Secondary Infertility – A misconception?

So how different is primary infertility to secondary infertility? If everything was straightforward conceiving the first time around, it may come as a complete shock if you find that it is taking a while to conceive this time around. However, the emotional stress one feels with secondary infertility is often just as great for those going through it for the first time…. which is why primary and secondary infertility cannot be compared with each other as they are the same thing but just at different times in a person’s life. Cruel comments of ‘…..you should be grateful that you already have a child’ and ‘….just be thankful for what you have’ hurts just as much for a woman trying for a second baby as it does when someone tells you to ‘just stop thinking about it and let nature take its course’ when you are desperately trying for a first!

Often the biggest step in deciding what to do if you suspect that you have secondary infertility is when to start worrying. The statistics show that even in a healthy couple without any reproductive problems, it can take up to two years for them to fall pregnant – 84% of them will conceive with one year and half of the remainder will conceive within two years resulting in 92% of couples conceiving overall. Many couples will find it hard to wait two years before consulting a doctor and since your chances of conceiving decrease with age, it often makes sense to seek help sooner rather than later. It has been suggested that if you suspect that you may have secondary infertility and are over the age of 35, that you seek help even after only six months of trying.

If you are convinced that you may have a problem you are not alone – about 1 in 7 couples have a problem in conceiving although the percentage of couples that experience secondary infertility in particular, is not known. Some couples do not seek help making it difficult to estimate how many couples are actually affected by it.

Secondary infertility can happen at any time and the causes, where they have been pinpointed, are almost identical to those of primary infertility. The problem can lie with a woman’s reproductive system; a man’s reproductive system or with both partners as follows:

In 27% of cases, an ovulatory problem with the woman is involved.
In 14% of cases, uterine/tubal damage (reproductive organs).
In 19% of cases, low sperm count or poor quality sperm is involved and in 39% of cases, disorders in both the man and women contribute.
This still leaves one third of cases in which the cause of infertility is not identified.

The statistics are telling but in the cold light of day are little comfort for the emotional stress it produces on a couple who are battling to provide a sibling for their first child.
However, in cases of unexplained infertility there is still hope …….one to two thirds of couples with unexplained infertility will conceive within three years if they keep on trying!!

So, if you have not conceived after a year of regular intercourse, without contraception, then make an appointment to see your GP – infertility is a joint problem so, ideally, go to see your GP as a couple. Early diagnosis and treatment of secondary infertility are especially important in older couples, particularly in the case of women over the age of 35 – in this case make an appointment after six months of trying to get pregnant. Where there is a history of amenorrhea (no periods), oligomenorrhoea (infrequent periods), pelvic inflammatory disease (PID), or if either of you have had treatment for cancer, again seek medical advice sooner rather than later as you will need to be referred to a specialist

Depending on your case history, your GP may refer you to a fertility specialist straight away, or may carry out initial investigations before deciding whether to refer you or not. The first stage will be an investigation of what the problem might be. Your doctor will need to establish that you are producing eggs, that your partner is producing sufficient numbers of sperm, and that the sperm are sufficiently strong and healthy to make the journey to meet your eggs.

Blood tests can be used to measure the levels of several substances in your blood including:

Serum progesterone. If you are having regular periods, a test done in the mid-luteal phase of your cycle (day 21 of a 28 day cycle) will confirm that you are ovulating. If you have an irregular cycle you can still have this blood test but it may be carried out later in your cycle, and then weekly after that until your period starts. Don’t forget that you could also try the at-home ovulation tests and monitors to check to see if you are ovulating – at time’s it helps to have some semblance of control over the testing process and they also work out a lot cheaper than having to go in for a scan every few
days to check for ovulation.

Serum gonadotrophins (FSH and LH). These levels can help identify whether you may have polycystic ovary syndrome or PCOS, or premature ovarian failure (i.e. early menopause). There are also a number of excellent at-home tests that can give you an early indication of whether you are peri-menopausal or not – they are urine based tests and if your FSH levels are elevated then your test result will be positive.

This is a hormone usually produced while you are breastfeeding but your levels can be raised if there is an underlying ovulatory disorder or a pituitary tumor. If you are not feeding a baby or toddler but still producing breastmilk this could be significant. A prolactin test may therefore be carried out if there are symptoms to indicate this could be the problem.

The next step is looking for blockages, damage and abnormalities in your reproductive system. Before you have any uterine investigations you will be screened for chlamydia and, if the results are positive, referred for treatment and contact tracing.

A new product that has hit our shores is an indicative panty-line called ‘Vianalyse’ – which will indicate whether you have a bacterial infection or a normal candida/yeast infection. The importance of knowing which infection you have is imperative since one can be treated over the counter and the other (a bacterial infection) in most cases needs to be treated with antibiotics prescribed by a Doctor. It is also extremely important for those undergoing IVF treatment to ensure that they are free of vaginal infections – bacterial or candida as it has been proven in clinical studies that these can affect the outcome of fertility treatment.

If you have a history of pelvic inflammatory disease (PID), have had a previous ectopic pregnancy or endometriosis you may be offered laparoscopy, investigative surgery using a telescopic viewing instrument, to see if your fallopian tubes are damaged.

Depending on the results of the earlier blood tests, you may be offered a hysterosalpingography (an X-ray that shows the inside of the womb and fallopian tubes) or a hysterosalping-contrast-sonography (using an ultrasound probe in the vagina to scan the fallopian tubes) to check for blockages or growths. Both these tests involve the injection of fluid into the womb, the flow of which can be traced by X-ray or ultrasound to reveal any blockages.

Pelvic ultrasound is used to identify polycystic ovaries or PCOS, so you may be offered one if your case history points in this direction

Your partner will be offered a semen test and an examination to check for swellings and blockages and other indications of a problem. If the results of the semen analysis indicate that there may be problems, then at least one if not more repeat tests should be offered at three-month intervals, to allow time for the production cycle to complete. One abnormal semen analysis is not enough to reach any firm conclusions!!
For those men who are either too busy or too embarrassed to go to the doctor to get checked out, there are also at-home sperm tests that can be used to check for the WHO recommended fertility standard sperm count (20mill per ml).

Sperm may die or be unable to swim in a straight line making it impossible for them to get anywhere near to fertilising an egg. Some men have an auto-immune response which means they produce antibodies that kill their sperm, other men may have ejaculatory problems.

Hormone disorders and tubal blockages also play their part in causing male infertility. Your partner’s sperm may also fail in quantity or quality (motility, shape and normality) as a result of illness, poor diet or lifestyle.

Men also become less fertile as they get older and again some experts suggest that a general decline in fertility starts from about age 35 in men too

Taking this first step in seeking medical help is stressful and you may be surprised at how upsetting it can be to admit that you have a problem and need help. Stress itself can affect your libido and whether and how often you feel like making love – for this reason you may be advised to contact a fertility support group and/or you may be offered counselling.

NCCWCH 2004:1 (National Collaborating Centre for Women’s and Children’s Health). 2004. Fertility: assessment and treatment for people with fertility problems. RCOG (Royal College of Obstetricians and Gynecologists’). www.rcog.org.uk [Accessed: February 2005].
NCCWCH 2004: 51
(NCCWCH 2004).
(Ford et al 2000, Singh et al 2003).