A few months ago, Claire*, a woman in her late 30s, walked into my office. Tall and confident, with a strong handshake and a wry smile, she was the owner of a small textile firm, married for five years, mother to a beautiful three-year-old child.
She was also sitting in the office of an infertility specialist facing something she had spent more than a year pretending was not happening. As she told me her story, her composure began to fray at the edges.
"I just don't understand it," she said. "My best friend and I got pregnant at the same time. It wasn't on purpose, it just happened that way. And we did prenatal yoga together and went shopping for baby clothes together, and she delivered three days after me and our children share a nanny now. It's amazing."
"And then?" I asked gently.
Claire was looking down at her lap and playing with the strap of her handbag.
"But then she got pregnant again. And Greg and I keep trying, but every month goes by and I'm not pregnant. Now she's having a second baby. And I'm just not understanding what's wrong. I mean, it's not like I'm infertile."
Claire's words were a refrain that too many women find themselves echoing to their physicians. Patients who are having difficulty conceiving their second child have a very difficult burden to bear. They often do not think of themselves as an infertile couple since they have already successfully conceived. And, as I explained to Claire, having a child once is not a magic potion that guarantees eternal fertility.
It is possible to get pregnant once and then experience difficulties the second time around--what is commonly known as secondary infertility. A diagnosis of secondary infertility maybe be rendered if:
- A couple who has already given birth without the use of medical support or fertility medications finds they are unable to get pregnant again or experiences recurrent miscarriages and
- They have been trying for one year if the woman is younger than 35 or
- They have been trying for six months if the woman is older than 35
Couples in these situations usually ask themselves the same questions as Claire did when she came to see me: "It was easy the first time. So why is it so difficult now?"
Possible Causes of Secondary Infertility
Causes of secondary infertility vary, but there are a number of factors that may be at play.
- Advanced reproductive age. The woman's age is one of the most common reasons for secondary infertility. Although a woman like Claire may have had no problem getting pregnant a few years ago, those interim years can change things. It's critical to understand that a woman is born with all of the eggs she will ever have. As a woman ages, her ovarian reserve will diminish. This means that her egg quantity and quality will decrease, while the chance of miscarriage increases. This is true whether or not she conceived easily in the past.
- Structural complications. Some other important factors relate to the structures in the pelvis which includes the fallopian tubes. Pelvic adhesions - which may be caused by endometriosis or prior abdominal surgeries - may make it difficult for the egg to be picked up by the fallopian tube. Without a connection that functions normally, pregnancy cannot result. In addition, if there were complications that developed during a prior delivery and a uterine infection resulted, she may have developed Asherman's syndrome (intrauterine adhesions) or adhesions that develop around the fallopian tube.
- Sperm quality and quantity. The third category to consider is the sperm. Just as a woman's fertility can change with time, so can a man's fertility. Changes in sperm quality and quantity may occur due to changes in health or new medications. A semen analysis is one of the basic aspects of the initial infertility evaluation.
- Weight gain. Weight can have a huge impact on the ability to conceive. Excessive weight gain can contribute to ovulatory dysfunction. With increased weight, insulin resistance can increase as well, which leads to elevated production of testosterone from the ovaries, a phenomenon that can further prevent normal ovulation. In men, excessive weight can also negatively affect sperm production by increasing estrogen levels.
- Smoking. Cigarette smoking in both the male and female can significantly impair the ability to conceive. And, smoking can seriously impact a woman's ability to carry a normal pregnancy.
Whatever the underlying causes for a woman's difficulty conceiving, talking with a specialist is the best way to untangle a web of confusing information and emotions. This includes the helpful "advice" from friends and family and the myriad ways people blame themselves when things don't go as planned.
Fertility treatments are constantly improving: pregnancy rates for infertile couples using Assisted Reproductive Technologies (ART) are currently higher than the average monthly fertility rates. Even if you already have a child, if you suspect secondary infertility, seek help from a fertility specialist as early as possible! Early evaluation is critical since, as time passes, certain treatment options may be more difficult to pursue.
- Medication. Medications that are used to enhance fertility include oral medications such as clomiphene citrate (Clomid) and injectable gonadotropins. Both are used to increase the number of eggs that are available for fertilization.
- Fertilization. Once the eggs are ready, doctor and patient will determine if the best way to proceed is via intercourse, intrauterine insemination (IUI) or in in vitro (in the lab). IVF has been useful in circumventing some of the tubal and pelvis disorders that can cause secondary infertility and is also helpful in increasing fertilization rates-even if a woman's fallopian tubes are already opened, as in the case of severe sperm-related abnormalities.
- Egg donation. In the case of women who are diagnosed with severely diminished ovarian reserve with no remaining ovarian function, egg donation is an option.
In Claire's case, after a thorough course of examinations, including ultrasounds, blood work, x-rays and semen analysis, we were able to come up with a plan of action that made her comfortable. Even leaving my office that first morning, her head was high again because she had taken control of her fears and asked for help.
It's important to remember that some couples will have an identifiable reason for their infertility, and some will not. Regardless of whether or not there is a ready diagnosis, every woman struggling with questions about her fertility can benefit from a consultation with a specialist. By garnering the support of a medical team trained to help people illuminate an uncertain road, by educating yourself about your body, your issues and your options, you can get started on your way to building the family you dream of having.
Even if, like Claire and Greg, you've already started.
*Names and details have been changed to ensure patient confidentiality