You may be well-informed about a variety of healthcare topics but there’s a good chance you’ve never heard of “secondary infertility.” It’s the inability to establish a clinical pregnancy after a previous pregnancy whether or not there was a live birth. While it may not be a mainstream topic, secondary infertility affects nearly three million couples, double the number from 1995. It also accounts for approximately one-third all visits to see a fertility specialist.

Secondary infertility is similar in many ways to primary infertility when a couple has been unable to get pregnant after a year of regular sex when not using birth control. However, with one child or more, this diagnosis creates unique challenges including a lack of social support and the complexity of already being a parent.

What causes secondary infertility?

Many of the causes of secondary infertility are the same as for primary infertility.

–Older age

Age-related issues are a common reason. This most likely explains some of the increase in numbers because women are waiting longer to start having children. If they have a first child in their thirties and plan a second child a few years later, they may experience problems getting pregnant again. Fertility rates drop sharply as a woman ages and it is more difficult to get pregnant after the age of 35.

Many women and men don’t fully understand how much their fertility declines with age and are given a false sense of security through media coverage suggesting there’s a proliferation of much older women giving birth.

Left undisclosed is that these women almost always had in vitro fertilization (IVF)¹ and likely used donor eggs from much younger women. Age-related decline in fertility is underscored by data from the Society for Assisted Reproductive Technology (SART) which shows the live birth rate per egg retrieval using assisted /reproductive technology (ART) is 53.9% for women younger than age 35, 40.2% for age 35-37, 26.0% for age 38-40, 12.6% for age 41-42, and 3.9% for women older than age 42.

Related content: IVF or IUI: Which is the Right Procedure for You?

Older age is associated with a variety of problems that may make it difficult to get pregnant, including the following:

• • • increasing reproductive hormonal problems
    • thyroid disease²
    • irregular ovulation and periods
    • infections that can scar fallopian tubes
    • fibroids that may be enlarging
    • newly developed polyps of the uterus
    • endometriosis³ in the pelvis that may worsen in time in some women
    • adenomyosis of the uterus⁴
    • weight gain

Even when these problems don’t occur, increasing age is always associated with a decreased quality or quantity of eggs. All of these are possible explanations for secondary infertility in women.

–Problems related to the first pregnancy

Problems achieving a second pregnancy may also be related to the first pregnancy, although this is not common. Scarring may result from a C-section (which occurs about 10% of the time) or there may be scarring of the uterus after a D&C following a miscarriage or placental complications. Other types of surgeries on the uterus may also have an impact.

–Male infertility

With secondary infertility, more than one factor is often responsible. And, as with primary infertility, men may have a role. In fact, male infertility is the primary medical issue in about 25% of infertility cases. It is a contributing factor another 25% of the time. 

A major reason for male infertility, approximately 50% of the time, is a low sperm count. Up to 90% of male infertility cases are due to a combination of low sperm count, poor quality sperm, or both.

• • • Sperm quality, quantity, or delivery

There are multiple explanations for a decline in sperm quality, quantity, or delivery. Sperm quality does decrease with age, although more slowly than the reduction of egg quality in women. An important one in secondary infertility is when the man is older along with his female partner.

• • • Other common causes of male infertility

In addition to older age, some other common causes of primary male infertility that can also result in secondary infertility, include: 

• • • • • The presence of a varicocele (a distended vein around the testes)
        • Sexually transmitted infections that cause epididymitis⁵ or other inflammation that reduces sperm function
        • Lifestyle and environmental factors
          • • Stress,
            • Being obese or overweight,
            • Abuse of alcohol or drugs,
            • Exposure to certain chemicals
        • Elevated temperature

Elevated temperature exposure around the testicles can be related to a low sperm count. The temperature in the groin area should be a couple of degrees cooler than the rest of the body for optimum sperm function.

Every degree above normal may result in a decline in sperm quality of about 40%. Exposure to excessive heat can result from a job (e.g. hot environment, sitting for prolonged periods), too much time in a hot tub, and even setting your laptop in your lap for long periods of time.

• • • • • Chronic illness

Chronic illness can also affect sperm. A thyroid condition can lower testosterone which affects sperm production. Importantly, secondary infertility for a woman may sometimes be associated with a new male partner who might have problems the first partner did not, including chromosomal damage from a genetic disorder.

–Other factors that can contribute to secondary infertility

For any woman, man or couple, other factors such as new medications, inadequate sleep, stress, poor diet or very high caffeine consumption (5 or more cups per day) may cause or contribute to secondary infertility.

How is secondary infertility diagnosed?

Multiple factors are often responsible for secondary infertility. Further, the problem may be due to one or both partners. Therefore, the diagnosis of the condition needs to be comprehensive but efficient.

A thorough evaluation is needed to identify the causal factors to determine the right treatment. This includes current health status, medical history, and especially, any medical events, health or life changes since the prior pregnancy. For practical purposes, there is little difference in the investigation and workup of primary and secondary infertility. For a person who did not have difficulty getting pregnant with the last pregnancy, it is important to identify factors that might have changed since that pregnancy,

Women will be asked about their last pregnancy and any complications. Menstrual cycle history and duration of not using contraception are important. Blood tests assess hormone levels associated with reproduction, including:

• • • AMH (antimüllerian hormone), a biomarker for ovarian reserve or fertility potential
    • TSH (thyroid-stimulating hormone) and thyroid antibodies for thyroid problems
    • prolactin, a hormone that can impact the hormones needed to trigger ovulation and support the luteal phase
    • if cycles are irregular
    • and sometimes progesterone to confirm ovulation

A pelvic ultrasound will be obtained to look at for any conditions that could be contributing to secondary infertility, including the following:

• • • antral follicle count that helps assess ovarian reserve,
    • cysts in the ovaries,
    • uterine problems such as fibroids or polyps or scarring inside the uterus
    • fallopian tube blockage

Men should almost always have a semen analysis to test for the number, motility, and shape of sperm, as well as other characteristics.

When should you see a specialist?

Recommendations for when to see a fertility specialist suggest that if you have frequent unprotected sex without becoming pregnant and are 35 or under you should seek treatment after a year. If you are over the age of 35 seek care after 6 months. And, if you’re 40 or older, seek someone after 3 months.

However, you should see your gynecologist or a fertility specialist right away if you have any of the following:

• • • irregular menstrual cycles
    • heavy bleeding
    • hormone problems
    • obesity
    • fibroids
    • endometriosis
    • pelvic adhesions
    • sperm problems
    • difficulty having intercourse
    • other health problems

It may be premature to begin fertility treatment but it’s important to know what the situation is and what can be done about it so that you can be proactive about your care.

What are the treatment options for secondary infertility?

As with primary infertility, treatment depends on the evaluation of test results and the prognosis for different possible treatments. If a woman is having problems with ovulation, treatment may include taking oral “fertility pills” to help produce regular ovulation and/or produce more eggs.

If there are issues with the fallopian tubes such as scarring or other blockage issues, surgery may be recommended or IVF may be the most appropriate treatment. Surgical removal of endometriosis lesions can result in pregnancy rates of 20% to 80%, depending on the severity of the disease. IVF may be recommended for severe endometriosis, severe tubal damage, or pelvic adhesions.

Older patients or those with diminished ovarian reserve where the quality and quantity of eggs has decreased can use egg donors if that is an acceptable option. Women with severe uterine problems such as scarring or a congenital abnormality can build their family with a gestational carrier⁶ where another woman carries the implanted embryo if that is an acceptable option for them.

For male factor issues such as poor sperm quality, erectile dysfunction, or other physiological issues, intrauterine insemination (IUI) or IVF⁷ may be recommended. When there’s been a prior vasectomy, a vasovasostomy or partial reversal⁸ (putting the ends of the sperm ducts back together) may be a good option. In cases where there are no sperm, a sperm donor with frozen sperm can be very successful if this is an acceptable option. And for all couples, the option of adoption can be very successful.

Related Content: Vasectomy: Why It’s a Better Choice for Men and Women

Challenges unique to secondary infertility

 RESOLVE⁹, the National Infertility Association refers to secondary infertility as a “very isolating diagnosis…that comes with its own set of stigma and support needs.”

When a couple already has one child, they often receive far less social support – if any – than couples facing primary infertility. They may be less likely to reach out for help and support. Since there are others also facing the same complex feelings that come with secondary infertility, RESOLVE recommends finding a support group or mental health professional with a focus on this problem.

RESOLVE offers advice for all couples facing infertility who must deal with questions and insensitive comments from others. Among other things, they recommend preparing answers in advance to common questions such as “when are you having another baby?”

Feelings of sadness, anger, or frustration are common with any infertility diagnosis, but already being a parent can add complexity. Couples may feel guilty at being unable to give their child a sibling. They worry about the impact of spending time and money trying for a second child.

Some experts advise establishing a plan including a timeline, how much money you’re willing to spend as well as what treatments you’re willing to try such as IVF or egg donation. All these decisions are important because they affect the entire family.

The bottom line when it comes to secondary infertility

Receiving a diagnosis of secondary infertility and seeking treatment is a challenge. One of the most difficult issues may well be how to live in the moment and enjoy the child you have. While you probably can’t avoid wondering and worrying if you can add another sibling, living for now, is important no matter how many children you.

***

References

---

1. IVF Is the Most Common Infertility Treatment, ARC Fertility. https://www.arcfertility.com/patient-resources/infertility-tutorial/what-is-ivf/

2. Thinking about Pregnancy? Think about Your Thyroid. ARC Fertility. Sept. 2015 https://www.arcfertility.com/thinking-about-pregnancy-think-about-your-thyroid/

3. What’s Known, New, and Ahead with Endometriosis. ARC^® Fertility Blog, Mar 2018 https://www.arcfertility.com/whats-known-new-and-ahead-with-endometriosis/
4. Adenomyosis. Symptoms & Causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/adenomyosis/symptoms-causes/syc-20369138
5. Epididymitis. Symptoms & Causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/epididymitis/symptoms-causes/syc-20363853

6. David, Adamson, MD. Gestational Carrier 101 – What You Need to Know, The Doctor Weighs In. Feb 2019 https://thedoctorweighsin.com/gestational-carrier-arrangements/

7. David Adamson, MD. IVF or IUI: Which is the Right Fertility Procedure for You? The Doctor Weighs In March 2020 https://thedoctorweighsin.com/ivf-iui-fertility-procedure/
8.  Fertility Options After Vasectomy.  American Society for Reproductive Medicine. https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/fertility-options-after-vasectomy/
9. Managing Infertility Stress, The National Infertility Association.  https://resolve.org/support/managing-infertility-stress/