“I fell pregnant with ease the first time, now I want a second and it’s just not happening – what can I do?”

Difficulty in having a baby after a pregnancy is known as secondary infertility. This situation is fairly common and very frustrating because it may have been so easy the first time. A couple is defined as having secondary infertility if, despite having achieved a pregnancy in the past (which may or may not have resulted in the birth of a child), they are unable to do so again, after a year or more of regular, unprotected intercourse (6 months if the female is over 35)..

One in six couples in Australia have a fertility problem. Not enough is known about the incidence of secondary infertility to be sure how many of these couples have had a pregnancy before, although it is not uncommon to conceive a first pregnancy with no difficulties and then have difficulties conceiving your second.

What Causes Secondary Infertility?

Secondary infertility has the same causes as primary infertility (when a pregnancy has never occurred despite regular, unprotected intercourse). These causes can be divided into four areas:

1. Sexual function:  Ideally, a couple should have intercourse every 2 – 3 days during the fertile period (just before and around time of ovulation) to maximize the chance of conception
2. Ovulation: For a pregnancy to occur a woman needs to be producing eggs. If your cycles are regular (25-30 days or so) its most likely that you are producing an egg.  With cycles that are not predictable because they vary each month can make timing of intercourse during the fertile time almost impossible. 
3. Sperm function: Not only do a couple need to be having intercourse at the right time that an egg is being released but the semen quality generally needs to be of a certain standard for most pregnancies to occur. The number of  normal shaped, forwardly moving sperm in the ejaculate is important.   
4. Tubal function: Equally important as the above for the sperm and egg to meet and fertilize the tubes must be open and working correctly. Tubal problems are more common in secondary than primary infertility (20% of couples compared to the usual 10% incidence) due to infective or inflammatory complications that can occur after delivery or the end of the pregnancy.

When Should We Start Investigations?

A couple is defined as infertile if they have been having regular unprotected intercourse for more than one year without getting pregnant for woman under the age of 36. This is the time to be referred to a fertility specialist if you are keen to start investigations. However, if you suspect there has been a change in ovulation, tubal or semen function, then it is reasonable to ask for a referral earlier. If you are over the age of 35, seeking assistance after 6 months of trying is also appropriate. Having investigations does not commit you to having treatment until you are ready.

What Do The Investigations Involve?

• Ovulation is tested with blood tests for a hormone called progesterone and in some cases, ultrasound scans can be used to track when an egg has been ovulated.
• Sperm function is tested by a semen analysis (needs to link to our section on the website around semen analysis’ if possible) s.If the first test is below normal requirements a second may be requested 3 months after the first. 
• Tubal Function If both ovulation and sperm function is normal, tubal function can be tested using an X-ray study called a hysterosalpingogram (HSG) or HyCoSY or an operation called a laparoscopy and dye.
   

What do the treatments involve?

Treatment is determined by the cause of the fertility issue. If no obvious cause is found, then a diagnosis of unexplained (idiopathic) infertility is made. Not having a reason for your fertility problem is very difficult, but this does not affect the chances of getting pregnant. Simple programs such as Ovulation Induction (if your cycles are irregular) or Intra Uterine Insemination (IUI) using the partner’s semen, would be the first step.

If there is a tubal problem, In Vitro Fertilisation (IVF) would be the treatment of choice depending on the semen quality. Semen problems are treated with IUI or IVF and sometimes sperm microinjection (a technique known as ICSI where a single sperm is injected into an egg in an attempt to fertilize the egg). Sometimes a couple has a combination of problems, so the above guidelines would be modified.

The age of the female will dictate the likelihood of success. If you are under the age of 36 then your chances are good, but unfortunately, some couples will not achieve a second pregnancy. This is more likely if the woman is aged above 38 or older. However, it is important to remember that you didn’t give up after the first month or no success when you were trying to conceive naturally. The same principle applies with fertility treatment – the more attempts you have, the more likely you are to conceive. However, it is important to have review sessions with your fertility specialist, so you can decide when it is appropriate to keep trying and when you should stop.

When You Have Secondary Infertility What Are Our Chances Of The Pregnancy Being Normal?

On average, one in five pregnancies end in miscarriage with the rate of miscarriage increasing as the woman’s age increases. Preparing yourself physically for a pregnancy by ensuring your diet is well balanced and you are within a normal weight range for your height is a great start as is starting to take folic acid (folate) 0.5mg before you get pregnant significantly reduces the risk of spina bifida, one of the most common birth defects.  Lifestyle choices that need to be considered include alcohol and caffeine consumption as well as cigarette smoking.

We Are Feeling A Lot Of Emotional Pain And Frustration. Is That Normal For Couples With Secondary Infertility?

Yes. The emotional impact of secondary infertility can be severe. For those who have had difficulty having a child or a pregnancy before, you now have to face reliving your infertility and its painful implications again. If you had no difficulty conceiving or carrying a pregnancy before, the initial reaction to realizing you have a fertility problem can be confusing and unbelievable for you both and .

Some couples deny the possibility of infertility and delay seeking medical investigation. Others sometimes blame their child and all these factors can impact negatively on your relationship with the child and each other. Doctors, nurses, and counselors can help you develop coping skills to deal with your emotional pain, guilt and frustration. It is also important to remember that you have the right to the family size of your choice. You are not being selfish and your efforts to get pregnant again will not deprive other couples who want to have a child.

What Can We Do To Improve Our Chances Of Getting Pregnant The Second Time?

If either of you smoke, you should stop. Smoking reduces the chance of getting pregnant, the response to treatment, and increases the risk of miscarriage and ectopic pregnancy. Even if the woman is not smoking, there is some evidence that these effects can occur as a result of passive smoking if her partner continues. Production of normal, moving sperm can also be affected if a man smokes.

Increased weight in the woman is another factor. This is common after the birth of a child but unfortunately, can lead to a reduction in regular egg production, with menstrual disorders and infertility as a result. Increased weight also adversely affects the chances of pregnancy after treatment. Often the loss of three to seven kilograms is sufficient to reverse this trend.

Non-prescription drugs such as marijuana, cocaine, and variants of these can affect fertility. In addition, care needs to be taken with some herbal medicines, which can affect a woman’s ovulation and/or response to treatment.

Infertility is usually referred to when discussing childless couples. Secondary infertility is a very real problem but much less obvious. People often think if you have one child then surely that is enough. But they’re wrong. When your freedom of choice is taken away it puts a different perspective on things. Not being able to choose or control whether you can have more children means losing that freedom of choice. The stress this places on a relationship and the costly financial aspect of secondary infertility has its own unique set of problems.

When couples are faced with infertility the first time around, both partners are usually in full-time paid employment, and with two incomes this eases the enormous financial situation, if ever so slightly. With secondary infertility, you are usually down to a single income and a toddler to add to your cost of living, not to mention the doctors bills, clothing, and kindergarten fees.

Those couples who have gone through infertility at any level will talk about how infertility controls and dominates their life, taking over every aspect of daily routine – existing from one cycle to the next to the point of obsession, always in anticipation of the hope for success. With secondary infertility, you have the added pressure of feeling guilty, because you already have had one child which you think should be enough. It is often difficult to find support.

Who Do You Talk To?

Who do you talk to – your coffee group friends, who already have baby number two or your infertile, childless friends who may find it hard to understand your feelings? Women with secondary infertility feel anguish and pain that people find difficult to comprehend. Both groups of friends may think that ‘one success’ is enough, leaving the secondary infertile couple feeling isolated and without support.

Access represents couples like you. Please feel free to contact us and we will try to help provide further information, support or put you in touch with the right people to help you at this difficult time.

For more information or to arrange a free private 1-on-1 consultation, please call us on 1300 337 845 (1300 FERTILITY).