Secondary infertility — difficulty conceiving after previously having children — can be a challenging diagnosis. It can lead to feelings of sorrow, guilt, depression, anxiety, jealousy, and more. You can still be grateful for and love your child(ren), but long for another. Yet there is still a stigma attached to secondary infertility despite affecting many families. 

"Secondary infertility is much more common than people expect," says Lisa Schuman, LCSW, a fertility-focused social worker and director of The Center for Family Building. "It may happen because of a medical issue, it could be an age-related problem, but the cause is unknown in many cases," explains Schuman. 

"It can take a while for people to absorb that they are experiencing secondary infertility," states Schuman, "as they got pregnant before and wonder why this can be happening now. It can be a lot to take in and understand."

Let's take a look at secondary infertility in more detail, and discuss what support is available.

What is secondary infertility?

The definition of secondary infertility is the inability to conceive or have a full-term pregnancy after previously having children. Secondary infertility occurs at about the same rate as primary (first-time) infertility. Therefore, it accounts for 50% of all infertility cases.

Especially if a couple had no problem getting pregnant the first time, people can brush aside the seriousness of secondary infertility, telling the couple to “just keep trying.” But if you've been actively trying to conceive for a year or more, or six months if you are over 35, then it's time to seek specialist advice.

If you know you have fertility issues, you or your partner has had previous gynecological problems, or you or your partner has sperm or sexual function issues, then you might want to seek help even sooner. 

A fertility specialist, reproductive endocrinologist, urologist, or OB/GYN is a good place to start investigating secondary infertility.

Potential causes of secondary infertility

In many cases, the causes of secondary infertility are the same as those for primary infertility.

For people with sperm, causes of infertility can include:

• Reduced testosterone levels
• Problems with sperm count and quality
• Certain medications
• Prostate problems such as prostate cancer, late-onset hypogonadism, or prostate enlargement
• Excessive weight gain
• Testicular varicocele (enlargement of veins in the scrotum that can lead to fertility problems)
• Antisperm antibodies

In people with ovaries, other causes may include:

• Reduced quantity and quality of eggs, which can happen with aging
• Scarring from previous surgeries such as a cesarean or dilation and curettage
• Conditions such as endometriosis, polycystic ovary syndrome (PCOS), fibroids, or pelvic infections like chlamydia
• Damaged or blocked fallopian tubes
• Breastfeeding
• Excessive weight gain
• Certain medications

However, as Schuman mentioned, clinicians might not find a direct cause for many cases of secondary infertility. Not finding a reason can make infertility even harder to accept, but it's not uncommon. Unexplained infertility happens in approximately 1 in 4 of all infertility cases.

“But we got pregnant easily the first time!”

It may be confusing to deal with infertility if you previously had no issues getting pregnant. But our bodies change over time, and secondary infertility could be related to a new issue that popped up — or got more serious — since the last time you were trying to conceive.

Examples include:

• Age. If there's one thing that’s for certain, it’s that you’ll be younger with your first child than with subsequent children. Both female and male fertility are affected by age. Sperm quality declines each year of a person’s life, potentially making it more difficult to conceive a healthy pregnancy with age (especially after 45). The effects of aging on fertility might be more pronounced if you waited a while between kids.
• A new infection or illness. If you’ve had any new illnesses in the time between your last child and now, that could change your chances of conceiving. A diagnosis of cancer and cancer treatment, for example, can affect fertility. If you’ve contracted a sexually transmitted infection, that too could impact your sperm health and casue secondary infertility.
• Complications during/after earlier pregnancies. If the person who carried the pregnancy experienced complications, such as ectopic pregnancy or a C-section, that may contribute to difficulty getting pregnant later on.

Diagnosis and treatments for secondary infertility 

As mentioned above, the starting point to finding out the cause of infertility is to see a specialist. They will be able to take a complete medical history and then decide on relevant tests to explore your fertility concerns.

For people with testes, this may include starting with a semen analysis. This is a good starting point to understand what is going on with a person’s sperm health. Semen or sperm analysis looks at the five main areas of sperm health, including:

1. Semen volume
2. Sperm count/concentration
3. Sperm motility (how they move)
4. Sperm morphology (how they are shaped)

For both partners, a physical examination may be advised to ensure there are no abnormal lumps or bumps that could indicate what is causing infertility. If a sexually transmitted infection (STI) is possible, then STI testing could be recommended. Blood tests can also be done to assess hormone levels in both partners.

For people with ovaries, further investigations such as an ultrasound scan, x-ray, or investigative laparoscopy (a minor surgery where the surgeon inserts a camera to look at the fallopian tubes, ovaries, and uterus).

Depending on the results of your investigations, there could be several treatment options:

• Medications for hormone or ovulation concerns
• Female surgical procedures to unblock fallopian tubes, remove scarring, or treat fibroids, endometriosis, or PCOS
• Male surgical procedures to treat a testicular varicocele, epididymal blockage, or to retrieve sperm
• Artificial reproductive techniques such as intrauterine insemination (IUI) or in vitro fertilization (IVF)
• Egg or sperm donation

The emotional impact of secondary infertility

Regardless of the cause of secondary infertility, it can have a significant emotional impact which you also need to consider and get support for. 

"Secondary infertility can hit people differently as they can feel blindsided by it," explains Lisa Schuman. "They find it hard to understand that they have been pregnant before and that their body cannot get pregnant again," she continues, "and it can lead to a lot of anxiety and depression." 

Schuman explains that research shows people with secondary infertility can be just as depressed as people experiencing primary infertility. However, many people don't appreciate what secondary infertility patients are dealing with, and attitudes towards people with secondary infertility can be challenging.

"Many people comment to people with secondary infertility that they should be grateful they already have a child," says Schuman, "but that person with secondary infertility has every right to be upset, depressed, and stressed."

Everyone's family-building journey is different. Some people don't want to have children, some would choose to have one child, and some families dream of having two or more children. "You need to embrace what makes your family complete and not feel you can't do that because other people say you should feel lucky you already have a baby," advises Schuman.

Secondary fertility can feel quite isolating. You may not feel comfortable attending regular infertility support groups if you already have a child. It can feel like many people around you don't empathize and that you have no one to turn to.

There is support available for parents facing secondary infertility:

• Counseling with a fertility-focused therapist can help you through your emotions and give you a safe space to discuss your feelings.
• The Center for Family Building holds online support groups for people who want to build a family, or have built a family through the use of donor sperm or donor eggs.
• Resolve also runs some support groups for secondary infertility; you can find their support groups here.