What is Secondary Infertility?

Written By Brianna Donnelly

My awesome Psychology student Brianna Donnelly has put together this piece on the experience of secondary infertility.

It’s incredible how often we are bombarded with “the” question: “When are you going to have a baby?” This question might feel harmless or completely inappropriate, depending on your personal circumstances. There are people who don’t want children, who are planning on having children, and those who can’t fall pregnant no matter how hard they try. This is infertility, which is an incredibly difficult experience that 1 in 6 Australian couples of reproductive age face. 

For those with a newborn, toddler or child, there are questions that are just as inappropriate.

“When are you going to give this little one a baby brother or sister?” “When is the next one coming along?” “Didn’t you always plan on having a big family?”

These are painful questions for the ears of couples with a child who, despite their efforts, cannot fall pregnant again. After experiencing a natural pregnancy, with or without complications, the last thing anyone expects is infertility. It can be extremely difficult to come to terms with infertility while your sleeping bundle of joy sleeps in the next room. What could possibly have happened in between having your first child and trying for another? This experience is known as secondary infertility.

What is secondary infertility?

Secondary infertility refers to the inability to conceive after one year of regular unprotected intercourse after a previous pregnancy in the reproductive age group. Instances of secondary infertility are underreported, although it is more prevalent in the population than primary infertility. This label includes individuals who experience continual poor pregnancy outcomes such as abortions or stillbirths after a previously successful pregnancy and birth.

There are a wide range of factors that may increase the risk of experiencing secondary infertility. Common risk factors include age, lifestyle, a new relationship and childbirth-related medical issues. 

Age

People are having children later, and this impacts the ease of conception for a second child. Age can affect pregnancy outcomes for both those who have undergone previous fertility treatment and those whose first child was conceived naturally. 

When a woman reaches the age of 35, infertility is redefined as the inability to conceive after six months of regular unprotected intercourse. It is important for women over the reproductive age of 35 to seek advice after six-months of trying to conceive so they can try earlier treatment.

Lifestyle

Being a parent is a rewarding experience, but not an easy one by far. Having a toddler may make it difficult to maintain a healthy and active sex life, which may mean partners are not having sex at the right time for conception. 

Lifestyle changes include diet and exercise habits. Doctors suggest regular, balanced diet rich in fish, grains and vegetables when trying to conceive, and no more than 2-3 hours of moderate exercise. However, diet and exercise are some of the first things sacrificed after having a child, making it easy to either put on weight or lose too much weight. 

New Partner

Either person in the couple can be responsible for both primary and secondary infertility. This can be an issue for both women who conceived their first child naturally and those who struggled with fertility issues. In couples, there is commonly a 50/50 split in terms of fertility issues. In new relationships, there is a completely new set of fertility issues to contend with that did not exist in the first conception. 

Childbirth-Related Medical Issues

Complicated c-section births, prior ectopic pregnancies, fallopian tube damage, cysts and fibroids from the first birth can interfere with future conception and pregnancies. Sometimes medical issues stemming from the first birth can be solved with treatment, however it is common that couples don’t realise there is an issue until they try for the second baby.

Relative to fertile individuals, persons suffering with secondary infertility are:

  • Almost 5x more likely to have gynaecological issues

  • Almost 2.5x more likely to have had a bad obstetric outcome in their previous pregnancy

  • 2x more likely to experience secondary infertility if they had a caesarean delivery

What causes secondary infertility?

Secondary infertility has the same causes of primary infertility. Access Australia divides the causes of secondary infertility into four areas.

  1. Sexual function

How often the couple are having intercourse and at what time in the menstrual cycle is an important factor. A couple should be having intercourse 2-3 times during the fertile period, which is 14-20 days before the next expected period.

  1. Ovulation

If the menstrual cycle is irregular, it is possible the woman is not producing an egg each month. This can be checked with blood tests that test for the progesterone hormone, as well as through ultrasound scans. 

  1. Sperm function

Having a previous pregnancy does not mean that the man has enough normal, mobile sperm per ejaculate required for conception. Sperm function can be tested via a semen analysis through two possible tests. 

  1. Tubal function

Tubal problems are twice as likely in secondary infertility than primary infertility. This is due to infective of inflammatory complications that can occur during the end of the previous pregnancy or after delivery. Tubal function is tested if both ovulation and sperm function are normal, via an X-ray study called a hysterosalpingogram or an operation called a laparoscopy and dye. This is tested prior to infertility treatment. 

What are the treatments for secondary infertility?

Possible treatment options for secondary infertility are determined based on its cause. Below is a list of common treatment options based on the causes described above.

  • Fertility drugs regulate or stimulate ovulation. They are considered for problems involving ovulation and for individuals who are ovulating to try and stimulate a better egg or extra egg(s). These include clomiphene citrate, gonadotropins, metformin, letrozole and bromocriptine. For more information on fertility drug options, visit https://www.mayoclinic.org/diseases-conditions/female-infertility/diagnosis-treatment/drc-20354313

  • Intra Uterine Insemination (IUI) involves injecting sperm directly into the uterus via a catheter. Either the partner’s sperm may be used or a donor’s sperm. This option is considered for diagnoses of unexplained fertility, when there is sperm dysfunction, when using frozen sperm, and for potential carriers not of an advanced maternal age. For more information on IUI, visit https://www.ivf.com.au/treatments/fertility-treatments/artificial-insemination-iui

  • In Vitro Fertilisation (IVF) involves combining the sperm and the egg outside the body to form a zygote which is then implanted into the uterus after 2-6 days. Either the same uterus the egg was taken from or another uterus may be used in this procedure. This option is primarily considered when there is a tubal problem, depending on the quality of the partner’s semen, or another person’s semen may be used. For more information on IVF, visit https://www.ivf.com.au/treatments/fertility-treatments/ivf-treatment

  • Intracytoplasmic sperm microinjection (ICSI) is a variation of IVF wherein a single sperm is injected into the oocyte using a high-resolution microscope equipped with micromanipulators. This option is considered for problems with sperm function when the sperm count is very low, or sperm are unable to penetrate the egg. For more information on ICSI, visit https://www.ivf.com.au/treatments/fertility-treatments/icsi-treatment

What are the unique challenges of secondary fertility?

Secondary infertility poses unique challenges, as sufferers experience fertility issues quite differently from primary infertile individuals. Here are several issues commonly reported by those who have suffered and are suffering from secondary infertility. 

Staying silent

Individuals with secondary infertility often feel isolated not only from the fertile world, but also the infertile world. Infertile individuals without children can often be insensitive to those with secondary infertility as they have not been able to conceive even one child and may perceive them as ungrateful. As a result, secondary infertile individuals feel guilty and ungrateful, and are twice as likely as primary infertile individuals to avoid infertility-related communication with people outside the closest family. 

There are triggers everywhere

Those with primary infertility tend to throw themselves into their work as a coping mechanism. However, as we age, the people around us generally all start to get married and have children at the same time, which is a struggle for all infertile individuals. 

As for secondary infertility, when you have a child, these triggers cannot be as easily avoided. It may be harder to turn down baby showers and ask to cut the baby-talk due to the stigma associated with secondary fertility that causes sufferers to stay silent. As a parent with secondary infertility, it is near impossible to avoid school functions and parties which can be an extremely difficult trigger.

Dismissal in the healthcare system

The stigma surrounding secondary infertility even translates to the healthcare system. Couples struggling with infertility report higher distress when their GP is uninformed or dismissive about treatment options, which may be particularly high in secondary infertility. Secondary infertile believe their experience is not considered as valid by their GPs due to the fact they already have a child at home. Martha, who experienced secondary infertility and went through IVF to conceive her second child, felt dismissed by her GP as if she had wasted their time.

The “Why are you here? You have already got one, you know, there shouldn’t be a problem” kind of thing. And I think that I was just… shocked that they could overlook how completely destructive this was… for all of us in the family.

Denial

For those who experienced difficulties with their previous successful pregnancy, they must live with the reminder of their infertility and what it means for their future. However, for those without difficulty conceiving before, the common initial reaction is denial, confusion, or disbelief. 

Some couples may prolong seeking medical or psychological services through denial, while others may blame their child. All these factors can impact the individuals, the couples, and the existing children negatively.

Sexual dysfunction

Having a child can notoriously impact a couple’s sex life. Sexual function is important for physical and marital health and is a common factor in infertility. Sexual dysfunction is more prevalent in secondary infertility than primary infertility, and includes lower reports of desire, arousal and satisfaction.

Sexual dysfunction can reduce one’s marital satisfaction and overall wellbeing, which can reduce their perceived quality of life. Marriages can falter when there is low sexual satisfaction and can result in additional stressors on top of wanting another child.

Tips for Those with Secondary Infertility

Your feelings are valid. It is common for couples experiencing secondary infertility to feel selfish – because you already have a child, and other couples are struggling to even have one. It is crucial to remember that each couple and individual is entitled to their frustration and desire for the family size of their choice. Having a child does not buffer against infertility-related stress.

Seek medical assistance. As discussed earlier, there are many factors associated with secondary infertility. After a year of trying to fall pregnant, those under 35 who should seek medical assistance, while those over 35 should seek assistance if there has been no luck after six months. Specialists, such as a reproductive endocrinologist, can help pinpoint other risk factors like hormone levels, fallopian tube damages, endometriosis, fibroids, ovarian conditions and ovulation disorders.

Check your partner’s fertility. Approximately one in three cases of fertility issues are related to male factors. Sperm quality and quantity can reduce over time, thus it is important to assess the fertility of both partners, rather than just the partner planning to carry the child.

Don’t hold your emotions in. Failure to conceive can cause anger, grief, hopelessness, depression, jealousy, fear and anxiety. Stress and anxiety levels of women experiencing infertility are often equivalent to those battling cancer. Unfortunately, as discussed earlier, cases of secondary infertility generally receive less support than primary fertility. Speaking to someone and communicating pain can ease the emotional burden of feeling like you must stay silent. If support from family and friends are insufficient or absent, a counsellor or support group can be useful for letting out your feelings and finding tools to help you cope with your emotions.

Take care of yourself. Having a new baby often means putting your own self-care on the backburner. Those who participate in mind/body programs in addition to medical treatment experience better outcomes than those seeking only medical treatment. A balanced diet, exercise, meditation and rest promote well-being and fertility.

Spend time with your child. You may feel guilty due to the perception that you are not grateful for the child you already have, or not being able to give them a sibling. A remedy for this is to spend quality time with your child – asking about their day, tucking them into bed, taking them to the park. This time is precious to both you and your child and will help keep your child’s life stable while your and your partner may feel less in control. Alternatively, if you are hiding your true emotions around your child and need to let it all out, you may arrange for a family member to take over for a little bit. This brief time can allow you to express some of that built up emotion before you see your child next.

Connect with your partner. Reading that negative pregnancy test for the millionth time is painful and can be just as difficult for your partner even though they are not the one planning to carry. It is common for the other partner to express their pain less as they feel they need to be strong and supportive for you. It is helpful for both of you to check in with each other and dedicate time to talk about how secondary infertility is affecting each of you. It is also important to have time dedicated to your relationship where you are not solely talking about the negatives in life. Planning date nights are a good way to keep the love flowing and lower your stress levels – the latter having an added bonus as lowering stress levels can improve fertility.

Resources

Information and Support

  • Australia’s National Infertility Network: Access Australia
    https://access.org.au/
    Access Australia is a great resource for information, support and referrals regarding fertility issues. By signing up as an Access member, you will be able to find a forum and support group tailored specifically to secondary fertility. Sign up here: http://signup.access.org.au/

  • Fertility Society of Australia (FSA)
    https://www.fertilitysociety.com.au/about/
    The FSA provides information about infertility issues, including the latest research on fertility treatments.

  • Jean Hailes for Women’s Health
    https://www.jeanhailes.org.au/health-a-z/fertility-pregnancy
    Jean Hailes for Women’s Health is a national not-for-profit organisation aimed at improving women’s health across Australia across all ages. There is a section on their website dedicated to fertility and pregnancy.

  • Sands: Miscarriage, Stillbirth & Newborn Death Support

https://www.sands.org.au/Pages/Category/supporting-bereaved-families
Sands is a volunteer-based organisation providing individualised care from one bereaved parent to another, giving them support and hope for the future, following the death of a baby. 

By searching “secondary fertility” in the group feed or starting a new discussion yourself, you can connect with other individuals and couples experiencing secondary infertility.

  • Your Fertility
    https://www.yourfertility.org.au/about-us
    Your Fertility offers facts about fertility for men, women, trans and gender diverse people in light of unique circumstances. This includes knowledge about how to reduce your risk factors, access to personal stories

Stories from the Secondary Infertility Community

Secondary Infertility and Miscarriages

Religious Perspective

Books

 For parents wanting to learn how to accept living with one child… 

One and Only: The Freedom of Having an Only Child, and the Joy of Being One
Lauren Sandler

Debunking the myth that only children are selfish, maladjusted “little emperors,” a prominent journalist makes a funny, tough-minded, and honest case for being and having an only child.

For parents wanting to cope with their loss and move forward…

 Wanting Another Child: Coping with Secondary Infertility
Harriet Fishman Simons

Parents experiencing infertility experience many of the losses of childless individuals but have unique issues to confront as well. Often, theirs is an unacknowledged loss which increases their sense of isolation. This book incorporates the narratives of 60 individuals coping with secondary infertility and draws on their experiences to validate the loss and suggest strategies for moving forward.

For the child of a secondary infertile couple…

 No Matter What Happens: A Story for Children When Secondary Infertility Happens
Cathie Quillet

Secondary infertility can impact every member of the family. Join this family on their journey through secondary infertility and show your children that they can become brave while they wait for their younger sibling.

References

Brianna Donnelly
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