Age is a major factor in female fertility. As a woman or any person born with ovaries approaches their 30s, their fertility begins to decline. This decline in fertility is because there are fewer eggs in the ovaries and the quality of the eggs diminish, as that person gets older. Not only does age affect one’s ability to get pregnant and safely carry the pregnancy to term but age of the egg can also affect the pregnancy itself, by increasing the risk of genetic or chromosomal differences in the embryo.

Problems with ovulation are a common cause of infertility, accounting for approximately 25 percent of all female infertility cases. In order to conceive without assistance, a person born with ovaries must ovulate (i.e. release an egg from the ovary into the fallopian tube). Ovulation is connected to that person’s menstrual cycle, or period, which takes place every 28 – 34 days, depending on the individual. Persons who experience a period greater than 35 days apart, or not at all, are probably ovulating infrequently or not at all and would, at a minimum, require ovulation induction with a trigger shot to help release the eggs.

At least one open (patent) and functioning fallopian tube is necessary for having any chance at unassisted conception occurring. Certain risk factors can affect tubal function and account for 35 percent of infertility in women and persons born with ovaries and uteri. They include:

-Previous Pelvic Infections e.g Chlamydia, Gonorrhea or Pelvic Inflammatory Disease

-Previous Pelvic/Abdominal Surgery e.g. surgery for ruptured ovarian cysts or ruptured appendix, cesarean section or other uterine surgery like D&C.

-Endometriosis

The test that is typically performed to assess tubal patency, i.e. to check if the fallopian tube(s) is open, is a hysterosalpingogram (HSG), which is an X-ray picture of the pelvis. A thin tube-like instrument passes into the cervix, then an X-ray dye is injected into the uterus. As the dye enters the uterus and fallopian tubes, an assessment can be done on the uterine and fallopian tube anatomy.

The cervix is located in the lower part of the uterus. Conditions of the cervix can affect fertility but are rarely the sole cause of infertility. The following can contribute to cervical health:

-Abnormal pap smear(s)

-Prior cervical biopsies

-Cervical surgery (cone biopsy)

-“Freezing” and/or laser treatment of the cervix

-The patient’s mother took DES (diethylstilbestrol) while she was pregnant

- Cervical Insufficiency leading to recurrent pregnancy loss

Cervical problems are generally treated with antibiotics, fertility medications, by intrauterine inseminations (IUI) or with a special stitch called a cerclage.

The uterus (womb) is where the fertilized egg implants and develops. Uterine abnormalities can account for 20 percent of female infertility and include:

-Uterine scar tissue (Asherman’s Syndrome)

-Polyps (bunched-up pieces of the endometrial lining)

-Fibroids

-Abnormally shaped uterine cavity

Problems within the uterus may interfere with implantation of the embryo or may increase the incidence of miscarriage. The test(s) typically performed to assess the uterine cavity include a hysterosalpingogram (HSG), sonohysterogram (SHG or SIS) or a Hysteroscopy. Similar to the HSG, during a SHG/SIS a thin tube-like instrument passes into the cervix while small amounts of saline are injected into the uterus under ultrasound guidance to assess the uterine cavity. This is often the first line screening test for uterine cavity abnormalities. Hysteroscopy, is the gold standard procedure for evaluation of (and fixing) the uterine cavity.

Surgery is sometimes required to further evaluate and possibly correct uterine cavity abnormalities such as Asherman’s syndrome, endometrial polyps, uterine septum or submucosal fibroids.

Pregnancy loss can occur at any time during the pregnancy. Loss of a pregnancy during the first trimester is often colloquially termed a Miscarriage. This is one of the most devastating experiences that can happen to a woman or person born with a uterus. Approximately two out of every 10 pregnancies may result in a miscarriage. Despite having suffered miscarriage(s), most persons go on to have a healthy pregnancy, after careful evaluation and appropriate management.

Women are considered to have recurrent pregnancy loss when they have two or three pregnancy losses in their lifetime. In about two out of every three cases of pregnancy loss, we are able to determine the cause of recurrent pregnancy loss.

The causes of recurrent pregnancy loss include:

-Genetic-chromosomal differences in the embryo/fetus

-Age of the eggs

-Uterine abnormalities such as septum, endometrial polyp and/or submucosal fibroid

- Cervix Insufficiency

-Hormonal defects (e.g low progesterone, thyroid problems, low vitamin D)

-Autoimmune disorders (e.g. lupus anticoagulant, anticardiolipin antibodies, etc)

-Clotting disorders (e.g. Factor V Leiden, Von Willebrand’s disease, PAI-1 mutation, etc)

Treatments vary depending on the cause of the recurrent pregnancy loss and may include the use of hormonal or anticoagulant medications, surgery, IVF, donor egg, surrogacy and/or pre-implantation genetic testing (PGT).