Written by: Leah Bedrosian, MPH
Published on: August 19, 2021
Updated on: July 1, 2022
Reviewed by: Denise John, PhD
Our science and research team launched goop PhD to compile the most significant studies and information on an array of health topics, conditions, and diseases. If there is something you’d like them to cover, please email us at [email protected].
If the careful timing of menstrual cycles isn’t working and you’ve been trying to conceive for a while, you may want to seek more options. This can be incredibly difficult emotionally, mentally, and physically. The good news is: There are many options for women, men, and couples who want to conceive. The research is starting to tell us more about new possible strategies and interventions that can help. And there is support—you are not alone.
How Long Do People Typically Try to Conceive?
Around 85 percent of couples conceive within a year of trying to become pregnant and most conceive long before the one-year mark. Infertility is defined as the inability to conceive a child within one year, or within six months if the woman is thirty-five or older (because it’s important to act sooner after this age). And while a small number of people end up conceiving on their own in their second year of trying, this is fairly uncommon (UCLA, 2011).
Potential Causes and Related Health Concerns
Fertility issues can be due to factors affecting the man, the woman, or both. One of the most common causes of infertility is maternal age. For most women, the ability to conceive decreases after the early thirties due to a decline in egg quality. Other reasons could be ovulation disorders, such as polycystic ovary syndrome (PCOS), tubal blockage caused by a history of sexually transmitted infections (STIs), uterine fibroids, endometrial polyps, endometriosis, or issues with the quality of the male’s sperm. Other times, the root cause of infertility cannot be pinpointed.
But regardless of the reason (or lack of one), fertility treatments can still help. In this article, we’ll discuss several lifestyle changes and treatments that may improve your probability of achieving pregnancy during a given menstrual cycle (defined as fecundability in the medical literature), as well as interventions that can improve fertility and chances of carrying a healthy baby to full term.
Causes of Female Infertility
Female infertility can be due to a number of causes, such as ovulation issues, infections, tubal blockages, hormonal imbalances, cysts, a misshapen uterus, as well as other diagnoses, including polycystic ovary syndrome (PCOS), endometriosis, primary ovary insufficiency (POI), or uterine fibroids (NIH, 2017c; Taymor, 2012).
Things to Tell Your Doctor before Trying to Conceive
For women: If you have a history of STIs, irregular periods, endometriosis, or pelvic inflammatory disease; have had miscarriages; or are undergoing cancer treatment, talk to your doctor as early as possible to discuss how this may affect your ability to conceive.
For men: Talk to your doctor if you’ve had previous issues conceiving with a partner, have a history of testicular or sexual problems, have a low sperm count, have testicular swelling, or have family members with a history of fertility issues. Certain medications can also affect fertility, so talk to your doctor about any prescriptions you or your partner are on.
Causes of Male Infertility
Male infertility can be caused by impaired sperm production or sperm development, impaired sperm motility, low sperm count, genetics, infections, or STIs (Taymor, 2012).
Miscarriages (early pregnancy loss) are an extremely common occurrence among women trying to conceive. Women with fertility issues have an even higher risk of miscarriage, and this risk increases with age (Hakim et al., 1995). Miscarriage is also common among women undergoing fertility treatments. Maternal obesity, smoking, and alcohol use have been associated with an increased risk of miscarriages, and a 2017 meta-analysis found that subclinical hypothyroidism was also related to increased risk of miscarriage (Agenor & Bhattacharya, 2015; Zhang et al., 2017).
A miscarriage does not mean you are infertile: It is usually a one-time occurrence, and you can begin ovulating and become pregnant soon after if you desire. If you’ve experienced a miscarriage, see your health practitioner and consider reaching out to others for support. Grieving is very normal—for more on healing after a pregnancy loss, read our Q&A with postpartum and loss doula Stephanie Matthias. If you’ve experienced multiple pregnancy losses, consider seeing a fertility specialist for further assessment and treatment. To learn more about miscarriage, see our Q&A with fertility specialist Kristin Bendikson, MD.
How Fertility Is Assessed
To assess female fertility, your health care provider will ask about your health history, including any history of previous STIs, pregnancies, miscarriages, or pelvic pain. They may start with a pelvic exam, ultrasound, or Pap smear to check for any obvious (to them) physical abnormalities. If nothing is immediately apparent from this initial screening, there are several more involved laboratory tests your doctor may also perform.
A blood test can be used to measure your hormone levels. Normal levels of progesterone indicate that you are ovulating properly each cycle, while follicle-stimulating hormone (FSH) and anti-Müllerian hormone (AMH) signal healthy egg production.
What Are Typical Ranges for Female Hormones?
To test your hormone levels, your health care practitioner will take a blood test and send it to a lab for testing.
• Typical progesterone levels are less than 3 nanograms per milliliter (ng/mL) during the follicular phase (start of menstruation until ovulation) and between 5 and 20 ng/mL during the secretory phase (ovulation until menstruation begins).
• Estradiol levels widely range throughout the menstrual cycle, from 15 to 350 picogram per milliliter (pg/mL) in premenopausal women. Levels are lowest at the beginning of the follicular phase and highest days prior to ovulation.
• AMH levels can be measured during any part of the menstrual cycle and typically range from 0.9 to 9.5 ng/mL.
• Basal FSH levels (FSH levels during the early follicular stage) are an indicator of ovarian age and have historically been used in prescreening women for fertility treatments. Normal values range from 5 to 20 milli-international units per liter (mIU/L). Higher levels of FSH are associated with lower chances of live births, but recent studies have questioned the utility of basal FSH prescreening (Scott et al., 2008).
X-rays or laparoscopy of your fallopian tubes may be used to determine whether there are any blockages. Scarring or uterine fibroids may be another cause of infertility, which can be identified through transvaginal ultrasound or a vaginal scope (hysteroscopy) (NIH, 2017b).
Infertility Diagnosis and Treatment for Couples
If a couple is seeking treatment for infertility, the relative fertility of both partners should be assessed, since many times there may be factors affecting both the man and the woman. For example, a woman may have partial tubal blockage that together with her partner’s low sperm count results in the inability to conceive. Diagnosis and treatment should be a partnership between the man and the woman to assess all aspects of fertility in order to optimize the probability of a successful pregnancy (Taymor, 2012).
Men can either be treated by their partner’s ob-gyn or choose to see a urologist. To diagnose male infertility, a complete medical history and exam will be taken to determine if there are any current infections, a history of STIs, or previous issues conceiving with another partner. A semen sample may be taken to determine viscosity and volume of semen, and motility, concentration, and morphology of sperm. A postcoital test may also be performed to determine if sperm is surviving in the woman’s cervical mucus, which could indicate a problem in either partner (Taymor, 2012).
Eating a diet high in polyunsaturated fatty acids is important, either from low-mercury fish or from a fish oil supplement. Reducing caffeine intake may be helpful. The research on meat intake and soy has been mixed.
Polyunsaturated Fatty Acids (PUFAs) and Fish
Polyunsaturated fatty acids (PUFAs) are critical for reproduction, specifically aiding in the development of the baby’s brain and eyes (NIH, 2019b). Studies have also suggested that PUFAs may promote fertility by improving egg quality and implantation (Gaskins & Chavarro, 2018). Several large-cohort studies have shown that women who report higher intakes of omega-3 PUFAs have higher fecundability and reduced risk of anovulation (no ovulation). Women who reported a higher intake of trans fatty acids were found to have greater risk of infertility and reduced fecundability (Chavarro et al., 2007; Mumford et al., 2016; Wise et al., 2018). (Trans fatty acids are a type of fat found primarily in fried and other foods that are made with partially hydrogenated oils, and they are known to raise cholesterol levels.)
So: Higher intake of PUFAs and lower intake of trans fatty acids are associated with enhanced fertility. The American Pregnancy Association (APA) recommends that women take a supplement containing both DHA and EPA starting up to six months prior to conception (APA, 2014). The FDA recommends that women who are pregnant, planning to become pregnant, or breastfeeding eat eight to twelve ounces a week of fish that is low in mercury in order to reap the health benefits (FDA, 2014).
Which Fish Are Lowest in Mercury and Best to Eat for Fertility?
Fish lowest on the food chain, such as salmon or shrimp, have the lowest levels of mercury because metals bioaccumulate up the food chain in larger fish, such as swordfish and bluefin tuna. Some studies, although not all, have suggested that women with higher mercury levels may have reduced fertility (Gaskins & Chavarro, 2018). Ideally, you want to eat a moderate amount of low-mercury fish and supplement with a good fish oil that contains both EPA and DHA. Vegans and vegetarians can get alpha-linolenic acid (which the body converts to EPA and DHA) from flaxseed oil, soybean oil, chia seeds, and walnuts, or they can get both EPA and DHA from an algal oil supplement.
There’s not a lot of research on meat consumption and fertility, but preliminary studies have suggested that eating meat may be associated with poor reproduction. A 2008 study found that for women, eating an additional serving of red meat, chicken, turkey, or fish daily was associated with an increased risk of infertility, whereas eating vegetable protein instead of animal protein was associated with a reduction in infertility risk (Chavarro et al., 2008). A separate study, in 2015, found that eating red meat prior to IVF treatment was associated with reduced likelihood of pregnancy (Braga et al., 2015). Further research is needed in this area to see if there is an actual link between meat consumption and fertility.
Women of reproductive age may fear soy because it contains very weak, estrogen-like compounds called phytoestrogens. Phytoestrogens have not been shown to negatively impact reproduction in clinical trials. Several small studies have even suggested that soy may be beneficial to women undergoing fertility treatments (Gaskins & Chavarro, 2018). Of particular note, a 2015 study found that among American women undergoing IVF, those who had the highest intake of soy phytoestrogens had 77 percent higher odds of a live birth (Vanegas et al., 2015). While there’s not yet evidence to recommend soy supplements for women trying to become pregnant, there is a lack of evidence for the soy scare that has plagued so many women. (For more, see this comprehensive summary of the state of the research on phytoestrogens and soy by reproductive endocrinologist Amber Cooper, MD, at the Vios Fertility Institute in St. Louis, Missouri.)
While it’s known that coffee intake during pregnancy should be limited because it’s a stressor to the baby, it has not been clear whether coffee and caffeine consumption are related to reduced fertility in women trying to conceive (WHO, 2019). A 2017 meta-analysis found evidence that caffeine intake may be associated with miscarriage risk. But the researchers did not find an association between caffeine and a woman’s or couple’s fertility (Lyngso et al., 2017). However, a study published after this meta-analysis was completed found that higher caffeine intake in males was associated with a lower live birth rate after IVF (Karmon et al., 2017). So you may want to cut back on your caffeine intake or discuss it with your doctor.
Nutrients and Supplements
Take a folic acid and iron supplement. Take a fish oil supplement if you’re not eating enough fish.
While it is well-established that taking folic acid (a type of B vitamin) during pregnancy can help prevent neural tube defects, there has been controversy over whether supplementing with folic acid (folate) prepregnancy is beneficial or perhaps harmful, with some studies suggesting that it may increase risk of miscarriage. A review published in 2016 found no evidence that folic acid supplementation had any effect on risk of fetal loss, miscarriage, or stillbirth (Balogun et al., 2016). And some more-recent studies published since that review have suggested that folic acid may reduce risk of miscarriage, while also conferring other benefits, such as lower risk of infertility and shorter time to pregnancy (Gaskins & Chavarro, 2018).
The CDC recommends that all reproductive-age women take 400 micrograms of folic acid per day (CDC, 2018). While you can get folic acid from certain vegetables (like spinach, asparagus, and Brussels sprouts) and fortified foods, you may be better off taking a daily multivitamin that contains folic acid and iron, which taken together have been shown to confer the most benefits for fertility (Gaskins & Chavarro, 2018). Twenty-seven milligrams of iron daily is recommended during pregnancy and between nine and ten milligrams of iron during lactation (NIH, 2019a). Make sure to also get enough omega-3 fatty acids, or take a fish oil supplement in addition to your prenatal multivitamin.
Lifestyle Changes for Infertility
Timing sex with ovulation is crucial when trying to become pregnant. Managing stress, avoiding alcohol and drugs, maintaining a healthy weight, and reducing your exposure to environmental toxins are also key.
Time of the Month
Having sex frequently around the time of ovulation is your best bet at getting pregnant because this is the time of the month when a mature egg is able to be fertilized. The fertile window typically begins a few days leading up to ovulation and can last twenty-four hours after ovulation. In a healthy woman with an average twenty-eight-day cycle, ovulation usually occurs at day fourteen of the cycle. You can track your cycle with various smartphone apps to predict ovulation (such as Clue or Moody App). There are also home urine tests that can predict ovulation by testing progesterone levels (we keep it simple with Clearblue). You may be able to recognize the signs that you are ovulating: having more interest in sex or a change in your vaginal discharge.
What Are the Phases of the Menstrual Cycle?
The menstrual cycle lasts between 24 and 38 days and may vary from cycle to cycle. It starts on the first day of your period and ends when your next period begins. It can be thought of as three distinct events: preovulation, ovulation, and postovulation.
During the preovulatory cycle (also called the follicular phase), menstruation occurs, and estrogen and progesterone levels are low as the uterine lining is shed. A regular period lasts for an average of five days. Then follicle stimulating hormone (FSH) signals that an egg should be prepared, which causes estrogen levels to rise as the egg grows. The second part of the follicular phase occurs when the period ends and the uterine lining is built back up again to prepare itself for egg implantation (this is called the proliferative phase).
About fourteen days before menstruation begins, ovulation occurs. Estrogen levels peak and then drop, which causes luteinizing hormone (LH) to be released and signals to the body to start ovulation (the release of the egg from the ovary).
In the postovulatory phase, before the start of the next period, the body prepares for a possible pregnancy by increasing progesterone and estrogen levels, which allows the uterine lining to build up again for implantation. This is called the luteal or secretory phase. If no fertilization happens, estrogen and progesterone levels will drop, menstruation will begin, and the whole cycle will start over again.
After stopping hormonal contraception use, it may take a while for your body to return to fertility. Studies have shown that it may take a few months after quitting hormonal contraceptives for your body to go back to normal. Twelve months after stopping birth control, pregnancy rates have been shown to be similar across different types of birth control (oral contraceptives and IUDs) so there don’t appear to be any long-term effects of birth control on fertility (Barnhart & Schreiber, 2009).
Protecting yourself from sexually transmitted infections is important for maintaining a healthy reproductive system. Pelvic inflammatory disease (PID) and STIs such as chlamydia can increase your risk of infertility by scarring the fallopian tubes. STIs such as gonorrhea may affect male sperm quality (Ochsendorf, 2008). Infections of the cervix related to human papilloma virus can affect cervical mucous, which may adversely affect female fertility (NIH, 2017c).
If you don’t know your STI status, get tested, and be sure your partner has been tested, too. Treating STIs as soon as possible helps to prevent long-term issues such as scarring or PID. If you are currently trying to conceive and have previously had STIs or PID, talk to your doctor about your medical history.
Maintaining a Healthy Weight
Being either overweight or underweight can cause fertility issues. Being underweight is associated with lower likelihood of becoming pregnant and higher risk of miscarriage (Oliveira, 2018). The risk of infertility is three times higher in women who are obese compared to nonobese women (Silvestris et al., 2018). Levels of anti-Müllerian hormone (AMH), which indicates ovarian function, have been shown to be lower in women who are obese, especially those with PCOS, in which AMH is often used as a marker for diagnosis (Dumont et al., 2015; Moy et al., 2015).
Body weight may also affect success rates with IVF, however this appears to be most significant for young women. For women over the age of 36, there is evidence that obesity may not be associated with reduced fertility (beyond the effect of age) (Silvestris et al., 2018; Sneed et al, 2008).
It’s been common medical practice to assume that losing weight prior to infertility treatments would boost fertility and to advise women with obesity to lose weight prior to starting treatments. The older studies supporting this recommendation tended to be of poor quality, and more recent, higher-quality research has not supported benefits from weight loss prior to IVF.
It’s difficult to reach definitive conclusions about the effects of weight loss on fertility because the lifestyle interventions used to achieve weight loss have multiple components—diets, bariatric surgery, social interactions and support groups, and exercise—that may affect fertility. Exercise alone would be expected to be helpful in the absence of weight loss, as a number of clinical studies have shown that physical activity can improve fertility in women (Mena et al., 2019).
What more recent research has revealed is that for women with unexplained infertility who are obese, losing weight before starting therapy for infertility does not improve fertility or IVF success. Further, weight loss has been linked to higher rates of miscarriage. One recent study of women with obesity and unexplained infertility compared an exercise program alone to a program combining exercise with a weight-loss diet. Weight loss did not increase fertility more than exercise alone. Four months of the program were followed by three cycles of infertility treatment, and there were as many healthy babies born to the women who increased their physical activity as to those who also dieted and lost weight (Legro et al., 2022; Sim et al., 2014).
Obesity can affect male fertility. According to a 2015 meta-analysis, couples in which the man is obese are more likely to experience infertility than couples in which the man is a healthy weight. Additionally, male obesity is associated with a significantly lower live birth rate from assisted reproductive technology (Campbell et al., 2015). A healthy body weight is beneficial for the quality of sperm and the concentration of male reproductive hormones. Higher sperm count and increased motility of sperm are also associated with healthy dietary patterns (Suliga & Głuszek 2020).
Exercise is an important aspect of a healthy lifestyle and is especially crucial for people who are obese and having trouble conceiving. A 2017 meta-analysis found that a low-calorie diet and exercise improved women’s pregnancy rates and ovulation (Best et al., 2017). Consistent physical exercise was found in one study to be associated with higher assisted reproductive technology success rates for women who were obese (Palomba et al., 2014). For men, six months of resistance training was shown in one study to reduce inflammation and oxidative stress in seminal fluid and to improve fertility (Hajizadeh Maleki & Tartibian, 2018). There isn’t solid evidence to indicate which type of exercise is best for fertility, and in general, what suits one person is different from what works for another.
For women, it’s important to note that exercising too often or engaging in physically strenuous activities can sometimes cause ovulation problems or dysmenorrhea (lack of periods). Some doctors recommend moderate, low-impact exercise as most beneficial for women who are trying to become pregnant. Talk to your doctor to develop an exercise program that is right for you.
Quitting Drinking and Smoking
Not only does drinking during pregnancy have significant risks for the fetus but drinking when trying to conceive can also pose problems. Alcohol has been shown to reduce female and male fertility, perhaps by impacting sperm quality (Fan et al., 2017; Karmon et al., 2017; La Vignera et al., 2013). If you’re having trouble conceiving, try reducing your alcohol intake.
Smoking can cause reproductive issues and impaired fertility. Cigarette smoking is associated with reduced ovarian function and lower pregnancy rates in women (Vanvoorhis et al., 1996). Male smoking is associated with reduced semen quality, sperm development, sperm maturation, and sperm function (Dai et al., 2015). Men and women should quit smoking before attempting to become pregnant.
Struggling with infertility can undoubtedly be stressful for women and men. And it may create a vicious cycle of stress leading to further problems conceiving. Although there has not been consistent evidence showing that stress is related to reduced fertility, many practitioners consider stress management, mental health, and emotional health to be integral to fertility treatment. Women with infertility report high levels of anxiety and depression, and infertility can lead to relationship issues as the partners attempt multiple treatments and deal with setbacks and disappointments (Rooney & Domar, 2018). It’s important to manage your stress through whatever means necessary: exercise, yoga, mind-body techniques, relaxation, massage, etc. Couples therapy may also help you work through relationship difficulties.
Reduce your exposure to endocrine disruptors as much as reasonably possible. Endocrine-disrupting chemicals are virtually everywhere these days—from inside our shampoo bottle to the lining of canned foods. This is not meant to freak to you out. We hope it might empower you—because the good news is that we’ve gotten better at identifying where these chemicals live and finding ways to reduce our exposure.
What Are Endocrine Disruptors?
Some endocrine disruptors that have been shown to affect fertility include phthalates, pesticides, parabens, triclosan, and heavy metals (Rattan et al., 2017). Endocrine disruptors are chemicals that affect various systems of the body by altering hormone levels. They have been linked to developmental disorders, birth defects, obesity, and other harmful outcomes in both children and adults. And the worst part is that they’re ubiquitous in our environments—found in personal-care products, household cleaners, perfumes, and even food products.
The EARTH study, which is sponsored by the National Institute of Environmental Health Sciences (NIEHS), recruited subjects from Massachusetts General Hospital to determine how self-reported exposure to environmental toxins over the course of a lifetime impacts female and male fertility. Thanks to this sort of research, we will better understand how endocrine disruptors like phthalates, pesticides, parabens, triclosan, and heavy metals affect our health. Until then, here’s how we’re reducing our exposure.
A checklist to help reduce your exposure to endocrine disruptors:
• Buy personal-care and household products that are free of endocrine disruptors and nontoxic to humans. You can check your products are on websites like Skin Deep by the Environmental Working Group. (Everything in the goop shop is clean, meaning that products do not contain ingredients known to be endocrine disruptors or toxic to humans).
• If revamping your entire personal-care-product and cosmetics portfolio seems like a complete nightmare right now, start with the products that you spread over the greatest surface area of your body. This could be a lotion, a body wash, or a sunscreen.
• Buy organic produce as much as possible.
• Eat fewer canned foods.
• Microwave your food in glass containers instead of plastic (which can leach into your food when heated).
• Avoid drinking beverages stored in plastic bottles.
• Eat wild-caught fish instead of farmed fish. Avoid salmon from the Atlantic in northern Europe, as it is known to be high in dioxins (Foran et al., 2005).
With many people delaying parenthood until later in life, egg freezing has become increasingly of interest as an option for preserving a woman’s fertility as she ages. The process involves injections of ovulation-stimulating medications that induce egg growth. The woman comes into the doctor’s office every few days for an ultrasound to check the eggs’ growth. The eggs are retrieved from the ovaries using a small needle, and then the eggs are frozen. To learn more about egg freezing, read our Q&A with reproductive endocrinologist Lisa Grossman Becht, MD.
For women who are undergoing cancer treatment, egg freezing may be recommended before chemotherapy, radiation, or surgeries that may impact fertility. Talk to your doctor or a fertility specialist to determine if this is necessary and what the best options are for you.
Conventional Treatment Options for Infertility
Infertility can be treated by a combination of ovulation-inducing medications and assisted reproductive technology. In certain cases, surgery may be recommended by your doctor.
There are several medications that women can take to stimulate ovulation. These medications can be taken alone as a first-line treatment for irregular or absent periods, or they may be given in combination with assisted reproductive technologies (ART). Clomiphene citrate (CC)—Clomid—is an oral medication that stimulates the pituitary gland to release more FSH and LH, which allow eggs to mature in the ovaries. Clomid is taken at the beginning of the menstrual cycle. Side effects may include flushing, ovarian pain, blurry vision, nausea, and headaches.
Another medication that stimulates ovulation is a class of hormones called gonadotropins. Human menopausal gonadotropin (hMG) is administered by injection and contains FSH, which stimulates ovulation. Other FSH products that are purified from urine are also used. Human chorionic gonadotropin (hCG), which is similar to LH, can also be injected to trigger the egg to release. Women who take gonadotropins have a high chance of twins and triplets.
Other medications may also be prescribed for related health issues. For example, metformin is an antidiabetic medication that can be used to treat infertility related to polycystic ovary syndrome (PCOS) or insulin resistance. Metformin can be taken alone or in combination with Clomid (Morley et al., 2017). Additional medications include letrozole, which decreases estrogen levels to stimulate egg release, and bromocriptine or cabergoline, which treat high levels of prolactin that may interfere with ovulation (NIH, 2017a).
Artificial Insemination (AI)
One of the most common fertility treatments that doctors start with when a couple is having trouble conceiving is AI. During AI, a woman’s ovulation is carefully monitored and medications such as Clomid or gonadotropins may be taken to stimulate ovulation. A semen specimen (produced beforehand by the male partner or from a sperm donor) is processed and placed into the uterine cavity of the woman, in a process that is fairly similar to a Pap smear.
Assisted Reproductive Technology (ART) and In Vitro Fertilization (IVF)
ART refers to any type of fertility treatment that involves fertilization outside of the body. The most well-known type of ART is in vitro fertilization (IVF) in which a mature egg is collected from the woman’s ovaries and fertilized by the man’s sperm in a lab. The fertilized egg or eggs are then transferred back to the woman’s uterus.
IVF may be used for women who have no fallopian tubes or fallopian tubes that are blocked, women with endometriosis, women with other types of fertility issues, or for issues with male sperm count or motility. Because IVF is an invasive procedure, it is generally used only after a couple has tried fertility drugs or AIH (artificial insemination from husband/partner).
Third-party-assisted ART may involve sperm donation or egg donation. Sperm or egg donors’ physical characteristics can be matched to those of the mother or father. A gestational carrier may be used if the woman can’t or shouldn’t become pregnant due to health reasons.
The CDC publishes ART success rates for fertility clinics in the US, which can be useful when deciding where to get treatment. And you can learn more about IVF in our Q&A with Marcelle Cedars, MD, the director of UCSF’s Center for Reproductive Health.
For certain conditions, including fallopian tubal obstruction, uterine fibroids, and polyps, your doctor may determine that surgery is necessary to treat those conditions, which may improve chances of becoming pregnant. Surgery may also be used to remove endometriosis tissue, which can double the chances of pregnancy according to the NIH (NIH, 2017a). A side effect of fallopian tube surgery is an increased risk of ectopic pregnancy (a pregnancy that occurs outside of the uterus).
Endometrial scratching is painful and has no proven benefits, yet it is still used in women wishing to increase chances of pregnancy. The hope is that it may promote implantation of the embryo. In this procedure, a device is inserted into the uterus, then drawn in and out and rotated to damage the lining of the uterus. It’s sometimes used on its own and sometimes just before the first round of IVF. Clinical trials have not shown a benefit for fertility when used with or without IVF (Metwally et al., 2022, Wong et al, 2022).
Alternate Treatment Options for Infertility
Combining conventional treatment options with other therapies can help you manage stress levels and support your mental health during this process. Trying to become pregnant can feel overwhelming—you don’t need to go through it alone.
Infertility can lead to feelings of unworthiness, depression, anger, anxiety, and significant stress for both partners. Additionally, couples may experience increased marital disputes or sex problems, and studies have shown that couples with infertility experience significantly greater depression and anxiety than fertile couples (Berardis et al., 2014). Depression can also exacerbate problems with fertility: A 2018 study found that male depression was linked to a lower chance of pregnancy in couples being treated for infertility (Evans-Hoeker et al., 2018).
A therapist can be an important outlet, either for partners individually or in couples therapy. A 2015 meta-analysis found that psychosocial interventions (such as cognitive behavioral therapy, CBT) were associated with improved pregnancy rates and mental health, especially for female partners. The study also found that large reductions in anxiety were associated with improved pregnancy rate, highlighting the importance of managing stress and anxiety preconception (Frederiksen et al., 2015). And ideally, all fertility approaches would be holistic and take into account the couple’s mental and physical health.
Incorporating mind-body techniques into daily life can be hugely beneficial for helping us manage stress. Yoga is one such practice in which postures (asana), breathwork (pranayama), and meditation are used to stretch the body and relax the mind. A 2018 review found that yoga decreased stress, pain, depression, and anxiety in people struggling to become pregnant (Darbandi et al., 2017).
Other mind-body techniques that may help decrease stress and improve mental health include meditation, float tanks, body scans, repetitive mantras, and deep breathing. Two studies have shown that mindfulness-based programs that incorporate various mind-body techniques can be beneficial for women with infertility. A 2019 study found that eight weeks of meditation, relaxation, guided imagery, and other mindfulness techniques reduced infertile women’s stress and depression (Nery et al., 2019). Another study found that women undergoing their first IVF treatment had improved quality of life and higher pregnancy rates when they took a six-week mindfulness-based intervention that incorporated breathwork, meditation, yoga, and body scans (Li et al., 2016).
Holistic approaches often require dedication and guidance, but research shows it can be effective. In a meta-analysis examining 4,247 women with infertility (in forty randomized clinical trials), pregnancy rates increased from 30 percent to 60 percent within three to six months when using Chinese herbal medicine (Reid 2015). Working closely with an experienced practitioner and certified herbalist is important. The American Herbalists Guild provides a listing of registered herbalists, whose certification is designated RH (AHG). Traditional Chinese medicine degrees include LAc (licensed acupuncturist), OMD (doctor of Oriental medicine), and DipCH (NCCA) (diplomate of Chinese herbology from the National Commission for the Certification of Acupuncturists). Traditional Ayurvedic medicine from India is accredited in the US by the American Association of Ayurvedic Professionals of North America (AAPNA) and the National Ayurvedic Medical Association (NAMA). There are also functional, holistic-minded practitioners (MDs, DOs, NDs, and DCs) who may use herbal protocols. There’s more on herbs to support fertility in our Q&A with Roy Upton, RH (AHG), DipAyu.
Vitex, also known as chasteberry, is the fruit of the chaste tree that is sometimes used in the treatment of reproductive disorders, such as premenstrual syndrome (PMS) and PCOS. While there is not much evidence for the use of vitex for infertility, it is included as an ingredient in various fertility supplements marketed to women. For example, a nutritional supplement called FertilityBlend contains vitex along with green tea extract, vitamins, folate, iron, magnesium, zinc, selenium, and l-arginine. In a small double-blind placebo-controlled pilot study, women who took FertilityBlend three times a day for three months had significantly more pregnancies (Lynn Marie Westphal et al., 2004). This positive finding was replicated in a subsequent larger controlled study (Westphal, Polan, & Trant, 2006). It’s unclear whether these benefits were due to the vitex or the other helpful nutrients in the supplement, such as folate, but regardless, these results are promising. Of possible concern: The manufacturer of FertilityBlend was involved in both studies.
Lactolycopene is a newly patented combination of lycopene and whey protein designed to increase bioavailability of lycopene, a bright-red carotenoid in tomatoes and other red fruits and vegetables. Lactolycopene was tested in a double-blind placebo-controlled randomized trial to investigate its effects on semen quality. Three months of supplementing daily with lactolycopene improved sperm motility and morphology in healthy men, increasing the proportion of fast sperm and normal morphology (Williams et all, 2020).
In traditional Chinese medicine, the Ren Channel begins at a woman’s uterus and ascends across the abdomen and chest up to below the lower lip. It is said to signify fertility and is often called the conception vessel. Some acupuncturists specialize in working with people who are trying to conceive, and acupuncture targeting the Ren Channel has been studied for use in combination with IVF treatment. There have been conflicting results regarding its efficacy. A 2017 meta-analysis found that women, particularly Asians, undergoing IVF who received acupuncture treatments had significantly increased pregnancy rates. These results were most pronounced during controlled ovarian hyperstimulation, when fertility medications are given to stimulate ovulation (Qian et al., 2017). However, a 2018 meta-analysis found that acupuncture on the day of embryo transfer is associated with a lower chance of pregnancy (Schwarze et al., 2018). Yet in a 2020 randomized controlled trial of seventy-two women undergoing IVF, acupuncture improved pregnancy success rates. Three sessions of acupuncture were conducted before and after embryo transfer: one week before, thirty minutes before, and thirty minutes after. Anxiety levels prior to embryo transfer were also reduced (Guven et al., 2020). It seems that acupuncture may be helpful or perhaps harmful to IVF success depending on the timing and conditions of treatment.
It’s well known that there is an orgasm gap: In heterosexual partnerships, men tend to orgasm more than women. In the context of trying to conceive, the male orgasm is necessary to release the sperm, although a small amount may be released pre-ejaculation. The female orgasm, meanwhile, has been thought to be unnecessary for pregnancy to occur. But some fertility experts believe we’ve overlooked this, and that the orgasm gap may be to blame for some couples’ infertility. The theory is that physical satisfaction of both partners results in a higher chance of pregnancy due to vaginal contractions that cause the sperm to be carried farther up, increasing chances of fertilization. This theory isn’t widely accepted in the medical community, and there are few studies to back it up. One small study from 2016 found that women who orgasmed during sex retained significantly more sperm than women who did not orgasm (King et al., 2016). Regardless, for everyone’s mutual satisfaction, it’s worth closing the orgasm gap (and you can learn more about that in our Q&A with therapist and professor Laurie Mintz, PhD, who wrote the book Becoming Cliterate).
Techniques to cope with the stress of infertility and its many treatments are hugely necessary for couples. One particular technique that has gained attention is a fertility massage, in which patients receive a massage prior to ART treatment. A 2015 study found that women who received an andullation massage with vibration and infrared heat on their abdomen prior to IVF embryo transfer had improved pregnancy and birth rates (Okhowat et al., 2015). The authors hypothesized that this was probably due to deep relaxation. (There is no evidence that massage can improve egg quality or quantity.)
New and Promising Research on Infertility
Innovative techniques are being developed to support healthy pregnancies and approach infertility with new perspectives.
How Do You Evaluate Clinical Studies and Identify Promising Results?
The results of clinical studies are described throughout this article, and you may wonder which treatments are worth discussing with your doctor. When a particular benefit is described in only one or two studies, consider it of possible interest, or perhaps worth discussing, but definitely not conclusive. Repetition is how the scientific community polices itself and verifies that a particular treatment is of value. When benefits can be reproduced by multiple investigators, they are more likely to be real and meaningful. We’ve tried to focus on review articles and meta-analyses that take all the available results into account; these are more likely to give us a comprehensive evaluation of a particular subject. Of course, there can be flaws in research, and if by chance all of the clinical studies on a particular therapy are flawed—for example with insufficient randomization or lacking a control group—then reviews and meta-analyses based on these studies will be flawed. But in general, it’s a compelling sign when research results can be repeated.
Men’s Biological Clock
While most women are well aware of their biological clock (a woman’s egg viability begins to decline in her thirties), less attention has been paid to men’s sperm quality as they age. And because the number of children born to older men has doubled in recent years, researchers are investigating the health effects of older paternal age. And they’ve found that it may come with health risks. Researchers at Rutgers University published a review in 2019 showing that older paternal age is associated with infertility, pregnancy complications, and adverse infant neurocognitive and psychological outcomes, including schizophrenia and autism. While the exact age at which these effects become more likely is not exactly clear, advanced paternal age has been described in the medical literature as somewhere between thirty-five and forty-five (Phillips et al., 2019). More awareness and education are needed to inform the public that men, too, have a biological clock that can affect not only their partner’s pregnancy but also their future child’s health.
Drug That May Extend Egg Viability
Researchers at Princeton University studied proteins called cathepsin B proteases that are found in both humans and Caenorhabditis elegans worms. When the researchers looked at these proteins in worms, they found that cathepsin B appeared to be most common in the worm’s eggs that had begun to degrade with age (similar to how women’s egg quality starts to decline with age), and less common in the healthier eggs that were more resistant to aging. The researchers then experimented with blocking the proteins halfway through the worm’s long reproductive window (which would be equivalent to the mid-thirties in humans) to determine how this would affect egg quality. They found that worms treated with the blocker drug had much less egg decline and more healthy eggs compared to the control worms who didn’t receive the blocker drugs (Templeman et al., 2018). Whether or not the findings are relevant to humans is not clear at this point, but it is intriguing that a simple drug might be able to lengthen the female reproductive window.
New Discovery for Male Infertility
Researchers from the Imperial College of London presented research at the European Association of Urology Conference in 2019 that may revolutionize the way that we approach male infertility issues. The researchers analyzed the sperm of men who had previously undergone unsuccessful IVF as well as the sperm of fertile men, for comparison. They found that in ejaculate samples, sperm from infertile men had more DNA damage than sperm from fertile men. But what was surprising was that when they analyzed the sperm pre-ejaculation, by taking samples from inside the men’s testes, they found that both the infertile and fertile men had similar sperm, without DNA damage.
This study suggests that there may be something about the ejaculatory process that damages sperm and creates fertility problems in some men. Several other studies have previously shown that IVF using testicular sperm yields higher success rates than ejaculated sperm (Esteves et al., 2015; Mehta et al., 2015).
Bone Marrow Stem Cells
One cause of infertility is primary ovarian insufficiency (POI), in which a woman’s ovaries stop their normal functioning before the woman turns forty. POI is most commonly treated with hormone replacement therapy to supply the hormones that the ovaries are no longer making, which can help with symptoms but unfortunately does not restore ovarian function. However, researchers have recently discovered that some women with POI who have undergone bone marrow transplants for cancer treatment have had their fertility spontaneously restored. Why? The theory is the ovaries may attract cells from other organs, such as bone marrow-derived stem cells, which help regenerate the ovaries.
A study published in 2018 by researchers in Spain found that infusing bone-marrow-derived stem cells into mice with impaired ovaries restored their ovarian function by increasing ovarian follicles. And it increased the number of embryos and the number of healthy mice born. They also found that human ovarian tissue that was treated with these stem cells had increased follicle growth (Herraiz et al., 2018). Following this study, researchers in India tested this stem cell therapy on a forty-five-year-old woman with POI with infrequent menstruation. The researchers successfully performed the treatment and the first healthy baby was born following bone-marrow-derived stem cell therapy (Gupta et al., 2018). A phase 4 clinical trial in Spain will be recruiting to study bone marrow stem cell ovarian transplantation in women with POI.
Spindle Nuclear Transfer
In early 2019, the first baby was born to three different parents in a clinical trial for infertility. Yes, you read that correctly. Using a novel (and controversial) technique called spindle nuclear transfer, researchers at the Institute of Life in Athens, Greece, combined the DNA of three different people: a thirty-two-year-old mother with a history of infertility, the father, and a female donor who provided an egg. The donor provided an egg, then researchers removed the nucleus of the egg, replacing it with the nucleus of the mother’s egg. The egg was fertilized with sperm from the father and the mother carried the pregnancy. The result? A healthy baby with DNA from three different people (Institute of Life, 2019).
While this is exciting, spindle nuclear transfer was initially meant for a different purpose: to avoid the passing down from mother to baby of fatal neurological disorders, such as Leigh syndrome, which causes genetic disruptions in the mitochondria of cells. Some experts argue that the potential risks of this therapy for the baby, which are largely unknown thus far, would be worth it only in extreme cases of neurological disorders, and that it’s not meant for women with infertility issues (Craven et al., 2018).
Clinical Trials for Infertility
Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.
In general, clinical trials may yield valuable information; they may provide benefits for some subjects but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering.
Where Do You Find Studies That Are Recruiting Subjects?
You can find clinical studies that are recruiting subjects on clinicaltrials.gov, which is a website run by the US National Library of Medicine. The database consists of all privately and publicly funded studies that are happening around the globe. You can search by disease or a specific drug or treatment you’re interested in, and you can filter by country where the study is taking place.
For women with uterine issues that prevent them from becoming pregnant (like endometriosis, polyps, birth defects, or scar tissue), uterine transplantation is a new procedure that has been shown to have some success. In 2014, a thirty-five-year-old Swedish woman gave birth after a uterine transplant from a sixty-one-year-old donor. Another baby was born to a woman who had undergone uterine transplant in the US in 2017. However, the procedure is high risk as it involves organ transplantation in a particularly sensitive area, and it has failed several times in other women. Because of this, uterine transplant is done only in the context of clinical trials.
Researchers at Brigham and Women’s Hospital will be recruiting women with absolute uterine factor infertility, who have either a malformed uterus or no uterus, to undergo a uterine transplant with the potential to undergo IVF treatment during the five-year follow up. The women’s uterine transplants will be removed at the end of the study. Similar studies are ongoing at the Cleveland Clinic in Florida, Baylor Research Institute in Texas, and Imperial College of London for uterine transplantation.
Sperm Selection Assay
In an attempt to increase the success rate of ART, Laura Giojalas, PhD, the director of the Center of Cellular and Molecular Biology at the National University of Cordoba in Argentina, is recruiting couples with male infertility to undergo sperm selection assay (SSA). SSA is an advanced technique that tests a sperm’s movement in response to an attractant molecule. SSA chooses the highest quality sperm with intact DNA, good motility, and viability that will have the highest chance of producing a healthy embryo. In the trial, after SSA, couples will undergo IVF, with the hope that SSA will improve fertilization and birth rate.
Apps to Help Cope
Meike Uhler, a physician at the Fertility Centers of Illinois, is studying a new mobile app for men with infertility called FertiStrong to complement the existing FertiCalm app for women. The app allows users to implement cognitive, behavioral, and social solutions to help with anxiety, depression, and stress. Participants will use the app for a month to determine whether it helps them cope through humor, relaxation, and self-nurturing. Both FertiStrong and FertiCalm can be found on Android and Apple phones for free.
Walnuts for Male Infertility
Howard Kim, MD, a physician at Cedars-Sinai, and Wendie Robbins, RN, PhD, a professor at UCLA’s School of Nursing, are testing whether walnuts improve sperm quality. In a previous study, adding walnuts to a Western diet was shown to improve healthy young men’s sperm. Researchers recently completed a clinical trial to determine whether eating two ounces of walnuts per day for three months can help improve sperm quality in men who are seeking treatment at fertility centers. Sperm motility was reported to be significantly better in the walnut group, but no improvement in fertility was reported.
Resources and Related Reading
• The CDC provides a listing of ART success rates for fertility clinics in the US.
• The CDC has a list of FAQs about infertility.
• The Cleveland Clinic provides information about diseases and conditions associated with infertility and how they may be treated.
• Path2Parenthood is a website with comprehensive information and resources for singles and couples trying to start a family.
• Resolve is a website with resources, support groups, and information about infertility.
• Star Legacy Foundation is a nonprofit with stillbirth resources, education, research, and stories.
• Project Alive and Kicking is a nonprofit with information and resources about pregnancy.
• Clue tracks your period and ovulation, giving fertility window suggestions.
• Moody App logs your menstrual cycle, changes in mood, and physical symptoms, while providing nutrition and wellness recommendations.
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This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The information and advice in this article is based on research published in peer-reviewed journals, on practices of traditional medicine, and on recommendations made by health practitioners, the National Institutes of Health, the Centers for Disease Control and Prevention, and other established medical science organizations; this does not necessarily represent the views of goop.