Jennifer* was 27 when she and her husband, Sam*, started "trying." They got married in their early 20s, knew they wanted to have multiple kids, and felt nothing was standing in the way of the next chapter of their relationship.
"Our lives, careers, and hearts reached a place where we realised we were ready to start trying," Jennifer recalled.
At 27, she wasn't racing against the biological clock, but soon she would feel stuck in time for almost two years. Jennifer and Sam tried to conceive for 20 months and experienced two early, back-to-back miscarriages during that time.
"That cycle of hope and disappointment is disheartening and exhausting in itself, and even more so because you're going through it privately," Jennifer recalled. She says she felt strangely disconnected from her body, and "during some of the darker moments, I cried in doctors offices, Ubers, the bathroom at work, you name it." She says her husband couldn't have been more supportive, and the pair relied mostly on each other for support. "The challenge definitely brought us closer together."
According to doctors and couples who have experienced it, struggling with infertility in your 20s can be an isolating experience. Often with little mental preparation — and peers who either get pregnant easily or don't plan to have children anytime soon — couples struggle to understand the experience.
The good news is that time is actually on their side, and fertility treatments tend to work better for younger couples.
Jennifer and Sam were among those who ultimately found success: "I visited a fertility specialist after about a year of trying, and at that point, I tried Clomid for a few months," Jennifer recounted. Clomid is an oral medication that helps stimulate ovulation. "While on Clomid, I got pregnant twice — the two early miscarriages — and a month later, when we decided to 'take a break' from trying, I ended up getting pregnant again. Nine months later, my son was born."
Jennifer says there were months when low progesterone levels suggested she may not have ovulated, which likely impacted their infertility struggles.
What causes infertility in your 20s
A couple are officially considered "infertile" if they are unable to achieve a successful pregnancy after one year of trying. Age is a major contributing factor, but since "peak fertility" typically lasts until a woman is in her early 30s, it does not offer an explanation for why women in their 20s struggle to conceive.
"The most common causes of infertility in this age group include ovulatory dysfunction, polycystic ovarian syndrome, tubal disease, and male factors, in which partners may have low sperm counts or poor motility," said Dr. Shefali Shastri of Reproductive Medicine Associates of New Jersey (RMANJ).
Let's break down each condition and how it is typically treated:
- Ovulatory dysfunction: This means a woman does not consistently ovulate properly (release an egg) each month or perhaps does not ovulate at all (anovulation). A problem involving ovulation is the most common form of female infertility and can often be addressed with drugs like Clomid.
- Polycystic ovarian syndrome: This is caused by a hormonal disorder, and symptoms include infrequent or long periods or excess male hormone (androgen) levels. Treatment includes weight management and medications to get your period back on track, including birth control pills, progestin therapy, or fertility drugs like Clomid.
- Tubal disease: If your fallopian tubes are blocked or damaged, it will be difficult for your egg to meet the sperm. Tubal disease can also block a fertilized egg from making its way to the uterus. Such damage can be caused by past STIs, scar tissue from abdominal surgery, endometriosis, or pelvic tuberculosis (which is uncommon in the US). Treatment includes surgery to repair the fallopian tubes or in vitro fertilisation (IVF).
- Male factors: Male-driven reasons for infertility can include low sperm count or quality, a lack of sperm production, testicular abnormalities, and trouble reaching climax; male factors may account for a third of all fertility issues. Underlying causes include past illnesses, infections, physical trauma, age, genetic disorders, hormonal problems, varicoceles, and lifestyle habits like smoking and exposure to heat or toxins. Lifestyle changes, as well as intrauterine insemination (IUI) or IVF, can be used to address these issues. IVF involves manually combining a harvested egg and sperm in a laboratory dish before transferring the embryo back to the uterus. During an IUI cycle, which is less expensive, a woman is given medication to cause her to ovulate more than one egg and then sperm is placed directly into the uterus to encourage conception.
Unexplained factors: If all tests for known female or male factors come back clear but a couple still cannot conceive, the cause is considered unknown. This accounts for about a third of all infertility cases.
Couples over 30 also deal with the above issues, but they have an additional set of potential challenges, which those in their 20s experience at a lower rate.
"As a woman ages and enters her mid to late 30s, we see the diagnosis of diminished ovarian reserve much more often than we do in younger women," Shastri explained. "Typically, women in their 20s will have a more robust egg reserve and therefore their chance of having a baby through fertility treatment will be higher as compared to older woman."
What exactly is ovarian reserve? Here's how it works: Every woman acquires all the eggs she'll ever have when she's a fetus in utero. (That means when your grandmother was pregnant with your mother, the egg you came from already existed!) When they're born, baby girls typically have about two million eggs. By puberty, you are down to about 400,000 to 500,000. As you age, the egg reserve gradually decreases, and by the time you reach menopause, you have very few.
You only need one egg out of those original two million to have a baby. But the more you have, the easier it is to complete fertility treatments. IVF, for example, involves harvesting eggs and hoping for a viable embryo once it meets the sperm in the lab. The more eggs you can harvest, the more viable embryos you can get.
It is possible for a woman in her 20s to have a lower egg number than expected for a woman of her age. "If we have a 25-year-old patient, whose egg reserve is consistent with a 40-year-old woman's reserve, then her chance of conception with IVF may be more consistent with that of a 40-year-old due to her egg reserve," Shastri explained. Still, the majority of women in their 20s do not deal with this, and young couples typically have a higher chance of conception. Shastri noted that "treatment options don't vary by age, but the chance of success does."
Feeling like you're failing at something easy
The simple math of ovarian reserves means that many couples dealing with infertility in their 20s often have numbers on their side — but that doesn't make it easy emotionally. Many younger couples have high expectations about their ability to conceive, based on the physiological factors outlined above.
"You assume that if you're young and in good health, you should be able to conceive," Shastri said. "When this isn't the case, it can be very tough to comprehend and accept." Additionally, couples in their 20s are often surrounded by friends who are getting pregnant easily. "This can amplify the situation and cause more distress," according to the doctor.
"After the first miscarriage, I realised that this might not be something we'd be able to do," Sam recalled. "It felt very strange, like we were failing at something that is supposed to be so easy." He says the experience made him and his wife a stronger, more vulnerable couple. "We knew we were each other's rock and support system through everything."
Shastri has noticed that younger patients may have a harder time coming to terms with the fact that there is a problem. "This is difficult for anyone, yet as women age, it may be more understandable that there are issues associated with ovarian reserve and egg quality that make it more difficult to conceive." Couples in their 20s might not be mentally prepared for the setback.
"Part of what makes it so hard is the 'but you're still so young!' commentary," Jennifer admitted. "For one thing, hearing that makes you feel guilty, because you know there are women older than you who are struggling with much more difficult odds. And for another, those words aren't comforting."
Young or not, Jennifer says, you're still dealing with the physical and emotional toll of taking fertility drugs, getting your blood drawn all the time, coping with miscarriages, and more.
This is a common ritual that couples of any age can relate to. "There are still many challenges that all couples diagnosed with infertility go through," Shastri said, "the diagnosis, the treatment, the early morning office visits, daily injections, and, perhaps the most trying, the waiting and not knowing if the treatment will be successful." Sometimes, the final steps repeat themselves for months on end.
Miscarriages are another struggle. They can be caused by hormonal issues, problems with the uterus or cervix, or chromosomal defects of the fertilized egg. The latter may be due to issues with the quality of the egg or the sperm, meaning the male partner can contribute to miscarriages as well.
Sam says he was surprised to learn how many people have multiple miscarriages. "It feels like something rare, and then when it happens to you, you feel ashamed or as if you shouldn't talk about it," he said. "Almost everyone we know that has tried to get pregnant has had at least one." They are in fact very common: data suggest 10 to 25 percent of all clinically recognised pregnancies will end in miscarriage. The chances of miscarrying increase as you age, but for women under 35, the rate is still 15 percent.
Of course, not every couple dealing with infertility achieves their goal of starting a family through medical interventions. Katie Schaber wrote about her journey to parenthood on her blog From If to When. Katie says she felt confused about dealing with it in her early 20s because women are so accustomed to equating fertility with our biological clocks. "I was only 23 years old at the time and recently married, so the news was a huge shock to me," she said.
Katie expected to get pregnant immediately after her wedding, but instead, what followed were nine months of frustration, anger, and failure getting pregnant, as she described it. "Infertility at any stage in life is traumatic, but going through it at such a young age changed me and it changed my relationships with almost everyone," she admitted. "I lost close friends. They were having babies, and I was spending my days getting ultrasounds and blood work."
Katie and her husband were dealing with minor male factor issues, but the biggest causes were anovulation, endometriosis, and pelvic adhesions (scar tissue). She recognises that the distance between herself and her former friends wasn't anyone's fault: "We simply could no longer connect." The upside? "I bonded with some amazing women, most of them online, who were going through similar experiences. I'm still great friends with many of them today."
After two surgeries and four failed IUIs, Katie and her husband decided that adoption, not IVF, was the best option for them. "In the end, I didn't care about being pregnant. I cared about becoming a mum," she said.
In November 2010, they announced their decision to pursue adoption. A year and a half later, they became parents. On her blog, she wrote: "We were matched with a baby girl due August 3. We met the expectant mother on June 29, and just three days later, we became parents through domestic infant transracial adoption. Our family was finally complete."
A different outlook on pregnancy and parenting
Katie says the process had a positive impact on her experience as a parent. "Obviously, parenting has its challenges and frustrations," she admitted. "But I always try to take a step back and appreciate every moment because I truly thought I would never get to experience being a mum." It's been five years since she adopted her daughter. "I still look at her every day and silently thank her birth mother for choosing me to be her mum," Katie said.
Jennifer, who was able to conceive and have a baby after 20 months and now has a 1-year-old, realises that her age may have helped her achieve her goal of starting a family: "Our experience with infertility was physically and emotionally taxing, as they all are, but relative to some people's experiences, I understand that we are lucky."
Her struggles also gave her a different outlook on pregnancy. "I was very, very sick throughout my entire pregnancy, but even though I was physically miserable, I was the happiest I'd ever been because those bodily challenges meant I was pregnant with a healthy baby," she recalled. "Along with that comfort, though, came a lot of fear. After losing two pregnancies, I felt very aware that I could lose another, and I didn't really let myself accept the pregnancy as real until I was about five months along."
Jennifer's husband, Sam, says the experience of dealing with infertility in their 20s helped him appreciate the miracle and process of having a child so much more, while also leaving them drained: "It has made us a little reluctant to commit to trying again." But they do plan to try.
* Names have been changed.