Female Infertility Causes

Identifiable Main Causes

The American College of Radiology suggests that ovulatory disorders are the primary cause of female infertility, accounting for 21% of cases, with polycystic ovary syndrome (PCOS) being the main cause of anovulatory infertility, affecting at least 7% of adult women and representing 70% of women with anovulation 1
The American College of Radiology recommends that PCOS be diagnosed with polycystic ovarian morphology (>25 small follicles in at least one ovary or ovarian volume >10 mL) on transvaginal ultrasound, along with clinical hyperandrogenism 1
Other hormonal disorders, including thyroid dysfunction, hyperprolactinemia, and adrenal disorders, require specific evaluation, as recommended by the MMWR Recommendations and Reports 2

The MMWR Recommendations and Reports suggest that lifestyle and environmental factors, such as being underweight or overweight, can reduce fertility 2
High caffeine consumption (>5 cups per day) reduces fertility, as reported by the MMWR Recommendations and Reports 2
Smoking, alcohol consumption, recreational drug use, and most commercial vaginal lubricants reduce fertility, according to the MMWR Recommendations and Reports 2

A focused clinical history, including duration of attempted pregnancy, coital frequency and timing, level of fertility awareness, and history of previous surgeries, hospitalizations, and severe illnesses, is essential for evaluating infertility, as recommended by the MMWR Recommendations and Reports 2
A physical examination, including height, weight, and BMI calculation, thyroid examination, and pelvic examination, is necessary for evaluating infertility, as suggested by the MMWR Recommendations and Reports 2

The MMWR Recommendations and Reports recommend that infertility evaluation should not be delayed after 6 months in women over 35 years old, instead of waiting 12 months 2
Early evaluation is also justified in women with a history of oligo-amenorrhea, known or suspected uterine/tubal disease, endometriosis, or a subfertile partner, as recommended by the MMWR Recommendations and Reports 2

The American College of Radiology recommends that tubal damage, which accounts for 14% of known infertility cases, is a recognized cause of female infertility 3, 4
History of salpingitis from chlamydia infection is specifically identified as a major cause of female infertility by the American College of Radiology 5
STI-related pelvic inflammatory disease leads to tubal scarring, occlusion, and peritubular adhesions that cause infertility, according to the American College of Radiology 5
Barrier methods that prevent STIs reduce risk of tubal infertility by 25%, as reported by the Centers for Disease Control and Prevention 6, 7
Endometriosis affects at least one-third of women with infertility and up to 10% of reproductive-aged women, and is recognized as a major female-specific cause of infertility by the American College of Radiology 5
Uterine cavity abnormalities interfere with implantation, causing inability to conceive or recurrent pregnancy loss, according to the American College of Radiology 3, 8
Ovulatory disorders, particularly PCOS, account for approximately 21% of female infertility cases, as reported by the American College of Radiology 4

The evidence for these causes is based on systematic reviews and guidelines from reputable organizations, including the American College of Radiology and the Centers for Disease Control and Prevention 3, 8, 4, 5, 6, 7

The American College of Radiology (2020) lists the main etiologies of female infertility as ovulatory disorders (≈21 % of cases), tubal damage (≈14 %), male factor (≈26 %), endometriosis (affecting roughly one‑third of infertile women), and uterine cavity abnormalities that interfere with implantation. 9
Uterine cavity abnormalities that contribute to infertility are limited to intra‑uterine synechiae, Müllerian anomalies, fibroids, and other implantation‑impairing conditions; uterine prolapse is not included among these. 10

Anatomically, uterine prolapse involves loss of pelvic‑floor support but does not damage the endometrial cavity, fallopian tubes, or ovarian function—structures essential for conception. 11
Guidelines on pelvic‑floor dysfunction emphasize quality‑of‑life issues such as urinary incontinence and defecatory dysfunction, noting that these conditions cause morbidity without affecting reproductive capacity. 11
Although severe prolapse could theoretically alter cervical position or coital mechanics, no clinical data document it as a significant contributor to infertility. 11

For reproductive‑age women presenting with infertility, the recommended evaluation focuses on established causes: assessment of ovulatory function (e.g., antral follicle count, ovarian volume via transvaginal ultrasound), tubal patency testing (hysterosalpingography), screening for PCOS, endometriosis, and male factor analysis. This recommendation follows the American College of Radiology (2020) guidelines. [9][10]
Uterine prolapse should not be a primary target in the infertility work‑up unless there is severe anatomical distortion that could mechanically impede intercourse or sperm transport—an exceptionally rare scenario lacking guideline‑level evidence. [9][10]