Written by Lucy Lines at Two Lines Fertility
About 1 in 7 couples in Australia encounter secondary infertility – the ability to get pregnant a second time – it’s actually more common than not being able to conceive in the first place. Let’s dive into what is secondary infertility and the potential causes of secondary infertility and unexplained infertility.
But just because it’s common doesn’t mean it’s easy to deal with… especially as you are now likely to have a circle of ‘mum friends’. They may all seem to be pregnant with their second/third whilst you are still stuck – but remember, The Rules are the same with secondary infertility as they are with primary infertility:
If you have not conceived after 12 months of regular, unprotected sex (6 months if you’re over 35), you should ask for a referral to a fertility specialist
There are lots of reasons for secondary infertility, among the possible causes are:
– impaired sperm production, function or delivery
– fallopian tube damage, ovulation disorders, endometriosis and uterine conditions
– complications related to prior pregnancy or surgery
– risk factor changes for you or your partner, such as age, weight and use of certain medications.
Let us investigate each of these separately.
Impaired sperm production, function or delivery & the link to Secondary Infertility
The old story that it only takes one sperm is true… it really does only take one. It could be that you have a low sperm count, or low motility, or really high abnormal forms, and you struck it lucky the first time.
The more motile, normally shaped sperm you have, the greater the chances are that one of them might make it to the egg. If the count is low (under 20 million per ml), the motility is low (less than 40% motile), and the abnormal forms are high (over 95%). The number of swimming sperm that can make it to the egg is reduced… you do only need one.. but if any/some/all of these parameters are below ‘normal’, then it could take longer to get pregnant. It doesn’t mean it’s impossible – just that it may take longer…
Depending on how many more children you want and how old the female partner is… you may elect just to keep trying, or you may choose to seek help from a fertility specialist.
It could also be that the sperm just aren’t doing their job or that they are not being deposited in the right place at the right time.
How could we tell if it’s the sperm that is the problem?
There would be no outward indication at all if the count, motility or abnormal forms are outside of the ‘normal range. A male ejaculate contains all sorts of other things as well as sperm, and there is no way to tell without actually having a semen analysis of exactly what those values might be.
A semen analysis is relatively easy to arrange and totally painless. Your GP should be able to request it, and the results should be available within a few days.
A semen analysis will assess several things.
– the volume of the sample (usually around 2-3mls)
– the number of sperm – or the count (anything over 20 million perms per ml is considered ‘normal, but men with counts less than that are still quite capable of fathering children naturally)
– how many of the sperm are moving (motility), and what percentage of those are swimming forwardly in a relatively straight line – also called ‘progressive motility’ (anything over 40% motile and 30% progressive motility is considered normal)
– how many of the sperm appear to be normally shaped – morphology (anything over 4% is ok)
– agglutination – this is whether the sperm all stick together at their heads or whether they are swimming independently. Sometimes, especially if there has been some damage to the testicles, the sperm heads can stick together. This makes it virtually impossible for the sperm to make their way to an egg and fertilise it.
If you ask your GP for semen analysis – make sure that they request it from an andrology lab and not from a pathology lab. Pathology labs are really good at assessing volume, count, and motility but are not especially good at assessing morphology or agglutination. These are both subjective tests done by a scientist looking down a microscope and making an assessment. The scientists in andrology labs are sperm specialists, and they are the best people to make those assessments. I’m pretty sure most pathology labs would agree with me on this one :)
Firstly, when you get these results – be careful not to be too horrified. The contents of an ejaculate do not determine how much of a man you are. Fertility is absolutely NOT linked to virility, and rarely has any connection to testosterone levels in your body.
Semen analyses can vary considerably from week to week and are heavily influenced by illness, fever and lifestyle. Some dietary changes and supplements can improve semen analysis results, and most male factor infertility issues can be easily overcome with IVF + ICSI. Provided there are no other fertility issues, results with IVF+ICSI are usually very good.
I always recommend that couples with a semen analysis below what the World Health Organisation says are ‘normal’ should see a reproductive endocrinologist or urologist who specialises in male fertility to rule out any underlying medical issues that might be causing the problem.
Potential secondary infertility causes;
Fallopian tube damage, ovulation disorders, endometriosis and uterine conditions
If your tubes are damaged, the sperm could have trouble making their way to the egg, which can cause secondary infertility, and the fertilised egg (zygote) could have trouble making its way back down the tube to the uterus to implant (did you know that fertilisation happens way up there in the tubes?).
If you are not ovulating regularly, it’s hard to know when the egg could be ready for fertilisation. If you have endometriosis or fibroids, or some other uterine condition, then it might be hard for the egg to be picked up by the fimbria (the little hands on the ends of your fallopian tubes that pick up the eggs from your ovaries). It might be tricky for the fertilised egg to make its way to the uterus and implant.
How could we tell if it’s tubes/ovulation/uterus/endometriosis that’s the problem?
The only way to know if your tubes are clear and undamaged and to check for fibroids is to have a Hysterosalpingogram (HSG) or a HyCoSy. Both of these tests involve injecting fluid through your cervix into your uterus and checking that the fluid flows out the ends of your fallopian tubes. With the HSG, the visualisation is done using X-Ray technology. With the HyCoSy, it is done using ultrasound. The HyCoSy enables better visualisation of the uterine cavity, making it easier to see any fibroids in your uterus.
The only way to diagnose endometriosis is by having a laparoscopy and actually visualising the peritoneal cavity (the bit inside your belly where most of your internal organs sit, including your uterus and bladder). 60% of women who complain of having painful periods have some level of endometriosis. It is not really clear exactly how much of an impact this has on fertility, but this can be the reason for your secondary infertility issues. Speaking to your GP about your endometriosis when you’re trying to conceive can assist your journey.
Ovulation disorders are easier to pick as it is the process of ovulation that causes you to have a period – without ovulation, there is no period. If your period is regular (between 25-33 days), you are most likely to ovulate somewhere between day 11-19. If your cycle is not regular, it is much harder to know when you are ovulating, making it hard to time everything so that there are sperm sitting and waiting for the egg when it arrives in the fallopian tubes, which can lead to secondary infertility. Tracking your cycle using ovulation tests (OPK) can help track when you are ovulating to help determine if this is your cause for secondary infertility.
What can we do about tubal blockages?
In the case of tubal blockages, an HSG is often enough to ‘flush’ the tubes out if there is a small blockage, but sometimes you will need a laparoscopy to clear it out or even possibly remove the tube is seriously damaged. Don’t worry, fimbria can collect eggs from either ovary; they’re very flexible!
If fibroids are found, then treatment will depend on where they are. If they’re in the uterine cavity and impacting the shape of the uterus, then your specialist will probably decide to remove them. Still, if they’re not affecting the shape of the uterus, and they’re not inside the uterus, then it’s likely they’re not really causing a problem, and your Dr might decide to leave them there. Your doctor is really the best one to make this call.
Endometriosis is a tricky one, and you should definitely take your doctor’s advice on this one as well. In Australia, some Drs are more experienced at dealing with endometriosis than others, and I can help you find one that suits your needs best. Endometriosis can be surgically removed, but you want to make sure you’ve got the right doctor doing the procedure to give you the very best chance of conceiving naturally afterwards.
If it’s an ovulation disorder – these can be triggered by weight gain and loss, lifestyle, diet and exercise, as well as several hormonal causes. Your hormones are very much affected by your environment, so managing stress, eating healthily, getting regular exercise and maintaining a healthy weight can really help reduce the chances of secondary infertility.
Complications related to prior pregnancy or surgery & secondary infertility
This could be something physical, like damage to your cervix or uterus, scar tissue after a caesarean, or adhesions after surgery stopping things from working the way that they should.
Or it could be something mental, something between you and your partner, something weighing you down, something you don’t talk about but should; it could be challenges of being a parent, lack of sleep, worry about having two.. all sorts of different things.
It’s unknown how much of an impact our mental health has on our ability to conceive, but I wholeheartedly believe that it’s always worth talking to someone about any worries you might have and finding a way through them.
If there is physical damage, then any treatment should be discussed with your fertility specialist. It may be that further surgery could help… but it may also be that further surgery could make it worse.
Risk factor changes for you or your partner, such as age, weight and use of certain medications
There are several risk factors for infertility – age, weight, smoking, alcohol consumption, for example… its very possible that you may fall into a different risk category now than you did when you conceived last time… perhaps you are drinking more, taking up smoking again, or maybe you gained or lost weight during or since your last pregnancy… all of these things can impact your ability to conceive.
What can we do to reduce your chances of secondary infertility?
It’s hard to know if any of these are the trigger… but it can do absolutely no harm to reduce the amount of alcohol you’re drinking, quit smoking and get yourself to a healthy weight range. A change of even 5% of your body weight can be enough to tip you back into a healthy range.
I am a big believer that it is not what the scales say – i.e. not what you weigh, that makes the difference. It is about being metabolically well – making sure that you are eating heaps of leafy green veggies, not eating too much sugar, getting some regular moderate exercise and generally taking care of yourself that is most important… whether that results in loss or gain of weight is really only secondary.
If you think this might be an issue for you, I have some really useful lists of foods to eat more of to up certain nutrients in your diet, foods to eat less of, and some to avoid. For more detailed and specific information, you should always consult a nutritionist, and there are a few specialise in Fertility Nutrition that I can put you in touch with.