The approach and treatment of Secondary Infertility

By Elena Trukhacheva MD, MSCI

President and Medical Director – Reproductive Medicine Institute (www.teamrmi.com)

In the immortal words of Baseball’s Yogi Berra “It’s Déjà vu all over again!” For many, Yogi’s words perfectly describe the struggle with secondary infertility, or difficulty getting pregnant a second time . . .or a third.

It is estimated that about 3 million people in 2005 suffer from secondary infertility (less than half the number that suffer from primary infertility). According to Resolve, a national infertility organization, that figure represents an increase from an estimated 1.8 million in 1995.

Secondary infertility is defined as the condition where a woman is unable to get pregnant or carry a pregnancy to term after already having had one or more children. Some experts put the added caveat of “after 12 months of trying to conceive naturally on their own,” to better qualify the term. Some experts define secondary infertility as occurring any time after a previous conception, whether that conception ended in a birth or a miscarriage.   Secondary infertility can occur whether the first conception was difficult or easy.  It can be due to female issues, male issues or a combination of both.

Whatever the exact nature of the definition, few disagree that secondary infertility, whether an adjunct to primary infertility or a new challenge all its own, can be a confounding and painful experience that seems to prevent many from creating the complete family of their dreams.

Many patients (and physicians) opt for the exact same plan that worked for you the first time. You may choose to try on your own, hoping for the possible reprieve from Infertility, Part 2.   Remember however, that if you had a diagnosed condition that caused primary infertility, chances are the same parameters still apply.  To give yourself the best opportunity within a reasonable amount of time, set limits. If you haven’t conceived naturally within 6 months to a year (less time if you’re over 40), consider going back to the drawing board and/or the original “architect,” whether that be your primary physician, OB/GYN or Reproductive Endocrinologist and Infertility (REI) specialist.

One thing that can be taken from this line of thinking, however, is a careful review of your first successful go around. Ask yourself the following:

*  Was it as easy as it seemed the first time or is that merely in comparison to the current struggle of secondary infertility?

*  Did you miscarry two or more times on the way to a healthy baby? Were these miscarriages investigated and found to be due to chromosomal abnormalities, which increase with age?

*  Was it ever suggested, prior to conception, that there might be issues that could cause a problem in conceiving or carrying a child (for example, abnormal hormonal levels; structural issues in the uterus, ovaries or fallopian tubes; a family history of infertility, and so on)?

Changes in age

Unless (or even if) your last child was born six weeks ago, time does march on! And from an infertility point of view, that’s never a good thing. One of the primary reasons for secondary infertility is the age of the mother.  Age related male infertility can also be a consideration, although Father Time does seem to be a bit more forgiving when it comes to the dads.  . Regardless of whose age we’re discussing, by definition, both you and your partner (should both parties remain the same!) will be older when you try to conceive your next child.  Fertility declines throughout the years, so the baby that popped up so easily in your 20’s, might not be as forthcoming in your 30’s or 40’s. The longer the interval between children, the more likely that time is not on your side. The fact that you have conceived, carried and delivered a baby are certainly positive predictors of your ability to do so, but realize that many cite the age of the mother as the primary reason for reproductive success. Is this true? Only time will tell.

Changes in health

As with primary infertility, your overall health does make a difference. While you may still be living the clean life, it doesn’t mean that your body hasn’t undergone changes all its own. Have you had an increase or decrease in your weight? BMI (body mass index) can certainly play a part in your fertility or lack thereof. Have you suddenly become a marathon or long-distance runner? This too can affect your metabolism and your body’s responses, including the reproductive ones. While these can be positive health changes, they can also upset the delicate balance that your body may be clinging to. Take a look at any lifestyle changes, good or bad, and discuss them with your physician to see if therein lies the culprit.

Occult, or not yet uncovered, chronic or acute illness can also play a role in reversing your fertility. Diabetes, autoimmune disease such as lupus, thyroid problems and a host of other issues, large and small, can also affect your ability to conceive and could be brewing without your knowledge. If you haven’t had a complete physical workup as well as a gynecological one, now would be the time.

Are you fresh from your first or last pregnancy? Still breastfeeding? Again, even subtle changes such as a shift in your sleep patterns can wreak havoc on your system, which can leave your fertility in less than fighting shape. Another thing to consider and discuss with your physician is any lasting effects from your previous pregnancy(ies). Could you have developed adhesions as a result of a caesarian section? Did you have problems with excessive bleeding that might indicate unresolved issues? Make sure that you check out normal from your last foray into baby making before jumping into the next.

The other large category of problems in secondary infertility is the status of the pelvic organs: Are you having abnormal bleeding (especially between periods) that might be indicative of a fibroid or a polyp in your uterus? Have you had any kind of abdominal surgery since your last delivery (appendectomy, gall bladder surgery, ovarian cyst removal)? All surgery is associated with a risk of scarring (adhesions), which may either block the fallopian tubes or pull them away from the ovaries so that they cannot pick up the ovulated eggs. The good news is that all of these conditions can be identified with the use of appropriate diagnostic tests that your doctor can order.

Changes in partners

You may be focusing on the wrong part of the equation, if you’re only thinking about what‘s different with you this time around. Remember, primary infertility is split fairly evenly between women’s issues, men’s issues and those issues that are shared by both. If you have changed partners since your last child, perhaps the problem lies with your other half.

Even if you’re with the same partner, once again, age can play a factor with men as well. More recent studies have shown that men over 40 have a decrease in the motility and morphology of sperm, reducing their fertile potential. In addition, DNA changes that come with age can also negatively impact a man’s sperm, making it abnormal and less likely to fertilize an egg.

And, just as with you, your partner’s health status can change in time as well, having a less than desirable effect on his contribution to the baby mix. If you’ve checked out in all areas, maybe it’s time to check…again.

 

Whether primary, secondary or both, Infertility can be managed and treated.  Options exist for helping you create the family of your dreams.

 

As one of the field’s devoted  female reproductive endocrinologists, Elena Trukhacheva, MD, MSCI, demonstrates a unique rapport and understanding of her patients.  As a woman and a mother, she takes pride in providing comprehensive care and strives to bring hope and support to her patients. Dr. Trukhacheva is Board Certified in the specialty of obstetrics and gynecology and in the subspecialty of reproductive endocrinology and infertility.

Dr. Elena Trukhacheva has devoted her professional life to academic medicine, research, and clinical practice in the field of Reproductive Endocrinology and Infertility. She received her medical degree from the Russian State Medical University in Moscow, Russia. She graduated magna cum laude in 2000 and received multiple awards for research and academic excellence during her studies. Dr. Trukhacheva completed her residency in Obstetrics and Gynecology at Baylor College of Medicine, consistently rated among the top medical schools in the country.

Following residency, Dr. Trukhacheva entered a three-year fellowship in Reproductive Endocrinology and Infertility at Northwestern University in Chicago. During fellowship she also received a Master of Science degree in Clinical Investigation. She has formal training in biostatistics, epidemiology, and the design of clinical research studies.

Dr. Trukhacheva is a speaker for the American College of Obstetrics and Gynecology. She also serves as a reviewer for the Fertility and Sterility journal and leads the Preimplantation  Genetic Diagnosis International Society (PGDIS) committee for Clinical Applications. She is a clinical assistant professor in Obstetrics and Gynecology at Midwestern University, and is actively involved in teaching medical students and OBGYN residents at the Midwestern University and at the Illinois Masonic Medical Center.

Her clinical interests include In Vitro fertilization, previous IVF failures, special approaches for poor responders, preimpantation genetic screening and diagnosis, as well as advanced laparoscopic and hysteroscopic gynecologic surgery.

Dr. Trukhacheva is fluent in English, Russian, and Ukrainian. A native of Russia, she now calls Chicago home.