July 07, 2021
Including the signs and causes of secondary infertility, possible tests and treatments, and what it can feel like.
Vidya Ledsham was still hooked up to an IV in the hospital, recovering from the C-section delivery of her son, when she asked her doctor when she and her husband, Chris, could start planning for a second baby. “We wanted to have another right away because we wanted kids close in age,” says Ledsham.
When Everett was a year old, they began trying to get pregnant again. “I thought we could just do the same things that had worked the first time,” she says. (Everett’s conception got a little nudge from a single dose of Clomid, a fertility medication that promotes ovulation.) But over the next five years, they did six cycles of fertility meds, then six cycles of IUI (intrauterine insemination, where a doctor inserts a thin tube through the cervix into the uterus to carry semen directly inside) and finally three cycles of IVF (in vitro fertilization, where the sperm and eggs are extracted, fertilized, and then an embryo is transferred into the uterus).
Her first IVF cycle resulted in a pregnancy, but she had a miscarriage. They did two more IVF cycles but never saw a positive pregnancy test. “We decided to call it quits. We had hit the wall in medical treatments,” she says.
The Ledshams are one of many couples who experience secondary infertility. The definition of secondary infertility is that you’ve been pregnant before but are having trouble getting pregnant again, says Jason Hitkari, a reproductive endocrinologist in Vancouver and president of the Canadian Fertility and Andrology Society. That definition applies whether you conceived easily the first time around or had difficulties. About one in six couples in Canada struggles with infertility, although that stat isn’t broken down into primary infertility (a couple who has never had a child after a year of trying to conceive) and secondary infertility. However, according to a 2012 study, about nine to 12 percent of couples worldwide with at least one previous live birth have difficulty getting or staying pregnant again.
What are the causes of secondary infertility?
The causes of secondary infertility are the same as primary infertility. In men, it means problems with sperm quality or delivery. In women, it can be due to conditions such as endometriosis or fibroids that damage the reproductive organs, or problems ovulating due to a condition such as polycystic ovary syndrome (PCOS) or an untreated thyroid issue, which can lead to lower levels of the hormone progesterone, irregular periods or ovulation difficulties. (Thyroid conditions can also affect sperm quality.)
Being overweight or underweight can also be an issue for women, sometimes contributing to irregular periods, ovulation difficulties or conditions like diabetes, which affects conception.
Age can play a role, too. “People struggle more with fertility as they get older, particularly as women get older,” notes Hitkari.
The age for a first pregnancy in Canada has been rising steadily since the mid-1960s, with an average age of 29 in 2016, according to Statistics Canada. A woman’s fertility (in particular, the number and quality of her eggs) starts to decrease in her 30s, and more so after age 35. For guys, sperm quality starts to decline between ages 35 and 40.
“If you’re having your first child at an older reproductive age, and then [try to have] the second one even later, then your age could be impacting, but I couldn’t say for certain that the rates of secondary infertility are going up,” says Hitkari. And sometimes, frustratingly, there is no reason at all that doctors are able to pinpoint, he says. This is called unexplained infertility, a diagnosis Hitkari says is given to about 20 percent of infertile couples. (Estimates of the rate of unexplained fertility vary—according to an article in the journal Reproductive BioMedicine Online, it’s closer to 50 percent.) Understandably, couples want to know “what changed” between conceiving their first and struggling to conceive another child, but sometimes, no matter how many tests you run, no matter how much you investigate, “sometimes it’s just hard to find out,” says Hitkari.
What are the warning signs of secondary infertility?
So how do you know if you are experiencing secondary infertility? If you’ve been unsuccessfully trying to get pregnant for a year (or for six months if you’re 35 or older or you have a diagnosed condition such as endometriosis or PCOS), talk to your healthcare provider about getting checked out. New changes like pain during sex or irregular periods can point to something else going on, but often there aren’t any signs at all.
A fertility workup by your family doctor will likely include a conversation with both partners about lifestyle factors that can affect fertility, like weight, alcohol use, recreational or prescription drug use, or consistent, ongoing exposure to harmful chemicals, like pesticides in the workplace. It will also likely include screening for any sexually transmitted infections and a blood test to check hormone levels.
For women, your doctor may refer you for a transvaginal (internal) pelvic ultrasound to look at your uterus and ovaries, for an X-ray dye test called a hysterosalpingogram (HSG) to see if your fallopian tubes are scarred or blocked, or for a sonohysterogram, an imaging test similar to an ultrasound, to examine the interior of the uterus for problems.
For men, your doctor may refer you for a test to determine sperm and/or semen quality, an ultrasound to look for problems with the testicles or prostate, or a blood test to look for genetic issues (for example, if the sperm concentration is very low, it may be due to an inherited condition). Infertility itself isn’t genetic, but some conditions that affect fertility, such as endometriosis and PCOS, tend to run in families.
Depending on what services your primary healthcare provider has access to, you may be referred to a fertility clinic for some of these tests. Yes, a few of these tests can be a little daunting (how many sitcom jokes are there about that semen sample?), but these investigations are useful to help you figure out a plan.
What are the treatment options for secondary infertility?
Once you and your doctor have test results, you can talk next steps, which tend to be the same as treatments for primary infertility. Depending on what your results say, your doctor may suggest a more conservative approach to treatment (rather than going directly to IVF) because you have been successful at getting pregnant before, says Hitkari. Treatment could include addressing lifestyle factors (for example, changing your ulcer medications, or cutting back on cannabis use, which can affect sperm quality) or prescribing fertility meds like clomiphene or letrozole to improve ovulation. Treatment might also involve minor surgery—such as to a polyp or fibroid in the uterus or a blockage in the ducts that transport sperm—and this may be enough to get things operational again and improve your chances of conceiving.
Other options include insemination via IUI, or transferring an embryo or a pair of embryos via IVF. This is the most costly, involved and invasive approach—but arguably the most direct.
Dealing with the emotional fallout
Not surprisingly, craving another child—that hollow ache, that feeling that your family is not complete—can be devastating for some people going through secondary infertility. “My dominant emotion with secondary infertility was guilt; the medical issues at play were my body,” remembers Ledsham. “I felt like I was letting down my husband and my son. I kept envisioning Everett’s life and what we wanted for him, and it was never to only have us. There was almost a fear of the future: What if something happens to my husband and me, and he’s alone?”
Leyla Tran, a mom in Chicago, went through a similar roller coaster of emotions. She and her husband got pregnant with their son, Luke, now nine, without medical intervention the first month they tried. When they started trying for a second child, she got pregnant without medical intervention twice, but both ended in miscarriage. Then they decided to use fertility meds and IVF, but this did not result in any pregnancies. “Not a lot of people understand what you’re going through. Having infertility without having kids, I think people are a little bit more sympathetic—they think, ‘Well, you don’t have a child and you want one, I get it,’” she says. “But when you already have a child and you’re trying for another, I think a lot of people think, ‘Well, you already have a child. Why are you so sad?’ That was really hard to explain to people.”
And because you’re already a parent, you’re pretty much constantly around other people who are growing their families—you’re seeing baby siblings at the playground and at school drop-off, and all the ultrasound pics and birth announcements posted online are almost unavoidable.
Clearly, there can be a lot of complex emotions around infertility. “Feeling devastated, feeling like something’s wrong with them, feeling like they’re not living up to what they’re supposed to be doing. Feeling panic, anxiety, confused, scared,” explains Amira Posner, a social worker in Toronto with a focus on infertility. People going through secondary fertility are dealing with extra layers, too, such as offhand hurtful remarks by people who assume you’re going to have more kids, or feeling disconnected from the parent friends you made the first time around. Maybe there’s also a sense of betrayal by a body that had once grown a child. And how about the guys? “Male and female counterparts struggle with this differently,” says Posner. “Generally speaking, the men I see are really positive and hopeful, and more like the rock.” Which means, of course, that men who are finding it hard to be the hopeful rock need support to figure out how to process everything, too.
Posner works with her clients to build skills to get through the tough times, whether they’re going through fertility treatments or learning to come to peace with infertility, through mindfulness techniques like breath work and yoga. Getting out of the research tunnel vision, where you endlessly scroll for studies and stories online, is definitely a good step, she says. “Move some of that angst into self-care and compassion and other ways of coping. What will help you thrive, as opposed to take you down the rabbit hole?”
Tran found solace in her faith, stepping back from social media, and meeting with a counsellor. “Talking to a stranger helped a lot. Just sorting out my feelings, and not reaching for the phone and texting or talking to a friend who may not understand. Looking back now, I think I put a lot on my friends who didn’t understand. It wasn’t really fair to them,” she says.
Ledsham, however, found that sharing her experiences online and with friends felt right. “You help destigmatize the feelings, and it’s very cathartic. And hopefully you’re surrounded by people who are not dismissive, and who are understanding, and who care. Because so many people don’t talk about it, you don’t know how many people are actually experiencing it. And you’d be surprised at how many other people have also gone through it as well.”
Ledsham started volunteering with Fertility Matters Canada, a national non-profit organization for fertility education, writing blog posts about her experiences and coordinating their weekly Facebook Live series on fertility topics. “Doing that work for the fertility community was kind of my therapy,” she says.
After three years of trying, Tran and her husband decided to stop fertility treatments. It took many months to get used to the idea of a family of three. “There was a moment when we were doing some apple-picking with my son, and I remember driving home and I told my husband, ‘I had a really good day today.’ I didn’t feel this heaviness, that I was missing something. I felt complete. I think that was when I felt like I was starting to get over this.”
But in a random twist of fertility fate not long after that, Tran became pregnant with twin boys without medical intervention, and the very-much-welcomed Levi and Cruz are now two and a half years old. (Her older son is now nine.)
Ledsham blogged recently about how hard it was to let go of a little spark of hope when her period was a few days late. “Do we still want another baby? The simple answer is no. We’ve moved on. We’ve focused on our lives as a family of three. We’re invested in our careers. We got a dog. Our son is almost eight years old. Starting over again now with a new baby would be…un-ideal. And we are happy as we are,” she wrote. “While I’m no longer getting anxious around the end of my cycle, or cry when I begin a new cycle, I have moments. Moments where I think, What if? Moments where I imagine myself with a positive pregnancy test in my hand, telling my husband the news in a playful and surprising way, telling my son he will finally be someone’s brother. These moments are fleeting, but they are there. I’ve pretended they weren’t, so that I can pretend I’m fully healed.”
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