friends, or a mental health professional.Source: ASRM

Educational reference only — not medical advice. Every fertility journey differs. Always consult your doctor or midwife.

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