Most of us assume a pregnancy just happens naturally – until it doesn’t. The truth is that one in six couples struggle with infertility. If you have been trying with regular, unprotected intercourse for a year and not getting pregnant, these three conditions should be on top of your suspect list. Aside from sperm-related issues on the male side (which can contribute to both difficulty getting pregnant and keeping the pregnancy), PCOS, endometriosis and POI are some of the most common among women struggling with infertility.

If you have some symptoms that match your experience, a visit to your OBGYN or a fertility specialist may be in order. Receiving a correct and timely infertility diagnosis can empower you to take targeted, effective action to overcome the root issue(s) - it’s the first step to reaching your goal.

PCOS (Polycystic Ovary Syndrome) 

PCOS is a common cause of infertility in women. Affecting an estimated 4-18% of reproductive-age women, PCOS accounts for a whopping 90-95% of anovulatory infertility (infertility due to lack of ovulation). PCOS occurs when your ovaries and/or adrenal glands produce an abnormally high amount of androgens. When produced in high quantities, these hormones can impact the development of ovarian follicles and the release of eggs during ovulation, and the development of cysts inside the ovaries. The cause of PCOS is unknown, though genes, insulin resistance, and inflammation have all been linked to PCOS.

How PCOS Causes Infertility

PCOS interferes with the female reproductive processes in multiple ways. 

• Irregular menstrual cycles can make it harder for couples to time their intercourse.
• Hormonal imbalance associated with PCOS can interfere with the hormone feedback loop necessary to facilitate egg maturation and ovulation. When eggs get “stuck” at immature stage in the ovaries and aren’t released to meet the sperm, pregnancy cannot occur.
• The same hormone imbalance can also prevent the thickening of the endometrium to welcome the implanting embryo, leading to implantation failures.
• Systemic inflammation associated with PCOS – and obesity common among women with PCOS - may harm egg quality.

Symptoms of PCOS: When to See a Doctor

If you are experiencing any of the following symptoms and have difficulty getting pregnant, it might be worth speaking to your doctor about PCOS:

• Irregular periods
• Acne
• Oily skin
• Hirsutism (excessive facial and body hair growth)
• Hair loss on the scalp
• Weight gain
• Darkening of the skin
• Pelvic pain (less common)
• Skin tags (less common)

While there is no single test that can identify PCOS, partially because there are multiple types of PCOS with different phenotypes, the condition can be diagnosed through medical history, a physical exam, ovarian ultrasound and blood tests that measure hormone, glucose and cholesterol levels.

Endometriosis

Endometriosis occurs when the endometrium, or the inner lining of the uterus, grows outside the uterus. Studies have shown that between 30% and 50% of women with endometriosis will experience infertility. Conversely, up to half of women struggling with infertility may have endometriosis.

How Endometriosis Causes Infertility

There are multiple theories as to how endometriosis interferes with conception.

• The condition can cause the formation of pelvic adhesions, which could prevent ovulation or make it difficult for egg and sperm to meet.
• The increase in the amount of fluid within the peritoneum (the lining of the abdomen), containing cytokines that harm the egg, sperm and fallopian tubes may contribute to infertility.
• Similar to PCOS, systemic inflammation associated with endometriosis may also negatively impact egg quality. More on the endometriosis-related inflammation’s impact on egg quality here.
• Chemical changes in the endometrium due to endometriosis-triggered immune system may decrease the ability of an embryo to implant properly and make it more difficult to maintain the pregnant after conception. 

Many women with endometriosis do get pregnant, although it may take longer and you may need fertility treatment to achieve your goal. Your chance of pregnancy with endometriosis depends on multiple factors, such as your age, your partner’s fertility, the severity of endometriosis and presence or absence of other factors contributing to infertility. A fertility specialist will be able to guide you through your potential options and what you can expect from each.

Symptoms of Endometriosis: When to See a Doctor

When you are finding it difficult to get pregnant and have these symptoms, a consultation with an OBGYN or reproductive specialist may be in order: 

• Severe menstrual cramps that are unrelieved by NSAIDs like aspirin or ibuprofen
• Periods lasting longer than seven days
• Long-term pain in the pelvis and lower back
• Heavy menstrual bleeding
• Bowel and urinary issues, such as pain, bloating, constipation, diarrhea and bloody stools or urine
• Nausea and vomiting
• Pain during intercourse
• Fatigue
• Bleeding between periods

In order to confirm the presence of endometriosis, your doctor may conduct a physical exam and an ultrasound and/or an MRI to visualize the pelvic organs. Endometriosis can be difficult to diagnose with imaging alone, and some physicians may recommend a diagnostic laparoscopy, while others can reach a diagnosis based on a combination of medical history and imaging.

POI (Premature Ovarian Insufficiency) or POF

Primary ovarian sufficiency (POI), also known as premature ovarian failure (POF), occurs when a woman’s ovaries stop working normally before age 40. POI can strike women as young as in their teens, and its prevalence is surprisingly high – around 3-4% according to a review of 31 studies. Causes of POI are not well-understood, although in about 10% of POI cases, POI can be traced back to genetic conditions like Turner Syndrome and Fragile X Syndrome, autoimmune conditions like thyroiditis and Addison disease, or iatrogenic causes like chemotherapy and radiation.

How POI Causes Infertility

 In women with POI, ovaries don’t produce a sufficient amount of estrogen. They contain much fewer immature eggs available for maturation and ovulation in each cycle, leading to anovulation. Some women with POI do ovulate occasionally, but the irregularity makes it difficult to time the intercourse for a pregnancy.

Between 5% and 10% of women with POI do get pregnant naturally without fertility treatment. Others may need IVF or even donor eggs, as their ovaries may not respond enough to fertility medications used in IVF cycles.

Symptoms of POI: When to See a Doctor

With POI, getting a diagnosis as soon as possible is key, since ovarian function can decline quickly. If you find out you have POI early enough, you may be able to work with a fertility specialist to develop and retrieve enough eggs to get pregnant. You may want to talk to your doctor about POI if you have these symptoms in addition to difficulty conceiving:  

• Hot flashes
• Night sweats
• Difficulty sleeping
• Reduced sex drive
• Problems with memory and concentration
• Vaginal dryness
• Headaches
• Anxiety or low mood
• Heart palpitations
• Joint stiffness
• Frequent urinary tract infections

Your age, symptoms, family history and your own medical history will inform your doctor in POI diagnosis. Blood tests to measure the levels of reproductive hormones, follicle-stimulating hormone (FSH) in particular, will be a part of your diagnostic testing.

If any of these symptoms rings a bell, take action. 

Your local fertility specialist should be one of your first stops if you don’t get pregnant in one year of trying (6 months if you are a woman over 35) or suspect one of these common conditions is holding you back on your fertility journey.

A quick diagnosis means you can start treatment sooner, which gives you a better chance of pregnancy. It also means you can make lifestyle changes to support your fertility, targeted to the diagnosis. (For example, if it turns out you have PCOS, you might start on an anti-inflammatory diet high in antioxidants.) As always, please reach out with questions. We are with you.