Written by Lucy Lines at Two Lines Fertility
About one in seven couples 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.
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’ and they may all seem to be pregnant with their second/third whilst you are still stuck – but just 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.
Lets investigate each of these separately
Impaired sperm production, function or delivery
What is it?
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, and 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%), then 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 to just 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 are 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, 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 a number of 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 fo 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 to fertilise it.
If you do ask your GP for a 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 as these are both a subjective test – done by a scientist looking down a microscope and making as 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 :)
What can we do about it?
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 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 that is below what the World Health Organisation say is ‘normal’, should go to see a reproductive endocrinologist or urologist who specialises in male fertility, just to rule out any underlying medical issues that might be causing the problem.
Fallopian tube damage, ovulation disorders, endometriosis and uterine conditions
What is it?
If your tubes are damaged, the sperm could have trouble making their way to the egg, 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 there ready for fertilisation, and 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) and it might be tricky for the fertilised egg to make its way to the uterus and then to implant
How could we tell if its 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 an ultrasound. The HyCoSy enables better visualisation of the uterine cavity, which can make 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 and it is not really clear exactly how much of an impact this has on fertility.
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) then it is most likely that you are ovulating somewhere between day 11-19. If your cycle is not regular, it is much harder to know when you are ovulating, which can make it hard to time everything so that there are sperm sitting and waiting for the egg when it arrives in the fallopian tubes.
What can we do about it?
In the case of tubal blockages, often an HSG is 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 if it 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, but if they’re not affecting the shape of the uterus, and they’re not inside the uterus, then its 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. Some Drs are more experienced at dealing with endometriosis than others, 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 a number of 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.
Complications related to prior pregnancy or surgery
What is it?
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.
What can we do?
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 just make it worse.
Risk factor changes for you or your partner, such as age, weight and use of certain medications
What is it?
There are a number of 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, taken 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?
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 – ie 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 off and some to avoid. For more detailed and specific information, you should always consult a nutritionist and there are a few who specialise in Fertility Nutrition that I can put you in touch with.