Secondary Infertility: What Causes It and What You Can Do

Lucy Lines
Feb 7, 2019
9 min read

Updated: May 21

Secondary infertility refers to the inability to conceive or carry a pregnancy to term after previously giving birth to one or more children without difficulty. In other words, it's when a couple experiences difficulty getting pregnant or sustaining a pregnancy after already having successfully had a child.

This can be due to a variety of reasons, including age, health changes, lifestyle factors or medical conditions that develop after the first pregnancy. It’s different from primary infertility, which is when a person or couple has never been able to conceive.

How common is secondary infertility?

Having worked as a lab embryologist and fertility educator for twenty five years, I’ve encountered many cases of secondary infertility – it's actually more common than not being able to conceive in the first place. About one in seven couples experience secondary 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' 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

(I can help you to find a fertility specialist if you're in Australia.)

What causes secondary infertility?

There are lots of factors that affect fertility. Among the possible causes of secondary infertility are:

Low sperm production, function or delivery
Poor sperm quality
Fallopian tube damage, ovulation disorders, endometriosis and uterine conditions
Complications related to previous pregnancy or previous surgery
Risk factor changes for you or your partner, such as age, weight, and use of certain medications

The first step to addressing and treating secondary infertility is to identify its cause. Let's investigate each of the potential causes separately.

Cause 1: Low sperm production, function or delivery

The old story that it only takes one sperm to make one child is true… it really does only take one. It could be that you have a low sperm count, or low motility, or 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, the motility is low, 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', it could take longer to get pregnant. It doesn't mean it's impossible – just that it may take longer.

How can we tell if the problem is impaired sperm production or function?

There would be no visible indication if your sperm 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 exactly what’s going on with the sperm itself without having a semen analysis.

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. This test will assess a number of things:

Quantity: The volume of the sample in millilitres (usually around 2-3mls).
Sperm count: The number of sperm (anything over 20 million sperm per ml is considered ‘normal', but men with counts less than that are still quite capable of fathering children naturally).
Motility: How many of the sperm are moving (anything over 40% motility is considered normal).
Progressive motility: What percentage of the motile sperm are swimming forwards in a relatively straight line (anything over 30% progressive motility is considered normal).
Morphology: How many of the sperm appear to be normally shaped (anything over 4% is ok).
Agglutination: 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.

What can we do about it?

If you do ask your GP for this fertility test, make sure that they request the semen analysis 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. That’s because these are both subjective evaluations done by a scientist looking down a microscope and making an expert appraisal.

The scientists in andrology labs are sperm specialists and they are the best people to make these assessments. I'm pretty sure most pathology labs would agree with me on this one :)

When you get the results of a semen analysis – don’t let yourself become upset if anything about your sperm is not ‘normal’. The contents of an ejaculate do not determine how much of a man you are. Fertility is absolutely NOT linked to virility and it rarely has any connection to testosterone levels in your body.

Semen analyses can vary considerably week on week and are heavily influenced by illness, fever and lifestyle. Some dietary changes and supplements can improve semen analysis results.

Depending on how many more children you want, and how old your female partner is, you may choose to just keep trying or choose to seek help from a male infertility specialist.

I always recommend that couples with a semen analysis below what the World Health Organisation says 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.

Some good news – 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.

Cause 2: Poor sperm quality

Sperm DNA fragmentation refers to damage or ‘breaks’ of genetic material in the sperm. This is sometimes a cause of secondary infertility, as sperm DNA can become fragmented due to the significant diet and lifestyle changes that happen after we become parents.

How can we tell if the problem is sperm quality?

Unfortunately, fragmentation of sperm DNA can’t be detected with a semen analysis. It can only be suspected if embryo development does not continue as expected after day 3 of development in an IVF cycle.

Sperm DNA fragmentation can be assessed with a separate and fairly expensive test, but this doesn't really tell us anything long term. It tells us only what the sperm looked like in that one ejaculate.

What can we do about it?

Many of my clients have seen significant improvements in embryo development, implantation and ongoing pregnancy rates after changes in diet and lifestyle, and more and more evidence of the impact of environmental toxins on sperm DNA fragmentation is turning up in the literature – this is one of the reasons I created the Detox WTF program and this is definitely worth investigating just in case it's the sperm DNA that’s causing the problem.

Cause 3. Fallopian tube damage, ovulation disorders, endometriosis and uterine conditions

If your fallopian 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 an egg could be there ready for fertilisation.

If you have endometriosis or fibroids or some other uterine condition, then it might be hard for the egg to be collected by the fimbria (the little hands on the ends of your fallopian tubes that pick up the eggs from your ovaries). It might also be tricky for the fertilised egg to make its way to the uterus to be implanted.

How can we tell if tubes, ovulation disorders, endometriosis or uterine conditions are the problem?

To check for fallopian tube blockage/damage and fibroids:

These two conditions can both be detected by one of two tests: a Hysterosalpingogram (HSG) or a Hysterosalpingo-contrast-sonography (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, and with the HyCoSy it’s 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.

To check if you have endometriosis:

The only way to diagnose endometriosis is by having a laparoscopy that visualises the entire 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’s still not really clear exactly how much of an impact this has on fertility.

To check for ovulation disorders:

Ovulation disorders such as polycystic ovary syndrome are easier to pick up, as it is the process of ovulation that causes you to have a period – without ovulation, there can be no period.

If your period is regular (between 25-33 days) then it’s most likely that you’re ovulating somewhere between day 11-19. But if your cycle isn’t regular, it’s much harder to know when you’re ovulating. This can make it difficult to time everything right – 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 procedure is enough to ‘flush' the tubes out if there is a small blockage. But sometimes you’ll need a laparoscopy to clear everything out, or even possibly remove the tube if it’s 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 inside or affecting the shape of the uterus, then it's likely they're not really causing a problem and your doctor might decide to leave them there.

Endometriosis is a tricky one, and you should definitely take your doctor’s advice on how to proceed. Some doctors 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 a disorder that affects ovulation, it may have been triggered by weight gain and loss, lifestyle, diet and exercise, or 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 – I can definitely help you get started with this!! I've got loads of tips and tricks in my eBook Preparing for Conception.

Cause 4. Complications related to prior pregnancy or surgery

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 causing you mental and emotional stress. Something between you and your partner, something weighing you down, something you don't talk about but should. It could be the challenges of being a parent, lack of sleep, worry about having two… all sorts of different things.

What can we do about it?

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. Choose a specialist Service (Melbourne only)

Cause 5. Risk factor changes for you or your partner, such as age, weight and use of certain medications

There are a number of risk factors for infertility – for example, advanced maternal age, weight, smoking, and/or alcohol consumption. It’s very possible that you may fall into a different risk category now than you did when you conceived the last time. Perhaps you are drinking more, have 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 about it?

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. A change of even 5% of your body weight can be enough to tip you back into a healthy range.

I’m a big believer that it’s not what the scales say that makes the difference (as in, it’s not how much you weigh), it’s about being metabolically well. Meaning that making sure you’re eating heaps of leafy green veggies, not having too much sugar, getting some regular moderate exercise, and generally taking care of yourself is what’s 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 altogether.

For more detailed and specific information, you should always consult a nutritionist. There are a few who specialise in Fertility Nutrition that I can put you in touch with.

If you're looking for some help preparing for conception, even if you've managed to fall pregnant before, check out my eBook Preparing for Conception or head here to book a time to chat with me about a plan!

Book a Chat with Lucy

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