Infertility is not being able to conceive after 12 months of regular, unprotected intercourse. It is more common than most people realise, affecting an estimated 8 to 12% of reproductive age couples globally, with female factors accounting for approximately 40 to 50% of all infertility cases in India. Yet it remains one of the most underdiscussed aspects of women's health, often surrounded by stigma, misinformation, and delayed diagnosis.
Many of the conditions that lead to infertility are treatable, and several are manageable if identified early. This blog covers the causes of female infertility, their symptoms, how they are diagnosed, and what treatment options are available.
What is Female Infertility?
Female infertility is inability to conceive or carry a pregnancy to term. It may be primary (never conceived) or secondary (difficulty conceiving after a previous pregnancy). Because infertility in women often presents without obvious symptoms many conditions are entirely silent until a couple begins trying to conceive routine gynaecological care and early investigation are essential.
Women up to 35 years of age who are attempting conception should engage in regular, unprotected intercourse for at least 12 months before initiating an infertility evaluation.
Top Causes of Female Infertility
There can be many different reasons for infertility in women. Here we have panned out the causes which could be the leading cause behind your inability to conceive.
Polycystic Ovary Syndrome (PCOS)
PCOS is the single most common cause of female infertility worldwide, responsible for approximately 70% of all anovulatory infertility cases. It is a complex hormonal disorder in which elevated androgen levels disrupt the normal development and release of eggs. Women with PCOS typically experience irregular or absent menstrual cycles, making it difficult to predict or achieve ovulation.
According to the WHO, PCOS affects an estimated 10 to 13% of reproductive women globally and up to 70% of those affected are undiagnosed. In India, the prevalence is compounded by rising rates of insulin resistance and obesity, both of which worsen PCOS related anovulation.
The good news: with appropriate management including weight optimisation, ovulation induction medications like clomiphene citrate, and in vitro fertilisation (IVF) when needed pregnancy rates are strong.
Fallopian Tube Blockage and Pelvic Inflammatory Disease (PID)
Tubal factors account for 20 to 35% of female infertility cases, making them the second most common cause. The fallopian tubes serve as the pathway through which the egg travels from the ovary to the uterus for fertilisation. When they are blocked, damaged, or scarred, this journey becomes impossible.
A hysterosalpingography (HSG) , an X-ray procedure that evaluates tubal patency, is the standard diagnostic tool. IVF effectively bypasses tubal blockage and remains the primary treatment pathway for women with bilateral tubal occlusion.
Endometriosis
Endometriosis is a condition in which tissue resembling the uterine lining grows outside the uterus on the ovaries, fallopian tubes, or pelvic cavity. This misplaced tissue responds to the monthly hormonal cycle as uterine tissue would: it thickens, breaks down, and bleeds but has nowhere to go, causing inflammation, adhesions, and scarring.
Endometriosis is present in 25 to 50% of infertile women, and infertility affects 30 to 50% of women diagnosed with the condition. Diagnosis of endometriosis requires laparoscopy for confirmation and is often delayed by years due to its symptomatic overlap with other conditions. Surgical removal of endometrial lesions improves natural conception rates; IVF is recommended for more advanced cases.
Persistent lower abdominal or pelvic pain may be indicative of conditions such as Endometriosis or Pelvic Inflammatory Disease.
Uterine Abnormalities: Fibroids, Polyps, and Structural Defects
Uterine factors including fibroids (leiomyomas), endometrial polyps, intrauterine adhesions (Asherman's syndrome), and congenital anomalies such as a septate uterus account for 10 to 15% of female infertility cases. These structural issues interfere with implantation, disrupt the uterine environment for embryo development, or physically obstruct the passage of sperm. Hysteroscopic removal of fibroids and polyps is a minimally invasive, highly effective intervention that substantially improves pregnancy outcomes.
Thyroid Disorders
Thyroid dysfunction both hypothyroidism and hyperthyroidism are a leading but frequently overlooked contributor to female infertility in India, where thyroid disorders are disproportionately prevalent. Thyroid hormones play a critical role in regulating the menstrual cycle, ovulation, and the hormonal environment necessary for implantation and early pregnancy.
Even subclinical hypothyroidism (mildly elevated TSH without overt symptoms) has been associated with reduced fertility, increased miscarriage rates, and adverse pregnancy outcomes.
Premature Ovarian Insufficiency (POI)
Premature ovarian insufficiency is the loss of normal ovarian function before the age of 40. Women with POI have reduced or absent follicular activity, resulting in irregular or absent periods, low oestrogen levels, and significantly diminished fertility. It affects approximately 1% of women under 40 and 0.1% of women under 30.
Causes include chromosomal abnormalities (such as Turner syndrome), autoimmune conditions, certain chemotherapy or radiation treatments, and in many cases, no identifiable cause is found. While natural conception remains possible in some women with POI during periods of spontaneous ovarian activity, egg donation IVF is currently the most effective treatment pathway.
Cervical Factors
The cervix plays a functional role in fertility: it produces mucus that facilitates sperm transport into the uterus during the fertile window. Cervical stenosis (narrowing of the cervical canal due to surgery or infection), abnormal cervical mucus, or previous cervical procedures can impede sperm entry and reduce fertility. Cervical factor infertility accounts for approximately 5 to 10% of cases and is typically diagnosed through postcoital testing and cervical evaluation. Intrauterine insemination (IUI), which bypasses the cervix entirely, is the primary treatment approach.
Lifestyle and Environmental Factors
In urban India, lifestyle related infertility is a rapidly growing concern. Delayed marriage and childbearing (ovarian reserve naturally declines with age, particularly after 35), obesity, chronic psychological stress, sedentary behavior, smoking, and exposure to endocrine disrupting chemicals in the environment all measurably impair female reproductive function. Unlike structural or genetic causes, many lifestyle related factors are modifiable, making them a high priority area for both prevention and intervention.
Female infertility can result from ovulatory dysfunction, structural uterine abnormalities, Endometriosis, tubal pathology, diminished ovarian reserve, and other reproductive or endocrine disorders.
How is Female Infertility Diagnosed?
A comprehensive fertility evaluation typically involves multiple investigations conducted in sequence. Standard assessments include:
- Hormonal blood tests: FSH, LH, AMH (ovarian reserve), oestradiol, TSH, prolactin, and androgens assessed at specific points in the menstrual cycle
- Transvaginal ultrasound: evaluates ovarian follicle count (antral follicle count), uterine structure, and the presence of fibroids, cysts, or polyps
- Hysterosalpingography (HSG): an X-ray procedure using contrast dye to assess tubal patency and uterine cavity shape
- Diagnostic laparoscopy: the gold standard for diagnosing endometriosis and pelvic adhesions; performed when clinical suspicion is high
- Hysteroscopy: direct visualisation of the uterine cavity to identify and treat polyps, fibroids, or adhesions
Expert Women's Health and Fertility Care at Artemis Hospitals, Gurugram
At Artemis Hospitals, Gurugram, the Department of Gynaecology and Women's Health offers comprehensive fertility evaluation and management, from initial hormonal workup and advanced imaging to laparoscopic surgery, ovulation induction, and assisted reproductive technology. The team includes experienced gynaecologists and reproductive medicine specialists who work alongside endocrinologists, radiologists, and genetic counselors to address the full clinical picture.
If you or someone you know has been trying to conceive without success, an early, thorough evaluation is the most important step. The sooner a cause is identified, the broader the range of treatment options available.
Article by Dr. Deepika Aggarwal
Chief - Laparoscopic Gynae & Robotic Surgery
Artemis Hospitals
