What is secondary infertility?
When you’ve just had a baby, the experience tends to make you go one of two ways: you either want to repeat the process again immediately, or you are determined to make contraception your best chum from here to eternity.
Seldom is any thought given to the notion of pregnancy not happening for a second, or subsequent time – and if you’ve had one baby without any trouble conceiving, why would it? Your fertility is something you have control of. Isn’t it?
Sadly, that’s not always the case, and for some women, even after one, two or three babies, secondary infertility can occur, and that can send shockwaves through even the most ‘with it’ mum.
Globally, although infertility rates have hardly changed in the last 20 years, secondary infertility has increased very slightly. A World Health Organisation study undertaken in 2010 and published in PLOS Medicine analysed 277 national surveys from 190 countries, and found that secondary infertility rates have risen by 0.4 per cent, while primary infertility levels have decreased by 0.1 per cent.
Of course, a woman who had a baby easily at 20 would perhaps not expect to conceive quite so quickly if she left it until she was 40 to have her second – but for mums still in their twenties and thirties, secondary infertility can be a bolt from the blue.
Professor Sheena Lewis from Queen’s University Belfast says that couples who are worried about experiencing secondary infertility should seek the same prompt investigation that those with primary infertility should – and that means flagging it up with their doctor after a year of unsuccessful trying.
“With secondary infertility a thorough history and examination on what may have changed in either the man or the woman since their last pregnancy is an important starting point,” she says. “This systematic approach will whittle out many of the causes. Investigations include tests of ovulation (Day 21 progesterone test), tests on egg quality and reserve (AMH test), tests on sperm volumes and activity (semenalysis) and tests on sperm DNA.”
Age is obviously a huge factor, and some women may have conceived with ease in an earlier relationship, but find they are struggling with secondary infertility when they try again for a baby with a new partner, or after a long gap between children.
“The woman’s age is one of the most important factors in conceiving a baby naturally or with the help of fertility treatment,” Professor Lewis says. “Age can cause a decline in fertility in many ways; the menstrual cycle can change and ovulation patterns shift, and the quality of the eggs a woman produces deteriorates with age too.”
Medics will also look out for ovulatory and tubal patency (blocked tubes) problems which can develop during a woman’s reproductive lifetime, perhaps as a result of medical conditions such as pelvic inflammatory disease or endometriosis.
Testing the male partner’s sperm quality is particularly important, Professor Lewis adds, as there is now a growing body of evidence to suggest that men’s fertility also wanes after 35.
“We used to think that a man’s fertility didn’t change with age. After all, Picasso fathered a child at 81, but research from the past few years shows that the quality of men’s sperm also declines over time, and this can result in secondary infertility too.”
Professor Lewis also cites lifestyle hazards, where couples do not take enough care of themselves to protect their ongoing fertility after having their first baby.
“The couple may be eating a fast food diet with too few antioxidants, smoking tobacco or taking recreational drugs; perhaps they’re drinking more alcohol, becoming heavier or have developed chronic illnesses such as diabetes since they conceived their last child,” she says.
“In the event that the cause of the infertility remains unexplained and assisted conception (IVF or ICSI) is the solution the findings from the Sperm Comet test can help direct treatment to the most effective way forward,” she concludes.
Case Study 1 – Karen, mum of three
“I thought secondary fertility would rob me of my longed-for third baby.”
“I got pregnant straight away when I was 25,” says mum-of-three Karen. “I had our first daughter Camilla, and then, just 23 months later, her sister Madeleine was born.”
Eager to have another baby after Madeleine, and to keep a small age gap between the siblings, Karen and her husband started trying to extend their family once more when Madeleine was a year old – and they had no reason to think they would have any problems.
“Despite our experiences with Camilla and Madeleine, it ended up taking 18 months to get pregnant again,” Karen explains, “but it wasn’t to be and sadly we lost the baby at eight weeks.”
To add to the couple’s misery, their loss was dealt with by an ‘awful’ doctor: “He said that lots of women have miscarriages that early and didn’t even realise, which might be true but was not much comfort to me. I actually told him: ‘You’re never just a little bit pregnant’.”
Mismanagement of the miscarriage meant Karen did not have a dilation and curettage (D&C) – a common procedure after the loss of baby. She ended up in hospital with an infection, which was when her thoughts focussed on her fertility, and whether she would be able to go on to ever have another successful pregnancy.
“I became a bit obsessed because I read that if you get an infection it can cause infertility. It had taken me 18 months to conceive the baby I ended up losing, so I was determined to get checked out, and see what was going on.”
A private endoscopy showed Karen’s fallopian tubes were clear, and a battery of other tests found no causes for concern either. But this didn’t ease her fears.
“Every time they said that nothing was wrong it made me try to find something that was simply because then they could solve it and I would get pregnant,” she says. It took two more years for Karen to conceive again, but this time she lost the pregnancy at nine weeks.
“I was devastated. I had miscarriage counselling and all I could think about was having another baby. It was becoming a strain on our marriage and because I was so busy thinking about this third child I wasn’t enjoying the two adorable daughters I already had.”
For Karen, a successful third pregnancy eventually happened six years after her second daughter was born, and after complementary therapy including supplements and kinesiology.
“We were about to go down the IVF route, and after five years of really taking care of myself and not drinking I let my hair down at a party. I assumed I was feeling so rough in the days after because of a hangover, but actually I was pregnant. It was an amazing pregnancy, and I was just so happy to eventually have the daughter I felt had been missing from our family.”
Case Study 2 – Francesca, mum of three
“Don’t stress – and don’t put your life on hold for it!”
“I was 34 when I had my first baby back in 2002. Although I had PCOS, I didn’t need fertility treatment, although I had been having some ‘exploratory’ tests in the lead up to becoming pregnant,” Francesca says. “The year after my first child was born we started thinking about having another, but as time went on nothing happened. We asked to be referred, and was subsequently advised to cut down significantly on carbohydrates and to take Metformin – both tactics to reduce insulin, as I were insulin-resistant which tends to go hand in hand with PCOS.”
Francesca says she then took this to the ‘extreme’ and cut out all carbs and lost weight, but still she didn’t become pregnant.
“I was then eventually ovarian drilling, and if that didn’t work, they would try Clomid,” she explains. “I was offered a cancellation appointment for the drilling and despite being desperate for another baby, I was a huge wimp and just couldn’t face doing it – I am petrified of hospital and procedures and I needed a bit more time to get my head around the thought of it. However, by the time the next available appointment came round I found out I was pregnant!”
Francesca flags up the importance of being in the right mind space to conceive – and not planning your entire life around pregnancy.
“Shortly before I fell pregnant, I remember very consciously thinking ‘right, get on with life’. It had been placed on pause for so long while I was waiting to get pregnant. It was always as though I couldn’t make a decision… whether to go on holiday, whether to change jobs, always because everything resolved around ‘but what if I get pregnant?’ So I decided to just get on with everything. I set up a new business, I converted the nursery into my office and then ‘it’ happened and I firmly put that down to a healthy diet, the Metformin, and finally stopping stressing about it all!
“Prior to that my life was a rollercoaster and each month I’d imagine I was pregnant. I’d have symptoms that were premenstrual but I was convinced were pregnancy. I’d work out when this imaginary baby was due and at what point I’d be telling all my friends. The crushing disappointment each month was hideous.
“It was a relief when I just stopped and decided to be grateful for what I had and got on with doing other things – and when I did that, I became pregnant! My second child was born when I was 39, but that’s not the end of my story because I then went on to have a surprise baby when I turned 40 – so no matter how hard you are trying now, and how desperate you are, never give up hope!”