Many people have never heard the term "secondary infertility" but it affects an estimated 10% of all couples, and can be emotionally devastating. What are the causes and what you can do to support your journey to conceiving baby number two?
When Jo, 35, and her husband decided to start a family, they were surprised by how quickly it happened. "I conceived the first month of trying," she says.
When their daughter turned two, they felt it was time to try for baby number two.
Their daughter is now nearly five, and after many medical tests, two miscarriages and a cycle of IVF, they still haven’t got an answer as to why they don’t have their much wanted second child.
Like growing numbers of people, they are experiencing secondary infertility, a term used to describe having trouble getting pregnant or carrying your next baby to term when you didn’t have any trouble with your first.
Says Jo, "I still don’t have an answer why it was so straightforward before, and so hard now."
"Meanwhile, people constantly ask me when we’re going to give our daughter a sibling and I have no idea how to respond."
What is secondary infertility?
Technically, a diagnosis comes when a woman has been unable to establish a clinical pregnancy after 12 months of having unprotected sex, but she previously had a clinical pregnancy.
So even people who have been pregnant before but never delivered a baby can experience it.
Secondary fertility actually occurs as often as primary infertility, and cases are on the rise. It now accounts for six out of 10 infertility cases.
One reason is that more of us are now having babies in our 30s than in our 20s. Biologically it becomes more difficult to conceive and carry a baby to term as we get older.
Only a few years can make a significant difference, as our ability to conceive and carry a healthy baby to term starts to fall more rapidly from our late 30s.
That’s because as well as declining egg quality making it harder to get pregnant in the first place, our risk of miscarriage rises, as you can see in this chart on the Risk of Miscarriage According to Maternal Age, published in the British Medical Journal.
A lot of the same factors involved in primary infertility are linked to secondary infertility, with doctors citing many potential causes, including:
Age
Egg reserve
Uterine factors: such as fibroids and endometriosis
Ovulation and hormone balance problems
Tubal issues
Complications from past births: such as scarring
Male factors: such as sperm quality and motility
Lifestyle factors: such as weight, nutritional deficiencies and sleep disruptions
Health conditions: such as thyroid problems
When should you seek help?
The guidelines are that if you are under 35, haven’t used contraception for a year and can’t become pregnant you should seek medical advice.
But for individuals or couples aged 35 to 40 don’t wait that long: seek assistance after six months.
And if you’re over 40? Seek help after three months.
These are broad guidelines, and fertility doctors say if you already have known medical issues that could impact fertility, such as painful or irregular periods, pelvic inflammatory diseases or if a male partner has known problems with sperm, do not wait and struggle alone.
Consulting a specialist obstetrician and gynecologist or making an appointment with a fertility clinic is a good idea even if you’re under 30.
That’s because assessing ovarian reserve (the quality and quantity of eggs) and sperm count can help fertility doctors understand what is happening and guide potential treatment options.
A fertility consultation will generally involve testing blood hormone levels, a pelvic ultrasound and a full medical history in a consultation with a fertility specialist.
Sometimes, the diagnosis is “unknown” infertility, which can be frustrating. In other situations, doctors can discover a cause.
Treatment options - for either diagnosis - include ovulation-boosting medication, intrauterine insemination (IUI) and in vitro fertilization (IVF).
What’s not often talked about is that age related fertility can vary significantly from person to person: some people’s fertility declines sooner than the charts suggest - even potentially from their 20s in a condition known as primary ovarian insufficiency (sometimes called early menopause).
Meanwhile, other people will conceive into their 40s.
Realising that the averages are just that - averages - and that it is key to understand what is going on in our own bodies specifically can be helpful.
You don’t need to wait for permission or to be a certain age before you can ask for assistance.
Sometimes people say their primary care doctor played down the possibility of secondary infertility and just told them to “keep on trying” and “it will happen” because they had a previous pregnancy.
Fertility specialist Dr. Aimee Eyvazzadeh champions self-advocating by not accepting passive care: “If you’re sitting somewhere and you want to go somewhere else, aren’t you going to plan for it?...You can be just as proactive about your fertility.”
What you can do to take care of yourself while seeking professional help
Focus on getting healthy
There’s a growing body of scientific data that shows nutrition, activity levels, body composition and even environmental toxins can have an impact on our reproductive hormones.
While refining your lifestyle isn’t a silver bullet and in some cases cannot address the underlying physical causes of infertility, a healthy body is a strong foundation for both increasing your fertility chances and for an ensuing healthy pregnancy.
The jury is still out on whether stress can be a cause of infertility, as it is an inherently difficult thing to study. (Though scientists have identified biologically plausible mechanisms by which chronic stress can influence our hormones and “switch off” fertility). What we do know is that struggling to have a baby is stressful, and what matters is that we are aware of options for self management and options for professional care.
Focus on finding support
Compounding the sense of stress that can occur with any medical issue, there is a huge emotional component to any fertility struggle - and secondary infertility is no exception. The diagnosis comes with its own specific stigmas and psychological challenges.
Secondary infertility can be extremely isolating as individuals and couples tend to receive far less social and emotional support than people with primary infertility. Many people also say they feel uncomfortable participating in support channels and groups if they already have a child.
But the need for support still very much exists.
The diagnosis can come with feelings of anger, depression, anxiety and powerlessness. Insensitive comments like “you should feel lucky you have one” can create feelings of guilt even when loving an existing child in no way precludes a right to want to further grow a family, or lessen the pain of that longing.
“I don’t know whether I should just feel grateful for my daughter and have that be enough,” says Jo. “People have told me I need to make my peace with having one child - but deep down I feel like I’ve failed.”
We cannot always control the outcome, but we can work on ways to deal with our situation and how we feel about it.
Focusing on how to get the support we need and taking time for ourselves is so important to caring for our mental and emotional health.