Why can’t you get pregnant again?
You have a wonderful family that is comprised of you, your significant other and your child, but something is missing. You have always wanted to have another child but have been struggling with making this dream a reality. Why is this the case? How common is it to have difficulty getting pregnant after already having a child? Are there things that you can do to help?
Infertility is classified into two types: primary and secondary. Primary infertility is when a woman isn’t able to get pregnant after 1 year of trying. If you’re over 35, the time frame is shortened to 6 months. Overall, an estimated 12% of couples in the United States have difficulty conceiving or staying pregnant. Secondary infertility is when a couple is having trouble conceiving after successfully becoming pregnant at least once before either together or with a previous partner. The National Survey of Family Growth estimates over 1 million couples struggle with it nationwide. It’s thought to affect around 10% of couples worldwide. Many studies, especially those in the US, don’t distinguish between primary and secondary infertility, so it’s challenging to know how many couples deal specifically with secondary. Secondary infertility often catches people off guard, especially if the first pregnancy happened without much effort. Couples who’ve had a previous pregnancy without difficulty think that they have “normal” fertility, but this isn’t always the case. Secondary infertility can occur due to an issue at any point in the natural, but the somewhat complicated, process required to become pregnant. Problems can occur with one or several of the essential steps, such as ovulation (egg is released), fertilization of the egg with sperm, travel of the fertilized egg to the uterus and implantation of the fertilized egg in the uterus. Both types often share the same causes. Both women and men can contribute to infertility with 35% of couples who experience infertility having issues with both partners. This is why it’s imperative for both the man and woman to have a complete infertility workup as soon as they feel they’re having trouble conceiving.
Most female infertility is due to an ovulation disorder. Almost 40% of women with infertility problems don’t consistently ovulate. This can be caused by several conditions, such as polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI), decreased egg production related to aging, thyroid/other endocrine disorders that affect hormone production and some lifestyle factors, such as weight, nutrition and alcohol/drug misuse. One of the most common causes of ovulation problems is PCOS. When a woman has this condition, her ovaries or adrenal glands produce too many hormones and this prevents the ovaries from releasing eggs. Another component of the disorder is that it causes cysts to develop on the ovaries and this further interferes with ovulation. A positive aspect is that there are effective treatments for PCOS.
The other main factor of female fertility complications is age. One 2018 study linked age as a statistically significant factor in secondary infertility when compared to primary infertility. The study demonstrated that the average age of couples was higher among those experiencing secondary infertility. However, this could also be a result of individuals trying to have a second child (or more) are older than those typically trying to get pregnant the first time. Scientifically, for women, fertility peaks around 20, begins to decline at 30 and has a significant reduction by 40. Not only do the quality and quantity of eggs decline over time, but the rate of miscarriage and chromosomal abnormalities increases, especially if the mother is 35 or older. According to the American College of Obstetricians and Gynecologists, healthy couples have about a 25% chance of getting pregnant in any given cycle up until their early 30s, but by 40, that chance dips to 10%. The American Society for Reproductive Medicine puts the chances even lower, at less than 5%. Every year that passes significantly decreases your chances of conceiving. This doesn’t mean that a successful pregnancy can’t happen at more advanced maternal ages, it just might take longer or be more challenging. This is encouraging because according to the Pew Research Center, women are more likely to have children than they were than a decade ago, they’re just waiting longer to have them.
Besides ovulation disorders and age, there are other things that can impact a woman’s ability to get pregnant. One of these is structural problems, which include specific conditions that affect the fallopian tubes or uterus. These are endometriosis, uterine fibroids/polyps, uterine scarring and abnormality in the shape of the uterus. Of these, endometriosis is especially important to highlight because it affects up to 10% of women and 25 to 50% of women with infertility have it. Unfortunately, it can be difficult to diagnose and may worsen with age. Scarring in the uterus can be a result of a previous cesarean delivery. This is referred to as isthmocele and can lead to inflammation in the uterus that affects implantation. Another possible cause of scarring in the uterus or fallopian tubes is infections, especially those from sexually transmitted infections, because they can trigger pelvic inflammatory disease (PID). PID can also affect cervical mucus and decrease fertility as well. The quicker an infection is treated, the less likely it is to impact fertility. Mounting evidence suggests that having more body fat can increase the risk of secondary infertility. Not a lot is known about how specific foods can affect fertility, but the bottom line is that maintaining a healthy weight is crucial. Weight gain is known to result in irregular ovulation. Other lifestyle factors, such as smoking, alcohol consumption and drug use, can increase your risk for infertility. Any previous surgery on your uterus or complications with a previous pregnancy also increases the risk. The relationship between autoimmune disorders and infertility isn’t fully understood. Typically, autoimmune disorders cause the body to attack its own healthy tissues, so this could happen to reproductive tissues, too.
Male infertility issues also play a role in a couple not being able to get pregnant 40 to 50 % of the time. In 8% of cases, it’s a male factor alone that is the reason a couple is having trouble getting pregnant. The most common issue is low sperm count. This can result from a variety of reasons, such as extreme temperature changes (ex. regular soaks in a hot tub), steroid use (ex. some supplements contain them), being overweight and smoking. Another possible cause is the decreased motility of the sperm.
If you’ve already had a successful pregnancy in the past, the whole idea of infertility can feel scary and complicated. This doesn’t mean it can’t be treated, so be proactive in seeking medical assistance. Typically, you’ll start with your primary care doctor or OB-GYN. If you’re not pregnant after a few months or feel your doctor isn’t taking the situation seriously, you should see a fertility specialist. The first step is to identify the cause. This usually means you’ll need to go through several different tests, like blood tests to look at hormone levels, ovulation tests, a pelvic exam, X-rays to view your fallopian tubes and a transvaginal ultrasound/other tests to view your uterus and cervix. Your doctor will also look into tests for your partner to determine sperm count and the viability/motility of the sperm. The doctor will also ask many questions about lifestyle changes that might’ve occurred since your last pregnancy, such as adding extra weight, taking new medications or having surgery, since these can impact your fertility. Regrettably, it’s common for doctors to not find a diagnosable reason for secondary infertility. In any case, all of this information will help your doctor to develop a treatment plan to increase your odds of conceiving.
There are many options to consider when talking about fertility. One of the main ones is medications because they’re often used to normalize hormones. Other medicines help to stimulate ovulation. Since PCOS is such a common cause of infertility, this class of medication along with lifestyle interventions, like getting to and maintaining a healthy weight, are essential. By doing these two things, up to 70% of women with PCOS have successful pregnancies. Sometimes, medications aren’t an option. Instead, you may need surgery to correct the problem. Thankfully, there are several effective surgical procedures that are minimally invasive and are used to treat uterine fibroids, uterine scarring or advanced endometriosis. In addition to medications and surgery, a successful pregnancy might involve advanced reproductive technology (ART). Two of the most common are intrauterine insemination (IUI) and in vitro fertilization (IVF). In IUI, sperm is collected and then inserted into the uterus at the time of ovulation. In IVF, a woman’s eggs are also collected. An egg is fertilized with the sperm in a lab where it’s developed into an embryo. Then, an embryo (or more than one) is implanted into a woman’s uterus. Depending on the cause of infertility and the age of the person, there is an estimated 15-20% pregnancy success rate per treatment cycle. According to the Center for Disease Control and Prevention’s (CDC) 2017 Fertility Clinic Success Rates Report, of the 284,385 ART cycles performed in 2017, there were 68,908 live births and 78,052 babies born. That’s a 24% success rate.
Once you find out that you’re having fertility problems, it’s essential for you and your partner to sit down and create a plan that outlines what you’re willing to try and for approximately how long. Part of this is researching and looking into different options, such as egg donation or embryo donation/adoption. Some things to consider are what type of treatments are you willing to do and how much money can you spend on each treatment? By discussing all of this upfront, it enables you to feel some control over your situation. Part of undergoing fertility treatment means precise scheduling of frequent tests and procedures, which can be a challenge when you’re already a parent. To make this easier, it’s helpful to enlist a friend or relative to help with child care. Another important decision is to choose a doctor’s office you’re comfortable with because you’re going to be spending a lot of time there.
The process of fertility treatments means endless doctor appointments, tests, procedures and medications. It also means sleepless nights, time/energy away from your little one and stress between you and your partner. So, it’s not surprising that secondary infertility can cause stress, anxiety, sadness, frustration, anger and loss for many couples. Even though you have a child already, it doesn’t make going through infertility any easier. Remember, you can be happy that you have a child and deeply sad that you’re struggling to have another. Most parents have a mental image of their ideal family and if they can’t make that happen, it can be devastating. It’s especially difficult as a parent because you’re immersed in the world of kids, so it’s impossible to avoid all the babies and pregnant women that remind you of what you’re missing. Well-meaning friends and family members may unknowingly ask insensitive questions about when you’re going to have another baby or why you’ve decided to only have one. No matter how many times you’ve been asked, “When will you have another baby?” the question still hurts.
People struggling with secondary infertility are often judged by family, friends and strangers. They frequently don’t receive much sympathy, in fact, they’re often told to appreciate the child they have (as if they don’t). This means they end up feeling as though they don’t have a right to be sad. In addition, many parents feel guilty for not giving their child a sibling and for putting some of their focus and resources away from that child. Add to this the guilt they feel when their child asks for a sibling. Due to the lack of sympathy, those experiencing secondary infertility are less likely to access support groups and talk to friends than those experiencing primary infertility, which potentially increases feelings of isolation, stress, anxiety and depression.
It’s essential to avoid blaming yourself or your partner for your infertility. Remember, it’s not an individual issue, but a couple issue. So, find ways to connect with your partner. Stay positive and talk about your feelings, voice your concerns and work together to form a plan to move forward. A key element is to focus on what you can control, such as managing your stress, living the healthiest lifestyle possible and searching for new/innovative solutions that might help you conceive. One of the most frustrating parts is that that there is so much waiting: waiting to ovulate, waiting for test results and waiting for next month to try again. Try to be patient and find things to do to help take your mind off the situation. When asked by others about why you haven’t had another child, come up with a quick comeback and commit it to memory to use in those situations. If your child is asking you for a sibling, be honest and tell them, “We’d like nothing more than to make you a big brother/sister. We hope it’ll happen.” Confide in those you trust. It’s helpful to tell people what words, phrases or actions would help support you the most. By steering them in the right direction with what you need/want at a particular time can lead to better communication and guide them to better help you through tough times. Always talk to your doctor if you are feeling symptoms of clinical depression, such as hopelessness and despair. If your emotions are interfering with your daily life, the American Society for Reproductive Medicine and The National Infertility Association have lists of support groups and specialty-trained mental health professionals that can help you. Another two resources are Resolve.org and FertilityIQ.
As more people are becoming parents in their late 30s or early 40s, the number of individuals facing infertility, including secondary infertility is increasing. Obviously, having successfully delivered a baby in the past makes it hard to deal with the struggle to conceive more children. The most important thing to remember is that, in the vast majority of cases, it’s not your fault and no one should feel guilty about wanting another child.