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Why You’re Not Getting Pregnant

From irregular ovulation to poor diet and nutrition—and the leading cause: male factor—we caught up with three top fertility doctors and a holistic fertility specialist to get the lowdown on the most common causes (and best treatments) of infertility.

Today nearly seven million American women suffer from infertility; that’s one in eight in the U.S. alone. Infertility is no longer a taboo topic: we’re on information overload about the leading causes—and most effective treatments—of this disease of the reproductive system that affects both women and men equally, but especially those of advanced maternal age. But there are no absolutes here. “Infertility is a multi-factorial problem—it’s a combination of things,” Brian Kaplan, a founder of the Fertility Centers of Illinois, explains. “It’s important for people to understand that.”

It’s advised that couples under age 35 trying to conceive for a 12-month period seek the help of a fertility specialist as soon as they detect a problem. “Push your ob/gyn to have a plan—be proactive,” cautions Kaplan, “particularly older patients.” When the woman is over 35, Kaplan encourages her to seek help after about six months of trying to conceive naturally, but the sooner you get to a diagnosis, the better the outcome will be.

Male Factor

According to renowned fertility specialist Dr. William Schoolcraft, founder of the Colorado Center for Reproductive Medicine, the “leading cause of infertility is male factor,” which is defined as anything from low sperm count and poor motility (i.e. slow swimmers) to structural abnormalities that can block the flow of sperm. How common is male factor? It accounts for a whopping 30-40 percent of infertility problems in couples.


The good news is there are things you can do to treat most male factor infertility issues. The bad news: men suffer from the emotional repercussions as much as women. “The first step is to see a doctor or urologist to diagnose the problem,” Dr. Schoolcraft says, “which can be treated with medication and surgery, depending on what it is.” A common work-around to low sperm count or motility is using in vitro fertilization (IVF), or a procedure called intracytoplasmic sperm injection (ICSI), in which a single sperm is injected into an egg. “With intercourse, only one out of four sperm make it up into the uterus,” explains Schoolcraft. Injecting a single sperm, using ICSI, may be all you need.


RESOLVE, the National Infertility Association, estimates that three to five million American women of reproductive age suffer from endometriosis, defined as a chronic disease of the reproductive system in which cells from the endometrium (lining of the uterus) grow where they’re not supposed to—outside the uterine cavity, causing blocked tubes that could prevent the egg and sperm from meeting, or the fertilized egg from traveling down the fallopian tubes normally (causing an ectopic pregnancy). Common symptoms of endometriosis are heavy and painful periods, pain during intercourse, and mild to severe cramping during menstruation.


The only way to really know if you’re suffering from endometriosis is through laparoscopy, a surgical procedure using a lighted tube to check for cysts in the abdomen. You can have these cysts removed during a laparoscopic procedure. “Some patients get pregnant 6 to 8 months after surgery,” Dr. Schoolcraft says. If pregnancy doesn’t occur, he recommends Clomid, insemination or—in more severe cases—IVF. 

Ovulatory Disorders

This is an all-encompassing term, and probably the single most common cause of infertility in women: it’s when ovulation fails to occur, or occurs on an inconsistent basis. Roughly 20 to 40 percent of female infertility stems from irregular ovulation—some women of reproductive age may never ovulate (which could be an indication of early menopause), while others may ovulate every three months. Hormonal imbalances, excessive exercise, excessive weight loss or gain, and excessive stress are all among the key causes that could throw a woman’s ovulation cycle off. Basically, anything in excess = bad for your reproductive system.


“Ovulatory disorders can be corrected by oral drugs such as Clomid, often with insemination,” says Dr. Schoolcraft. “I would only recommend 3-4 Clomid attempts before moving onto IUI with injectable drugs—but that carries a bigger risk of multiples.” Success rates increase with IVF; Dr. Schoolcraft suggests older patients go straight to in vitro fertilization once they have a diagnosis.

Polycystic Ovarian Syndrome (PCOS) 

“This is a very complex condition—an ovulation dysfunction that originates in the ovary… It’s an enigma,” says Dr. Kaplan. “It’s not a disease that anybody presents the same way.” Many patients who have PCOS don’t even know it (less than 25 percent are diagnosed) since there’s such a wide spectrum of symptoms seemingly unrelated to each other, such as lack of ovulation, abnormal menstrual cycle, excessive weight gain, acne, unusual facial hair, and infertility. “PCOS drives our patients a little crazy, because they read textbooks and they say, ‘I don’t fit this criteria or that characteristic.’” 


“The no. 1 way to treat PCOS is through diet and exercise,” says Tami Quinn, co-founder of Pulling Down the Moon, a leading holistic clinic of integrative care for infertility, with locations in Chicago, D.C. and Oklahoma. Metformin, a drug used to help normalize the body’s use of insulin and return hormones back to a balanced state, is not tolerated by a lot of women, Quinn cautions.

Being Over- or Underweight 

“Being too thin or too heavy can disrupt the hormonal function,” says Quinn. Research also proves that exercising too much can negatively impact your fertility outcome. Quinn believes that nutrition and supplementation is the future of treating infertility. 


Women should be counseled on their nutrition; supplements like fish oils, Vitamin D, probiotics, high-quality prenatal vitamins (Quinn recommends Pulling Down the Moon’s own brand which is triple certified), and CoQ10 can help egg quality, and are beneficial for male factor too. “The sooner women get in to see us the better,” Quinn says. “Ideally we’d like women implementing changes three months prior to IVF.”


“Generations before us didn’t understand that infertility is complex, and it’s not just a matter of stress. There’s more to it than that,” says Dr. Kaplan. Stress plays a roll in all disease, including infertility, “but if stress would be the only factor causing infertility, it would have to be extreme…something that is really catastrophic.” If a woman is indeed dealing with such an extreme level of stress, it can play a roll in suppressing the function of the hypothalamus, which controls the pituitary gland, which in turn controls the thyroid and adrenal glands and the ovaries—ultimately leading to irregular periods. Bottom line: You’d have a telltale sign if stress and stress alone were interfering with your reproductive system.


“Once you are stressed you can go down a very dark rabbit hole very quickly,” counsels Quinn. She suggests looking for ways to manage your stress levels at the very outset of treatment—find a support group, see the staff psychologist at the fertility clinic, do yoga for fertility, meditate, or do something special with your partner—acupuncture can also be a great stress reducer. “As soon as you know you’re going to a fertility doctor, go to a holistic center,” she says.

Tubal Disease

Part of determining the cause of a woman’s infertility is examining whether she has a mechanical issue, like blocked tubes, from infection. Dr. Kaplan says: “Let’s say she has beautiful eggs, and he has great sperm…but they have to have a milieu—a place where they can get together and fertilize.” Part of the workup is always some form of radiological assessment to make sure the tubes are open and/or the uterus is okay.


Tubal disease has been less of a factor over the last decade or two. “If you look at the ‘60s and ‘70s, tubal disease was when a woman had blocked tubes, or scarred tubes from infection or chlamydia, or from endometriosis, causing structural problems,” explains Kaplan. Now, doctors go straight to IVF to treat tubal disease.

Age (or Egg Factor)

“Age in a woman is still the most critical variable [in her fertility],” says Dr. Kaplan. Women are born with all their eggs—approximately one to two million at birth—and we lose them every month, in both quantity and quality. By puberty we only have 300,000 left, and only about 300 will eventually mature and be released through ovulation. “That gradual loss of eggs is called atresia—so by the time you reach menopause, at 51, you don’t have eggs left.” 


That continual loss of eggs—like the aging process itself—is irreversible. ”You can’t treat that; you can’t make more eggs,” Dr. Kaplan says. But if you look at why the incidence of infertility is so common, it’s the average age of a woman seeking fertility: around 35 or 36. “We call that an egg factor.” The egg is not what it used to be; it’s deteriorated. “Our job as infertility physicians is to make sure we manage all the things we can to make sure those eggs are as good as they can be.” Examples include: quitting smoking, losing weight if you’re obese, managing thyroid problems, and taking supplements like the aforementioned fish oils, Vitamin D, probiotics, high-quality prenatal vitamins, and CoQ10, which all help egg quality.


Smoking has a negative impact on fertility, primarily by extending the time to conception. Smoking tobacco and marijuana can lower male sperm count and motility but it should be noted, says Dr. Jain, that smoking is a modifiable risk factor. “It may worsen other forms of infertility such as male factor, but in and of itself is not usually viewed as a primary cause of infertility.” Long-time female nicotine users can experience infertility problems, too, causing irregular ovulation, among other things.


Plain and simple: quit. The one piece of good news here is that the effects of smoking (both legal and illegal substances) are, in some cases, reversible. A few months before trying to conceive you should kick the habit and get both your bodies ready for what’s ahead. The healthier you are, the better equipped you’ll be to conceive and maintain a healthy pregnancy. 

Low Progesterone

“Low progesterone and its role in fertility has been a controversial topic for over 30 years,” says Dr. Jain. “After ovulation, the egg follicle—now called a corpus luteum—takes on a new role of producing progesterone in order to support embryo implantation and early pregnancy,” he explains. Lack of sufficient progesterone during this phase of the menstrual cycle is called Luteal Phase Defect (or LPD), and can lead to disordered development of the uterine lining and/or inadequate maintenance of the lining to support a growing pregnancy. “Although LPD as an independent cause of infertility has yet to be proven, it is possible that women with other medical problems (such as thyroid or prolactin abnormalities) may have abnormal luteal function.” 


Many reproductive endocrinologists will prescribe progesterone supplements in the form of pills, vaginal suppositories and/or injections, which can help thicken the uterine lining to allow the embryos to attach.