Secondary Infertility Is the Infertility Women Don't Talk About
Most of us have a picture in our minds of how our lives will look at one point or another — and if that snapshot involves multiple children, struggling to get pregnant a second time can present a painful and emotional roadblock; a gaping hole in the family unit you hoped you’d someday have.
Secondary infertility, according to the World Health Organization (WHO), is “when a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth.”
For women under 35, the couple is considered to have infertility after 12 months of trying to conceive and if a woman is over 35, they’re considered to have infertility after six months of trying, explains Jacqueline Ho, M.D., a reproductive endocrinologist and infertility expert at Keck Medicine of USC.
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Elise G., a mom of two based in the Boston area, experienced secondary infertility with her second child. “With our first, we got married, went off birth control thinking it would take a while to get pregnant, and we were pregnant the very first month,” she says. “My assumption was that when we were ready to try again for a second, we could control the timing.”
But after nine months of trying, she made an appointment with a reproductive endocrinologist. After a slew of standard tests, results revealed that she had low-normal numbers for female hormone levels (FSH) and her husband had low-normal levels for sperm count and motility, two factors that can contribute to infertility.
The inability to conceive after a previous pregnancy affects some 10% of couples worldwide, although pregnancies such as miscarriages can be included in the definition of secondary infertility, Dr. Ho explains. Many studies, particularly those in the U.S., don’t differentiate between primary infertility (when couples have not become pregnant after at least one year of trying) and secondary infertility, so it’s hard to know how many women deal with the experience of struggling to have a second child.
That means couples going through this often feel siloed. “People struggling with secondary infertility can feel left out of the infertility conversation because they already have at least one child,” says Angela K. Lawson, Ph.D., a psychologist at Northwestern Medicine Fertility and Reproductive Medicine.
“I definitely felt like I couldn't discuss this — especially with friends who I knew had struggled with fertility issues with their first or were currently struggling with fertility,” Elise says. “We had a beautiful two-year-old. So many people struggle to get to the point that we were at, and it seemed so selfish to feel sorry for myself that I couldn't conceive a second time.”
But ultimately, struggling to conceive is struggling to conceive — and it can be highly distressing. In Elise’s case, as one of eight children, the idea of siblings was important to her. She always wanted at least two.
Here, some common contributing factors that can increase your risk of secondary infertility as well as what to do if you find yourself in the situation.
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What factors can contribute to secondary infertility?
Age. It’s the most important factor associated with infertility. “The quality and quantity of eggs decline over time,” explains Kara Goldman, M.D., an assistant professor of obstetrics and gynecology and medical director of fertility preservation at Northwestern University Fertility and Reproductive Medicine. The rate of miscarriage and chromosomal abnormalities increases with age, too, particularly starting after age 35, adds Dr. Ho. Approaching 35 with a husband 10 years her senior, Elise found this to be true with her secondary infertility.
Lifestyle changes. When it comes to diet, there's a lot we still don't know about how specific foods may or may not affect fertility, but maintaining a healthy weight is key. Weight gain can also lead to irregular ovulation, an important factor that influences the ability to get pregnant, explains Dr. Ho, as can excessive, strenuous exercise. Other lifestyle factors like smoking and alcohol consumption can also put you at higher risk for infertility.
Surgery or complications with a previous pregnancy. If you had a C-section with your first baby, for example, surgery in the abdomen and pelvis can lead to scar tissue formation. “The fallopian tubes are fragile structures that can be blocked when there is inflammation and scar tissue nearby,” Dr. Ho says. If they’re blocked, the egg can’t make it to the uterus and the sperm won’t be able to reach the egg, which is fertilized in the fallopian tube. If you experience retained placenta, a rare condition when some or all of the placenta stays in your uterus after delivery, you may be at a greater risk of developing scar tissue, too. Other procedures in the uterus such as a dilation and curettage (D&C) to remove tissue from the uterus also come with the potential risk of scar tissue, she says. Lastly, while rare, if you experience extremely heavy bleeding after delivery, that can affect cells in your brain involved in hormone production needed to ovulate regularly, explains Dr. Ho.
Male factor infertility. A partner’s decreased sperm count — potentially from lifestyle factors such as smoking — also plays a role in fertility, experts say. In fact, 40 to 50 percent of the time, male factor infertility is in play. While, for women, there can be a tendency to blame yourself (especially if you’ve already had a previous pregnancy), infertility involves two people.
In Elise’s case in particular, her husband’s sperm count and motility wound up being much lower than tests revealed originally, and it was confirmed that this was contributing to their infertility. Ultimately, in-vitro fertilization (IVF) wound up being the route the couple took and it did work, resulting in the second baby Elise had always pictured. But she says she wants people to know that despite the burden of infertility almost entirely falling on the female, “infertility is not a women’s issue, it is a couple’s issue.”
What should you do if you’re experiencing secondary infertility?
First, you want to undergo a complete infertility evaluation, says Dr. Goldman. This will include a detailed history of your cycle, imaging of your fallopian tubes and uterus, a look at ovarian reserve (how many eggs you have left), and a semen analysis.
The general recommendation with infertility is that if you’re under 35, to see a doctor after one year of trying to conceive, and if you’re over 35 to see a doctor after six months of trying. But you don’t have to wait. “In all cases of infertility it may be appropriate to seek care sooner than these recommended time-frames,” Dr. Goldman says.
After all, early intervention may identify a treatable problem or — in the case of low egg supply — may allow you to take action earlier with methods such as IVF than you otherwise would have.
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Secondary infertility comes with a slew of mental health hurdles.
On top of a complete evaluation, it’s important to address any emotions you’re struggling with. People tend to mistakenly believe that if it’s not easy for you to conceive then you must be doing something wrong — a thought process that can contribute to stress and guilt, Lawson says.
Then there’s other people. “Many parents who are experiencing secondary infertility tell me they have been judged for being upset about their difficulty conceiving and for not already having a second child,” says Lawson. (Think: “You should just be happy you have one child” or “Your child needs a sibling”).
How to handle it all? Five suggestions from experts below:
Remember that emotions aren’t ‘either or.’ You can be happy to already have a child and deeply sad that you’re struggling to have another, Lawson says.
Be honest about what you’re going through. Women experiencing secondary infertility can be less likely to access support groups and talk to friends than those experiencing primary infertility, potentially furthering feelings of isolation, stress, anxiety, and depression, says Emily Dossett, M.D., a clinical assistant professor of psychiatry and behavioral sciences at the Keck School of Medicine of USC. But being able to express your true feelings with a supportive team can help you feel emotionally validated and can help generate strategies to cope with your experience, says Lawson. If you’re struggling to open up, consider starting the conversation with a friend or family member by sharing both your experience and your fear of being judged, suggests Lawson.
Help others help you. Tell people what words, phrases, or actions would help support you, Lawson suggests. For example, if you’re just looking for someone to hear you out, you can say something like, “It would be so helpful just to have someone who will listen to me.” If you want help finding resources or just someone to do something fun with to take your mind off of everything, those are fine things to say, too. Steering people in the right direction with what you need and want at a particular time can lead to better communication and help loved ones (including your partner) better help you through tough times.
Seek additional help. If your emotions are interfering with your day-to-day life, medical societies such as the American Society for Reproductive Medicine and The National Infertility Association have lists of support groups and specialty-trained mental health professionals that can help you work through challenging emotions.
Don’t lose hope. Many different factors can play a role infertility, notes Dr. Ho, and you and your doctor can best address your individual situation. “The message I would convey to other women going through infertility is to trust the process and be open to modern-day technology advances for fertility,” she says. (IVF success rates tend to be in the 30 to 40 percent range for women under 35.) “If anyone can handle the burden of all of this, it is women.”
