Why can't I get pregnant? Symptoms, causes & Infertility treatment options

How is infertility diagnosed?

Infertility, in healthcare terms, is when a couple has struggled to get pregnant after having frequent, unprotected sex for over 12 months [1]. There are two types of infertility: primary and secondary. Primary infertility is when a couple has never conceived before and struggles with their first pregnancy. Secondary infertility is when a couple has conceived previously, but is now struggling to get pregnant [2]. 

Whilst most terminology and studies refer to couples, infertility can also apply to the experience of an individual, such as those on a solo fertility journey.

Why can’t I get pregnant?

Struggling to conceive can feel like an uphill battle, but you are not alone. One in every seven couples experiences difficulties getting pregnant [2]. For some, it just takes a little longer than usual. But sometimes, there might be another reason you find you can’t conceive. 

Aging and infertility

Fertility naturally declines as we age. Women are at their most fertile in their 20s. After age 30, fertility starts to decline, becoming more stark after your mid-thirties. Once we reach the age of 45, we are likely to start noticing signs of perimenopause, when ovulation and conceiving become more unpredictable [3, 4]. We spoke to Dr Natalie Crawford, OB-GYN and Medical Advisor at Natural Cycles, about how aging affects fertility: 

“At age 34 and on, we start to see dramatic drops in the chances of getting pregnant each month. So much so, if you are attempting conception for the first time at age 35, your chance of getting pregnant is 12% per month, at age 38, it is 5% per month, at age 40, it is 3% per month. These rates are even lower after age 40."
- Dr Natalie Crawford, Double Board-Certified Obstetrician-Gynecologist, Natural Cycles Medical Advisor

Medical conditions and infertility

Sometimes, infertility can be a consequence of a pre-existing medical condition. Many of the risks relate to hormonal imbalances or conditions affecting the reproductive organs, including: 

• Polyendocrine Metabolic Ovarian Syndrome (PMOS): Formerly known as polycystic ovary syndrome (PCOS), PMOS is a hormonal condition that affects ovarian function, resulting in more frequent anovulatory cycles. It is thought to affect 1 in 10 women in the UK. The most common symptom is irregular periods, though many women show no symptoms at all [5].

• Primary Ovarian Insufficiency (POI): POI is a dysfunction of the ovaries before the age of 40, characterized by a lack of menstruation for four months, high levels of follicle-stimulating hormone, and low levels of estrogen. POI, previously referred to as premature ovarian failure, is different from premature menopause, as ovulation and periods still occasionally occur, and there is still a chance of getting pregnant naturally. Unfortunately, today, in up to 90% of POI cases, the cause is unknown [6]. 

• Endometriosis: This chronic inflammatory condition is characterized by tissue resembling the uterine lining growing outside of the uterus, usually in other parts of the pelvic region. While there is debate over the exact relationship between endometriosis and infertility, one theory is that the excess tissue can interrupt ovulation or the ability for a fertilized egg to travel down the fallopian tubes [7]. 

• Fibroids: These non-cancerous growths affect the uterus, but are very common and, in most cases, do not cause any issues. However, some people may experience symptoms such as heavy or painful periods. Depending on their location, fibroids can affect fertility by preventing implantation from occurring [8].  

• Pelvic inflammatory disease (PID): PID is an infection of the female reproductive system, causing symptoms such as pain during sex, lower belly pain, and heavy periods [9]. PID sometimes causes infertility due to scar tissue on the fallopian tubes interfering with fertilization. 

• Thyroid conditions: If you have an underactive thyroid (hypothyroidism), your thyroid gland does not produce enough thyroid hormones [10]. Untreated, this can impact the function of your ovaries, sometimes causing irregular periods and a higher chance of miscarriage or pregnancy complications [2].

Many individuals with these conditions can get pregnant and have a healthy birth. But if you think you have a condition that can affect fertility, or have symptoms of a condition, speak to your doctor. 

Lifestyle and infertility

Your overall health and everyday life can also have an effect on your chances of getting pregnant, including: 

• Medications and drugs: Some medications or treatments can impact your ability to get pregnant. Long-term use of anti-inflammatory drugs, such as ibuprofen, can make conceiving more difficult, and chemotherapy can impact ovarian function. Use of recreational drugs can also be detrimental to fertility [2].

• Very low or high BMI: Weight is a highly personal topic, but knowing its potential impact on fertility is worthwhile. Being very overweight or underweight can affect our ovaries and disrupt ovulation [2]. 

• Smoking: Smoking tobacco increases your risk of a delay in getting pregnant, increasing your overall likelihood of both primary and secondary infertility [11]. Smokers are also more likely to have an earlier menopause than non-smokers [12].

• Alcohol: Several studies have shown that all levels of alcohol intake impact your chances of getting pregnant. They also suggested that the impact increases as the amount you drink increases, so the more alcohol you consume, the bigger the effect on fertility [13]. 

• Stress: Though there is not much research specifically linking stress and infertility, we do know that stress affects our reproductive hormones and can delay or prevent ovulation, which, in turn, can impact fertility [2].

Male infertility

Around one-third of infertility cases are due to a male reproductive issue, while a third are linked to female reproductive issues and the remaining are a combination or unknown. The most common cause of male infertility is problems with the testicles. Varicoceles is a condition involving a large vein on the testicle that is present in around 40% of men with fertility issues. Other causes of male infertility include low sperm count or motility, hormonal imbalances, or blockages in the reproductive organs [14]. If you are struggling to get pregnant with your male partner, it’s important to explore both of your fertility to learn more about what might be stopping you from conceiving. 

Unexplained infertility

Unfortunately, not everyone has a clear cause behind their struggle to get pregnant. This is known as unexplained infertility, and accounts for a large number of infertility cases — around a quarter [2]. 

How long does it take to get pregnant?

In general, if the woman is under 40, over 80% of couples will conceive naturally within 12 months if they are regularly having unprotected sex. The odds reduce to 25% if you have been trying to get pregnant for over three years [2]. 

It may take longer to get pregnant the older you are, too. One study of 2,962 North American couples found that 79% of women aged 25 to 27 became pregnant within one year, compared to 56% of those aged 40 to 45 [15]. 

Try not to compare your fertility journey to that of others. Every individual or couple will take a different length of time to get pregnant, and the fertility experience is highly personal.

Can you get pregnant when you’re not ovulating?

To understand this question, let’s have a quick recap of how conception works. During ovulation, your ovaries release a mature egg cell. At this point, the egg cell lives for 12 to 24 hours, during which a sperm cell can fertilize it [16]. Since sperm can live for up to five days in the female reproductive system, your fertile window — when unprotected sex can lead to pregnancy — is actually six days long [17].

With this in mind, yes, you can get pregnant by having sex at a time in your cycle when you are not ovulating, as long as it is within the fertile window. However, ovulation must occur for pregnancy to happen. If ovulation does not happen in a cycle (known as an anovulatory cycle), there is no egg cell available for the sperm to fertilize, and you cannot get pregnant.  

Fertility and irregular cycles

A common symptom of fertility issues is cycle irregularities, as they can indicate a problem with ovulation [18]. Irregular periods (or irregular cycles) are defined when one or more of the following are true: 

• Your menstrual cycles are shorter than 21 days or longer than 35 days

• Your cycle length varies by more than 7-9 days 

• You experience three months without a period

• Your periods last longer than seven days

• You bleed much more or less than usual during your period

• You have unexplained bleeding or spotting that happens outside of your period

• You experience severe period pain

[19]

Most of us experience the occasional irregularity, which is usually nothing to worry about. Many individuals with irregular cycles also go on to have successful pregnancies. But it is always a good idea to speak to your doctor if you have concerns, as sometimes cycle irregularities can be a symptom of ovulatory conditions, such as PMOS [19]. 

How do I increase my chances of getting pregnant?

There is always an element of chance when it comes to getting pregnant, and for some people, it will take a little longer than expected. But there are a few things you can try at home to increase your likelihood of getting pregnant. 

Have sex regularly

When you are trying to get pregnant, it is generally recommended to have unprotected sex every two to three days [20]. For some people, this can feel like a lot of pressure, especially if libido changes throughout the menstrual cycle, or you are feeling stressed about fertility. 

As we explained earlier, there is only a six-day fertile window in each cycle during which pregnancy can occur [17]. If you track your cycle with Natural Cycles, the NC° app will show you when the best time to have sex is so that you can focus your efforts on them. It might also help to remember that it only takes one sperm cell to meet an egg and lead to pregnancy, and that in each ejaculation there are millions of sperm [16]!

“I’ve seen countless women with abnormal bleeding, pain or other severe symptoms with periods, missing or irregular periods, who have conditions like endometriosis, adenomyosis, fibroids, PMOS, perimenopause, etc…if you’re trying to get pregnant, understanding what happens during the parts of the cycle, when ovulation is happening, when intercourse should happen, will optimize your chances of conceiving”
- Dr. Karen Tang, Board-Certified Gynecologist, Natural Cycles Medical Advisor.

Reduce stress

Stress is a daily part of many people’s lives, and while a little is normal, too much stress can take its toll on our health and fertility. It can be easier said than done, but reducing stress in your daily life might help boost your chances of getting pregnant. Stress relief is different for everyone, so find what works for you, whether that is exercise, spending time with family or friends, or mindful activities like journaling [21].  

Quit smoking

Smoking has a significant impact on both female and male infertility, and smokers have double the rate of infertility than non-smokers in both sexes [12]. If you or your partner smokes, this is a great time to try quitting. The risk of infertility increases with the number of cigarettes smoked per day, so any reduction can help improve your chances of getting pregnant [12]. It can be hard to quit a habit like smoking, so reach out to your doctor or pharmacy for help, or there are free resources online, such as this ‘quit smoking’ guide from the CDC. 

Maintain a healthy weight

Losing or gaining weight can be a difficult journey, but even small changes can make a big impact on your chances of getting pregnant. For example, if you have a high BMI and suffer from PMOS, weight loss of only 5% can make significant improvements in symptoms and cycle regularity [5]. Try regular aerobic exercise, such as swimming or walking, along with healthy eating to support healthy weight loss. If you are trying to gain weight, make sure you are eating enough calories to support any exercise you are doing. Always speak to a doctor if you are struggling with your weight, have worries about your BMI, or if your weight is contributing to mental health struggles. 

Consume a balanced diet

No matter what your BMI is, the food you eat can go a long way toward supporting your fertility. Try to avoid trans fats, refined carbohydrates, and foods with added sugars (such as margarines, deep-fried foods, and candy). Instead, try to follow a Mediterranean-style diet rich in fiber, omega-3 fatty acids, and plant protein, which can help support your fertility [22, 23]. 

Exercise regularly

Regular exercise is also related to improved fertility outcomes. For those with PMOS and a high BMI, regular aerobic or resistance exercise can improve fertility, regardless of weight loss [24]. There is less research focused on those without PMOS or a high BMI. However, we know that exercise reduces the risk of some health conditions, such as cardiovascular disease, and supports stress reduction and mental health, which may contribute to improved fertility outcomes, regardless of your BMI [25]. 

It is important to balance energy output through exercise, as over-exercising can sometimes disrupt the menstrual cycle [24]. Make sure you are eating enough to balance your exercise, and speak to your doctor before making changes to your diet.

“The same factors that keep you healthy also can help improve your egg quality. Similarly, the factors that cause inflammation are toxic and lead to an increased rate of cellular damage inside our eggs. This is why I always recommend you control the factors you can to limit inflammation and improve your egg quality in the ways that you can: diet, exercise, sleep, stress management, and limiting toxins”
- Dr Natalie Crawford, Double Board-Certified Obstetrician-Gynecologist, Natural Cycles Medical Advisor

Infertility treatment options

If you’ve been struggling to get pregnant for a while, there are fertility treatment options available to help individuals and couples conceive. 

Often, your doctor will first suggest addressing any lifestyle factors, such as smoking or weight, that might be influencing your fertility. They may also prescribe medication to treat conditions or hormone imbalances. If you experience irregular or absent ovulation, and there is no clear cause, your doctor might recommend using drugs to stimulate your ovaries to release an egg. This treatment is called ovulation stimulation, and can sometimes be used in conjunction with other fertility treatments, too [1].

Your doctor might recommend surgery if there is anything anatomical in your reproductive system affecting your ability to get pregnant. For example, they may suggest removing fibroids or polyps, repairing damaged or blocked fallopian tubes, or removing tissue associated with endometriosis [1]. 

In some cases, your doctor might suggest intrauterine insemination (IUI) or in vitro fertilization (IVF). IUI is when sperm is placed in the uterus around the time of ovulation, and can be used with ovulation stimulation. IVF is the combination of a sperm cell and an egg cell in a laboratory, followed by transferring the embryo into the uterus [1].

When to see a doctor

You should always speak to your healthcare provider if you have any questions about getting pregnant, infertility, or things that might impact your ability to get pregnant, especially if 

• You are over the age of 35

• You have irregular periods

• You have been trying to get pregnant for more than one year

• You have any medical conditions that can impact fertility

• You have had treatment for cancer

• You have a medical condition that could be passed on to your baby

• You take regular medication that could impact fertility or pregnancy

• You think you have, or may have previously had, a sexually transmitted infection (STI) 

[2, 20] 

“I recommend starting a fertility evaluation if not pregnant after 12 months of trying. However, due to the age related impact on infertility, older women should schedule a fertility consultation sooner. For women aged 35-39, I recommend starting the workup after 6 months of trying to conceive. Women age 40 and older should consider an earlier evaluation, either immediately or after 3 months of trying without success.”
- Dr Natalie Crawford, Double Board-Certified Obstetrician-Gynecologist, Natural Cycles Medical Advisor

More than a cycle tracker

Getting pregnant is based on your menstrual cycle, so the more you know about it, the more informed you can be. Natural Cycles uses biomarkers and a one-of-a-kind algorithm to predict your ovulation and fertile window, letting you know when sex is most likely to lead to pregnancy. You can also log any symptoms you experience in the NC° app, such as spotting or PMS. At the end of each cycle, you’ll receive a cycle report outlining the length of your cycle, ovulation timing, and the length of your period, alongside any recorded symptoms. You can then download the report to share with your doctor, making it easier to highlight any irregularities. 

Many users have found success conceiving with Natural Cycles. One study of NC° Plan Pregnancy users found the median time to get pregnant was four cycles. For those under the age of 35, with no known fertility issues, the median was two cycles. Get pregnant faster with Natural Cycles [26].