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Secondary Infertility: Evaluation and Treatment

By Jerald S. Goldstein, M.D.
Published in Resolve for the journey and beyond, Winter 2011

The diagnosis of secondary infertility can be emotionally very difficult. Recently a patient told me of how alone she felt speaking to a “friend” of hers who told her, “You should be happy you have one child already.” Approximately 30 percent of infertility is secondary infertility—the inability to conceive or have a full-term pregnancy after having had children without difficulty before. Couples that are experiencing secondary infertility are reluctant to reach out to others, including support groups, and others may feel like they are already blessed with one child and should be happy with that.

Diagnosis of both primary and secondary infertility is defined as one year of attempting to become pregnant without success. For women over 35, evaluation is recommended if you have been unable to conceive after six months. The causes of secondary infertility are similar to the causes of primary infertility. However, the workup should focus on specific factors that have changed with you or your partner since having your first child. Infertility treatment is focused on the specific cause of the problem, and reviewing your recent history is very important in making a diagnosis.

Specific causes of secondary infertility include:

Maternal Age: The mother’s age is one of the most common reasons for secondary infertility. Couples often delay trying for another child because they believe that conception will occur without difficulty. The natural decline in ovarian function is the single most important factor in fertility. It is important to realize that women are born with all of the eggs they will ever have. As a woman ages, the egg quality decreases, and the chances of miscarriage increases. Men, however, produce new sperm every day.

Pelvic/tubal factors: Sexually transmitted disease, endometriosis and a history of ruptured appendix can lead to pelvic adhesions that interfere with the ability of the egg to be picked up by the fallopian tubes. For example, if there were complications during a prior delivery and a woman developed a uterine infection, or if she underwent a difficult pelvic surgery, she may be at risk for a condition known as Asherman’s syndrome (intrauterine adhesions as a result of scarring after uterine surgery), or adhesions around the fallopian tubes which prevent the tube from capturing the ovum during ovulation.

Male factor: Changes in sperm quality or quantity may occur due to changes in health or beginning certain new medications. I continue to be amazed, for example, at the number of couples I see in which the male was given testosterone supplementation by a family practice doctor or internist. The effect of such treatment decreases male sperm production dramatically and can often take a year to get back to normal after stopping the medication.

Life style issues: Factors such as weight can have an impact on the ability to conceive. Excessive weight contributes to ovulatory disorders. As a woman’s weight increases, insulin resistance may increase as well, leading to elevated production of male hormones, such as testosterone, which affect ovulation. For men, excessive weight can increase male estrogen levels which can negatively affect sperm production. Cigarette smoking can also impact egg quality and increase complications during a pregnancy.

Fertility medications such as clomid or injectible gonadotropins are used to increase the number of eggs available for fertilization, either naturally or with intrauterine insemination, or in vitro fertilization. The use of IVF allows us to bypass pelvic/tubal problems, and also increases fertilization in cases of severe sperm related abnormalities. When the issue is diminished ovarian function, egg donation is an option for those with secondary infertility.

Current treatment has improved dramatically, thus encouraging couples to seek help in overcoming fertility challenges. For example, the pregnancy rates for couples using assisted reproductive technology (ART) now exceed the monthly fertility rate for couples without fertility problems. Early evaluation allows people to be aware of any problems that may exist and to explore treatment options that may be helpful in improving their chances of successful conception.

Jerald S. Goldstein, M.D., a native Texan, is certified by the American Board of Obstetrics and Gynecology in both Obstetrics and Gynecology and Reproductive Endocrinology and Infertility and is medical director of Fertility Specialists of Texas in Dallas. He is the author of scientific publications in peer-reviewed journals including Fertility and Sterility and Obstetrics and Gynecology and has lectured on a variety of topics related to reproduction and fertility. Dr. Goldstein’s areas of expertise include in vitro fertilization, recurrent pregnancy loss, polycystic ovarian syndrome, endometriosis, donor egg, pre-implantation genetic diagnosis and fertility preservation in couples undergoing therapy for cancer.

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