Infertility 101: Get to the Root Cause

From all my years in practice and speaking with women who are suffering, I know how grave the desperation, anxiety, and loneliness are for those struggling with infertility. Too commonly unaddressed, millions of women suffer in secrecy and begin to doubt their bodies.

According to the most recent data from the CDC, 6.9 million or 11 percent of women aged 15 to 44 have used fertility services in the US. At least one million women are considered infertile, defined as being unable to conceive for a consecutive 12-month period. For women over 35, infertility is defined by it taking longer than 6 months to get pregnant.

Not all women want to conceive, but if you have painful or irregular periods, mood problems prior to your period, breast cysts, or early menopause, chances are high that your hormones are out of whack. I believe reproductive wellness is a gateway to the bigger picture of a woman’s health. It’s two sides of the same coin: just as your reproductive health may signal a larger problem with your health in general and point to issues that may need your attention as you age beyond the reproductive window, problems in your general health may affect your reproductive health.

Based on research and my own patients, I see four common causes of infertility. Some are complex to treat; others can be improved with key lifestyle changes.

Here’s the rundown:

  1. Inflammation and its link to infertility, and how to tackle it
  2. PCOS leads to infertility, and what it takes to get it under control
  3. Excess estrogen and its role in infertility, and how to balance it
  4. HPA Axis imbalance & how to calm it down

Let’s go at this one by one.


The one cause that few doctors or women consider in fertility issues is inflammation. Yet, inflammation can cause problems like swollen fallopian tubes that don’t transport the egg properly, preventing fertilization. Or women with endometriosis, in which tissue that normally lines the uterus grows on the ovaries, bladder, or bowel. As the rogue tissue grows where it doesn’t belong, it creates inflammation that causes pain, infertility, and can even act like superglue and cause adhesions that make organs to stick to one another. What a mess! Organs that are stuck together instead of sliding over one another seems to make it harder to get pregnant, and the superglue effect isn’t just on the outside, it affects the innermost parts of your female organs, such as tubes, ovaries, and the uterus.

In short, excess, prolonged inflammation is like a woodstove that keeps burning until the house is torched. It’s a problem of persistent immune activation, which can be the result of many factors from environmental toxins to high stress to genetic predisposition. The main ammunition of the immune system as it becomes overzealous is to flood the body with noxious chemicals, known as cytokines. These chemical mediators can destroy tissue and lead to scar and pain in targeted tissues such as the ovary, tubes, and thyroid, leading to infertility.

What’s the real problem? The root cause of all disease is inflammation, whether you’re struggling with infertility, depression, cancer, aging, or another condition. Inflammation is like trying to clean up the house while a frat party is in progress: we use functional medicine as a tool to suss out the causes of inflammation and then reverse them. The downstream result is typically a better mood, or maybe even a live baby. When it comes to infertility, the obvious situations involving inflammation are when you develop antibodies to sperm (called antisperm antibodies), recurrent miscarriage, and autoimmune thyroiditis. Inflammation is a background problem in other conditions that affect fertility too, such as endometriosis, fibroids, infection (such as the scar tissue of pelvic inflammatory disease), and the insulin block of polycystic ovary syndrome.

Inflammation is designed to occur for about three days, then resolve as healing occurs. Just like you cut your finger—ouch, it hurts and then it’s over. But the problem with chronic inflammation is that it doesn’t resolve after three days. Over my career, I’ve seen thousands of women who caught chlamydia in their twenties, and even 10 years later, they have signs of inflammation even though the infection is long gone. Yikes!

Eradicating inflammation could improve fertility and associated symptoms.  This is the foundation of a functional medicine approach—including the increased consumption of proven anti-inflammatory agents such as organic vegetables and fruits, omega-3s, vitamin D, n-acetyl cysteine, and resveratrol.  The supplement Chasteberry has also been found to improve fertility and ease PMS.

Polycystic Ovary Syndrome (PCOS)

Irregular periods and signs of excess androgens are the telltale signs of PCOS. Not only will PCOS put you at risk for weight gain, acne, and excess hair growth, it is the number one most common reason for infertility. The most common hormone condition in women of reproductive age, PCOS affects 20 to 30 percent of women and can interfere with fertility by blocking regular monthly ovulation. After menopause, PCOS continues to put women at greater risk of heart disease, metabolic syndrome, and diabetes. It’s bad news all around.

So what is PCOS? Known as polycystic ovary syndrome, this condition causes the sex hormones to become unbalanced for reasons we don’t quite understand. Women with PCOS start making more androgens, which causes the symptoms of high androgens such as acne and rogue hairs.

Here’s what confuses most people: not all women with excess androgens have PCOS, and not all women with PCOS have high androgens. While they do overlap, the difference is that PCOS is characterized by insulin resistance and ovarian cysts. Sadly, PCOS goes widely undetected; among women eventually diagnosed with it, 70 percent had not been previously diagnosed.[1] That’s why it’s so hard to treat.

With PCOS, diet and exercise are proven to ease the decree. As little as one 20-minute brisk walk per day can result in a 7 percent weight loss.[2] Even in adolescent girls with PCOS, weight loss corrects irregular periods, normalizes androgens, and improves cardiovascular risk factors.[3] Studies found that yoga was more effective than other forms of exercise at improving insulin resistance in PCOS.[4] Eating a low-glycemic index food plan reduces androgens by up to 20 percent.[5]

Add in extra fiber to expel excess testosterone and eat more zinc-rich foods to bolster ovulation, fertility and menstruation. Avoid sugar and choose healthy oils, especially omega-3s found in wild Alaskan salmon or a fish oil supplement. Studies found that these lifestyle changes will not only curb your PCOS or high androgens, but will make you feel healthier.

Examine Estrogen

Excess estrogen is one of the main drivers of infertility. Estrogen dominance is paired with low progesterone. In proper proportion, these hormones are like the two sides of a seesaw, shifting rhythmically back and forth over the course of the menstrual cycle. It’s essential to maintain the delicate balance between these two hormones to feel your most vital.  You’ll suspect your progesterone is off if you have miserable periods, feel full of rage, and suffer from headaches and sleep disorders.  When estrogen is high and progesterone is low, you’ll have a tendency toward infertility.

Fortunately, there are many simple ways to fight excess estrogen. The easiest is to reduce alcohol and cut caffeine, with the added benefit of helping lower cortisol as well. We know that alcohol raises your level of estrogen and can disrupt the function of the liver. Even one glass of wine a day increases breast cancer risk by 11 percent. Yikes! If you have symptoms of excess estrogen, I recommend fewer than four servings a week. Better yet, stick to a glass of wine only on a special occasion, and you’ll be good to go.

Aim to get more fiber to purge the gut of extra estrogen. We know that increased fiber will lower your estrogen levels and likely reduce your risk of breast cancer. Regardless of age, I recommend that you consume 35 to 45 grams of fiber per day as part of a healthy food plan; most women only consume about 13 grams per day. Even with seven or more servings of fresh fruits and vegetables per day, most women need medicinal fiber, taken as a supplement.

The next step is to avoid xenoestrogens. As I hope I’ve shown you, endocrine disruptors such as bisphenol-A and phthalates can cause havoc. Do what you can to minimize your exposure to environmental toxins. Avoid canned food, plastic food containers, and fish with a high mercury content. Take off your shoes when you go inside to prevent the spread of pesticides and other nasty chemicals used on streets and gardens. Buy organic when you can, especially fruits and vegetables that don’t have skin you have to peel. They seem minuscule but all of these steps can add up.

Did you know that too much red meat is linked to higher estrogen levels? The connection between meat and estrogen is profound. When you eat conventionally raised red meat, estrogen overload is more likely. When you go meatless, your estrogen decreases. Not surprisingly, vegetarians have the edge here. This could be due to the hormones in the meat, the type of bacteria cultivated in the guts of people who eat a lot of meat, or a combination of factors. We do know that a meat-based diet is linked to higher body mass index and that too much of the wrong type of saturated fat raises estrogen. When you reverse your estrogen dominance, you clear the path toward a healthy weight and reduce the incidence of estrogen-dominant conditions such as diabetes, metabolic syndrome, and certain forms of breast, ovarian, and endometrial cancer.

Disrupted HPA Axis

The Hypothalamic-Pituitary-Adrenal (HPA) axis is a feedback loop by which signals from the brain trigger the release of hormones, such as cortisol, needed to respond to stress. Because of its function, the HPA axis is also sometimes called the stress circuit. It’s a doozy that impacts two other hormone systems: Thyroid and Gonads. When cortisol is dysregulated (i.e., too high, then over time, too high and too low, and ultimately, too low), it alters thyroid and gonadal function, making it harder to lose weight and conceive. PCOS is a good example: altered HPATG is associated with irregular menstruation, hirsuitism (excess hair growth), and infertility.

If we’re talking about PCOS and cortisol, I’ll add that hypervigilance is what I discuss in The Hormone Cure as the key reason for hormonal imbalance in women, including the hormone issues linked to infertility. I find hypervigilance in about 91 percent of my patients. Hypervigilance creates high cortisol, and since cortisol’s main job is to raise glucose levels, the net result is that you get higher blood sugar levels and a greater risk of insulin resistance. When cells become numb to insulin, serum insulin levels rise, and high insulin seems to be directly toxic to the ovary, causing higher production of testosterone. That’s one of the mechanisms of PCOS. Crush cortisol by finding ways to dance differently with stress.

Meanwhile, targeting the thyroid could warm up those hormones and bring fertility up. If you collect fluid from inside the pelvis of women with endometriosis, there are at least 13 different markers of inflammation that create a molecular signature of endometriosis. One more example is autoimmune thyroiditis, the cause of 95 percent of low thyroid function. Every cell in your body has receptors for thyroid hormone, and low thyroid function (defined as a TSH > 2.0) is associated with a greater risk of infertility. The cause is autoimmune, meaning that your immune system gets overactivated, perhaps beginning in the gut, and attacks and ultimately destroys thyroid tissue. You need a healthy level of thyroid hormone to cycle regularly and conceive.

We also know that hormones do all kinds of harm to our bodies when not kept in their proper place. Low progesterone and high androgens, chiefly testosterone, cause infertility. Ask your doctor to check your insulin levels, especially if you face any of the telltale signs of insulin resistance, which include midsection weight gain, fatigue, tension, low mood, and decreased immunity.

Not easy going. Fertility is one complicated puzzle.  Please don’t go at this alone. I encourage you to work closely with a functional medicine or integrative medical specialist to determine if any of these issues are contributing to infertility. It’s too easy for your hormones to get whacked, and regaining balance is the key to fertility. Bring yourself the much deserved healing, often stemming from lifestyle changes that encourage balance, reduce stress and eliminate inflammation.

Check out my book The Hormone Cure for more secrets to solve your hormonal troubles.


[1] March WA, Moore VM, Willson KJ, et al. “The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria.” Human Reproduction 25 (2010): 544–51. doi: 10.1093/humrep/dep399.

[2] Sheehan MT. “Polycystic ovarian syndrome: diagnosis and management.” Clinical Medicine and Research 2 (1) (2004): 13–27

[3] Lass N, Kleber M, Winkel K, et al. “Effect of Lifestyle Intervention on Features of Polycystic Ovarian Syndrome, Metabolic Syndrome, and Intima-Media Thickness in Obese Adolescent Girls.” Journal of Clinical Endocrinology and Metabolism 96 (11) (2011): 3533–40.

[4] Nidhi R, Padmalatha V, Nagarathna R, Ram A. “Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome.” International Journal of Gynaecology and Obstetrics 24 (4) (2012): 223–27.

[5] Smith RN, Mann NJ, Braue A, et al. “The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial.” Journal of the American Academy of Dermatology 57 (2) (2007): 247–56; Smith R, Mann N, Mäkeläinen H, et al. “A pilot study to determine the short-term effects of a low glycemic load diet on hormonal markers of acne: a nonrandomized, parallel, controlled feeding trial.” Molecular Nutrition and Food Research 52 (6) (2008): 718–26.


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Sara Gottfried MD About Sara Gottfried MD

Sara Gottfried, MD is the New York Times bestselling author of the new book, Younger: A Breakthrough Program to Reset Your Genes, Reverse Aging, and Turn Back the Clock 10 Years. Her previous New York Times bestsellers are The Hormone Cure and The Hormone Reset Diet. After graduating from Harvard Medical School and MIT, Dr. Gottfried completed her residency at the University of California at San Francisco. She is a board-certified gynecologist who teaches natural hormone balancing in her novel online programs so that women can lose weight, detoxify, and slow down aging. Dr. Gottfried lives in Berkeley, CA with her husband and two daughters.