Congenital adrenal hyperplasia (CAH) can affect fertility in people of any gender, and in both classic and nonclassic CAH. While the impact on women’s reproductive health has long been understood, more recent research is revealing how classic CAH can affect men’s fertility.

Since CAH causes hormone imbalances that affect sexual function and development, it’s not surprising that CAH can interfere with reproduction. However, there are options to overcome these challenges, and it’s possible to get pregnant and lower your risk for complications with CAH.

Read on to learn about ways CAH can affect men’s and women’s reproductive health.

How CAH Can Affect Fertility in Women

According to Mayo Clinic, women with congenital adrenal hyperplasia may run into challenges while trying to get pregnant or during pregnancy and childbirth. As CAH research and fertility treatments improve, fertility rates among women with the classic form of CAH may become as high as 90 percent. This is around the same as in the general population.

For women with well-managed nonclassic CAH, which is considered to be the milder type, fertility rates may be only slightly reduced. Still, women with either form of CAH may run into some challenges conceiving or carrying a pregnancy due to hormone imbalances and other features of the condition.

CAH and Your Chances of Getting Pregnant

Some ways CAH can affect conception are due to hormone imbalances, while others may be related to uncomfortable sex.

Hormone Imbalances

Congenital adrenal hyperplasia causes women to produce higher levels of androgens than average. Sometimes referred to as “male sex hormones,” androgens like testosterone are usually present in females in lower levels, according to Cleveland Clinic.

As CAH research and fertility treatments have improved, fertility rates among women with the classic form of CAH have become as high as 90 percent.

High androgens may affect women’s reproductive function in a few ways. First, the body can convert excess androgens into estrogen. When this happens, your body senses that estrogen levels are too high and stops releasing gonadotropins. Gonadotropins, such as follicle-stimulating hormone (FSH) and luteinizing hormone (LH), are hormones that regulate the function of your ovaries. Ovarian function is essential to reproduction.

Androgen excess also reduces your body’s sensitivity to progesterone, a hormone that supports the early stages of pregnancy. When your body is less sensitive to progesterone, you’re less likely to stay pregnant if you get pregnant. It’s common for women with CAH to have high progesterone levels, which impacts gonadotropin production.

Lower progesterone sensitivity can also cause your body to produce more LH, a hormone that helps ovarian follicles mature enough to release eggs. Too much LH can trigger the ovaries to release more androgens, which intensifies their fertility-reducing effects.

High levels of LH are also common in women with polycystic ovary syndrome (PCOS). PCOS is one of the most common causes of women’s infertility because it disrupts the menstrual cycle and can cause anovulation (a lack of ovulation). About 40 percent of women with nonclassic CAH also have PCOS.

Uncomfortable Sex

Hormone imbalances, as well as psychological and anatomical factors in classic CAH, can also make sex uncomfortable. In one small study, 37 percent of participants with classic CAH had never had vaginal intercourse, while 81 percent reported pain during sexual intercourse.

These physical factors can make some women less likely to have sexual intercourse, according to the American Medical Journal. This reduces their chances of getting pregnant naturally. High progesterone in classic CAH can also thicken cervical mucus and make it harder for sperm to travel through the fallopian tubes.

Risks During Pregnancy

Some preliminary (early and nondefinitive) research suggests that women with untreated classic and nonclassic CAH have a higher risk of spontaneous miscarriages. If you have classic CAH, it’s important to work with your endocrinologist during pregnancy to manage your hormone levels and prevent potential complications.

Women with CAH should work closely with their healthcare team to manage risks during pregnancy and childbirth.

Risks During Childbirth

Vaginal delivery may be riskier for some women with classic CAH. High androgen levels in early development can cause the pelvis and birth canal to be narrow, which can lead to challenges with natural childbirth. In these cases, cesarean section (C-section) may be recommended.

How CAH Can Affect Fertility in Men

According to Mayo Clinic, men with classic CAH might experience fertility problems, especially if their CAH is not well treated. Most fertility issues in men with CAH come from testicular adrenal rest tumors (TARTs), which are growths in the testes.

TARTs are benign (noncancerous) and affect around 40 percent of men with classic CAH. Researchers believe these growths may start developing before birth. Researchers aren’t sure exactly how TARTs occur, but in one theory, adrenal gland cells move to the testicles and form the growths while the embryo is developing. Later, high levels of adenocorticotropic hormone (ACTH) stimulate them to grow into tumors. TARTs are usually on both sides.

Low Sperm Levels

TARTs can lower sperm production in men with CAH. Low sperm levels due to TARTs are the leading cause of infertility in men with CAH.

Testicular rest tumors are common in men with CAH. These noncancerous growths can interfere with fertility.

The TARTs reduce blood flow in the testes, which reduces their overall function. They can also block seminiferous tubules, which are the coiled tubes inside the testes that produce sperm.

Less Testosterone Produced in the Testicles

TARTs can also lower levels of testosterone produced in the testicles by decreasing testicular function. Increased adrenal androgens (androgens from the adrenal glands) can also reduce gonadotropins in men. Just like in women, gonadotropins drive sexual and reproductive function.

LH stimulates testosterone production in the testes. When it’s suppressed, the testes don’t produce as much testosterone. This low testosterone in the testes may not directly cause reduced fertility, but it can further reduce sperm production or affect the health of the sperm.

Low testosterone can also cause erectile dysfunction and low sex drive, which can make conception more challenging.

Work With Your Healthcare Team

If you or your partner has CAH and you’re trying to have a baby, it’s important to work closely with your healthcare team. Modern fertility treatments and CAH medications can improve your chances of getting pregnant and carrying your pregnancy to term.

Your endocrinologist can help you balance your hormones to increase your sperm count or prepare your body for pregnancy. A trusted fertility specialist can also work with you to address specific challenges that affect your fertility.

If you’re a woman with CAH and are in the early stages of pregnancy, your endocrinologist may recommend changes to your dosing of glucocorticoids. They can also refer you to a fertility specialist to learn more about fertility treatments like in vitro fertilization (IVF) if you continue experiencing infertility.

If you’re a man with CAH and infertility, high-dose glucocorticoid treatment may help shrink TARTs to improve fertility. Your doctor may recommend preserving healthy sperm before TARTs grow larger.

Talk to your healthcare team for fertility treatment recommendations based on your specific CAH type and circumstances.

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