Secondary Infertility

Secondary infertility is difficulty conceiving, or carrying a pregnancy to term, after you have already had a child. It is one of the most common reasons people come to a fertility practice and one of the least talked about, partly because it does not match what most people picture when they hear the word infertility.

Having conceived before is not a guarantee that you will again

The most frequent thing we hear is some version of it worked the first time, so why not now. It is a reasonable question, and the answer is that fertility is not a fixed trait. It is a snapshot of your body, your partner's body and your age at one particular moment. Several years have usually passed since that first pregnancy, and a great deal can change in that window.

That also means a previous pregnancy should not be used as a reason to delay an evaluation. The workup for secondary infertility is the same full evaluation as for anyone else, and it covers both partners.

What changes between a first pregnancy and a second

The single most common factor is simply elapsed time. Egg quantity and quality both decline with age, and the gap between a first and second attempt is often three to five years or more — enough to move someone into a meaningfully different prognostic group even when nothing else has changed.

Dr. Paul Gindoff makes the related point that AMH predicts egg yield rather than egg quality, and that age is what carries the quality question. You can read his full discussion of age, AMH and patient choice.

Beyond age, things that can be new since the first pregnancy include:

• Ovarian reserve. A lower remaining egg supply than before, assessed through AMH, antral follicle count and day-3 bloodwork.
• Uterine changes. Fibroids, polyps or scar tissue, including scarring following a caesarean section or a uterine procedure.
• Tubal factor. Blockage or damage that was not present before, sometimes following infection, surgery or an ectopic pregnancy. This is assessed with anHSG.
• Progression of an existing condition. Endometriosis and PCOS are not static, and either can affect you differently than it did before.
• Sperm parameters. Male factor is present in nearly half of couples with a delay in conceiving, and semen parameters change over time too. If your partner has not had a semen analysis this time round, that should be an early step rather than a last one.
• Thyroid and other endocrine changes. Thyroid function and prolactin are simple to test and treatable when abnormal.
• Nothing identifiable. As with a first pregnancy, a complete evaluation can come back normal. That is unexplained infertility, and it does not mean nothing can be done.

When to be seen

The thresholds are the same as for a first pregnancy: if you are under 35 and have been trying for a year without success, or over 35 and trying for six months, it is a good time to be evaluated. Come sooner if your cycles have become irregular, if you have a known condition such as endometriosis or PCOS, if you have had a pregnancy loss, or if the delivery or recovery of your first child involved a complication affecting the uterus.

If your first child was conceived with fertility treatment, bring those records. We generally will not repeat recent testing — we will use it to move you forward. See fertility testing and diagnosis for what an evaluation involves.

How it is treated

Treatment follows the diagnosis rather than the label. Where ovulation is the problem, getting ovulation to happen reliably is the mainstay. Where the evaluation points to sperm, tubes, the uterus or ovarian reserve, treatment is directed at what the workup found, and may involve IUI or IVF. Which approach is appropriate is determined individually by the treating physician after the full evaluation, not from one result in isolation.

The part nobody prepares you for

Secondary infertility tends to get less sympathy than primary infertility, including from people close to you, and often from yourself. Being told you should be grateful for the child you have is both true and completely beside the point — wanting another child is not ingratitude for the first.

It also tends to come with a particular kind of isolation: you may no longer fit in with friends who are having second children easily, and you may not feel entitled to the support networks built around infertility. Both of those feelings are common and neither is a reason to put off being seen. We have written more about secondary infertility and why it is so rarely discussed.

Common questions

Consultation is free for new patients; we bill health insurance where you have coverage that applies. Call 212-685-2229 or contact our team to discuss your evaluation. If you have been treated elsewhere, you can also request a fertility second opinion.