Secondary Infertility: A Common, Underrecognized Condition

Secondary infertility is generally defined as the inability of a couple to conceive a child after a year of unprotected intercourse, when one or both partners have previously conceived. A very common problem, secondary infertility can account for as much as 40% of infertility cases. The treatment for this phenomenon, however, is sporadic and often delayed by patients and physicians, mainly because of the misbelief that if an individual has previously conceived, that person will always be fertile.

The workup and treatment for secondary infertility should be the same as for primary infertility. The woman’s age is critical in infertility, yet it is rarely the rate-limiting step. The man’s age, although not as significant a factor, also plays a role in reduced pregnancy rates.

Women are born with a set number of oocytes, which deteriorate in quantity and quality with increased age. Menopause is the point in time when the oocyte pool has been exhausted. The decrease in fertility with age is significant after 35 years and becomes dramatic after 40 years. This decrease in ovarian reserve results in not only a decline in pregnancy rates, but also a significant increase in miscarriage rates, because of the increasing fragility of the eggs.

Often with secondary infertility, there has been a change of partners, which creates a different paradigm. Therefore, a full workup is necessary for both partners. Also in secondary infertility, there is often an increase in time elapsed between pregnancy attempts. During this period various pathologies can evolve or worsen, decreasing the potential for fertility. Endometriosis, uterine pathology (especially fibroids), and deterioration of sperm parameters are some of the most common etiologies, and they should be assessed vigorously.

The history of the initial pregnancy is also important. Delay in conception with a first pregnancy may indicate a lower fertility potential manifesting itself with increasing time. Complications during delivery and postpartum, such as retained placenta and postpartum dilation and curettage, also may lead to uterine pathology with intrauterine adhesion formation and, subsequently, secondary infertility. In addition, lifestyle changes increasingly are being associated with diminishing fertility. Excessive weight gain and the role of stress and anxiety have been shown to have significant reproductive repercussions.

In conclusion, secondary infertility is a very common problem that is often ignored, with treatment delayed as a result of mistaken beliefs. For these couples, both partners should have an aggressive workup and treatment, designed appropriately, as with primary infertility.